The use of intraoperative ultrasound for diagnosis and stadiation in pancreatic head neoformations. Int J Surg. 2015;21 Suppl 1:S55-S58. [PMID: 26118609 DOI: 10.1016/j.ijsu.2015.04.091]

Initial Application of Fluorescence Imaging for Intraoperative Localization of Small Neuroendocrine Tumors in the Pancreas: Case Report and Review of the Literature

BACKGROUND

Indocyanine green is commonly used for laparoscopic hepatectomy but remains uncommon in pancreatic surgery. Given the increasing number of small neuroendocrine tumors found in the pancreas and the heavy reliance on laparoscopic ultrasound for intraoperative localization, we attempted to use indocyanine green for these tumors. Our results show good localization and have the potential to provide a valuable clinical aid.

CASE PRESENTATION

This case report details five patients with preoperative diagnosis of pancreatic neuroendocrine tumors of small endocrine tumors, intraoperative successful localization, and successful completion of laparoscopic partial resection of pancreatic tumors by indocyanine green fluorescence staining; none of the patients experienced serious complications after surgery and were discharged from the hospital, and routine pathology confirmed that four cases were pancreatic neuroendocrine tumors of G1 stage, and one case was pancreatic neuroendocrine cell hyperplasia.

CONCLUSION

Fluorescence imaging technology safely aids in the intraoperative localization of small pancreatic neuroendocrine tumors.

Intraoperative Ultrasound During Surgical Exploration in Patients with Pancreatic Cancer and Vascular Involvement (ULTRAPANC): A Prospective Multicenter Study

BACKGROUND

Determining the resectability of pancreatic cancer with vascular involvement on preoperative computed tomography imaging remains challenging, especially following preoperative chemotherapy and chemoradiotherapy. Intraoperative ultrasound (IOUS) may provide real-time additional information, but prospective multicenter series confirming its value are lacking.

PATIENTS AND METHODS

This prospective multicenter study included patients undergoing surgical exploration for pancreatic cancer with vascular involvement. All patients underwent IOUS at the start of explorative laparotomy. Primary outcomes were resectability status as defined by the National Comprehensive Cancer Network and the extent of vascular involvement.

RESULTS

Overall, 85 patients were included, of whom 74 (87%) were post preoperative chemotherapy, and mostly following FOLFIRINOX regimen (n = 57; 76%). On the basis of preoperative imaging, 34 (40%) patients were staged as resectable (RPC), 32 (38%) borderline resectable (BRPC), and 19 (22%) locally advanced pancreatic cancer (LAPC). IOUS changed the resectability status in 32/85 (38%) patients (p < 0.001), including 8/19 (42%) patients with LAPC who were downstaged (4 to BRPC, 4 to RPC), and 22/32 (69%) patients with BRPC who were downstaged to RPC. Among patients with presumed superior mesenteric artery (SMA) involvement, 20/28 (71%) had no SMA involvement on IOUS. In 15 of these 20 patients a pancreatic resection was performed, all with R0 SMA margin.

CONCLUSION

IOUS during surgical exploration for pancreatic cancer and vascular involvement downstaged the resectability status in over one-third of patients, which could facilitate progress during surgical exploration. This finding should be confirmed by larger studies, including detailed pathology assessment. Trial Registration www.trialregister.nl (NL7621).

Highly Sensitive Exosome Detection for Early Diagnosis of Pancreatic Cancer Using Immunoassay Based on Hierarchical Surface-Enhanced Raman Scattering Substrate

Exosomes have emerged as potential biomarkers for pancreatic cancer (PaC). However, it is still challenging to get quantitative detection of exosomes with the specific surface receptors. In this study, a highly sensitive detection system is first constructed for the direct quantitation of specific exosomes in real samples using hierarchical surface-enhanced Raman scattering substrate (H-SERS substrate) and rapid enrichment strategy magnetic beads @ exosomes @ SERS detection probes (MEDP). It is found that the detection system (MEDP @ H-SERS substrate) could provide a 3.5 times higher SERS intensity compared with MEDP sandwich immunocomplex only. Moreover, LRG1-positive exosomes (LRG1-Exos) and GPC1-positive exosomes (GPC1-Exos) are chosen to distinguish PaC through exosome proteomics and database screening. The lower limit of detection (LOD) is 15 particles µL-1 using the MEDP @ H-SERS substrate. Significantly, the detection in clinical samples shows that the innovative combination of LRG1-Exos and GPC1-Exos could improve the diagnostic efficiency of PaC, with an area under the operating characteristic curve (AUC) of 0.95. Even for the early-stage PaC, the diagnostic accuracy is still high (AUC = 0.95). Collectively, the findings indicate that the MEDP @ H-SERS substrate has great potential for the early diagnosis of PaC.

Intraoperative contrast-enhanced ultrasound can have a crucial role in surgical decision-making during hepato-pancreatico-biliary surgery - Analysis of impact and input

OBJECTIVE

To assess the impact and procedural input of intraoperative ultrasound (IOUS) with contrast-enhanced ultrasound (CEUS) and ultrasound elastography on surgical decision making during the procedure and consequently the outcome after hepato-pancreatico-biliary (HPB) surgery.

MATERIALS AND METHODS

Data of 50 consecutive patients, who underwent HPB surgery from 04/2018 to 07/2018 were prospectively collected for this study. During surgery, IOUS with a high-resolution ultrasound device using CEUS after bolus injection of 2.4-5 ml dulphur hexafluoride microbubbles using a 6-9 MHz probe and a share wave and strain elastography was performed by an experienced examiner. Process and time analysis were carried out using mobile phone timer.

RESULTS

The IOUS with CEUS and elastography correctly identified 42 malignant tumors and 4 benign lesions. In 3 cases, the examination provided false positive result (identifying 3 benign lesions as malignant) and in 1 case a malignant lesion was incorrectly assessed as benign (sensitivity 97,7%, specificity 57,1%, PPV 93,3% and NPV 80%).The specific question by the surgeon could be answered successfully in 98% of the cases. In 76% of the cases, there was a modification (42%) or a fundamental change (34%) of the planned surgical approach due to the information provided by the IOUS. Within the last group, the IOUS had a major impact on therapy outcome. In 7 patients an additional tumor resection was required, in 5 patients the tumor was assessed as inoperable, and in total in 5 patients an intraoperative RFA (4/5) or postoperative RITA (1/5) was required.Regarding procedural input, there was only a slight, but significant difference between the transport and set-up times before the intraoperative use (mean: 14 min 22 s) and the return transport (mean 13 min 6 s), (p = 0,038). The average examination time was 14 minutes, which makes only one third of the overall time demand.

CONCLUSION

Combination of IOUS with CEUS and elastography in oncological HPB surgery provides valuable information that affects surgical decision-making. The procedural input of about 45 minutes seems to be a good investment considering the improvement of the surgical procedure and a significant modification of the therapy approach in the majority of the cases.

Current controversies and advances in the management of pancreatic adenocarcinoma

Pancreatic adenocarcinoma is a lethal disease with a mortality rate that has not significantly improved over decades. This is likely due to several challenges unique to pancreatic cancer. Most patients with pancreatic cancer are diagnosed at a late stage of disease due to the lack of specific symptoms prompting an early investigation. A small subset of patients who are diagnosed at an early stage have a better chance at survival with curative surgical resection, but most patients still succumb to the disease in a few years. The dismal overall prognosis is due to suspected micro-metastasis at an early stage. Due to this reason, there is a recent interest in treating all patients with pancreatic cancers with systemic therapy upfront (including the ones that are surgically resectable). This approach is still not the standard of care due to the lack of robust prospective data available. Recent advancements in treatment regimens of chemotherapy, radiation and immunotherapy have improved the overall short-term survival but the long-term survival still remains poor. Novel approaches in diagnosis and treatment have shown promise in clinical studies but long-term clinical data is lacking. The following manuscript presents an overview of the epidemiology, diagnosis, staging, recent advances, novel approaches and controversies in the management of pancreatic adenocarcinoma.

A Prospective Clinical Trial to Determine the Effect of Intraoperative Ultrasound on Surgical Strategy and Resection Outcome in Patients with Pancreatic Cancer

Surgical exploration in patients with pancreatic or periampullary cancer is often performed without intraoperative image guidance. Although intraoperative ultrasound (IOUS) may enhance visualization during resection, this tool has not been investigated in detail until now. Here, we performed a prospective cohort study to evaluate the effect of IOUS on surgical strategy and to evaluate whether vascular involvement and radicality of the resection could be correctly assessed with IOUS. IOUS was performed by an experienced abdominal radiologist during surgical exploration in 31 consecutive procedures. IOUS affected surgical strategy by either (i) having no effect, (ii) determining tumor localization, (iii) evaluating vascular involvement or (iv) waiving surgery. Radicality of the resections and vascular contact were determined during pathologic analysis and compared with preoperative imaging and IOUS findings. Overall, IOUS influenced surgical strategy in 61% of procedures. In 21 out of 27 malignant tumors, a radical resection was achieved (78%). Vascular contact was assessed correctly using IOUS in 89% compared with 74% of patients using preoperative imaging. IOUS can help the surgical team to assess the resectability and to visualize the tumor and possible vascular contact in real time during resection. IOUS may therefore increase the likelihood of achieving a radical resection.

Staging laparoscopy with ultrasound and near-infrared fluorescence imaging to detect occult metastases of pancreatic and periampullary cancer

Introduction

Up to 38% of pancreatic and periampullary cancer patients undergoing curative intended surgery turn out to have incurable disease. Therefore, staging laparoscopy (SL) prior to laparotomy is advised to spare patients the morbidity, inconvenience and expense of futile major surgery. The aim of this study was to assess the added value of SL with laparoscopic ultrasonography (LUS) and laparoscopic near-infrared fluorescence imaging (LFI).

Methods

All patients undergoing curative intended surgery of pancreatic or periampullary cancer were included prospectively in this single arm study. Patients received an intravenous infusion of 10 mg indocyanine green (ICG) one or two days prior to surgery to allow LFI. Suspect lesions were analyzed via biopsy or resection. Follow-up visits after surgery occurred every three months.

Results

A total of 25 patients were included. Suspect lesions were identified in 7 patients: liver metastases (n = 2; identified by inspection, LUS, and LFI), peritoneal metastases (n = 1; identified by inspection only), and benign lesions (n = 4; identified by inspection or LUS). Quality of LFI was good in 67% (10/15) of patients dosed one day and 89% (8/9) dosed two days prior to surgery. A futile laparotomy was averted in 3 patients (12%). Following SL the primary tumor was resected in 20 patients. Two patients (10%) developed metastases within 3 months after resection.

Conclusions

Despite current preoperative imaging modalities metastases are still identified during surgery. This study shows limited added value of LUS during SL in patients with pancreatic or periampullary cancer. LFI was of added value due to its high negative predictive value in case of suspect hepatic lesions identified by inspection.