Physical and psychological morbidity after axillary lymph node dissection for breast cancer

PURPOSE

Alternatives to axillary lymph node dissection (ALND) are being developed amid controversy surrounding the therapeutic benefit and overall utility of this routine surgical procedure. Although potential negative side effects associated with ALND are known, we set out to examine whether these side effects contribute significantly to patient reports of quality of life and mental health.

PATIENTS AND METHODS

We surveyed 222 women who had received an ALND as part of breast cancer surgery. All women underwent a physical therapy assessment of range of arm/shoulder motion and completed the Modified Post-operative Pain Questionnaire, the Pain Disability Index, the McGill Pain Questionnaire (short form), the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, and the Mental Health Inventory.

RESULTS

Seventy-two percent of the women experienced arm/shoulder pain, weakness, or numbness in the week before the interview, and range of motion of the affected arm/shoulder was impaired in 73% of the women. Severity of pain was reported to be low to moderate, and younger patients experienced greater pain than older patients. Pain severity correlated positively with the number of lymph nodes removed and receipt of chemotherapy and was not significantly related to length of time since surgery or receipt of radiation therapy. Generally high levels of cancer-specific quality of life and mental health were reported. Quality of life was significantly predicted by the McGill Pain Questionnaire, and mental health was significantly predicted by the Pain Disability Index and the physical therapy assessment.

CONCLUSION

Surgery-related symptoms after ALND persist for a majority of women with breast cancer and are not significantly related to time since surgery or receipt of radiation therapy. These symptoms and associated disability are significantly predictive of cancer-specific quality of life and mental health.

Preoperative chemoradiation for patients with locally advanced adenocarcinoma of the pancreas

BACKGROUND

Improved resectability is a major theoretical benefit of preoperative chemoradiation for pancreatic cancer. Since 1994, patients at Duke University Medical Center with locally advanced pancreatic cancer have been treated with multimodality preoperative therapy. The purpose of this study was to review our experience with preoperative therapy for locally advanced pancreatic cancer and determine if an aggressive neoadjuvant regimen would not only downstage these tumors pathologically but also improve the odds of complete surgical resection.

METHODS

The charts of 25 patients treated with neoadjuvant chemoradiation at Duke University Medical Center with biopsy-proven, locally advanced adenocarcinoma of the pancreas were reviewed. Tumors were defined as locally advanced based on radiographic or intraoperative evidence of disease that abuts the superior mesenteric artery or vein (n = 22) or involves lymph nodes that are within the proposed radiation field (n = 3). All 25 patients received external beam radiotherapy (median dose 4500 cGy) in daily fractions of 180 cGy over 5 weeks. All patients concurrently received 5-fluorouracil (FU), and many also received mitomycin C or cisplatin, or both. Patients were given a 3- to 4-week break before a restaging computed tomographic (CT) scan was performed. Three patients were not restaged: one died from metastatic disease; one was reclassified as having a neuroendocrine tumor; and one was lost to follow-up.

RESULTS

On restaging after neoadjuvant therapy, 64% of patients had stable or decreased primary tumor size. Radiographically, two patients appeared potentially resectable, and seven others developed evidence of metastatic disease. Eight patients underwent exploration, but only five could be resected. Of the five patients resected, only one had negative margins and negative lymph nodes. This patient had significant pancreatitis on initial exploration. After neoadjuvant therapy, he had a complete response radiographically, and there was no residual cancer in his resection specimen. Pathologic examination of the other resection specimens suggested that despite significant tumor fibrosis, malignant cells persist even at the periphery of the lesions.

CONCLUSION

Although neoadjuvant chemoradiation has many theoretical advantages in managing pancreatic malignancy, true pathologic downstaging of locally advanced lesions into tumors that can be removed with negative nodes and margins appears to be a rare event with currently used therapeutic regimens.

Matrix metalloproteinase (MMP) inhibition selectively decreases type II MMP activity in a murine model of pancreatic cancer

BACKGROUND

Basement membrane degradation is a critical component of tumor invasion and metastasis that is facilitated by the family of enzymes known as matrix metalloproteinases (MMPs). MMP-2 and MMP-9 are two subtypes that have specifically been identified in tumors of gastrointestinal origin. We have previously shown that broad inhibition of these enzymes with the MMP inhibitor BB-94 improves survival in a murine model of pancreatic cancer. The purpose of this study was to determine MMP-2 and MMP-9 activity in orthotopic tumors from mice treated with and without BB-94.

METHODS

Ten million cells of a moderately differentiated pancreatic cancer cell line (HPAC) were implanted orthotopically into Balb/c nu/nu mice. The mice were treated with BB-94 or vehicle control for 70 days or until death. At necropsy, tumors were harvested, total protein was extracted, and MMPs were purified from 400 microgram of crude protein extract by gelatin-Sepharose affinity chromatography. Relative enzyme levels and activity of MMP-2 and MMP-9 were determined by Western blot and gelatin zymography.

RESULTS

Tumors from treated animals were significantly smaller than those from nontreated animals. MMP-2 was present in greater amounts in both treated and nontreated animals than MMP-9. Active MMP-2 was present in both groups but significantly decreased in animals treated with BB-94. Active MMP-9 was absent in both groups, whereas levels of latent MMP-9 appeared lower than those of MMP-2 in all samples.

CONCLUSIONS

Activated MMP-2 and not MMP-9 in HPAC cells grown in nude mice suggests that this MMP subtype is more critical in the phenotypic behavior of such tumors. Furthermore, attenuated levels of active MMP-2 in animals treated with the enzyme inhibitor BB-94 suggest that previously observed improvements in survival correlate with the level of MMP-2 activity.

Prognostic significance of soluble interleukin-2 receptor-alpha in adenocarcinoma of the pancreas

Soluble interleukin-2-receptor-alpha (sIL-2Ralpha) serum concentrations were examined in chronic pancreatitis patients, patients with cystadenocarcinoma of the pancreas, patients with adenocarcinoma of the pancreas and healthy blood donors. sIL-2Ralpha serum concentrations in pancreatic cancer patients were significantly higher than those of normal control subjects or chronic pancreatitis patients. In patients with adenocarcinoma of the pancreas no significant differences were found between sIL-2Ralpha and tumor size, grading, resectability and lymph node involvement. In Kaplan-Meier regression analysis patients with adenocarcinoma of the pancreas with low sIL-2Ralpha levels (<500 U/ml) lived significantly shorter than patients with sIL-2Ralpha concentrations above 500 U/ml (P < 0.01), suggesting that determination of sIL-2Ralpha serum concentrations could provide additional important information about prognosis.

Incidence of breast carcinoma-related lymphedema

BACKGROUND

Of the 2 million breast carcinoma survivors, perhaps 15-20% are living currently with posttreatment lymphedema. Along with the physical discomfort and disfigurement, patients with lymphedema also must cope with the distress derived from these symptoms.

METHODS

To review the medical literature for the question of lymphedema incidence, a comprehensive, computerized search was performed. All publications with subject headings designating breast carcinoma-related lymphedema from 1970 to the present (116 reports) were found, and each summary or abstract was read. Of the 116 reports, 35 discussed the incidence of lymphedema. Of these, seven reports since 1990 from five countries with the most relevance to current patients were then chosen for greater analysis and comparison.

RESULTS

The incidence of lymphedema ranged from 6% to 30%. The source of patients, length of follow-up, measurement techniques, and definition of lymphedema varied from report to report. In general, reports with shorter follow-up reported lower incidences of lymphedema.

CONCLUSIONS

The definitive study to determine the incidence of lymphedema has not been performed to date. There has been no prospective study in which patients have been followed at intervals with accurate measurement techniques over the long term.

[Concomitant chemoradiotherapy in the therapeutic strategy of adenocarcinoma of the exocrine pancreas and stomach]

The prognosis of pancreatic adenocarcinoma remains poor, with a 5-year survival rate lower than 5%. Resection, the gold standard treatment, can be performed in less than 10% of patients. Following surgery, the median survival is 12 months for the most favorable cancer patients. Concomitant chemoradiation, as an adjuvant treatment is superior to surgery alone, in terms of survival; controlled trials are currently performed. Neoadjuvant chemoradiation is a new approach, potentially able to increase survival and resection rate. This work justifies the role of these schemes, in terms of modalities and potential advantages. A second part is dedicated to gastric carcinoma, with a review of the current results of chemoradiation, whose efficiency, even though a trend can be observed, remains to be proven. Prospective adjuvant combined treatments are ongoing, in France and in the States.

Prognostic value of cell proliferation (Ki-67 antigen) and nuclear DNA content in clinically resectable, distal bile duct carcinoma

BACKGROUND

The aim of this study was to investigate the prognostic value of cell proliferation (Ki-67 antigen) and DNA content in patients resected for distal bile duct carcinoma (DBDC).

METHODS

Formalin-fixed tumor specimens of 35 patients with resected DBDC and a long-term clinical follow-up were analyzed. MIB-1 antibody was used for Ki-67 antigen detection to determine the proportion of proliferating cells. DNA content was measured using flow cytometry.

RESULTS

A significant correlation was found between a low MIB-1 index (<20%) and survival (P <.05). Of the 35 tumor specimens, 34 specimens were evaluable by flow cytometry: 22 carcinomas were diploid (65%), and 12 were aneuploid (35%). The median DNA index of aneuploid tumors was 1.36 (range, 1.09 to 1.76). No correlation of DNA-ploidy with survival time was found.

CONCLUSION

In contrast to DNA-ploidy pattern, Ki-67 antigen expression showed prognostic significance in resectable DBDC. A Ki-67 positive ratio of > or =20% was associated with decreased survival time.

Survival following pancreatic carcinoma: a follow-up study of all cases recorded in Malmö, Sweden, 1977-1991

BACKGROUND

The aim of this follow-up study was to assess whether there has been any increase in the percentage of patients offered attempted curative surgery for pancreatic carcinoma and whether the overall survival rate has improved, during the time period 1977-1991.

METHODS

Details of new cases of pancreatic carcinoma arising in the population of Malmö during the study period were retrieved from the Local Tumour Register in Lund, Sweden. In all, 740 patients were found; 575 of these were diagnosed before death. Kaplan-Meier analysis was used to calculate overall survival rates, and Cox regression analysis was used to assess survival in relation to year of diagnosis after adjustment for sex, age at diagnosis and stage of disease.

RESULTS

Cytological or histopathological evidence of the disease was given in 95 per cent of cases. The overall 5-year survival rate was 0.5 per cent (three of 575). Curative surgery was attempted in 24 patients (4.2 per cent); the proportion undergoing curative surgery increased in the last part of the study. Two of the 24 patients in this group survived for 5 years.

CONCLUSION

The prognosis in pancreatic carcinoma remains dismal. Attempted curative surgery still is the only hope for cure, but the group of patients that can be offered this possibility is very limited. In this study, an increase was found in the proportion of patients who were offered attempted curative surgery, but there was no statistically significant increase in the 5-year survival rate following surgery.

The importance of surgery and accurate axillary staging for survival in breast cancer

AIMS

The purpose of this study was to investigate, within the context of the Danish Breast Cancer Cooperative Group (DBCG) programmes, whether a dedicated surgical approach had a significant bearing on the outcome of breast cancer treatment.

METHODS

From 1 January 1980 to 31 December 1990, patients below 70 years of age with operable breast cancer from Odense University Hospital (n=743) were compared with those from the rest of Denmark (denoted rest-DK) (n=15,419). All patients were treated according to nationwide DBCG guidelines and reported to the DBCG Data Centre. The potential median observation time was 11.2 years (range 6.0-16.9). Patients underwent mastectomy or breast conserving therapy, and high risk lymph-node positive patients had adjuvant systemic therapy with or without radiotherapy.

RESULTS

Comparing total patients series, overall survival (OS) was significantly superior in patients from Odense compared with rest-DK (P=0.02), with 10-year OSs of 62% (95% CI: 58-65%) and 56% (55-57%), respectively. In subgroups, the OS of low-risk node negative patients (protocol A) in Odense compared with rest-DK was significantly better (P=0.02); 10-year OS was 78% (73-84%) versus 72% (70-73%). Among the high-risk pre-menopausal patients (protocol B), the OS was significantly better in Odense (P=0.009); 10-year OS was 67% (60-75%) versus 53% (51-55%) in rest-DK. Post-menopausal high-risk patients (protocol C) did not differ significantly in OS between Odense and rest-DK (P=0.61). Locoregional control in the Odense series was superior compared with rest-DK. More lymph nodes were recovered and examined from the axilla in the Odense series than in rest-DK, a median of 10 vs. 6 nodes. In the Odense series, a significantly higher proportion of pre-menopausal patients had positive lymph nodes, predominantly one to three positive nodes, and subsequently a lower proportion of pre-menopausal patients had negative lymph nodes compared with rest-DK (P=0.02), indicating a more accurate staging in Odense vs. rest-DK. The survival benefit among the patients from Odense cannot be explained by stage migration alone, but seems to represent a true survival advantage. Overall mortality was significantly lower in the Odense series compared with rest-DK. Whether or not this difference could be explained by lower background mortality in the Odense series or was caused by superior treatment is discussed.

CONCLUSIONS

The extent of surgery seems important for locoregional tumour control and accurate axillary lymph-node staging. In combination, these might lead to superior recurrence-free and overall survival, although differences in background mortality cannot be ignored. Surgery, therefore, might represent a risk factor by itself.

[Is axillary dissection in clinically lymph node-negative breast carcinoma further indicated?]

BACKGROUND

In the treatment of breast cancer, the indication for adjuvant systemic treatment was extended also to nodal negative tumor stages in the last years. For that reason, the indicator status of axillary dissection lost some of its importance. Therefore, in node negative patients, the necessity of axillary dissection and the use of definitive axillary radiotherapy, which causes less morbidity, may be reconsidered.

METHODS

In a review of the related literature, we present international treatment experiences related to axillary dissection, axillary radiotherapy and "sentinel node dissection" (SLND). In addition, our long-term experiences in 19 patients with clinically negative axillary nodes treated by conservative surgery without axillary dissection but axillary radiotherapy, are reported.

RESULTS

The median rate of axillary recurrences with axillary radiotherapy is 2.0%, the regional (supraclavicular and retrosternal) recurrence rate 2.7%. With axillary dissection, axillary recurrences occur in 1 to 2%, in nodal negative stages in 0 to 1%, the median regional recurrence rate is 2.2%. A meta-analysis presented in 1995 by the Early Breast Cancer Study Group showed no significant difference in the regional recurrence rate or the overall survival between axillary dissection and axillary radiotherapy. With SLND, usually only one axillary node is excised. With the help of molecular and immunohistochemical methods, SLND may predict axillary involvement with high precision.

CONCLUSIONS

Definitive radiotherapy of the axilla is a valid treatment option for patients without palpable axillary nodes with the potential advantage of being less cost intensive and better tolerated. If the indication for systemic therapy is no more dependent on the axillary status, axillary dissection may be replaced by axillary radiotherapy. In small tumors without risk factors and without indication for systemic therapy, SLND seems to be the best treatment option.

Is there a place for central pancreatectomy in pancreatic surgery?

Tumors located in the neck of the pancreas that are not small and superficial enough to be enucleated are usually resected with a pancreaticoduodenectomy or left splenopancreatectomy. Such operations may cause digestive disorders, glucose intolerance, and late postsplenectomy infection. Central pancreatectomy is a segmental resection whereby the cephalic stump is sutured and the distal stump anastomosed with a Roux-en-Y jejunal loop. The purpose of this study was to evaluate whether central pancreatectomy has a place in pancreatic surgery. Thirteen patients with the following tumors underwent central pancreatectomy: five endocrine tumors, one mucinous and six serous cystadenomas, and one solid cystic-papillary tumor. Mean operative time was 250 minutes. Operative mortality was zero. Complications occurred in three patients (23%). At mean follow-up of 68 months, no recurrences were found. Postoperative oral glucose tolerance, pancreolauryl, and fecal fat excretion tests were normal in all patients. We believe that central pancreatectomy does have a place in pancreatic surgery; it is a reliable technique for benign or low-grade malignant tumors and has a surgical risk similar to that of standard operations. Its principal advantage is that it preserves pancreatic parenchyma and the anatomy of the upper gastrointestinal and biliary tract and the spleen better than pancreaticoduodenectomy or distal pancreatic and splenic resection. (J Gastrointest Surg 1998;2:509-517.)

[Comparison of color Doppler ultrasonography and endoscopic ultrasonography for preoperative evaluation of the mesenteric-portal axis in pancreatic lesions]

AIM OF THE STUDY

This prospective study was undertaken to evaluate the accuracy of ultrasonography combined with colour Doppler and endoscopic ultrasonography for predicting superior mesenteric and portal vein involvement in pancreatic diseases.

MATERIAL AND METHODS

The study was prospective. Forty-four patients were included. Ultrasonography with colour Doppler was performed in 30 patients, endoscopic ultrasonography in 43. Prediction of superior mesenteric vein or portal vein involvement was blindly assessed by physicians without knowledge of results of other imaging methods. Resectability or potential resectability (n = 34) and irresectability (n = 10) were assessed in all patients by surgery. Thirty patients underwent a pancreaticoduodenectomy.

RESULTS

For endoscopic ultrasonography the sensitivity (0.90), the specificity (0.88), the positive predictive value (0.69) and the negative predictive value (0.97) were better than those observed with ultrasonography and Doppler (050, 0.88, 0.69, 0.97, respectively). The specificity of computed tomography (0.96) was better than that of endoscopic ultrasonography but predictive negative values were similar.

CONCLUSIONS

Imaging methods to predict superior mesenteric or portal vein involvement in pancreatic diseases are becoming increasingly numerous, complex, and expensive. Endoscopic ultrasonography has a better diagnostic value for correctly predicting resectability than ultrasonography with Doppler. However, for decision making, usefulness of these methods seems to be limited.

Review article: current practice and future perspectives in detection and diagnosis of pancreatic cancer

Pancreatic cancer is the tenth most prevalent malignancy and the fifth most common cause of cancer death in the developed world. Less than 10% of patients survive for more than 1 year following diagnosis and the 5-year survival rate (0.4%) is the lowest of any cancer. The poor prognosis associated with this diagnosis led in the past to therapeutic nihilism on the part of clinicians who were all too aware of the limitations of their available therapeutic strategies. Breaking this therapeutic impasse requires a significant expansion in the knowledge of clinicians concerning the pathogenesis and behaviour of pancreatic cancer. Recent advances in the scientific understanding of the aetiology of pancreatic cancer has facilitated progress towards the development of promising and innovative approaches to the early detection and diagnosis of pancreatic cancer. While acknowledging that pancreatic cancer will continue to present significant challenges to both scientists and clinicians in the foreseeable future, it is becoming increasingly clear that recent advances in our scientific knowledge base holds the potential to significantly improve prognosis for patients. The challenge facing both scientists and clinicians is how best to translate such promising scientific advances into survival and quality of life benefits to patients.

Lymphatic mapping and sentinel node biopsy in breast cancer

BACKGROUND

Sentinel lymph node biopsy is a recently developed, minimally invasive technique for staging the axilla in patients with breast cancer. It has been suggested that this technique will avoid the morbidity associated with more extensive axillary dissection. A wide range of different methods and materials has been employed for lymphatic mapping, but there has been little consensus on the most reliable and reproducible technique.

METHODS

This is a comprehensive review of all published literature on sentinel node biopsy in breast cancer, using the Medline and Embase databases and cross-referencing of major articles on the subject.

RESULTS AND CONCLUSION

Sentinel node biopsy is a valid technique in breast cancer management, providing valuable axillary staging information. The optimal technique of lymphatic mapping utilizes a combination of vital blue dye and radiolabelled colloid. However, there remain controversial issues which require to be resolved before sentinel node biopsy becomes a widely accepted part of breast cancer care.

Laparoscopic evaluation in pancreatic cancer

Pancreatic cancer continues to carry a poor overall prognosis. The majority of patients have advanced disease at the time of presentation. Dynamic, contrast-enhanced computed tomography (CT) has become the radiographic study of choice in the pre-operative staging of patients with pancreatic cancer. While it has been shown to be highly sensitive in determining unresectability of peri-ampullary tumors, the ability of CT to predict accurately which tumors can be safely resected is still limited. Laparoscopic staging of peri-ampullary tumors is superior to dynamic CT in visualizing small liver and peritoneal metastases. The addition of laparoscopic ultrasound during laparoscopic staging enhances the ability of laparoscopy to determine resectability of these tumors and approaches the accuracy of open exploration without increasing significant morbidity or mortality. Patients who are deemed unresectable at the time of laparoscopy can undergo palliative biliary and/or gastric bypass procedures laparoscopically and further minimize the morbidity of laparotomy.

Molecular metastases in stage I pancreatic cancer: improved survival with adjuvant chemoradiation

BACKGROUND

Reports of improved survival rates for patients with resected adenocarcinoma of the pancreas coincide with the adoption of adjuvant chemoradiation protocols. The impact of nodal micrometastases demonstrated by molecular assays and adjuvant therapy on survival of patients with stage I pancreatic cancer has not been adequately assessed.

METHODS

A retrospective analysis of postoperative chemoradiation on survival in 61 patients undergoing resection of pancreatic adenocarcinomas from 1984 to 1997 was performed. Archival tumors and regional nodes from 25 patients with stage I cancers were tested for a Kiras oncogene mutation using polymerase chain reaction and analysis for restriction fragment length polymorphisms (PCR/RFLP).

RESULTS

Adjuvant chemoradiation was associated with improved survival for stage I (P < .01), but not stage III, disease. Seventeen (68%) of 25 patients with stage I disease tested had evidence of mutant Kiras in one or more regional nodes. Survival did not differ for patients with molecular micrometastases. Six of 17 (35%) patients with micrometastases received adjuvant chemoradiation and had improved survival (P < .05).

CONCLUSIONS

The majority of patients with stage I pancreatic cancer have PCR/RFLP evidence of lymph node micrometastases. Adjuvant chemoradiation improves survival in these patients by treating micrometastases not detected by histology. Adjuvant chemoradiation should be used for patients with stage I pancreatic cancers.

Standard versus extended lymphadenectomy associated with pancreatoduodenectomy in the surgical treatment of adenocarcinoma of the head of the pancreas: a multicenter, prospective, randomized study. Lymphadenectomy Study Group

OBJECTIVE

The study was conducted to determine whether the performance of an extended lymphadenectomy and retroperitoneal soft-tissue clearance in association with a pancreatoduodenal resection improves the long-term survival of patients with a potentially curable adenocarcinoma of the head of the pancreas.

SUMMARY BACKGROUND DATA

The usefulness of performing an extended lymphadenectomy and retroperitoneal soft-tissue clearance in conjunction with a pancreatoduodenal resection in the treatment of ductal adenocarcinoma of the head of the pancreas is still unknown. Published studies suggest a benefit for the procedure in terms of better long-term survival rates; however, these studies were retrospective or did not prospectively evaluate large series of patients.

MATERIALS AND METHODS

Eighty-one patients undergoing a pancreatoduodenal resection for a potentially curable ductal adenocarcinoma of the head of the pancreas were randomized to a standard (n = 40) or extended (n = 41) lymphadenectomy and retroperitoneal soft-tissue clearance in a prospective, multicentric study. The standard lymphadenectomy included removal of the anterior and posterior pancreatoduodenal, pyloric, and biliary duct, superior and inferior pancreatic head, and body lymph node stations. In addition to the above, the extended lymphadenectomy included removal of lymph nodes from the hepatic hilum and along the aorta from the diaphragmatic hiatus to the inferior mesenteric artery and laterally to both renal hila, with circumferential clearance of the origin of the celiac trunk and superior mesenteric artery. Patients did not receive any postoperative adjuvant therapy.

RESULTS

Demographic (age, gender) and histopathologic (tumor size, stage, differentiation, oncologic clearance) characteristics were similar in the two patient groups. Performance of the extended lymphadenectomy added time to the procedure, although the difference did not reach statistical significance (397 +/- 50 minutes vs. 372 +/- 50 minutes, p > 0.05). Transfusion requirements, postoperative morbidity and mortality rates, and overall survival did not differ between the two groups. When subgroups of patients were analyzed, using an a posteriori analysis that was not planned at the time of study design, there was a significantly (p < 0.05) longer survival rate in node positive patients after an extended rather than a standard lymphadenectomy. The survival curve of node positive patients after an extended lymphadenectomy could be superimposed onto the curves of node negative patients. Survival curves in node negative patients did not differ according to the magnitude of the lymphadenectomy. Multivariate analysis of all patients showed that long-term survival was affected by tumor differentiation (well vs. moderately vs. poorly differentiated, p > 0.001), diameter (< or = 2.0 cm. vs. > 2.0 cm., p < 0.01), lymph node metastasis (absent vs. present, p < 0.01) and need for 4 or more units of transfused blood (< 4 vs. > or = 4, p <0.01).

CONCLUSIONS

The addition of an extended lymphadenectomy and retroperitoneal soft-tissue clearance to a pancreatoduodenal resection does not significantly increase morbidity and mortality rates. Although the overall survival rate does not differ in the two groups, there appears to be a trend toward longer survival in node positive patients treated with an extended rather than a standard lymphadenectomy.

Lymph node metastasis in breast cancer: common prognostic markers lack predictive value

BACKGROUND

The purpose of this study was to determine whether routine biologic tumor markers can predict lymph node status. The authors attempted to discover whether predictors of axillary lymph node metastasis based on biologic characteristic of primary breast cancers exist.

METHODS

Eight hundred and fifty-one patients with invasive breast cancer who underwent surgical treatment, including axillary lymph node dissection, at a tertiary referral center were studied. Univariate and multivariate analysis were performed on prospectively gathered data from a breast cancer registry, including pathology, site of primary lesion in the breast, estrogen and progesterone receptor status, DNA index, S-phase fraction, nuclear grade, and extensive intraductal component. Outcome was determined by (1) the presence of any lymph node metastasis and (2) the presence of 10 or more lymph node metastases.

RESULTS

The only independent predictors of lymph node metastasis were primary tumor size and pathology. For predicting 10 or more metastases, only size and ER-negative status were independent predictors. These factors accounted for less than 20% of the regression, implying that more than 80% of lymph node metastases are not explained by the regression model. Lymph node metastases were seen in 8.3% of T1a, 15.3% of T1b, and 30.7% of T1c lesions.

CONCLUSIONS

Biologic tumor markers are not reliable predictors of lymph node metastasis, except possibly for T1a lesions, therefore direct pathologic evaluation of lymph node status cannot be abandoned. Efforts to determine lymph node status through other methods such as sentinel lymph node biopsy are warranted.

Complications of axillary lymph node dissection for carcinoma of the breast: a report based on a patient survey

BACKGROUND

Axillary lymph node dissection is commonly performed as part of the primary management of breast carcinoma. Its value in patient management, however, has recently been questioned. Few studies exist that document long term complications.

METHODS

Four hundred thirty-two patients with Stage I or II breast carcinoma who were free of recurrence 2-5 years after surgery were identified. A cross-sectional survey was conducted to determine the prevalence of long term symptoms and complications as perceived by the patient, and patient and treatment factors that may have predicted complications were determined. Three hundred thirty of the 432 (76%) completed a mailed, self-administered questionnaire. In addition, the medical records of the 330 patients were reviewed. Patient and treatment factors were analyzed with logistic regression.

RESULTS

Numbness was reported by 35% of patients at the time of the survey. Pain was noted in 30%, arm swelling in 15%, and limitation of arm movement in 8%. Eight percent reported episodes of infection or inflammation at some point since the diagnosis of breast carcinoma. The majority of symptoms were mild and interfered minimally with daily activities. Younger age (P=0.001) was associated with more frequent reporting of pain. Numbness was more common in younger patients (P=0.004) as well as in those with a history of smoking (P=0.012). There was a positive association of limitation of arm motion with adjuvant tamoxifen therapy (P=0.016). Arm swelling was associated with both younger age (P=0.004) and greater body surface area (P=0.008). Radiation therapy was associated with a higher frequency of infection or inflammation in the arm and/or breast (P=0.001).

CONCLUSIONS

Mild symptoms, especially pain and numbness, are common 2-5 years after axillary lymph node dissection. The frequency of inflammation or infection in patients treated with radiation to the breast or chest wall after an axillary lymph node dissection may be greater than previously appreciated. Severe complications or symptoms that have a major impact on daily activities are uncommon. These findings should help health care providers and their patients with breast carcinoma weigh the pros and cons of axillary lymph node dissection.

Importance of hospital volume in the overall management of pancreatic cancer

OBJECTIVE

To determine whether hospital volume is associated with clinical and economic outcomes for patients with pancreatic cancer who underwent pancreatic resection, palliative bypass, or endoscopic or percutaneous stent procedures in Maryland between 1990 and 1995.

SUMMARY BACKGROUND DATA

Previous studies have demonstrated that outcomes for patients undergoing a Whipple procedure improve with higher surgical volume, but only 20% to 35% of patients with pancreatic cancer qualify for curative resection. Most patients undergo palliative procedures instead with a surgical bypass or biliary stent.

METHODS

Analysis of hospital discharge data from all nonfederal acute care hospitals in Maryland identified all patients with pancreatic cancer who underwent a pancreatic resection, palliative bypass, or stent procedure between 1990 and 1995. Hospitals (n = 48) were categorized as high-, medium-, and low-volume providers according to their average annual volume of these procedures. Multivariate regression was used to examine the association between hospital volume and in-hospital mortality rate, length of stay, and hospital charges, after adjusting for differences in case mix and surgeon volume.

RESULTS

Increased hospital volume is associated with markedly decreased in-hospital mortality rates and a decreased or similar length of stay for all three types of procedures and with decreased or similar hospital charges for resections and stents. After adjustment for case mix differences, the relative risk (RR) of in-hospital death after pancreatic resection was 19.3 and 8 at the low- and medium-volume hospitals, respectively, versus the high-volume hospital; after bypasses, the RR of death was 2.7 and 1.9, respectively; and after stents, the RR was 4.3 and 4.8, respectively.

CONCLUSIONS

Patients with pancreatic cancer who are to be treated with curative or palliative procedures appear to benefit from referral to a high-volume provider.

Shoulder movement after the treatment of early stage breast cancer

At 18 months after surgery and post-operative radiotherapy, the function of the ipsilateral shoulder joint was assessed both subjectively and objectively in 141 patients with early stage breast cancer. Half of the patients said that function was reduced compared with before (any) treatment. Overall, 48% had measured limitation of at least one shoulder movement. Mastectomy patients had more problems than those who had a wide local excision (79% versus 35%) as did those (node positive patients) who had axillary irradiation (73%) compared with those who did not (35%). Patients with dysfunction of shoulder movement before radiotherapy had a 60% chance of persistent movement problems at 18 months, compared with 24% of those with normal postoperative function. Informal exercise did not appear to have had any impact on the development of movement limitation.

Outcome in breast cancer managed without an initial axillary lymph node dissection

PURPOSE

The role of an elective axillary lymph node dissection (AxLND) in the initial management of patients with early stage breast cancer has recently become controversial. The objective of this current study is to review the reasons as to why patients from a single institution were managed without an initial AxLND and their outcome in terms of survival and recurrence rates.

MATERIALS AND METHODS

A retrospective analysis was conducted on 126 women referred to the Princess Margaret Hospital with the diagnosis of breast cancer who did not undergo an initial AxLND.

RESULTS

The median age of this population was 69 years, with the vast majority (93%) being post-menopausal. Fifty-seven patients had T1 tumors and the remainder had T2-3 tumors. Adjuvant radiation therapy to the breast was administered to 65 patients and systemic adjuvant treatment was administered to 24 patients. In approximately one-third of these cases, the reasons cited for not performing an AxLND were related to the patient's age, a medical contraindication, or the patient's choice. The 5-year actuarial cause-specific survival was 92%; the local breast relapse-free rate (RFR) was 85% and the axillary RFR was 86%. No patients in this study experienced debilitating symptoms from their axillary disease. Only 16 patients underwent a subsequent AxLND, with the lymph nodes being pathologically uninvolved in six of these patients.

CONCLUSION

This study supports the concept that. in selected patients, adopting an approach of a delayed AxLND does not appear to compromise the patients' outcome, with only 13% of patients requiring a subsequent AxLND.

Adjuvant therapy for pancreatic cancer: back to the future

PURPOSE

The role of adjuvant therapy in the management of pancreatic cancer, resected with curative intent, remains controversial. This editorial review updates the status of adjuvant therapy in this context and introduces the first North American co-operative group study in this arena in roughly 20 years.

RESULTS

To the extent that there has been a "standard" of care in this context, it has been defined in large part by the early work of the Gastrointestinal Study Group (GITSG). Their trial was activated in the mid 1970's using split course radiation therapy and bolus 5-FU. In the intervening 20 + years the morbidity/mortality of pancreaticoduodenectomy (PDD) has been dramatically reduced; concurrently, understanding of prognostic factors impacting on outcomes for resected patients has been significantly enhanced. In major centers the mortality of PDD is roughly 1% and survival has been shown to correlate with a number of factors including tumor size, nodal involvement, and margin status. With currently available techniques doses of continuous course radiation therapy in the range of 50-55 Gy to sites of pancreatic tumor resection and adjacent lymph node regions have been given in a number of trials with acceptable morbidity. 5-FU sequencing and administration have been advanced and gemcitabine, an agent with clear radiosensitizing properties, has been approved for use against pancreatic cancer.

CONCLUSIONS

Following PDD increasing numbers of physiologically intact patients are confronting the survival statistics associated with resected pancreatic cancer. Their interest in improved therapeutic outcomes, combined with the noted improvements in radiation and chemotherapeutic management, has set the stage for renewed and intensified study. Accordingly, the intergroup mechanism of the Cancer Therapy and Evaluation Program (CTEP) of the NCI has designed, approved, and activated a modern Phase III, adjuvant protocol incorporating recently gained knowledge in this management context. Prospective randomization will be utilized to compare gemcitabine and 5-FU as single agents before and after chemoradiotherapy with 5-FU. Successful and timely completion of this newly activated intergroup study, RTOG 97-04, will establish a current, cooperative group experience, data base, and standard in the context of adjuvant therapy for pancreatic cancer and serve to provide momentum for further studies.

Polyploidization and exit from cell cycle as mechanisms of cultured melanoma cell resistance to methotrexate

Numerous malignant neoplasias are found to contain varying proportions of high-ploidy cells. Although the role they play in the tumor is poorly understood, several lines of evidence suggest that these cells could be especially resistant to various aggressions, a possibility of great interest in cancer treatment. In the present study, we tested this hypothesis through the analysis of the presence of high-ploidy cells following the administration of the chemotherapeutic agent methotrexate. We also determined the expression of two proliferation markers, PCNA and CDK1, after methotrexate-treatment. Cultured cells from the murine melanoma B16F10 were treated with high doses of methotrexate for seven days prior to determination of DNA content and proliferation markers. Our results showed an obvious increase in the mean ploidy of this population. Specifically, there was a dramatic reduction in the proportion of tetraploid cells (predominant in the original population), and an increase in the proportion of cells with higher ploidies, particularly those whose DNA content was greater than 8c, including some cells with ploidies greater than 16c. Furthermore, there was a reduction in the number of PCNA-expressing cells and the reduction was much more marked in the case of CDK1 that was almost absent in the modal-ploidy treated cells. These alterations concerning ploidy and expression of proliferation markers had completely reverted two weeks after withdrawal of the drug. Our results indicate that methotrexate at a high dosage selects a cell population heterogeneous concerning its ploidy level, composed of one subpopulation of high-ploidy cells and another of modal-ploidy cells that, considering its lack of CDK1 expression, would remain in a latent state to evade the effects of the drug.

Genomic fluidity is a necessary event preceding the acquisition of tumorigenicity during spontaneous neoplastic transformation of WB-F344 rat liver epithelial cells

The genomic evolution of a cohort of WB-F344 rat liver epithelial cell lineages undergoing spontaneous neoplastic transformation was followed to define the mechanistic relationship between genomic instability and progression to the neoplastic phenotype. Eighteen independent populations of WB-F344 cells (initiated from a single diploid-founding population) were subjected to 12 cycles of selective growth at confluent cell density, and cellular DNA contents were measured after each selection cycle. Flow cytometry demonstrated significant gains in the amount of G1 DNA after selection cycles 3, 6, and 7 in 44% (8 of 18), 89% (16 of 18), and 39% (7 of 18) of the cell populations, respectively. All populations subsequently lost DNA and returned to a diploid or pseudo-diploid DNA content within 1 to 2 selection cycles after the appearance of an increased DNA content. Additionally, appearance and subsequent disappearance of aneuploid or tetraploid subpopulations was observed in 11% (2 of 18) and 83% (15 of 18) of the experimental lineages, respectively. Although perturbations of G1 DNA content were apparent as early as selection cycle 3, at least 8 cycles of selective growth were required for the acquisition of tumorigenicity. While the independent lineages demonstrated significant fluctuations in G1 DNA content between selection cycles 3 and 8, the majority (11 of 13) of the populations contained a diploid or pseudo-diploid DNA content at the time tumorigenicity was expressed. Genomic instability preceded the acquisition of tumorigenic potential in rat liver epithelial cells subjected to selective growth conditions of maintenance at confluence, and may be required for its expression.

Cytogenetics and the surgeon: an invaluable tool in diagnosis, prognosis and counselling of patients with solid tumours

BACKGROUND

Cytogenetic studies have become an important part of tumour characterization. In a minority of tumours cytogenetic and/or molecular studies may be of help for diagnosis, selection of treatment protocols and predicting outcome.

METHODS

This article reviews the literature on solid tumour translocations and established family cancer syndromes. In addition, the potential importance of genetics in management of patients with breast, ovarian and pancreatic carcinoma is reviewed.

RESULTS AND CONCLUSION

Cytogenetic analysis of tumours may help confirm the diagnosis when conventional histology demonstrates no evidence of differentiation along a particular tissue pathway. For patients with well defined cancer syndromes, cytogenetic and molecular analysis offers the prospect of screening to reduce the risk of malignant disease. For many malignancies the underlying genetic anomalies are gradually being elucidated. Further studies designed to demonstrate the significance of these findings can only be undertaken if tumour material is collected and stored in optimal conditions for cytogenetic and/or molecular biological studies.

Periampullary adenocarcinoma: analysis of 5-year survivors

OBJECTIVE

This single-institution experience retrospectively reviews the outcomes in a group of patients treated 5 or more years ago by pancreaticoduodenectomy for periampullary adenocarcinoma.

SUMMARY BACKGROUND DATA

Controversy exists regarding the benefit of resection for periampullary adenocarcinoma, particularly for pancreatic tumors. Many series report only Kaplan-Meier actuarial 5-year survival rates. There are believed to be discrepancies between the actuarial 5-year survival data and the actual 5-year survival rates.

METHODS

From April 1970 through May 1992, 242 patients underwent pancreaticoduodenal resection for periampullary adenocarcinoma at The Johns Hopkins Hospital. Follow-up was complete through May 1997. All pathology specimens were reviewed and categorized. Actual 5-year survival rates were calculated. The demographic, intraoperative, pathologic, and postoperative features of patients surviving > or =5 years were compared with those of patients who survived <5 years.

RESULTS

Of the 242 patients with resected periampullary adenocarcinoma, 149 (62%) were pancreatic primaries, 46 (19%) arose in the ampulla, 30 (12%) were distal bile duct cancers, and 17 (7%) were duodenal cancers. There was a 5.3% operative mortality rate during the 22 years of the review, with a 2% operative mortality rate in the last 100 patients. There were 58 5-year survivors, 28 7-year survivors, and 7 10-year survivors. The tumor-specific 5-year actual survival rates were pancreatic 15%, ampullary 39%, distal bile duct 27%, and duodenal 59%. When compared with patients who did not survive 5 years, the 5-year survivors had a significantly higher percentage of well-differentiated tumors (14% vs. 4%; p = 0.02) and higher incidences of negative resection margins (98% vs. 73%, p < 0.0001) and negative nodal status (62% vs. 31%, p < 0.0001). The tumor-specific 10-year actuarial survival rates were pancreatic 5%, ampullary 25%, distal bile duct 21%, and duodenal 59%.

CONCLUSIONS

Among patients with periampullary adenocarcinoma treated by pancreaticoduodenectomy, those with duodenal adenocarcinoma are most likely to survive long term. Five-year survival is less likely for patients with ampullary, distal bile duct, and pancreatic primaries, in declining order. Resection margin status, resected lymph node status, and degree of tumor differentiation also significantly influence long-term outcome. Particularly for patients with pancreatic adenocarcinoma, 5-year survival is not equated with cure, because many patients die of recurrent disease >5 years after resection.

Pancreatic adenocarcinomas with DNA replication errors (RER+) are associated with wild-type K-ras and characteristic histopathology. Poor differentiation, a syncytial growth pattern, and pushing borders suggest RER+

The clinical and pathological features of carcinomas of the pancreas with DNA replication errors (RER+) have not been characterized. Eighty-two xenografted carcinomas of the pancreas were screened for DNA replication errors using polymerase chain reaction amplification of microsatellite markers. Cases with microsatellite instability in at least two markers of a minimum of five tested were considered RER+. RER status was correlated with histological appearance, karyotype of the carcinomas when available, K-ras mutational status, and patient outcome. Three (3.7%) of the eighty-two carcinomas were RER+. In contrast to typical gland-forming adenocarcinomas of the pancreas, all three RER+ carcinomas were poorly differentiated and had expanding borders and a prominent syncytial growth pattern. Neither a Crohn's-like lymphoid infiltrate nor extracellular mucin production were prominent. Ductal adenocarcinomas of the pancreas typically contain a mutant K-ras gene, yet all three RER+ carcinomas had wild-type K-ras. One of the three RER+ carcinomas was karyotyped and showed a near diploid pattern. All three of the RER+ tumors were removed via Whipple resection. One of the three patients is free of disease 16 months after pancreaticoduodenectomy, one is alive and free of tumor at 52 months but developed two colon carcinomas during this period, and the third died of pancreatic cancer at 4 months. None of the three patients had a family history of colorectal carcinoma. A review of the K-ras wild-type carcinomas in a previously characterized series of pancreatic carcinomas with known K-ras mutational status identified two additional cancers with poor differentiation, a syncytial growth pattern, and pushing borders. Both of the cancers were diploid and both patients were longterm survivors (over 5 years). The inclusion of such patients in previous prognostic studies of pancreas cancer may explain the failure of histological grade to be a predictor of prognosis. These data suggest that DNA replication errors occur in a small percentage of resected carcinomas of the pancreas and that wild-type K-ras gene status and a medullary phenotype characterized by poor differentiation, and expanding pattern of invasion, and syncytial growth should suggest the possibility of DNA replication errors in carcinomas of the pancreas.

[Identification of axillary sentinel node by lymphotropic dye in breast cancer. Feasibility study apropos of 128 cases]

AIM OF THE STUDY

The goal of this study was to evaluate the technical feasibility of sentinel node biopsy in breast cancer and its predictivity of axillary node status.

PATIENTS AND METHODS

Between January 1996 and June 1997, 128 patients with invasive breast carcinomas, referred to the Cancer Center of Strasbourg and Lyon (France), underwent lymphatic mapping (Patent Blue dye) and sentinel node biopsy followed by axillary clearance (Berg's level I to II).

RESULTS

Sentinel node was identified in 76.5% of cases and was predictive of axillary status in 94.9% of cases. The false negative rate of the procedure was 5.1%. Sentinel lymph node was involved in 43.9% of cases and it was the only one involved in 30.2% of cases. The sensitivity of the procedure was 94% (CI: 95% = [88%-98%]) and its specificity 100%.

CONCLUSION

Actually considered as new attractive procedure under ongoing evaluation in prospective controlled trials, this study confirms the feasibility and reproductibility of lymphatic mapping and sentinel node biopsy, first stage before entering a new era of minimally invasive axillary surgery in breast cancer.

[Role of adjuvant chemoradiotherapy in the therapeutic strategy of exocrine adenocarcinoma of the pancreas]

The prognosis of pancreatic adenocarcinoma remains poor, with a 5-year survival rate lower than 5%. Resection, the gold standard treatment, can be performed in less than 10% of patients. Following surgery, the median survival is 12 months for the most favorable patients. Concomitant chemoradiation, as an adjuvant treatment is superior to surgery alone, in terms of survival, controlled trials are currently performed. Neoadjuvant chemoradiation is a new approach, potentially able to increase survival and resection rate. This work justifies the role of these schemes, in terms of modalities and potential advantages.

[Fight against cancer of the exocrine pancreas: stagnation or progress? The point of view of the Fondation française de cancérologie digestive (FFCD)]

This paper updates recent trends concerning ductal pancreatic cancer. Knowledge of the cellular mechanisms has improved, and new developments in imaging allow a more accurate staging. Although operative mortality sharply decreased during these last 15 years, the prognosis of pancreatic carcinoma remains dismal, due to late diagnosis, as only one out of ten patients is considered for curative resection. Therapeutic research groups, and among them the Fondation française de cancérologie digestive (FFCD), do their best to develop new therapeutic strategies, including post-operative or preferentially pre-operative radio-chemotherapeutic adjuvant treatments, and to improve chemotherapy in metastatic cancers.

[Surgical treatment of cancer of the pancreas]

Resection of the pancreas is still the only way to cure patients with pancreatic cancer. Morbidity and mortality rates following pancreatico-duodenectomy for adenocarcinoma of the pancreas have decreased. Survival has improved during the past several decades.

[Therapeutic approaches of adenocarcinoma of the exocrine pancreas. Trends in 1997]

The prognosis for adenocarcinoma of the pancreas remains poor. Besides surgical treatment of operable localised tumours, many questions are raised: what is the role of adjuvant therapies, chemo-radiotherapy, pre-operative or post-operative combinations, and what is the role of radiotherapy or chemo-radiotherapy during surgery? In the case of inoperable tumours, there is no consensus on the role and the value of various protocols whose toxicity is generally high. Improvements in treatment must come from a better understanding of the role of various prognostic factors (biological markers in particular).

Survival following pancreaticoduodenectomy with resection of the superior mesenteric-portal vein confluence for adenocarcinoma of the pancreatic head

BACKGROUND

The survival of patients who underwent pancreaticoduodenectomy with or without en bloc resection of the superior mesenteric-portal vein (SMPV) confluence for adenocarcinoma of the pancreatic head was compared.

METHODS

To be considered for surgery, patients were required to fulfil the following computed tomography criteria for resectability: (1) absence of extrapancreatic disease, (2) no evidence of tumour extension to the superior mesenteric artery (SMA) or coeliac axis, and (3) a patent SMPV confluence. Tumour adherence to the superior mesenteric vein (SMV) or SMPV confluence was assessed at operation and en bloc venous resection was performed when necessary to achieve complete tumour extirpation.

RESULTS

Seventy-five consecutive patients underwent pancreaticoduodenectomy, 44 without venous resection and 31 with en bloc resection of the SMPV confluence. There were no perioperative deaths in either group; late (more than 6 months) occlusion of the reconstructed SMPV confluence contributed to the death of two patients. Median survival in the 31 patients who required venous resection at the time of pancreaticoduodenectomy was 22 months, and that for the 44 control patients was 20 months (P = 0.25).

CONCLUSION

Patients with adenocarcinoma of the pancreatic head who require venous resection during pancreaticoduodenectomy for isolated tumour extension to the SMV or SMPV confluence (in the absence of tumour extension to the SMA or coeliac axis) have a duration of survival no different from that of patients who undergo standard pancreaticoduodenectomy. These data suggest that venous involvement is a function of tumour location rather than an indicator of aggressive tumour biology.

Should pancreaticoduodenectomy be performed in octogenarians?

As the population in the United States ages, an increasing number of elderly patients may be considered for pancreaticoduodenal resection. This high-volume, single-institution experience examines the morbidity, mortality, and long-term survival of 727 patients undergoing pancreaticoduodenectomy between December 1986 and June 1996. Outcomes of patients 80 years of age and older (n = 46) were compared to those of patients younger than 80 years. In these older patients, pancreaticoduodenectomy was performed for pancreatic adenocarcinoma (n = 25; 54%), ampullary adenocarcinoma (n = 9; 20%) distal bile duct adenocarcinoma (n = 5; 11%), duodenal adenocarcinoma (n = 2; 4%), cystadenocarcinoma; (n = 2; 4%), cystadenoma (n = 1; 2%), and chronic pancreatitis (n = 2; 4%). When compared to the 681 concurrent patients younger than 80 years who were undergoing pancreaticoduodenectomy, the two groups were statistically similar with respect to sex, race, intraoperative blood loss, and type of pancreaticoduodenectomy performed. Patients 80 years of age or older had a shorter median operative time (6.4 hours vs. 7.0 hours; P = 0.02) but a longer postoperative length of stay (median = 15 days vs. 13 days; P = 0.01) and a higher complication rate (57% vs. 41%; P = 0.05) when compared to their younger counterparts. Pancreaticoduodenectomy in the older group resulted in a 4.3% perioperative mortality rate compared to 1.6% in the younger group (P = NS). In the subset of patients undergoing pancreaticoduodenectomy for periampullary adenocarcinoma (n = 495), patients 80 years of age or older (n = 41) had a median survival of 32 months and a 5-year survival rate of 19%, compared to 20 months and 27%, respectively, in patients younger than 80 years (n = 454; P = 0.77). These data demonstrate that pancreaticoduodenectomy can be performed safely in selected patients 80 years of age or older, with morbidity and mortality rates approaching those observed in younger patients. Based on these data, age alone should not be a contraindication to pancreaticoduodenectomy.

Pancreatic cancer resection in elderly patients

BACKGROUND

Pancreatic cancer resection is considered a high-risk procedure in patients aged 70 years or older.

METHODS

Some 398 patients with pancreatic adenocarcinoma, observed between 1990 and 1995, were reviewed. Operative outcome and survival of 33 patients aged 70 years or more were compared with findings in 85 younger patients who underwent resection.

RESULTS

Resectability was not significantly different between the elderly and younger patients; neither were mortality or overall morbidity. However, patients aged 70 years or more had more relaparotomies (P < 0.01) and more haemorrhagic complications (P < 0.001). Nutritional recovery after resection was satisfying even for elderly patients (body-weight gain and increase in serum albumin concentrations, P < 0.05). Univariate analysis showed a moderately poorer survival in the elderly (P = 0.09). Multivariate analysis demonstrated that tumour diameter, grading and Union Internacional Contra la Cancrum stage were independent prognostic factors, whereas age was not.

CONCLUSION

Patients aged 70 years or more can benefit from pancreatic cancer resection similarly to younger patients.