Pancreas cancer -- duct cell adenocarcinoma: survival in relation to site, size, stage and type of therapy

Total Pancreatectomy: Indications, Advantages and Disadvantages - A Review

Background: Total pancreatectomy is an obligatory surgical procedure in locally advanced or centrally located pancreatic neoplasms to achieve complete tumour clearance. Owing to sound understanding of tumour biology and evolution in intervention technique and improved postoperative care, nowadays the indications of total pancreatectomy have taken a significant change. Aim: To review the indications of total pancreatectomy and its advantages and disadvantages under current perspectives. Method: Major databases, including PubMed, EMBASE, Science Citation Index Expanded, Scopus and the Cochrane Library, were searched for studies of total pancreatectomy and the results reported by various authors were summarized. Results: The indications of total pancreatectomy in subjects diagnosed with chronic pancreatitis were classified into four subgroups, including "Tumour", "Trouble", "Technical difficulties" and "Therapy-refractory pain". Today, total pancreatectomy has more specific and different indications than before. Currently, IPMN (intraductal papillary mucinous neoplasm) seems to have the most essential indication quantitatively. Morbidity and mortality related to total pancreatectomy are more profoundly decreased than before due to improvements in the operative techniques and post-operative managements. Some of the metabolic disorders are reported as major disadvantages of total pancreatectomy. Conclusion: Despite the disadvantages of total pancreatectomy, it remains an inevitable procedure for subjects with chronic pancreatitis, improvements in operative techniques and postoperative management ensuring long-term survival, a better quality of life, and diminished mortality and morbidity rates.

Total pancreatectomy compared with pancreaticoduodenectomy: a systematic review and meta-analysis

Aim: To assess whether total pancreatectomy (TP) is as feasible, safe, and efficacious as pancreaticoduodenectomy (PD).

Materials and Methods: Major databases, including PubMed, EMBASE, Science Citation Index Expanded, Scopus and the Cochrane Library, were searched for studies comparing TP and PD between January 1943 and June 2018. The meta-analysis only included studies that were conducted after 2000. The primary outcomes were morbidity and mortality. Pooled odds ratios (ORs), weighted mean differences (WMDs) or hazard ratios (HRs) with 95 percent confidence intervals (CIs) were calculated using fixed effects or random effects models. The methodological quality of the included studies was evaluated by the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool.

Results: In total, 45 studies were included in this systematic review, and 5 non-randomized comparative studies with 786 patients (TP: 270, PD: 516) were included in the meta-analysis. There were no differences in terms of mortality (OR: 1.44, 95% CI: 0.66–3.16; P=0.36), hospital stay (WMD: −0.60, 95% CI: −1.78–0.59; P=0.32) and rates of reoperation (OR: 1.12; 95% CI: 0.55–2.31; P=0.75) between the two groups. In addition, morbidity was not significantly different between the two groups (OR: 1.41, 95% CI: 1.01–1.97; P=0.05); however, the results showed that the TP group tended to have more complications than the PD group. Furthermore, the operation time (WMD: 29.56, 95% CI: 8.23–50.89; P=0.007) was longer in the TP group. Blood loss (WMD: 339.96, 95% CI: 117.74–562.18; P=0.003) and blood transfusion (OR: 4.86, 95% CI: 1.93–12.29; P=0.0008) were more common in the TP group than in the PD group. There were no differences in the long-term survival rates between the two groups.

Conclusion: This systematic review and meta-analysis suggested that TP may not be as feasible and safe as PD. However, TP and PD may have the same efficacy.

Ductal Adenocarcinoma of the Pancreas: Clinicopathologic Features and Survival

Aims and Background

The prognosis after surgical resection for pancreatic cancer has not been clearly defined because conflicting results have been reported.

Methods

Fifty-five patients who underwent surgical resection for pancreatic carcinoma between 1970 and 1987 were retrospectively reviewed to determine factors influencing long-term survival.

Results

The actuarial 5-year survival rate for all 55 patients was 12.5 %. Type of operation, tumor stage, direct extension into adjacent organs, grading and lymph node involvement were found to significantly influence survival. Age, sex, tumor site, size, invasion into peripancreatic tissue, invasion of lymphatic vessels and small veins, perineural Infiltration, tumor necrosis, round cell infiltrate at the tumor margin, associated chronic pancreatitis, and atypia of pancreatic ductal epithelium demonstrated no predictive capacity. No 5-year survival was observed among the patients who underwent vascular resection. Three of 9 patients who underwent left-sided pancreatectomy for cancer of the tail of the pancreas survived more than 5 years. Multivariate analysis confirmed that lymph node involvement, moderate-poor histologic tumor differentiation, and treatment with total pancreatectomy were signicantly associated with a worse prognosis.

Conclusions

Lymph node status, grading of the tumor and type of operation have a significant impact on prognosis in resected pancreatic cancer.

Perfusion CT estimates photosensitizer uptake and biodistribution in a rabbit orthotopic pancreatic cancer model: a pilot study

RATIONALE AND OBJECTIVES

It was hypothesized that perfusion computed tomography (CT), blood flow (BF), blood volume (BV), and vascular permeability surface area (PS) product parameters would be predictive of therapeutic anticancer agent uptake in pancreatic cancer, facilitating image-guided interpretation of human treatments. The hypothesis was tested in an orthotopic rabbit model of pancreatic cancer, by establishing the model, imaging with endoscopic ultrasound (EUS) and contrast CT, and spatially comparing the perfusion maps to the ex vivo uptake values of the injected photosensitizer, verteporfin.

MATERIALS AND METHODS

Nine New Zealand white rabbits underwent direct pancreas implantation of VX2 tumors, and CT perfusion or EUS was performed 10 days postimplantation. Verteporfin was injected during CT imaging, and the tissue was removed 1 hour postinjection for frozen tissue fluorescence scanning. Region-of-interest comparisons of CT data with ex vivo fluorescence and histopathologic staining were performed.

RESULTS

Dynamic contrast-enhanced CT showed enhanced BF, BV, and PS in the tumor rim and decreased BF, BV, and PS in the tumor core. Significant correlations were found between ex vivo verteporfin concentration and each of BF, BV, and PS.

CONCLUSIONS

The efficacy of verteporfin delivery in tumors is estimated by perfusion CT, providing a noninvasive method of mapping photosensitizer dose.

Involvement of angiotensin II type 2 receptor (AT2R) signaling in human pancreatic ductal adenocarcinoma (PDAC): a novel AT2R agonist effectively attenuates growth of PDAC grafts in mice

We have recently discovered the potential involvement of angiotensin II type 2 receptor (AT2R) signaling in pancreatic cancer using AT2R deficient mice. To examine the involvement of AT2R expression in human PDAC, expressions of AT2R as well as the major angiotensin II receptor (type 1 receptor, AT1R) in human PDAC and adjacent normal tissue was evaluated by immunohistochemistry and real time PCR using surgically dissected human PDAC specimens. In immunohistochemical analysis, relatively strong AT1R expression was detected consistently in both normal pancreas and PDAC areas, whereas moderate AT2R expression was detected in 78.5% of PDAC specimens and 100% of normal area of the pancreas. AT1R, but not AT2R, mRNA levels were significantly higher in the PDAC area than in the normal pancreas. AT2R mRNA levels showed a negative correlation trend with overall survival. In cell cultures, treatment with a novel AT2R agonist significantly attenuated both murine and human PDAC cell growth with negligible cytotoxicity in normal epithelial cells. In a mouse study, administrations of the AT2R agonist in tumor surrounding connective tissue markedly attenuated growth of only AT2R expressing PAN02 murine PDAC grafts in syngeneic mice. The AT2R agonist treatment induced apoptosis primarily in tumor cells but not in stromal cells. Taken together, our findings offer clinical and preclinical evidence for the involvement of AT2R signaling in PDAC development and pinpoint that the novel AT2R agonist could serve as an effective therapeutic for PDAC treatment.

Pancreas cancer survival in the gemcitabine era

After multiple positive studies, gemcitabine, approved for the treatment of pancreas cancer by the FDA in 1977, became standard of care. Whether this therapeutic advance has translated into longer survival for pancreas cancer patients in general has not been established. This study, derived from SEER (Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute) data, compared the survival experiences of the gemcitabine (1998–2004) and pre-gemcitabine (1988–1997) eras for 7,151 patients who had metastatic disease and did not undergo extirpative surgery, 14,369 patients who had not undergone surgery and had metastases, 5,042 patients who had undergone surgery and did not have metastases, and 5,011 patients who had undergone surgery and had metastases. Calculated survival time ratios (TR) were adjusted for radiotherapy history, grade, nodal status, loco-regional extent of disease, age, race, and gender. For those who did not undergo extirpative surgery, improvements in survival in the gemcitabine era (1998–2004) versus the prior time period (1988–1997) seen for patients with metastatic cancer (TR = 1.20, 95% c.i. 1.15–1.25) were not seen for those without metastatic cancer (TR = 1.05, 95% c.i. 1.00–1.15). For those who did undergo extirpative surgery, improvements were much more dramatic for those with metastatic cancer (TR = 1.61, 95% c.i. 1.45–1.80) than those without metastases (TR = 1.23, 95% c.i. 1.15–1.31). The results are consistent with the notion that the promising findings with respect to gemcitabine in the controlled clinical trials have found expression in the general population of patients with pancreas cancer.

High risk of venous thrombosis in patients with pancreatic cancer: a cohort study of 202 patients

To estimate the risk of venous thrombosis associated with pancreatic malignancies we followed a cohort of patients with pancreatic cancer (n = 202). We calculated incidence rates of venous thrombosis and compared this with population rates using a Standardised Morbidity Ratio (SMR). The effects of location, histology and treatment were assessed by Cox-modelling. The incidence of venous thrombosis was 108.3/1000 patient-years (95% confidence interval (CI) 64.4-163.8), 58.6-fold increased (SMR 58.6, 95% CI 36.9-92.9). Patients with a tumour of the corpus/cauda had a 2-fold increased risk compared with those with a tumour of the caput. Patients treated with chemotherapy had a 4.8-fold increased risk (HR(adj) 4.8, 95% CI 1.1-20.8), whereas radiotherapy did not increase the risk. In a postoperative period of 30 d, patients had a 4.5-fold increased risk of venous thrombosis (HR(adj) 4.5, 95% CI 0.5-40.9). The risk was 1.9-fold increased in the presence of distant metastases (HR(adj) 1.9, 95% CI 0.7-5.1). Anti-thrombotic prophylaxis seems warranted in the first month after surgery, during and after treatment with chemotherapy, and when distant metastases have been diagnosed.

Analysis of Ki-67 antigen expression, DNA proliferative fraction, and survival in resected cancer of the pancreas

BACKGROUND

Prognostic markers for pancreas cancer, such as CEA, CA19-9, ploidy analysis, and S-phase determination using flow cytometry, have not been consistently predictive. We chose to evaluate nuclear proliferation, as measured by the MIB-1 monoclonal antibody and digital image analysis, as a prognostic marker in pancreatic carcinoma, and compare the findings with DNA ploidy and S-phase analysis. MIB-1 identifies the Ki67 antigen present in nuclei of cells in all phases of the cell cycle except G0.

METHODS

We retrospectively reviewed 33 patients with pancreatic adenocarcinoma resected for cure between 1989 and 1994 with available fixed tissue. Sectioned tissue was stained with MIB-1, and the number of positively stained nuclei determined and expressed as a MIB-1 labeling index (LI) by quantitative image analysis. Disaggregated nuclei were analyzed by flow cytometry using standard techniques.

RESULTS

MIB-1 LI for pancreas cancers was heterogeneous within and between cancers. The MIB-1 LI for the cancers was 28 +/- 15 (median 29). There was no correlation between survival and MIB-1 expression (R(2) = 0.03). Likewise, there was no correlation between MIB-1 LI and percentage of cells in S-phase, G(2)/M, or total proliferating cells (S+G(2)/M; R(2) = 0.01), nor was there a difference between MIB-1 LI and ploidy (P = 0.88).

CONCLUSIONS

We conclude that in our patient population, nuclear proliferation in pancreatic cancer, as determined by expression of Ki67 nuclear antigen, does not appear to correlate with survival and is not a useful prognostic marker. Despite intuitive thoughts to the contrary, there is no correlation between cell cycle analysis as determined by flow cytometry and Ki67 expression in pancreas cancer. Current methods of assessing prognosis after curative resection of cancer of the pancreas, including lymph node and margin status, tumor size, and possibly DNA ploidy as determined by flow cytometry, are not augmented by the assessment of nuclear proliferation by image analysis using the MIB-1 monoclonal antibody.

Review article: current treatment and optimal patient management in pancreatic cancer

This review analyses the current state of knowledge and understanding concerning the optimum treatment and therapeutic management of patients who suffer from pancreatic cancer. It outlines recent advances in scientific understanding and assesses their potential future value to clinicians in confronting this disease. Despite a significant expansion in scientific knowledge relating to factors underlying the early development of pancreatic carcinoma, the clinician continues to be restricted to a severely limited therapeutic armoury for this disease. Local therapies (surgery and radiation) are inevitably of limited value in the face of a disease that is normally encountered at a stage where metastasis is already highly developed. Despite such limitations, however, surgery performed in specialist units may be of value for 10-20% of patients, with a 5-year survival rate in such units of between 10 and 24%. This may be improved even further by appropriate use of adjuvant treatment. The advanced stage of the disease when normally encountered emphasizes the potential value of systemic treatment in this therapeutic area. Unfortunately systemic treatment (chemotherapy) has been found to be ineffective to date in significantly extending survival, with a low rate and duration of remission being identified in most trials. The challenge for both the health service and the pharmaceutical industry is to harness recent and future developments in scientific knowledge to the practical benefit of clinicians. Where cure is possible it should be vigorously pursued; where it is not, in this field above all others, clinicians have a duty of care. To achieve this it is necessary to abandon the therapeutic nihilism that has characterized the attitudes of clinicians towards this disease in the past. It is time that such nihilism was replaced by a recognition of the challenges and the opportunities available to clinicians in enhancing the quantity and quality of life available to patients. The dictum of 'curing whenever possible but caring always' should be the future therapeutic philosophy used to guide clinicians in this important and rapidly changing therapeutic area.

Diagnosis and staging of pancreatic cancer by endoscopic ultrasound

The aim of this study was to evaluate the usefulness of and problems associated with endoscopic ultrasonography (EUS) in the diagnosis and pre-operative staging of pancreatic cancer. 96 patients suspected of having pancreatic cancer were pre-operatively examined with EUS. 37 of these 96 patients had pancreatic cancer. Results of the EUS imaging were compared with findings of histology and/or surgery, and the patient's clinical course. The sensitivity and specificity of EUS for diagnosing pancreatic cancer were 89% and 97%, respectively. EUS had excellent sensitivity regardless of tumour size or location. EUS was accurate (90%) in determining tumour size in pancreatic cancers less than 3 cm in maximum diameter, but not for tumours greater than 3 cm (30%). The accuracy of tumour (T) and nodal (N) staging were 64% and 50%, respectively. EUS is a promising method for the early diagnosis and pre-operative staging of pancreatic cancers, but requires further refinement.

A randomized trial of endoscopic drainage methods for inoperable malignant strictures of the common bile duct

BACKGROUND

Although metallic stents remain patent longer than plastic stents, the optimal palliation of inoperable malignant biliary strictures remains controversial because of the high cost of metallic stents and short patient survival.

METHODS

A total of 101 patients (mean age 72.5+/-12.9 years) with malignant strictures of the common bile duct were included in this study, after three exclusions for technical failure (n = 3) and one for noncompliance with study design. The etiology of the strictures included pancreatic cancer (65), cholangiocarcinoma (21), ampullary tumor (3), and metastatic lymph nodes (12). Patients were randomized to receive either an 11.5F polyethylene stent to be exchanged in case of dysfunction (group 1, n = 33), an 11.5F stent to be exchanged every 3 months (group 2, n = 34), or a self-expanding metallic Wallstent (group 3, n = 34).

RESULTS

Endoscopic procedures were successful (including complete relief of jaundice) in 97.1 % of cases. Procedure-related morbidity was 11.9%, and mortality was 2.9%. Bilirubinemia after 48 hours (37.2%+/-21.7% decrease from the preoperative level) did not differ between groups. Patients were followed for a mean of 166 days (median 143, range 0 to 596 days). Overall survivals were not different between groups, but complication-free survival for groups 2 and 3 was longer than that of group 1 (p < 0.05). Cumulated hospital days were 7.4+/-1.5, 10.6+/-1.7, and 5.5+/-1.4 (groups 1, 2, and 3, respectively) (p < 0.05; analysis of variance). Cost analysis showed that metallic stents were advantageous in patients surviving more than 6 months, whereas a plastic stent was advantageous in patients surviving 6 months or less.

CONCLUSIONS

Metallic stents and plastic stents exchanged every 3 months are valuable alternatives for increasing complication-free survival in patients with malignant strictures of the common bile duct. Metal stents are advantageous in patients with the longest life expectancy.

Value of helical computed tomography, angiography, and endoscopic ultrasound in determining resectability of periampullary carcinoma

BACKGROUND

High-quality preoperative radiographic evaluation is crucial in selecting patients with periampullary carcinomas who are candidates for surgical exploration and tumor resection while minimizing the rate of unnecessary laparotomy.

METHODS

Twenty-one consecutive patients were prospectively investigated using helical computed tomography (CT) scanning, endoscopic ultrasonography (EUS), and selective visceral angiography (SVA) to determine tumor resectability. All patients were explored and resectability determined.

RESULTS

Helical CT had a sensitivity of 63%, a specificity of 100%, and an overall accuracy of 86%. EUS had a sensitivity of 75%, a specificity of 77%, and an overall accuracy of 76%. SVA had a sensitivity of 38%, a specificity of 92%, and an overall accuracy of 71%.

CONCLUSIONS

Helical CT scanning is the best preoperative imaging test to determine tumor resectability. EUS is more sensitive than CT for tumor detection, but underestimates resectability. SVA is no longer helpful in the preoperative evaluation of these malignancies.

Combined modality treatment with accelerated radiotherapy and chemotherapy in patients with locally advanced inoperable carcinoma of the pancreas: results of a feasibility study

Between July 1990 and September 1993, 32 patients with locally advanced irresectable adenocarcinoma of the pancreas, histologically proven by laparotomy, were involved in our study. Patients were treated with hyperfractionated, accelerated radiotherapy and simultaneous application of 5-fluorouracil and folinic acid. Chemotherapy was given on days 1,2 and 3. Determination of the target volume for radiotherapy was carried out by computerized axial tomography. The total tumour dose of 44.8 Gy was applied relative to the 90% isodose in two daily fractions of 1.6 Gy, resulting in ten fractions per week. On the first three days of radiotherapy, 600 mg m-3 of 5-fluorouracil and 300 mg m-3 of folinic acid were given i.v. According to response, chemotherapy was repeated in 4-week intervals. The median survival time for all patients was 12.7 months, compared with 3-7 months after palliative surgery (historical control). The median progression-free interval was 6.6 months. Toxicity and therapy-induced morbidity were recorded according to WHO criteria. Nausea and vomiting of WHO grade I and II occurred in 72.1% and of grade III and IV in 27.9% of the patients. WHO grade I and II diarrhoea was seen in 11 patients. The overall incidence of leucopenia and thrombocytopenia was 37.4%; severe side-effects (WHO III-IV) occurred in 9.3% of all patients. One patient experienced a severe mucositis (WHO III). This combined modality treatment consisting of accelerated hyperfractionated radiotherapy and chemotherapy turned out to be feasible for patients with locally advanced, irresectable pancreatic cancer. The therapy could be applied in a short period of time, approximately half the time used in conventional therapy schemes.

Clinical relevance of serological markers in the detection and follow-up of pancreatic adenocarcinoma

Pancreatic adenocarcinoma is a relatively common malignancy and its incidence is increasing. Prognosis in these patients is poor, and surgery, the only effective treatment, saves only a minority of patients. The number in this small group of patients might be increased by early detection of pancreatic tumours. This review examines the current status of pancreatic tumour associated proteins in the detection of pancreatic cancer. As well as existing markers, the review also reports on newer markers that may offer advantages over existing ones in the detection of pancreatic adenocarcinoma. This is particularly important because recent studies have identified high-risk groups susceptible to pancreatic cancer. Future research in pancreatic cancer should be directed at earlier detection, and tumour markers may play an important role in this process.

Staging of carcinoma of the pancreas and ampulla of Vater. Tumor (T), lymph node (N), and distant metastasis (M) as prognostic factors

Between 1984 and 1987, 472 Norwegian patients with histologically or cytologically verified carcinoma of the pancreas (N = 442) and ampulla of Vater (N = 30) were accrued and TNM staged according to UICC. The influence of the T, N, and M categories on long-term survival was evaluated. The T1a and T1b tumors of stage I pancreatic carcinoma had a comparable survival (p = 0.68-0.95). A higher T category (T1-T3) predicted a more dismal prognosis (p = 0.000). The T1 and T2 carcinomas of the ampulla of Vater had a comparable favorable prognosis, and the T3 and T4 tumors had a comparable unfavorable prognosis. The N1 vs N0 (p = 0.000-0.01) and M1 vs M0 categories (p = 0.00-0.003) predicted a more dismal prognosis for both pancreatic and ampullary carcinoma. By logistic regression analyses, pancreatic tumor extension into peripancreatic fat or nerves and invasion of ampullary carcinomas into duodenal wall, unfavorably influenced the N1 category (p = 0.000-0.04) and tumor diameter influenced the M1 category (p = 0.002-0.04) both for pancreatic and ampullary carcinoma. The T, N, and M categories all independently influenced survival of pancreatic carcinoma (p = 0.000-0.003). Only the N category (p = 0.01) influenced the prognosis of ampullary carcinomas.

Digestive and nutritional consequences of pancreatic resections. The classical vs the pylorus-sparing procedure

Digestive and nutritional alterations are a common occurrence after pancreatic resections. The authors report the results of a multiparametric evaluation performed in a group of 26 patients submitted to total or cephalic pancreatectomy. Patients were divided into two groups according to the surgical procedure; group A (n = 13) included gastroresected patients and group B (n = 13) included those submitted to pylorus-sparing pancreatic resection. Subclinical digestive and absorptive impairment has been found in 61.5% of group A patients; the nutritional status was clinically poor in four cases from the same group. Digestive alterations have also been found in 69.2% of group B cases, but nutritional status was always satisfactory in the whole group. The more positive results obtained with the pylorus-sparing technique encourage wider adoption of this procedure.

Overexpression of HER2/neu oncogene in pancreatic cancer correlates with shortened survival

For the purpose of determining the prognostic significance of HER2/neu oncogene in pancreatic and ampullary cancers, 21 pancreatic cancers of ductal origin and six cancers of the ampulla of Vater were studied immunohistochemically using the monoclonal antibody (MAb) CB11, specifically reactive with HER2/neu product. Staining of the epithelium of the normal duct and acini was negative or weakly positive. Moderately and strongly positive reactions indicated the overexpression of this gene, and were found in 10 of 21 (47.6%) pancreatic cancers of ductal origin and in 2 of 6 (33.3%) ampullary adenocarcinomas. Overexpression of HER2/neu was closely and inversely related to the survival of the patients with pancreatic cancer of ductal origin: 19.1 +/- 11.7 mo for those not overexpressing vs 7.3 +/- 3.8 mo for the overexpressors (p < 0.01). Among the pancreatic cancer group, 11 patients underwent cancer resection. The average survival for the 7 with nonoverexpressing cancer was 21.4 +/- 14.3 mo vs 10.5 +/- 3.6 mo for those with overexpressing tumor. Among those not undergoing resection, the average survival for the 4 with nonoverexpressing cancer was 15.0 +/- 3.8 mo as contrasted to 5.2 +/- 2.1 mo for the overexpressors (p < 0.01). Although the number of patients is small, these findings suggest that the overexpression of HER2/neu gene product may be frequently found in pancreatic cancer of ductal origin and may be one of the useful prognostic biomarkers for this cancer.

Long-term survival after resection for ductal adenocarcinoma of the pancreas. Is it really improving?

OBJECTIVE

The authors review their recent experience with resected pancreatic ductal adenocarcinoma.

SUMMARY BACKGROUND DATA

Ductal adenocarcinoma of the pancreas has traditionally had a 5-year survival rate less than 10% after curative resection. Recently, several groups have reported markedly improved 5-year survival rates (approaching 25%) for patients undergoing curative resection.

METHODS

Institutional experience with 186 consecutive patients (1981-1991) with pathologic diagnoses of ductal adenocarcinoma undergoing pancreatic resection was reviewed. Histologic specimens of all 3-year survivors (n = 31) were re-reviewed by two pathologists, one internal and one external; nonductal pancreatic cancers then were excluded.

RESULTS

After histologic re-review, 12 patients did not have ductal adenocarcinoma, leaving a total of 174 patients for analysis (102 men, 72 women; mean age 63 years, range 34-82 years). Mean follow-up was 22 months (range 4-109). Classical pancreaticoduodenectomy was performed in 71%, pylorus-preserving resection in 9%, and total pancreatectomy in 20%. Hospital mortality was 3%. Twenty-eight patients (16%) had macroscopically incomplete resections; 98 (56%) had lymph node metastases within the resected specimens, and 21 patients (12%) had extensive perineural invasion. Overall actuarial 5-year survival was 6.8%. Five-year survival was greater for node-negative versus node-positive patients (14% vs. 1%, p < 0.001), and for smaller (< 2 cm) versus larger tumors (20% vs. 1%, p < 0.001). The 5-year survival for the subset of patients with negative nodes and no perineural or duodenal invasion (69 patients) was 23% (p < 0.001). Mean survival of the 12 excluded patients was 53 +/- 7 months compared with 17.5 +/- 1 months in the 174 patients with ductal pancreatic cancer.

CONCLUSIONS

Five-year survival for patients undergoing pancreatic resection for lesions deemed to be clinically "curable" intraoperatively and histologically reviewed/confirmed to be ductal adenocarcinoma of the pancreas is approximately 7%. Survival is greater (23%) in the subset of patients with negative nodes and no duodenal or perineural invasions. Pathologic review of all patients with pancreatic ductal cancer adenocarcinoma is mandatory if survival data are to be meaningful.

Results of resection for cancer of the exocrine pancreas: a study from the French Association of Surgery

A multicentre retrospective study was carried out to analyse short- and long-term results of 787 pancreatic resections performed for cancer between 1982 and 1988. The postoperative mortality rate was 10 per cent and the morbidity rate 35 per cent. Age above 70 years and systemic organ failure independently influenced operative mortality. In patients surviving more than 30 days the median survival was 12.3 months and the actuarial survival rate at 5 years 12 per cent. The 5-year survival rate was lower for patients with lymph node involvement than for those without (4 versus 20 per cent, P = 0.001). The operative mortality rate was higher after total pancreatectomy than pancreatoduodenectomy (17 versus 8 per cent, P = 0.015). The median survival time and 5-year survival rate after total pancreatectomy and pancreatoduodenectomy were 11 versus 14 months and 3 versus 15 per cent respectively. Of the clinical and pathological factors studied, location of the tumour in the left pancreas was most strongly related to survival, with no survivors at 4 years. These results suggest that resection should be avoided in patients over 70 years old with systemic organ failure. Pancreatoduodenectomy remains the best procedure for resection, total pancreatectomy being performed only in patients with multifocal carcinoma or those in whom a safe pancreatic anastomosis cannot be constructed.

Prognostic significance of DNA ploidy in adenocarcinoma of the pancreas. A flow cytometric study of paraffin-embedded specimens

BACKGROUND

The prognostic significance of tumor DNA ploidy in patients with cancer of the pancreas has not been defined because conflicting results have been reported.

METHODS

DNA content was measured in 56 ductal adenocarcinomas of the pancreas. DNA ploidy status was evaluated by flow cytometry in nuclei isolated from paraffin-embedded tumor tissues.

RESULTS

An abnormal DNA stemline was observed in 27 (48%) patients. The percentage of aneuploid tumors was significantly increased in tumors classified as Stage III/IV (53%) compared with those classified as Stage I (22%). A borderline significant association existed between DNA ploidy and radicality of surgery (P = 0.08). The median survival of patients with diploid carcinomas was 6.9 months (standard error, +/- 0.9) in comparison to 4.5 +/- 1.2 months for patients with aneuploid tumors (P = 0.013 by generalized Wilcoxon test; P = 0.023 by generalized Savage test). Although a selection bias cannot be excluded, survival of patients with a radical resection was longer than that of patients with a nonradical resection (P = 0.0008 and P = 0.0085, respectively). In addition, presence of distant metastasis (P = 0.0006 [Wilcoxon test] and P = 0.033 [Savage test]) could be identified as a prognostic factor. In a Cox regression model, results of surgery and DNA ploidy were independent prognostic variables.

CONCLUSIONS

Because DNA ploidy has a significant impact on prognosis in pancreatic cancer, it should be used as a variable for stratified randomization of patients in therapeutic trials.

Ductal adenocarcinoma of the pancreas. Histopathological features and prognosis

Between 1972 and 1987, curative surgical resection (RO) was performed in 81 patients with ductal adenocarcinoma of the pancreas. In this study, slides from surgical specimens were reviewed, and histopathological features of the carcinomas were retrospectively reevaluated. Tumor stage was the most important prognostic factor: In UICC stages I, II, and III, the median survival times were 13, 16, and 8 mo, respectively. Lymph node involvement and direct extension of the tumor into adjacent peripancreatic tissue, as well as invasion into peripancreatic organs were found to significantly influence survival. Tumor infiltration of the lymphatic vessels was present in 74% of the resected carcinomas and significantly correlated with survival time. There was no relationship between survival and tumor size; furthermore, histological grade of differentiation, age, and sex had no influence on prognosis.

Carcinoma of the pancreas and papilla of Vater: presenting symptoms, signs, and diagnosis related to stage and tumour site. A prospective multicentre trial in 472 patients. Norwegian Pancreatic Cancer Trial

During the period 1984-87, 472 patients with histologically or cytologically verified carcinoma of the pancreas (n = 442) or the papilla of Vater (n = 30) were accrued. Diagnostic investigations were performed in accordance with the ordinary routines of 38 Norwegian hospitals. Jaundice at presentation, found in 47% of the patients, indicated a relatively low staging. Abdominal pain or weight loss, present in 72% and 58%, respectively, indicated higher staging. The sensitivities of the diagnostic investigations were 1) endoscopic retrograde cholangiopancreatography (ERCP), 79%, and computed tomography (CT), 75%; 2) ultrasonography (US), 57%; angiography performed in 18% to assess unresectability, sensitivity, 43%; fine-needle aspiration cytology performed in 27%, sensitivity, 86%; and percutaneous transhepatic cholangiography (PTC) performed solely on papillar and head tumours in 16%, sensitivity, 85%. In stage I, PTC and ERCP had a sensitivity of 78%; CT, 52%; and US, 40%. Patient's, physician's, and diagnostic delay averaged 1.8, 2.4, and 4.0 months, respectively. The delays were shortest in stage I and papillar carcinomas.

DNA ploidy, S-phase fraction, and G2 fraction as prognostic determinants in human pancreatic cancer

The DNA ploidy, S-phase fraction (SPF), and G2 fraction of pancreatic cancer tissue was measured by flow cytometry in 95 patients. Forty-nine per cent (n = 47) had a diploid DNA index, and 51% (n = 48) of tumours were aneuploid. Aneuploid tumours and high-grade tumours had significantly higher S-phase and G2-fraction values than diploid tumours or low-grade tumours. Diploid and tetraploid tumours had a more favourable prognosis than non-tetraploid aneuploid tumours (p = 0.0020) during the mean follow-up of 6 years. The type of therapy (p = 0.07), histologic grade (p = 0.06), SPF (p = 0.1), and G2 fraction (p = 0.02) had predictive value in survival analysis as well. In multivariate survival analysis, including flow-cytometric, histologic, and clinical variables, diploidy and tetraploidy had independent predictive value. The results suggest that flow cytometry might be used in grading of pancreatic cancer. Such a grading would have practical value if new modes of therapy are being developed. Forty-one per cent of multiple samples had a heterogeneous DNA index when multiple samples were used. Consequently, flow cytometric analysis of pancreatic cancer using multiple samples is recommended.

Interstitial brachytherapy for pancreatic cancer: report of seven cases treated with 125I and a review of the literature

Since 1975, seven groups of investigators have reported clinical results of interstitial brachytherapy (IBT) for pancreatic cancer. The reports are comprised of data from 254 patients, 21 of whom died in the postoperative period for an overall operative mortality rate of 8.7%. Operative mortality rate range from 0% to 32% in individual reports. Most patients have been treated with 125I, although 25 patients were treated with 198Au seeds. Most investigators report combining IBT with external beam radiation therapy (EBRT) +/- adjuvant chemotherapy. In general, IBT has been associated with considerable morbidity. Median patient survival time has not exceeded 15 months. This report describes an additional seven patients with locally unresectable pancreatic cancer, without distant metastases, treated primarily with 60 to 100 Gy matched peripheral dose (MPD) by 125I IBT. One patient died postoperatively of a pulmonary embolus. Four of the remaining six patients were also treated with modest doses (10.5 to 30 Gy) of EBRT late in the course of the disease for local tumor progression. One developed a pancreaticocutaneous fistula, and one developed exacerbation of pre-existing diabetes mellitus. The median patient survival time from the date of IBT was 7 months (range: 0 to 21 months). One patient is alive without clinical evidence of cancer 9 months after IBT.

Prognostic factors in human pancreatic cancer, with special reference to quantitative histology

A retrospective clinicopathologic study was done on 111 patients with a pancreatic ductal adenocarcinoma. The mean follow-up period was 6 years. By means of interactive morphometry six nuclear morphometric features were measured in biopsy specimens from the primary tumours. Volume-corrected mitotic index (M/V index) was estimated in the same sections. Histologic grading was done in accordance with the WHO. The M/V index (p = 0.002), the nuclear area of the 10 largest nuclei (NA10) (p = 0.025), the histologic grade (p = 0.0956), the nuclear area (NA) (p = 0.038), the standard deviation of the nuclear perimeter (SDPE) (p = 0.033), and the standard deviation of the nuclear area (SDNA) (p = 0.0430) predicted survival in univariate analysis. The type of surgery performed was a significant prognosticator too (p = 0.0131). A multifactor regression analysis of survival including clinical and histologic factors identified the M/V index as the most important prognosticator (p = 0.009), followed by the type of surgery performed (p = 0.022). Other histologic factors had no independent prognostic value. Our results suggest the use of morphometric features instead of the conventional histologic grading in predicting survival of pancreatic ductal adenocarcinoma.

Patterns of growth and metastases of induced pancreatic cancer in relation to the prognosis and its clinical implications

To understand high malignancy of pancreatic cancer, the growth and metastatic patterns of pancreatic cancer induced in Syrian hamsters were examined. In this model, induced tumors resemble the human disease morphologically, clinically, biologically, and immunologically. In the current study, primary-induced cancer and transplants of pancreatic cancer cell line (PC-1) into the SC tissue or pancreas of homologous hosts were used. In the primary-induced pancreatic cancer, perineural invasion was the most common path (88%), followed by lymphogenic (31%) or vascular (2%) metastases. Inoculation of PC-1 cells into the pancreas resulted in 100% tumor take within 3 weeks. Of 19 intrapancreatic allografts, all showed peritoneal invasion, 5 (26%) liver metastases, 3 (16%) lymph node metastases, 17 (89%) perineural invasion, and none vascular invasion. Even microscopic tumors were found to metastasize primarily via perineural spaces. It was also demonstrated, for the first time, that cancer cells take this route to reach distant tissues, including the lymph nodes. Intraductal spreading occurred in both primary cancers and intrapancreatic allografts either continuously or discontinuously. The patterns of discontinuous intraductal tumor expansion imitated tumor multicentricity. Although perineural invasion was the most common feature of primary cancer and intrapancreatic allografts, lymphatic, hepatic, and vascular invasion and metastases usually occurred in advanced cases. Environmental factors seem to influence expansion and metastases, as evidenced by differences in growth and in metastatic patterns between SC and intrapancreatic allografts.

Implications of peritoneal cytology for staging of early pancreatic cancer

Cytologic examination of peritoneal washings was performed in 40 patients with pancreatic ductal adenocarcinoma (35 head, 5 body) whose tumors had been selected as potentially resectable by computed tomographic (CT) findings. Saline (100 mL) was instilled and aspirated at laparoscopy in 27 patients and at laparotomy in 13. Malignant cells were found in the peritoneal washings in 12 of 40 patients (30%): 29% in cancers of the pancreatic head versus 40% in the body; 33% at laparoscopy versus 23% at laparotomy; and in 4 of 8 patients with ascites versus 8 of 32 without ascites. The cytology was positive in 6 of 8 patients (75%) who had a prior percutaneous needle biopsy versus 6 of 32 (19%) of those who did not (p less than 0.01). Liver metastases were found in six patients, all with negative cytology. One of 10 pancreatic head cancers with positive cytology was resectable versus 13 of 25 with negative cytology (p less than 0.05). Survival was significantly longer in patients with negative cytology. We conclude that (1) pancreatic cancer sheds malignant cells into the peritoneum early and commonly; (2) laparoscopic lavage is an effective means of cytologic study; (3) ascites is not a precondition for cytologic study, nor does its presence necessarily imply carcinomatosis; (4) intraperitoneal spread of cancer cells may be promoted by tumor biopsy; (5) cytologic findings provide an additional index of resectability; and (6) cytologic findings appear to correlate with duration of survival. This study shows that even "localized" pancreatic cancer is often not contained and suggests caution with biopsy of potentially curable lesions.

DNA ploidy and cell-cycle analysis in pancreatic and ampullary carcinoma: flow cytometric study of formalin-fixed paraffin-embedded tissue

The cellular DNA content of formalin-fixed, paraffin-embedded specimens from 47 ductal adenocarcinomas of the pancreas and 5 adenocarcinomas of the ampulla of Vater was analysed using flow cytometry. Ploidy and the fraction of cells in the S and G2M phases were determined and correlated with tumour stage and grade as well as patients' survival. Cell populations with aneuploid DNA content were observed in 15% of the tumours. The S + G2M fractions ranged between 1% and 10%. Compared to non-neoplastic tissue of the pancreas the S + G2M fraction was significantly higher in the carcinomas. Cox regression analysis revealed the S + G2M fraction as an independent prognostic factor (p less than 0.05). Ploidy was of no prognostic value for survival, but correlated weakly with tumour stage and tumour grade. All patients without lymph node metastases at time of surgery had diploid tumours. Aneuploidy was restricted to tumours in advanced stages and tended to be more frequent in high-grade tumours.

Volume-corrected mitotic index in human pancreatic cancer. Relation to histologic grade, clinical stage, and prognosis

A retrospective study was performed on 59 pancreatic cancer patients diagnosed during 1970-1988. The mean follow-up time of all individual patients was 6.9 months (range, 0-37 months). Histologic grade, clinical stage (UICC), and volume-corrected mitotic index (M/V index) were correlated to the survival of patients. Histologic grade (p = 0.167) and clinical stage (p = 0.066) were not related to overall survival with statistical significance. The M/V index was significantly associated with overall survival (p = 0.004). M/V index (p = 0.004), clinical stage (p = 0.029), and histologic grade (p = 0.126) predicted survival at 1 year after diagnosis. M/V index divided grade-II tumors into two prognostically different groups (p = 0.050). Seven of 59 patients who survived more than 12 months had an M/V index less than 2, and patients who survived less than 6 months had significantly higher M/V index values (chi-square = 528.3, p less than 0.001). The metastasizing potential of pancreatic cancer and lymph node involvement was also associated with the M/V index. Histologic grade and M/V index were positively correlated (chi-square = 38.6, p less than 0.001, r = 0.702). On the basis of our results, it seems that the M/V index is better than histologic grade or clinical stage in predicting survival of pancreatic cancer patients. This result suggests the potential use of the M/V index in selecting patients for different modes of therapy.

Pancreatic resection for pancreatic cancer

In the majority of patients, pancreatic resection is performed for a proved carcinoma or for a mass in the pancreas with clinical features of carcinoma. Preoperative preparation is similar to that for other cancer operations, and good nutritional status and normal clotting factors are important. In many patients with resectable lesions, preoperative histologic diagnosis is not possible.

Pancreatic cancer in 1988. Possibilities and probabilities

Pancreatic adenocarcinoma is increasing in frequency, generally grows without symptoms until late in its natural history, and presents many discouraging unresolved problems in management. This review analyzes the status of current modalities of diagnosis, staging, and treatment. The limitations of those methods are defined, and possible improvements and new directions are suggested. A strategy for a rational and humane approach to pancreatic cancer is developed with the goal of maximizing quality as well as quantity of life.

Combined modality treatment of localized unresectable adenocarcinoma of the pancreas

Since 1978, 86 patients with unresectable localized adenocarcinoma of the pancreas have been treated with a combined modality program using radioactive iodine 125-Implantation, external beam radiation, and systemic chemotherapy. Three treatment approaches were used with sequential modifications of the technique based on the course of disease and patterns of failure. Group 1 was comprised of 13 patients treated with a combination of implantation followed by a planned external radiation dose of 5000 to 6000 cGy delivered in 6 weeks. Group 2 included patients treated as in Group 1 followed by adjuvant chemotherapy. The most recent group of 54 patients, Group 3, has been treated since 1981 with implantation into the tumor of radioactive Iodine 125 seeds (12000 cGy minimal peripheral dose), perioperative chemotherapy (5-FU, Mito-C), and external beam irradiation (5000-5500 cGy) followed by further chemotherapy. Incidence of perioperative mortality has been reduced from 31% (10/32) in Groups 1 & 2 to 7% (4/54) in Group 3. Clinical local control of tumor has been excellent in all three groups (84%). Analysis of the Group 3 results indicate that the problem of distant metastasis, in spite of adjuvant chemotherapy, still remains overwhelming (64%)--especially to the liver--and requires development of more effective regimens. Median survival in the three groups of patients is 5.5, 11.3, and 12.5 months. The 2-year survival is 0, 15, and 22%, retrospectively in the three groups.

[Perioperative staging and the Münster TNM classification in ampullary and pancreatic cancer]

From 1974 to 1982 607 patients with diseases of the pancreas were treated at the Surgical University Clinic of Münster/West Germany. 256 of those suffered from pancreatic and 42 from ampullary cancer. All patients were grouped according to a TNM-System for pancreatic cancer developed for that particular purpose. Of the curative resections performed (n = 73) with a resection rate of 78.6% for ampullary and 15.6% for pancreatic cancer, a distinct preponderance of early stages (T1N0M0/T2N0M0 greater than 60%) was noticed for the first, of late stages for the latter (T1N0M0/T2N0M0 = 25%). The frequencies of distant metastases for all operations also differed significantly, being 9.5% respectively 43.4% at the time of operation (p less than 0.05). At the low mean survival time for palliative operations an mean survival time of 40.3 months for the Whipple operation was evaluated, of 28.0 months for total pancreatectomy. At the stage T1N0M0/T2N0M0 the mean survival time was greater than 63 months.

Histological and fine structural features of pancreatic ductal adenocarcinomas in relation to growth and prognosis: studies in xenografted tumours and clinico-histopathological correlation in a series of 75 cases

Histology and fine structure of pancreatic ductal adenocarcinomas were assessed with respect to their significance for tumour growth and prognosis. The histological parameters included glandular differentiation, nuclear anaplasia, nuclear size, and mitotic activity (number of mitoses per high power field). Using these criteria three grades of malignancy were distinguished. They correlated well with the growth kinetics of seven human pancreatic ductal adenocarcinomas transplanted into nude mice. The tumour doubling time of a G 3 carcinoma was about half that of a G 1 carcinoma. On electron microscopy the tumour grade was reflected in the degree of functional differentiation of the neoplastic duct cells. In an additional clinicopathological evaluation of 75 patients operated upon for ductal adenocarcinoma of the pancreatic head, a positive relationship was found between grade and duration of symptoms until diagnosis. Moreover, the G 1 tumours showed generally a lower stage symptoms until diagnosis. Moreover, the G 1 tumours showed generally a lower stage at the time of surgery than G 2 and G 3 carcinomas. Finally, the median survival times correlated significantly with the tumour grade. From the various parameters used nuclear grade proved to be the most significant prognostic criterion, since a separate morphometric study revealed a very close correlation between median nuclear size of the tumours and survival time.

Combined modality treatment of pancreatic cancer: implications for the surgeon

Since pancreatic cancer is still increasing and has a poor prognosis, there is great interest in improving treatment results by combined modality approaches. This paper considers the most appropriate studies to analyze the status of treatment and future implications for surgeons. With new radiation sources and more sophisticated treatment plans, intra- and post-operative radiotherapy now has an established role in local tumor control. Combination chemotherapy has yielded response rates of 40-45% and improved chemotherapy will play a role in the treatment and perhaps in the prevention of disseminated disease. Although it seems likely that chemotherapy combined with newer radiotherapeutic technique could improve treatment results in advanced pancreatic cancer, treatment-related and limiting toxicity still must be defined. There are suggestions that more surgeons become involved in the combined modality approach, as both radiotherapy and chemotherapy may be more valuable in primary management. The unsatisfactory results of surgical treatment imply the need for adjuvant treatment, which must be tested in randomized multicenter trials. Future efforts will require an interdisciplinary approach to this disease.

Exocrine pancreatic tumours and their histological classification. A study based on 167 autopsy and 97 surgical cases

Based on histopathological examination of 264 exocrine pancreatic tumours (167 autopsy and 97 surgical) from the files of the Institute of Pathology, University of Hamburg, over a 15-yr period (1966-1980), a histogenetic classification is proposed. In addition to the more common neoplasms this also includes rarer and more recently defined entities. Of the 264 tumours, 250 were of duct origin, 10 acinar and four of uncertain histogenesis. Ductal adenocarcinoma, subdivided into a well-differentiated and a poorly-differentiated type, was most frequent (81.1%), followed by its variants: pleomorphic giant cell carcinoma 5.3%, adenosquamous carcinoma 3.8%, and mucinous carcinoma 1.1%. All these had a poor prognosis. Serous cystadenoma (1.1%), mucinous cystic tumour (1.5%) and intraductal papilloma (0.8%), which were rare tumours and mostly apparent in surgical material, proved to be benign or of only latent malignancy. The group of tumours of acinar cell origin consisted of the solid and cystic tumour (2.7%) with favourable prognosis and the acinar cell carcinoma (1.1%). No pancreatoblastoma was observed. The pleomorphic carcinomas of the small cell type (1.5%) were classed as tumours of uncertain histogenesis.

New surgical approaches to pancreatic cancer

Surgery as the best means to careful staging is stressed, in spite of many other methods of staging. Especially in those instances where resection is remotely possible it is proposed that, if possible, surgery should be done in centers specializing in this type of operation. A final opinion on the use of extended pancreatectomy awaits additional data. It is stressed that the surgeon should be fully aware of combined modality programs for treating pancreatic cancer and that new surgical techniques be considered as their proper employment demands. Finally, possible new techniques, such as intraoperative photoradiation using a laser and hematoporphyrin, intraoperative radiation therapy and heat, and the use of microwave-induced hyperthermia are discussed. The surgeon may well find that what is new in surgical treatment of cancer of the pancreas lies in a combined modality approach, primarily using intraoperative therapy.

Acinar cell cystadenocarcinoma of human pancreas

A 7000 g cystic tumor replacing the body and tail of the pancreas was resected in a 64-year-old man. Numerous peritoneal implants confirmed its malignant nature. Light microscopy of both the primary tumor and the implants revealed distinctive cytoplasmic eosinophilia and apical granules. Ultrastructural examination demonstrated numerous zymogen granules and abundant, rough endoplasmic reticulum, which confirmed that the tumor was composed of acinar cells. No mucinous or serous differentiation was detected. We have not found report of a similar tumor.