[Adenocarcinoma of the exocrine pancreas: management and therapeutic hopes]

INTRODUCTION

Pancreatic carcinoma is a major public health concern, as it kills more than 6,000 people each year in France.

CURRENT KNOWLEDGE AND KEY POINTS

The main risk factor demonstrated by concordant case-control studies is cigarette smoking. Pancreatic carcinoma is generally diagnosed at an advanced stage. Results of radical surgery are still poor. In most of the reported series, less than 25% of the patients survive at five years.

FUTURE PROSPECTS AND PROJECTS

Postoperative radiochemotherapy slightly increases the hope of cure. In locally advanced tumors, radiochemotherapy, sometimes preoperative, allows some patients to survive more than two years. Though results of palliative chemotherapy remain very poor, some clinical benefit has been observed in randomized trials comparing this treatment with the currently best supportive treatment.

The role of sentinel lymph node biopsy in breast cancer

BACKGROUND

Lymphatic mapping and sentinel lymph node (SLN) biopsy are new techniques that accurately provide crucial staging information while inflicting far less morbidity than complete axillary dissection. As these techniques continue to gain acceptance, issues such as adequacy of training, certification, and outcomes measures become increasingly important. The purpose of this paper is to report the initial lymphatic mapping experience at the H Lee Moffitt Cancer Center and Research Institute and to provide a detailed description of the technical aspects of lymphatic mapping.

STUDY DESIGN

From April 1994 to April 1998, 700 patients with newly diagnosed breast cancers underwent an IRB-approved prospective trial of lymphatic mapping using a combination of Lymphazurin (USSC, Norwalk, CT) blue dye and filtered technetium 99m-labeled sulfur-colloid. Failure of the procedure was defined as the inability to detect an SLN by either radiocolloid uptake within a lymph node by the gamma probe or the inability to visualize blue staining of a lymph node. Learning curves were then generated as the failure rate versus serial number of patients for each of the 5 surgeons involved in this study.

RESULTS

The SLN was identified in 665 of 700 patients (95.0%). A total of 1,348 SLNs were successfully removed, of which 238 (17.7%) were positive for metastatic disease in 176 of 665 patients (26.5%). In patients who underwent a complete axillary dissection after SLN biopsy, SLNs were identified in 173 of 186 patients (93.0%). Of the 173 patients, 53 patients (30.6%) had positive SLNs and 120 patients (69.4%) had negative SLNs. In the 120 patients with negative SLNs, one patient was found to have disease on complete dissection, for a false-negative rate of 0.83% (95% CI: 0.02%, 4.6%). A learning curve representing the mean of the 5 surgeons' experience indicates that on average 23 patients are required by an individual surgeon to achieve a 90% +/- 4.5% success rate and 53 patients are required to achieve a 95% +/- 2.3% success rate (p = 0.05).

CONCLUSIONS

These data validate lymphatic mapping and SLN biopsy as indispensable tools in the surgical treatment of breast cancer. With adequate multidisciplinary training, these techniques can be readily implemented at institutions treating breast cancer.

Pancreatic cancer in patients with chronic pancreatitis: a challenge from a surgical perspective

Chronic pancreatitis (CP) is generally considered as a risk factor for pancreatic adenocarcinoma (PAC). However, the cumulative risk differs among the epidemiological studies. In the individual patient, the differential diagnosis between PAC and CP cannot be always resolved preoperatively and even intraoperatively. In those cases, the uncertainty can only be answered with histological studies of the resected specimen after a radical resection, provided that this type of surgery can be performed with a reasonable risk in a surgically fit patient. The type of resection depends on the location of the suspicious mass. For masses in the tail of the pancreas, a distal pancreatectomy is the procedure of choice. For suspicious lesions in the head of the pancreas, a pancreatoduodenectomy (PD) should be performed. The surgeon and the patient should also acknowledge that a radical resection will occasionally be performed for a suspected malignancy only to find that another etiology (i.e. CP) accounts for the suspicious pancreatic mass. In the presence of a strong suspicion for an underlying malignancy in a patient with head dominant CP, PD should probably be preferred over the newer organ-preserving Beger and Frey procedures, since it is an adequate procedure for both CP and PAC.

Predictors of Axillary Lymph Node Metastasis in T1 Breast Carcinoma

This study was designed to determine the predictors of axillary lymph node metastasis in T1a (≤0.5 cm), T1b (>0.5 cm and ≤1.0 cm), and T1c (>1.0 cm and ≤2.0 cm) breast cancers. The charts of 204 patients who underwent axillary lymph node dissections for T1 breast carcinomas at our institution were reviewed. Of these, 23 (11%) patients had T1a cancers, 55 (27%) patients had T1b cancers, and 126 (62%) patients were diagnosed with T1c lesions. Fifty patients (24.5%) had axillary node metastases. Of those with T1a lesions, one (4.3%) patient had axillary node involvement, compared with 9 (16.4%) patients with T1b and 40 (31.7%) patients with T1c lesions. Nodal involvement was significantly increased in T1c cancer compared with either T1a (odds ratio = 8.24; P < 0.05) or T1b (odds ratio = 2.73; P < 0.05). Similar results were found in tumors with grade 3 nuclear pleomorphism (odds ratio = 10.45 versus grade 1 and 3.46 versus grade 2; P < 0.05). The presence of lymphovascular invasion was also associated with an increased likelihood of nodal involvement (odds ratio = 3.15; P < 0.05). Predictors of axillary lymph node metastasis in T1 breast carcinomas include increasing tumor size, grade 3 nuclear pleomorphism, and the presence of lymphovascular invasion. These predictors may have a role in stratifying patients with T1 breast carcinomas into subgroups that may benefit from less invasive methods of evaluating axillary lymph node status.

Complications of level I and II axillary dissection in the treatment of carcinoma of the breast

OBJECTIVE

To assess the complications of level I and II axillary lymph node dissection in the treatment of stage I and II breast cancer, with breast-conservation surgery and mastectomy.

SUMMARY BACKGROUND DATA

The role of axillary dissection for staging, and as an effective means of controlling regional nodal disease, has long been recognized. As small and low-grade lesions have been detected more frequently, and as its therapeutic impact has been questioned, axillary dissection has increasingly been perceived as associated with significant complications.

METHODS

Two hundred patients, 112 of whom had breast-conservation surgery with axillary dissection and 88 of whom had total mastectomy with axillary dissection, were evaluated 1 year or more after surgery for arm swelling as well as nonedema complications. All patients had arm circumference measurements at the same four sites on both the operated and nonoperated sides.

RESULTS

No patient had an axillary recurrence. The mean difference in circumference on the nonoperated versus operated side was 0.425 cm +/- 1.39 at the midbiceps (p < 0.001), 0.315 cm +/- 1.27 at the antecubital fossa (p < 0.001), 0.355 cm +/- 1.53 at the midforearm (p < 0.005), and 0.055 cm +/- 0.75 at the wrist (n.s.). Seven patients (3.5%) had mild swelling of the hand. Heavy and obese body habitus were the only significant predictors of edema on multivariate analysis. One hundred fifty-three (76.5%) patients had numbness or paresthesias of the medial arm and/or axilla after surgery; in 125 (82%) of these, the problem had lessened or had resolved on follow-up assessment.

CONCLUSIONS

The characterization of a level I and II axillary dissection as a procedure with significant complications does not appear justified based on this experience.

Identification of sequences required for inhibition of oncogene-mediated transformation by pp32

Oncogenic potential in prostate cancer is modulated in part by alternative use of genes of the pp32 family. This family includes the tumor suppressor pp32, expressed in normal tissue, and the pro-oncogenic genes pp32r1 and pp32r2 that are found principally in neoplastic cells. At the protein level, pp32, pp32r1, and pp32r2 are approximately 90% identical, yet they subsume opposite functions. In this study, we identify the region of pp32 associated with the ability to inhibit oncogene-mediated transformation in a rat embryo fibroblast system, an in vitro correlate of tumor-suppressive activity. Deletion and truncation analysis define a region spanning pp32 amino acids 150-174 as absolutely required for inhibition of transformed foci elicited by RAS and MYC. Comparison of pp32 with the pp32r1 sequence by moving averages of sequence identity reveals divergence over this region; pp32r2 also differs in this region through truncation after pp32 amino acid 131. The deletion experiments and the experiments of nature therefore converge to demonstrate that tumor-suppressive functions of pp32 reside in amino acids 150-174. Identification of this minimal tumor-suppressive region should help elaborate the pathways and mechanisms through which pp32 family members exert their functions.

Intensified adjuvant therapy for pancreatic and periampullary adenocarcinoma: survival results and observations regarding patterns of failure, radiotherapy dose and CA19-9 levels

PURPOSE

Primary endpoints were 1. To determine if, in the context of postoperative adjuvant therapy of pancreatic and nonpancreatic periampullary adenocarcinoma, continuous infusion (C.I.) 5-fluorouracil (5-FU) and leucovorin (Lv), combined with continuous-course external-beam radiotherapy (EBRT) to liver (23.4-27.0 Gy), regional lymph nodes (50.4-54.0 Gy) and tumor bed (50.4-57.6 Gy), followed by 4 months of C.I. 5-FU/Lv without EBRT could be given with acceptable toxicity. 2. To determine an estimate of disease-free and overall survival (DFS, OS) with this treatment in this context. Secondary endpoints were 1. To observe the effects of therapy at two different dose levels of irradiation, and 2. To observe for correlations among DFS, OS and CA 19-9 levels during therapy.

METHODS

Patients received C.I. 5-FU 200 mg/m2 and Lv 5 mg/m2 Monday through Friday during EBRT, and 4 cycles of the same chemotherapy without EBRT were planned for each 2 weeks of 4, beginning 1 month following the completion of EBRT. Therapy was to begin within 10 weeks of surgery and patients were monitored for disease recurrence, toxicity, and CA 19-9 levels before the start of EBRT/5-FU/Lv, before each cycle of C.I. 5-FU/Lv, and periodically after the completion of therapy. There were two EBRT dosage groups: Low EBRT, 23.4 Gy to the whole liver, 50.4 Gy to regional nodes and 50.4 Gy to the tumor bed; High EBRT, 27.0 Gy to the whole liver, 54.0 Gy to regional nodes, and 57.6 Gy to the tumor bed.

RESULTS

29 patients were enrolled and treated (23 with pancreatic cancer, and 6 with nonpancreatic periampullary cancer). Of these, 18 had tumor sizes > or = 3 cm and 23 had at least one histologically involved lymph node; 6 had histologically positive resection margins. Mean time to start of EBRT/5-FU/Lv was 53 +/- 2 days following surgery. The first 18 patients were in the Low EBRT Group and the last 11 in the High EBRT Group. Toxicity was moderate and manageable, including a possible case of late radiation hepatitis. Median DFS was 8.3 months (pancreatic cancer patients 8.5 months) and OS was 14.1 months (pancreatic cancer patients 15.9 months). Among patients with pancreatic cancer, results were similar for the Low and High EBRT Groups (DFS: 8.3 vs. 8.6 months; OS: 14.4 vs. 16.9 months, respectively). With a mean follow up of 2.6 +/- 0.3 years for the surviving patients and a minimal follow-up of 2.5 years, 27 of 29 pts have relapsed and 25 pts have died. A rise in CA 19-9 levels preceded clinical relapse by 9.1 +/- 1.5 months. Time to first relapse by site showed inverse correlation with dose of radiotherapy to that site: peritoneal (5 +/- 1 month), hepatic (7 +/- 0.9 months), regional nodes/tumor bed (9.6 +/- 1.8 months). Mean postresection CA 19-9 level was 63.3 +/- 16.2 U/ml. Postresection CA 19-9 values did not correlate with survival, margin status, or with the identification of metastatic carcinoma in resected lymph nodes. However, among patients with histologically involved nodes in the resected specimen, postresection CA 19-9 values did correlate with the number of positive nodes identified (p = 0.05).

CONCLUSIONS

Although toxicity was acceptable, survival results were not improved over those seen with standard adjuvant treatment. Most patients relapsed before the planned chemotherapy cycles were completed, or within 100 days thereof, suggesting disease resistance to C.I. 5-FU/Lv as used in this study. Although this regimen is not recommended for further study, the doses of EBRT utilized may be suitable for evaluation with other chemotherapy combinations. Postoperative CA 19-9 levels did not correlate with survival, but did correlate with the number of histologically involved lymph nodes found in the resected specimen among node-positive patients. Moreover, rising CA 19-9 levels anticipated ultimate clinical failure by 9 months.

Behavioral effects of cocaine on a transgenic mouse model of cortical-limbic compulsion

We previously created a transgenic mouse model of cortical-limbic induced compulsions in which dopamine D1 receptor-expressing (D1+) neurons in restricted regional subsets of the cortex and amygdala express a neuropotentiating cholera toxin (CT) transgene. These 'D1CT' mice engage in complex behavioral abnormalities uniquely resembling human compulsions, such as non-aggressive biting of cagemates during grooming, repeated leaping and episodes of perseverance of any and all normal behaviors. Because both compulsions and cocaine-induced behaviors may represent forms of psychomotor activation that have a shared or overlapping neurological basis, we have examined the behavioral response of these 'compulsive' mice to cocaine. In both control and D1CT mice, cocaine increased the amount of time spent engaged in typical cocaine-dependent stereotypies such as locomotion, sniffing, or gnawing, while the remainder of behaviors within their normally complete behavioral repertoires decreased. Cocaine also decreased, rather than facilitated, the incidence of D1CT transgene-induced compulsion-like behaviors such as repeated leaping and perseverance of any and all normal behaviors. The indistinguishable cocaine responses of D1CT and normal mice, as well as the masking (rather than potentiation) of D1CT mouse compulsion-like behaviors by cocaine, suggests that cortical-limbic induced compulsions are significantly different in their origin or circuitry from cocaine-induced stereotyped behaviors. Specifically, these data suggest that the motor circuits stimulated in compulsions represent only a subset of the parallel circuits stimulated by cocaine. These data are, thus, consistent with the hypothesis that topographically restricted subsets of parallel cortical-striatal-thalamic loops induce different types of compulsive behaviors.

Pancreatic cancer: a report of treatment and survival trends for 100,313 patients diagnosed from 1985-1995, using the National Cancer Database

BACKGROUND

The National Cancer Database is an electronic registry system sponsored jointly by the American College of Surgeons Commission on Cancer and the American Cancer Society. Patients diagnosed with pancreatic adenocarcinoma from 1985 to 1995 were analyzed for trends in stage of disease, treatment patterns, and outcomes.

STUDY DESIGN

Seven annual requests for data were issued by the National Cancer Database from 1989 through 1995. Data on 100,313 patients were voluntarily submitted using a standardized reporting format.

RESULTS

The anatomic site distribution was: head, 78%; body, 11%; and tail, 11%. The ratios of limited to advanced disease (Stage I/Stage IV) were 0.70 for tumors in the head, 0.24 for body tumors, and 0.10 for tail tumors. Of all patients, 83% did not have a surgical procedure and 58% did not have cancer-directed treatment. Resection was done for 9,044 (9%) patients, including 22% of those with Stage I disease. The overall 5-year survival rate was 23.4% for patients who had pancreatectomy, compared with 5.2% for those who had no cancer-directed treatment.

CONCLUSIONS

Overall survival rates for pancreatic cancer have not changed in 2 decades. A small minority of patients presented with limited, resectable disease, but the best survival rates per stage were achieved after surgical resection. Five-year survival rates after resection reported herein corroborated the improved survival rates of more recent large, single institution studies.

Prognostic Factors Associated with Resectable Adenocarcinoma of the Head of the Pancreas

A retrospective study of patients with surgically resectable adenocarcinoma of the pancreatic head was undertaken to determine which prognostic factors are independently associated with improved survival. Thirty-four men and 41 women (mean age, 61.9 years) had resection for adenocarcinoma of the pancreatic head between 1980 and 1997 at Rush-Presbyterian-St. Luke's Medical Center. Surgical resections included 15 total pancreatectomies, 43 pyloric-preserving procedures, and 17 standard Whipple procedures. Thirty-six patients received adjuvant radiation and/or chemotherapy. Overall median survival was 13 months, with a 5-year survival of 17 per cent. Thirty-day surgical mortality was 1.3 per cent. Significant factors that negatively influenced survival using univariate Kaplan-Meier analysis were: positive resection margin (P = 0.01), intraoperative blood transfusion (P = 0.01), and lymph node metastases (P = 0.01). Presenting signs and symptoms, patient demographics, operative procedure, tumor size, histologic differentiation, and adjuvant therapy did not have a significant impact on survival. Using multivariate Cox regression analysis, the only significant independent factors improving survival were the absence of intraoperative blood transfusion (P = 0.02) and a negative resection margin (P = 0.04). Performing pancreaticoduodenectomy for adenocarcinoma of the head of the pancreas with negative microscopic margins of resection and without intraoperative transfusion significantly improves survival.

OCD-Like behaviors caused by a neuropotentiating transgene targeted to cortical and limbic D1+ neurons

To study the behavioral role of neurons containing the D1 dopamine receptor (D1+), we have used a genetic neurostimulatory approach. We generated transgenic mice that express an intracellular form of cholera toxin (CT), a neuropotentiating enzyme that chronically activates stimulatory G-protein (Gs) signal transduction and cAMP synthesis, under the control of the D1 promoter. Because the D1 promoter, like other CNS-expressed promoters, confers transgene expression that is regionally restricted to different D1+ CNS subsets in different transgenic lines, we observed distinct but related psychomotor disorders in different D1CT-expressing founders. In a D1CT line in which transgene expression was restricted to the following D1+ CNS regions-the piriform cortex layer II, layers II-III of somatosensory cortical areas, and the intercalated nucleus of the amygdala-D1CT mice showed normal CNS and D1+ neural architecture but increased cAMP content in whole extracts of the piriform and somatosensory cortex. These mice also exhibited a constellation of compulsive behavioral abnormalities that strongly resembled human cortical-limbic-induced compulsive disorders such as obsessive-compulsive disorder (OCD). These compulsive behaviors included episodes of perseverance or repetition of any and all normal behaviors, repetitive nonaggressive biting of siblings during grooming, and repetitive leaping. These results suggest that chronic potentiation of cortical and limbic D1+ neurons thought to induce glutamatergic output to the striatum causes behaviors reminiscent of those in human cortical-limbic-induced compulsive disorders.

Pancreaticoduodenectomy with or without extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma: comparison of morbidity and mortality and short-term outcome

OBJECTIVE

This prospective, randomized, single-institution trial was designed to evaluate the end points of mortality, morbidity, and survival in patients undergoing standard versus radical (extended) pancreaticoduodenectomy (including distal gastrectomy and retroperitoneal lymphadenectomy).

SUMMARY BACKGROUND DATA

Numerous retrospective reports and one prospective randomized trial have suggested that the performance of an extended lymphadenectomy in association with a pancreaticoduodenal resection may improve long-term survival for some patients with pancreatic and other periampullary adenocarcinomas. Many of these previously published studies can be criticized for their retrospective and nonrandomized designs, for the inclusion of nonconcurrent control groups, and for their small numbers.

METHODS

Between April 1996 and December 1997, 114 patients with periampullary adenocarcinoma were enrolled in an ongoing, prospective, randomized trial at The Johns Hopkins Hospital. After intraoperative verification of completely resected periampullary adenocarcinoma, the patients were randomized to receive either a standard pancreaticoduodenectomy (removing only the peripancreatic lymph nodes en bloc with the specimen) or a radical pancreaticoduodenectomy (standard resection plus distal gastrectomy and retroperitoneal lymphadenectomy). All pathology specimens were reviewed and categorized. The postoperative morbidity, mortality, and short-term outcomes were examined.

RESULTS

Of the 114 patients randomized, 56 underwent a standard pancreaticoduodenectomy and 58 a radical pancreaticoduodenectomy. The two groups were statistically similar with regard to age and gender, but there was a higher percentage of white patients in the radical group. All the patients in the radical group underwent distal gastric resection, whereas 86% of the patients in the standard group underwent pylorus preservation. The mean operative time in the radical group was 6.8 hours, compared with 6.2 hours in the standard group. There were no significant differences between the two groups with respect to the intraoperative blood loss, transfusion requirements, location of primary tumor, mean tumor size, positive lymph node status, or positive margin status. There were three deaths in the standard group and two in the radical group. The complication rates were 34% for the standard group and 40% for the radical group. Patients undergoing radical resection had a higher incidence of early delayed gastric emptying but had similar rates of other complications, such as pancreatic fistula, wound infection, intraabdominal abscess, and need for reoperation. The mean total number of lymph nodes resected was higher in the radical group. Of the 58 patients in the radical group, only 10% had metastatic carcinoma in the resected retroperitoneal lymph nodes, and none of those patients had the retroperitoneal nodes as the only site of lymph node involvement. The 1-year actuarial survival rate for patients surviving the immediate postoperative periods was 77% for the standard resection group and 83% for the radical resection group.

CONCLUSIONS

These data demonstrate that radical pancreaticoduodenectomy (with the addition of a distal gastrectomy and extended retroperitoneal lymphadenectomy to a standard pancreaticoduodenectomy) can be performed with similar morbidity and mortality to standard pancreaticoduodenectomy. However, the survival data are not sufficiently mature and the numbers of patients enrolled are not adequate to allow firm conclusions to be drawn regarding survival benefit.

Carcinoma of the Pancreas

Carcinoma of the pancreas remains a formidable challenge for clinicians. Pancreatic cancer is the tenth most common type of new cancer, and according to estimates of the American Cancer Society, 29,000 new cases occurred in 1998. The relative frequency of the disease is compounded by its lethality. Pancreatic cancer accounts for 5% and 6% of cancer deaths among men and women respectively, making it the fourth leading site of cancer deaths. In 1998, an estimated 28,000 deaths from pancreatic cancer were expected. The five-year relative survival rate for pancreatic cancer between 1986 and 1993, as reported by the NCI Surveillance, Epidemiology, and End Results Program, was only 4%. Although this was a statistically significant increase from the 3% five-year survival rate for pancreatic cancer between 1974 and 1976 it remained the lowest survival rate among all reported sites. By comparison, survival for gastric and esophageal cancers during the more recent reporting period were 19% and 12% respectively.

Sentinel lymph node biopsy after percutaneous diagnosis of nonpalpable breast cancer

PURPOSE

To determine the technical success rate of sentinel lymph node biopsy in women with nonpalpable infiltrating breast cancer diagnosed by using percutaneous core biopsy and to determine the frequency with which sentinel lymph node biopsy obviated axillary dissection.

MATERIALS AND METHODS

Retrospective review revealed 33 women who underwent sentinel node biopsy after percutaneous core biopsy diagnosis of nonpalpable infiltrating breast cancer. Sentinel nodes were identified with radioisotope and blue dye; the procedure was technically successful if sentinel nodes were found at surgery. All sentinel nodes were excised. Axillary dissection was performed if tumor was present in sentinel nodes.

RESULTS

Sentinel nodes were found at surgery in 30 women (91%). Sentinel nodes were identified with both radioisotope and blue dye in 22 (73%) of these women, with only radioisotope in six (20%), and with only blue dye in two (7%). Sentinel nodes were found in 12 (80%) of 15 women in the first half of the study versus all 18 (100%) women in the second half (P = .08). Sentinel nodes were free of tumor in 23 (77%) of 30 women. In six (86%) of seven women with tumor in sentinel nodes, the sentinel nodes were the only nodes with tumor.

CONCLUSION

Sentinel node biopsy was successful in 30 women (91%) with nonpalpable infiltrating carcinoma diagnosed with percutaneous core biopsy and obviated axillary dissection in 23 women (70%). Using both radioisotope and blue dye may increase the success rate. A learning curve exists, and success improves with experience.

Is axillary lymph node dissection indicated for early-stage breast cancer? A decision analysis

PURPOSE

Axillary lymph node dissection (ALND) has been a standard procedure in the management of breast cancer. In a patient with a clinically negative axilla, ALND is performed primarily for staging purposes, to guide adjuvant treatment. Recently, the routine use of ALND has been questioned because the results of the procedure may not change the choice of adjuvant systemic therapy and/or the survival benefit of a change in adjuvant therapy would be small. We constructed a decision model to quantify the benefits of ALND for patients eligible for breast-conserving therapy.

METHODS

Patients were grouped by age, tumor size, and estrogen receptor (ER) status. The model uses the Oxford overviews and three combined Cancer and Leukemia Group B studies. We assumed that patients who did not undergo ALND received axillary radiation therapy and that the two procedures are equally effective. All chemotherapy combinations were assumed to be equally efficacious.

RESULTS

The largest benefits from ALND are seen in ER-positive women with small primary tumors who might not be candidates for adjuvant chemotherapy if their lymph nodes test negative. Virtually no benefit results in ER-negative women, almost all of whom would receive adjuvant chemotherapy. When adjusted for quality of life (QOL), ALND may have an overall negative impact. In general, the benefits of ALND increase with the expected severity of adjuvant therapy on QOL CONCLUSION: Our model quantifies the benefits of ALND and assists decision making by patients and physicians. The results suggest that the routine use of ALND in breast cancer patients should be reassessed and may not be necessary in many patients.

Pancreaticoduodenectomy with or without extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma: comparison of morbidity and mortality and short-term outcome

OBJECTIVE

This prospective, randomized, single-institution trial was designed to evaluate the end points of mortality, morbidity, and survival in patients undergoing standard versus radical (extended) pancreaticoduodenectomy (including distal gastrectomy and retroperitoneal lymphadenectomy).

SUMMARY BACKGROUND DATA

Numerous retrospective reports and one prospective randomized trial have suggested that the performance of an extended lymphadenectomy in association with a pancreaticoduodenal resection may improve long-term survival for some patients with pancreatic and other periampullary adenocarcinomas. Many of these previously published studies can be criticized for their retrospective and nonrandomized designs, for the inclusion of nonconcurrent control groups, and for their small numbers.

METHODS

Between April 1996 and December 1997, 114 patients with periampullary adenocarcinoma were enrolled in an ongoing, prospective, randomized trial at The Johns Hopkins Hospital. After intraoperative verification of completely resected periampullary adenocarcinoma, the patients were randomized to receive either a standard pancreaticoduodenectomy (removing only the peripancreatic lymph nodes en bloc with the specimen) or a radical pancreaticoduodenectomy (standard resection plus distal gastrectomy and retroperitoneal lymphadenectomy). All pathology specimens were reviewed and categorized. The postoperative morbidity, mortality, and short-term outcomes were examined.

RESULTS

Of the 114 patients randomized, 56 underwent a standard pancreaticoduodenectomy and 58 a radical pancreaticoduodenectomy. The two groups were statistically similar with regard to age and gender, but there was a higher percentage of white patients in the radical group. All the patients in the radical group underwent distal gastric resection, whereas 86% of the patients in the standard group underwent pylorus preservation. The mean operative time in the radical group was 6.8 hours, compared with 6.2 hours in the standard group. There were no significant differences between the two groups with respect to the intraoperative blood loss, transfusion requirements, location of primary tumor, mean tumor size, positive lymph node status, or positive margin status. There were three deaths in the standard group and two in the radical group. The complication rates were 34% for the standard group and 40% for the radical group. Patients undergoing radical resection had a higher incidence of early delayed gastric emptying but had similar rates of other complications, such as pancreatic fistula, wound infection, intraabdominal abscess, and need for reoperation. The mean total number of lymph nodes resected was higher in the radical group. Of the 58 patients in the radical group, only 10% had metastatic carcinoma in the resected retroperitoneal lymph nodes, and none of those patients had the retroperitoneal nodes as the only site of lymph node involvement. The 1-year actuarial survival rate for patients surviving the immediate postoperative periods was 77% for the standard resection group and 83% for the radical resection group.

CONCLUSIONS

These data demonstrate that radical pancreaticoduodenectomy (with the addition of a distal gastrectomy and extended retroperitoneal lymphadenectomy to a standard pancreaticoduodenectomy) can be performed with similar morbidity and mortality to standard pancreaticoduodenectomy. However, the survival data are not sufficiently mature and the numbers of patients enrolled are not adequate to allow firm conclusions to be drawn regarding survival benefit.

Major vascular resection as part of pancreaticoduodenectomy for cancer: radiologic, intraoperative, and pathologic analysis

Intraoperative assessment is inaccurate in defining the relationship of a pancreatic head neoplasm to adjacent vascular structures. We evaluated the ability of preoperative contrast-enhanced CT to predict the need for vascular resection during pancreaticoduodenectomy and examined the resected vessels for histologic evidence of tumor invasion. During a 7-year period, 63 patients underwent pancreaticoduodenectomy with en bloc resection of adjacent vascular structures for a presumed pancreatic head malignancy. Clinical, radiologic, operative, and pathologic data were reviewed and analyzed. Fifty-six patients underwent resection of the superior mesenteric-portal vein confluence, three patients required inferior vena cava resection, and the hepatic artery was resected and reconstructed in eight patients. The operative mortality rate was 1.6%, and the overall complication rate was 22%. CT predicted the need for resection of the superior mesenteric or portal veins in 84% of patients. Pathologic analysis revealed tumor invasion of the vein wall in 71% of resected specimens. Tumor invasion of vascular structures adjacent to the pancreas can be predicted with preoperative CT and should alert the surgeon that vascular resection may be required. Histologic evidence of tumor cell infiltration of vessel walls was present in the majority of the resected specimens.

Salicylates inhibit NF-kappaB activation and enhance TNF-alpha-induced apoptosis in human pancreatic cancer cells

INTRODUCTION

Tumor necrosis factor (TNF-alpha)-induced apoptosis is limited by its coactivation of nuclear factor kappa B (NF-kappaB)-dependent anti-apoptotic genes. Sodium salicylate (NaSal) inhibits NF-kappaB activation by limiting phosphorylation and degradation of its bound inhibitor protein, IkappaB-alpha. We examined whether NaSal enhances TNF-alpha-induced apoptosis in cultured human pancreatic cancer cell lines.

METHODS

Two cultured human pancreatic cancer cell lines were studied. PANC-1 and BxPC-3 cells were serum-starved for 12 h, pretreated or not for 1 h with NaSal (5-20 mM), and then stimulated with recombinant human TNF-alpha (400 units/ml). Western blots of cytoplasmic lysates were performed to demonstrate IkappaB-alpha phosphorylation and degradation. Western blots of nuclear extracts were performed to assess nuclear translocation of NF-kappaB. In separate cultures, apoptosis was measured 4.5 h after TNF-alpha stimulation by both ELISA detection of interhistone DNA fragments and flow cytometry with propidium iodide staining.

RESULTS

TNF-alpha induced IkappaB-alpha phosphorylation and degradation, which was inhibited by NaSal in both cell lines. TNF-alpha-induced apoptosis (DNA fragmentation) increased significantly when BxPC-3 cells were pretreated with NaSal. Flow cytometry confirmed this, demonstrating increases in apoptotic cell fractions: 8.5% (untreated), 9.3% (TNF-alpha alone), 14.9% (15 mM NaSal), and 22.9% (NaSal and TNF-alpha). In contrast, no increases in apoptosis were measured in the PANC-1 cell line among the various treatment groups.

CONCLUSIONS

NaSal enhances TNF-alpha-induced apoptosis while inhibiting IkappaB-alpha phosphorylation and degradation in BxPC-3 human pancreatic cancer cells.

Tagging sentinel lymph nodes: a study of 100 patients with breast cancer

The aim of this study was to evaluate in breast cancer patients the feasibility of sentinel lymph node (SLN) identification and the sensitivity of this technique to detect node metastases. Between January and July 1997, SLNs were tracked with Evans Blue dye in 100 patients with breast cancer who then underwent complete level I/II axillary lymph node dissection (ALND). All SLNs were examined by haematoxylin-phloxin-saffron (HPS) staining and immunohistochemistry (IHC) of multiple sections. The findings for the SLNs were compared with results on ANLD. Axillary SLNs were identified in 83 patients (detection rate = 83%; 95% confidence interval (CI) 74-90%). Axillary SLNs were detected in 58/83 cases (70%) at level I only, and in 69/83 (83%) at levels including level I. Histologically positive axillary SLNs were found in 45% (37/83) of patients, including 2 patients with malignancy (micro-metastases) detected by IHC only. The sensitivity of axillary SLN to detect axillary lymph nodes metastases was 37/39 = 95% (95% CI 83-99%). SLNs of the internal mammary chain (IMC) were dissected for 33 tumours of the median or inner quadrants and detected in 26/33 = 79% of cases (95% CI 61-91%). In our experience, the overall sensitivity of SLN identification as a predictor of node (axillary or IMC) metastases was 41/43 = 95% (95% CI 84-99%), confirming the usefulness of the procedure.

Prognostic factors for patients with breast cancers 1cm and smaller

The widespread use of mammography has resulted in the detection of an increasing number of small invasive breast cancers, i.e. those that are 1cm and smaller. Patients with these small cancers generally have a low incidence of axillary lymph node metastases, and this has led some to question the routine use of axillary dissection in these patients. In addition, the prognosis of these patients is generally favorable, and the routine use of adjuvant systemic therapy is difficult to justify. Nonetheless, some patients with these small invasive cancers will have axillary nodal involvement and/or develop metastatic disease. The identification of this prognostically unfavorable subset of patients within this otherwise favorable group is an important goal of clinical research. In this article, we review the available literature on prognostic factors for patients with breast cancers 1cm and smaller to help determine which of these features might be of value in the identification of patients at risk for axillary lymph node involvement and/or metastatic disease.

Reexploration for periampullary carcinoma: resectability, perioperative results, pathology, and long-term outcome

OBJECTIVE

This single-institution experience retrospectively reviews the outcomes of patients undergoing reexploration for periampullary carcinoma at a high-volume center.

SUMMARY BACKGROUND DATA

Many patients are referred to tertiary centers with periampullary carcinoma after their tumors were deemed unresectable at previous laparotomy. In carefully selected patients, tumor resection is often possible; however, the perioperative results and long-term outcome have not been well defined.

METHODS

From November 1991 through December 1997, 78 patients who underwent previous exploratory laparotomy and/or palliative surgery for suspected periampullary carcinoma underwent reexploration. The operative outcome, resectability rate, pathology, and long-term survival rate were compared with 690 concurrent patients who had not undergone previous exploratory surgery.

RESULTS

Fifty-two of the 78 patients (67%) undergoing reexploration underwent successful resection by pancreaticoduodenectomy; the remaining 26 patients (34%) were deemed to have unresectable disease. Compared with the 690 patients who had not undergone recent related surgery, the patients in the reoperative group were similar with respect to gender, race, and resectability rate but were significantly younger. The distribution of periampullary cancers by site in the reoperative group undergoing pancreaticoduodenectomy (n = 52) was 60%, 19%, 15%, and 6% for pancreatic, ampullary, distal bile duct, and duodenal tumors, respectively. These figures were similar to the 65%, 14%, 16% and 5% for resectable periampullary cancers found in the primary surgery group (n = 460). Intraoperative blood loss and transfusion requirements did not differ between the two groups. However, the mean operative time was 7.4 hours in the reoperative group, significantly longer than in the control group. On pathologic examination, reoperative patients had smaller tumors, and the percentage of patients with positive lymph nodes in the resection specimen was significantly less. The incidence of positive margins was similar between the two groups. Postoperative lengths of stay, complication rates, and perioperative mortality rates were not higher in reoperative patients. The long-term survival rate was similar between the two resected groups, with a median survival of 24 months in the reoperative group and 20 months in those without previous exploration.

CONCLUSIONS

These data demonstrate that patients undergoing reoperation for periampullary carcinoma have similar resectability, perioperative morbidity and mortality, and long-term survival rates as patients undergoing initial exploration. The results suggest that selected patients considered to have unresectable disease at previous surgery should undergo restaging and reexploration at specialized high-volume centers.

Modulation of oncogenic potential by alternative gene use in human prostate cancer

Only a small percentage of primary prostate cancers have genetic changes. In contrast, nearly 90% of clinically significant human prostate cancers seems to express high levels of the nuclear phosphoprotein pp32 by in situ hybridization. Because pp32 inhibits oncogene-mediated transformation, we investigated its paradoxical expression in cancer by comparing the sequence and function of pp32 species from paired benign prostate tissue and adjacent prostatic carcinoma from three patients. Here we demonstrate that pp32 is expressed in benign prostatic tissue, but pp32r1 and pp32r2, closely-related genes located on different chromosomes, are expressed in prostate cancer. Although pp32 is a tumor suppressor, pp32r1 and pp32r2 are tumorigenic. Alternative use of the pp32, pp32r1 and pp32r2 genes may modulate the oncogenic potential of human prostate cancer.

Treatment of cancer of the exocrine pancreas

BACKGROUND

The incidence of cancer of the exocrine pancreas varies among populations, being the fourth or fifth cause of cancer death in the West. Outcome remains poor and opinions remain divided over the optimal management of the condition.

METHOD

A computer literature search was made of the MEDLINE database from January 1990 to December 1997 and selected other studies.

RESULTS

Indications and contraindications for surgery, indications for stenting, indications for resection, the technique of palliative procedures and of resection, chemotherapy, radiotherapy, and combined treatments and other treatments are discussed and recommendations made.

CONCLUSIONS

Irrespective of tumor size or spread, resection if feasible gives the best survival rates. Careful patient selection is required, however, to exclude those patients for whom surgical resection has no benefit. Nonsurgical procedures including endoscopic stenting in patients with high operative risk or short survival expectancy can significantly improve quality of life. The place of adjuvant therapies remains controversial and further controlled trials are required to demonstrate their efficacy.

Sentinel lymph node biopsy and axillary dissection in breast cancer: results in a large series

BACKGROUND

Axillary lymph node dissection is an established component of the surgical treatment of breast cancer, and is an important procedure in cancer staging; however, it is associated with unpleasant side effects. We have investigated a radioactive tracer-guided procedure that facilitates identification, removal, and pathologic examination of the sentinel lymph node (i.e., the lymph node first receiving lymphatic fluid from the area of the breast containing the tumor) to predict the status of the axilla and to assess the safety of foregoing axillary dissection if the sentinel lymph node shows no involvement.

METHODS

We injected 5-10 MBq of 99mTc-labeled colloidal particles of human albumin peritumorally in 376 consecutive patients with breast cancer who were enrolled at the European Institute of Oncology during the period from March 1996 through March 1998. The sentinel lymph node in each case was visualized by lymphoscintigraphy, and its general location was marked on the overlying skin. During breast surgery, the sentinel lymph node was identified for removal by monitoring the acoustic signal from a hand-held gamma ray-detecting probe. Total axillary dissection was then carried out. The pathologic status of the sentinel lymph node was compared with that of the whole axilla.

RESULTS

The sentinel lymph node was identified in 371 (98.7%) of the 376 patients and accurately predicted the state of the axilla in 359 (95.5%) of the patients, with 12 false-negative findings (6.7%; 95% confidence interval = 3.5%-11.4%) among a total of 180 patients with positive axillary lymph nodes.

CONCLUSIONS

Sentinel lymph node biopsy using a gamma ray-detecting probe allows staging of the axilla with high accuracy in patients with primary breast cancer. A randomized trial is necessary to determine whether axillary dissection may be avoided in those patients with an uninvolved sentinel lymph node.

Axillary clearance in operable breast cancer: still a necessity?

Complete axillary dissection, as part of radical mastectomy, was the standard of care for the first three-quarters of this century. Long-term follow-up of these patients showed substantial cure rates for positive-node patients before systemic therapy was available, indicating a therapeutic value to nodal dissection. There was also good control of the axilla; axillary recurrence after removal of positive nodes was quite low. Even today, in patients with positive nodes, complete axillary clearance as part of a modified radical mastectomy or a breast conservation approach with lumpectomy leads to control of the axilla and complete axillary staging, allowing medical oncologists to tailor their systemic treatment to the total number of nodes involved. Today, due to a combination of factors including patient awareness and the ability of mammography to detect smaller lesions, many women present with small cancers that carry a much lower risk of axillary involvement. Whereas a complete dissection is indicated for patients with clinically involved nodes, a level I-II dissection is the standard in most centers for patients with clinically negative nodes. In those patients with very small (T1a, T1b) cancers, the role of sentinel lymphadenectomy is being explored; it may spare these patients the morbidity of complete axillary dissection.

Correlation between spiral computed tomography, endoscopic ultrasonography and findings at operation in pancreatic and ampullary tumours

BACKGROUND

Spiral computed tomography (CT) allows high-resolution examination of the pancreas, surrounding vascular structures, lymph nodes and liver. Endoscopic ultrasonography (EUS) also allows high-resolution imaging of the pancreas and adjacent structures but is an invasive procedure. With the availability of spiral CT, the role of EUS in the investigation of patients with suspected pancreatic or ampullary tumours is unclear.

METHODS

Forty-eight patients with clinical suspicion of a pancreatic or ampullary tumour underwent both spiral CT and EUS. Thirty-four patients had surgical exploration, of whom 17 underwent pancreatic resection and 17 had biliary and gastric bypass. The results of spiral CT and EUS were compared with the operative findings.

RESULTS

The final histological diagnosis was ductal adenocarcinoma (24 patients), ampullary carcinoma (six), serous cystadenoma (two) and chronic pancreatitis (two). EUS demonstrated 33 and spiral CT 26 of the 34 primary lesions. EUS was particularly useful in the assessment of small resectable tumours missed by spiral CT. The sensitivity and specificity of EUS and spiral CT for detecting involvement by the tumour of the superior mesenteric vein, portal vein and lymph nodes were similar, but EUS was less effective at evaluating the superior mesenteric artery.

CONCLUSION

EUS is an important additional investigation after spiral CT in patients with a suspected pancreatic or ampullary tumour.

Laparoscopic pancreatic surgery

BACKGROUND

Potential applications for laparoscopic surgery in pancreatic disease include (1) staging of pancreatic malignancies; (2) palliation of pancreatic malignancies; (3) pancreatic resections for benign and malignant disease; and (4) pancreatic drainage procedures.

METHODS

A review of the literature is presented. In addition, original data on a series of 5 laparoscopic pancreatic distal resections and 10 laparoscopic cystogastrostomies are presented.

RESULTS AND CONCLUSIONS

Laparoscopy may have a role in the staging of patients with pancreatic malignancies; however, with high-quality preoperative imaging, the percentage of patients who will benefit from laparoscopy may be as low as 5%. For palliation, both cholecystoenterostomy and choledochoenterostomy can be performed laparoscopically. The former is technically straightforward but has a higher failure rate; the latter is technically difficult and currently not suitable for widespread adoption. Laparoscopic gastroenterostomy is a straightforward means of palliating gastrointestinal obstruction. Patients appear to benefit from laparoscopic distal pancreatic resection but not from laparoscopic pancreaticoduodenectomy. Patients appear to benefit from laparoscopic pseudocyst decompression.

The prognostic significance of lymph node metastasis and intrapancreatic perineural invasion in pancreatic cancer after curative resection

To investigate the prognostic factors of pancreatic cancer, a retrospective analysis of 193 patients who underwent curative resection was conducted. Of the 193 patients, 38 (20%) survived for more than 5 years, the 5-year survival rates for stages I, II, II, and IV disease being 41%, 17%, 11%, and 6%, respectively. According to a multivariate analysis, lymph node metastasis, intrapancreatic perineural invasion, and portal vein invasion were significant prognostic factors. Subsequently, a subgroup analysis concerning nodal metastasis and intrapancreatic perineural invasion was performed in 126 patients with records of these histological findings. In the group of patients without nodal metastasis, the 5-year survival rate for those without perineural invasion was 75%, whereas that for those with perineural invasion was 29%, the difference in survival of these subgroups being significant (P < 0.02). In the group of patients with nodal metastasis, the 5-year survival rate for those without perineural invasion was 17%, while that for those with perineural invasion was 10%. The most favorable 5-year survival of 89% was observed in the subgroup of patients with stage I disease without perineural invasion. Thus, pancreatic adenocarcinoma categorized by the combination of these independent types of biological behavior showed 5-year survival rates ranging from very high to low, indicating that these two factors play an important role in the prognosis of this disease.

Initial experience with sentinel node biopsy in breast cancer at the National Cancer Center Hospital East

BACKGROUND

Axillary lymph node dissection is an important procedure in the surgical treatment of breast cancer. Axillary lymph node dissection is still performed in over half of breast cancer patients having histologically negative nodes, regardless of the morbidity in terms of axillary pain, numbness and lymphedema. The first regional lymph nodes draining a primary tumor are the sentinel lymph nodes. Sentinel node biopsy is a promising surgical technique for predicting histological findings in the remaining axillary lymph nodes, especially in patients with clinically node-negative breast cancer, and a worldwide feasibility study is currently in progress.

METHODS

Intraoperative lymphatic mapping and sentinel node biopsy were performed in the axilla by subcutaneous injection of blue dye (indigocarmine) in 88 cases of stage 0-IIIB breast cancer. Sentinel lymph nodes were identified by detecting blue-staining lymph nodes or dye-filled lymphatic tracts after total or partial mastectomy. Finally, axillary lymph node dissection was performed up to Levels I and II or more.

RESULTS

Sentinel lymph nodes were successfully identified in 65 of the 88 cases (74%). In the final histological examination, the sentinel lymph nodes in 40 cases were negative, including four cases with non-sentinel-node-positive breast cancer (specificity, 100%; sensitivity, 86%). In nine (31%) of the 29 cases with histologically node-positive breast cancer, the sentinel lymph nodes were the only lymph nodes affected. Axillary lymph node status was accurately predicted in 61 (94%) of the 65 cases.

CONCLUSIONS

Although it was the initial experience at the National Cancer Center Hospital East, sentinel node biopsy proved feasible and successful. This method may be a reasonable alternative to the standard axillary lymph node dissection in patients with early breast cancer.

The impact of prophylactic axillary node dissection on breast cancer survival--a Bayesian meta-analysis

BACKGROUND

Because of the general acceptance of the NSABP B-04 study, prophylactic axillary node dissection for women with clinically negative axillae is considered diagnostic, but not therapeutic, by many oncologists. Nevertheless, several authors have shown that B-04 did not include enough patients to exclude a small survival advantage.

METHODS

A Bayesian meta-analysis of the available literature was performed comparing standard treatment to standard treatment without axillary node dissection. Six randomized controlled trials were identified, consisting of nearly 3000 patients and spanning four decades.

RESULTS

All six trials showed that prophylactic axillary node dissection improved survival, ranging from 4% to 16%, corresponding to a risk reduction of 7%-46%. Combining the six trials showed an average survival benefit of 5.4% (95% CI = 2.7-8.0%, probability of survival benefit > 99.5%). Adjusting for biases in the individual studies did not alter the conclusions, nor did subset analysis of Stage I patients.

CONCLUSIONS

Axillary node dissection improves survival in women with operable breast cancer. Nevertheless, two important limitations of this analysis are noteworthy. Few of the patients in the six trials had T1a tumors, so extrapolation of these results to this subset (and those with nonpalpable tumors) may be inappropriate. Essentially no patients in the six trials were treated with adjuvant therapy, as contrasted to current clinical practice. It is possible that the risk reduction seen in this meta-analysis may be diminished in patients receiving adjuvant chemotherapy. Despite these limitations, this study suggests that axillary dissection should be performed in most women with palpable tumors for diagnostic, as well as therapeutic, purposes.

Chemoradiotherapy in the management of localized tumors of the pancreas

In western countries, carcinoma of the pancreas remains the most lethal of the common malignancies. Even the favorable "organ-confined" tumors present a considerable challenge. The lack of anatomic barriers to local infiltration and the biological propensity for early lymphatic, perineural, and vascular invasion are nearly insurmountable obstacles to complete surgical eradication of this malignancy. Various combinations of chemotherapy and radiotherapy (RT) have been used with marginal but measurable success. Earlier trials conducted by the Gastrointestinal Tumor Study Group established roles for 5-fluorouracil chemotherapy and RT in the treatment of patients with resectable or locally advanced pancreatic cancer. More recently, computed tomography-guided conformal RT and a variety of intraoperative RT techniques have enabled more reliable sterilization of the local surgical field and escalation of doses to potentially curative levels (7000 cGy) for unresectable lesions. Chemotherapy dose intensification through the use of portable programmable pumps for protracted venous infusions and the development of active systemic agents in addition to 5-fluorouracil suggest that an effective combination chemotherapeutic regimen might soon be developed. This report reviews the current standards of practice and integrates recent developments to construct a modern algorithm for the use of chemoradiotherapy in the management of localized (nonmetastatic) pancreatic cancer. The likely directions of future investigations are also discussed.