Evolving preoperative evaluation of patients with pancreatic cancer: does laparoscopy have a role in the current era?

Radiologic Occult Metastases in Pancreatic Cancer: Analysis of Risk Factors and Survival Outcomes in the Age of Contemporary Neoadjuvant Multi-agent Chemotherapy

BACKGROUND

Radiologic occult metastatic disease (ROMD) in patients with pancreatic ductal adenocarcinoma (PDAC) who undergo contemporary neoadjuvant chemotherapy (NAC) has not been well studied. This study sought to analyze the incidence, risk factors, and oncologic outcomes for patients who underwent the NAC approach for PDAC.

METHODS

A retrospective review analyzed a prospectively maintained database of patients who had potentially resectable PDAC treated with NAC and were offered pancreatectomy at our institution from 2011 to 2022. Multivariable regression analysis was performed to assess risk factors associated with ROMD. Kaplan-Meier curves with log-rank analyses were generated to estimate time-to-event end points.

RESULTS

The study enrolled 366 patients. Upfront and borderline resectable anatomic staging comprised 80% of the cohort, whereas 20% had locally advanced disease. The most common NAC regimen was FOLFIRINOX (n = 274, 75%). For 55 patients (15%) who harbored ROMD, the most common site was liver-only metastases (n = 33, 60%). The independent risk factors for ROMD were increasing CA19-9 levels during NAC (odds ratio [OR], 7.01; confidence interval [CI], 1.97-24.96; p = 0.008), indeterminate liver lesions (OR, 2.19; CI, 1.09-4.39; p = 0.028), and enlarged para-aortic lymph nodes (OR, 6.87; CI, 2.07-22.74; p = 0.002) on preoperative cross-sectional imaging. Receipt of palliative chemotherapy (p < 0.001) and eventual formal pancreatectomy (p = 0.04) were associated with survival benefit in the log-rank analysis. The median overall survival (OS) of the patients with ROMD was nearly 15 months from the initial diagnosis, with radiologic evidence of metastases occurring after a median of 2 months.

CONCLUSIONS

Radiologic occult metastatic disease remains a clinical challenge associated with poor outcomes for patients who have PDAC treated with multi-agent NAC.

Socioeconomic and Geographic Disparities in the Referral and Treatment of Pancreatic Cancer at High-Volume Centers

Importance

Treatment at high-volume centers (HVCs) has been associated with improved overall survival (OS) in patients with pancreatic ductal adenocarcinoma (PDAC); however, it is unclear how patterns of referral affect these findings.

Objective

To understand the relative contributions of treatment site and selection bias in driving differences in outcomes in patients with PDAC and to characterize socioeconomic factors associated with referral to HVCs.

Design, Setting, Participants

A population-based retrospective review of the Oregon State Cancer Registry was performed from 1997 to 2019 with a median 4.3 months of follow-up. Study participants were all patients diagnosed with PDAC in Oregon from 1997 to 2018 (n = 8026).

Exposures

The primary exposures studied were diagnosis and treatment at HVCs (20 or more pancreatectomies for PDAC per year), low-volume centers ([LVCs] less than 20 per year), or both.

Main Outcomes and Measures

OS and treatment patterns (eg, receipt of chemotherapy and primary site surgery) were evaluated with Kaplan-Meier analysis and logistic regression, respectively.

Results

Eight thousand twenty-six patients (male, 4142 [52%]; mean age, 71 years) were identified (n = 3419 locoregional, n = 4607 metastatic). Patients receiving first-course treatment at a combination of HVCs and LVCs demonstrated improved median OS for locoregional and metastatic disease (16.6 [95% CI, 15.3-17.9] and 6.1 [95% CI, 4.9-7.3] months, respectively) vs patients receiving HVC only (11.5 [95% CI, 10.7-12.3] and 3.9 [95% CI, 3.5-4.3] months, respectively) or LVC-only treatment (8.2 [95% CI, 7.7-8.7] and 2.1 [95% CI, 1.9-2.3] months, respectively; all P < .001). No differences existed in disease burden by volume status of diagnosing institution. When stratifying by site of diagnosis, HVC-associated improvements in median OS were smaller (locoregional: 10.4 [95% CI, 9.5-11.2] vs 9.9 [95% CI, 9.4-10.4] months; P = .03; metastatic: 3.6 vs 2.7 months, P < .001) than when stratifying by the volume status of treating centers, indicating selection bias during referral. A total of 94% (n = 1103) of patients diagnosed at an HVC received HVC treatment vs 18% (n = 985) of LVC diagnoses. Among patients diagnosed at LVCs, later year of diagnosis and higher estimated income were independently associated with higher odds of subsequent HVC treatment, while older age, metastatic disease, and farther distance from HVC were independently associated with lower odds.

Conclusions and Relevance

LVC-to-HVC referrals for PDAC experienced improved OS vs HVC- or LVC-only care. While disease-related features prompting referral may partially account for this finding, socioeconomic and geographic disparities in referral worsen OS for disadvantaged patients. Measures to improve access to HVCs are encouraged.

A Consensus Meeting on Expert Recommendations on Operating Specifications for Laparoscopic Radical Resection of Hilar Cholangiocarcinoma

Background: With advances in techniques and technologies, laparoscopic radical resection of hilar cholangiocarcinoma (HCCA) has gradually been carried out in major medical centers in China. Its feasibility and safety have been accepted by a group of Chinese surgical experts. Methods: To standardize perioperative management of HCCA by using laparoscopic resectional approach, to ensure safety of the patient with standardized management, improve prognosis of the patient, and enable proper application and refinement of this surgical approach, the expert group on specifications for laparoscopic radical resection of HCCA in China organized a consensus meeting. Results: Laparoscopic radical resection of HCCA is difficult and associated with high risks. Appropriate patients should be carefully selected and this surgical approach should be promoted gradually. The experts met and arrived at 16 recommendations on perioperative management of HCCA by using laparoscopic surgery. There were three recommendations on preoperative diagnosis and evaluation; one recommendation on surgical principles of treatment; one recommendation on indications and contraindications; one recommendation on credentialing, staffing, and equipment; nine recommendations on laparoscopic techniques in different stages of operation; and one recommendation on indications for conversion to open surgery. Conclusion: Laparoscopic surgery for HCCA is still in the early phase of development. This consensus provides a clinical reference with the aim to promote and to facilitate its further development.

Pancreatic cancer in 2021: What you need to know to win

Pancreatic cancer is one of the solid tumors with the worst prognosis. Five-year survival rate is less than 10%. Surgical resection is the only potentially curative treatment, but the tumor is often diagnosed at an advanced stage of the disease and surgery could be performed in a very limited number of patients. Moreover, surgery is still associated with high post-operative morbidity, while other therapies still offer very disappointing results. This article reviews every aspect of pancreatic cancer, focusing on the elements that can improve prognosis. It was written with the aim of describing everything you need to know in 2021 in order to face this difficult challenge.

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.

Determining the CA19-9 concentration that best predicts the presence of CT-occult unresectable features in patients with pancreatic cancer: A population-based analysis

BACKGROUND

Serum CA19-9 concentration may be useful in triaging patients with pancreatic cancer for more intensive staging investigations. Our aim was to identify the CA19-9 cut-point with the greatest accuracy for detecting unresectable features not identified by CT scan, and to examine the performance of this and other cut-points in predicting the outcome of staging laparoscopy (SL).

METHODS

Patients with pancreatic cancer were drawn from two state-wide cancer registries between 2009 and 2011. We used classification and regression tree (CART) analysis to identify the CA19-9 cut-point which best predicted the presence of imaging-occult unresectable features, and compared its performance with that of a number of alternative cut-points. We then used logistic regression to test the association between CA19-9 concentration and detection of unresectable features in patients who underwent SL.

RESULTS

From the CART analysis, the optimal CA19-9 cut-point was 440 U/mL. CA19-9 ≥ 150 U/mL had a similar Youden Index, but greater sensitivity (69% versus 47%). This remained true for those who had obstructive jaundice at the time of CA19-9 sampling. CA19-9 concentration greater than or equal to 110 U/mL, 150 U/mL and 200 U/mL was associated with significantly greater odds of unresectable features being detected during SL.

CONCLUSION

Elevated serum CA19-9 concentration is a valid marker for CT-occult unresectable features; the most clinically appropriate cut-point appears to be ≥ 150 U/mL irrespective of the presence of jaundice. Clinical trials which evaluate the value of CA19-9 in the staging algorithm for pancreatic cancer are needed before it is routinely used in clinical practice.

Preoperative prediction of futile surgery in patients with radiologically resectable or borderline resectable pancreatic adenocarcinoma

BACKGROUND AND AIM

The aim of this study is to identify the predictive factors for futile surgery in patients with radiologically resectable or borderline resectable pancreatic cancer and to develop a prediction model.

METHODS

This retrospective study included patients who underwent pancreatic surgery for pancreatic cancer between 2006 and 2017. To identify independent risk factors for futile surgery, logistic regression and random forest analyses were performed in the training cohort, based on which a nomogram was established. The predictive accuracy and discriminative ability of the nomogram were validated in the validation cohort.

RESULTS

Of 389 patients who underwent pancreatic surgery, the laparotomy was futile in 40 patients (10.3%). In the training cohort, the univariate and multivariate logistic regression analyses revealed that serum carbohydrate antigen 19-9 level of ≥ 150 U/mL (P = 0.003), the presence of suspicious lymph node (P = 0.013), and more extensive peripancreatic tumor infiltration (P < 0.001) were independent predictive factors for futile surgery. The bootstrap-corrected concordance index of the nomogram was high in the training cohort, 0.826 with a 95% confidence interval of 0.745-0.907. This model also showed a good discriminative performance in the validation cohort, with a concordance index of 0.831.

CONCLUSIONS

We established and validated a novel nomogram that predicts the risk of futile surgery due to occult distant metastasis in patients with radiologically resectable or borderline resectable pancreatic cancer.

Opportunity Lost? Diagnostic Laparoscopy in Patients with Pancreatic Cancer in the National Surgical Quality Improvement Program Database

BACKGROUND

Routine preoperative staging in pancreas cancer is controversial. We sought to evaluate the rates of diagnostic laparoscopy (DLAP) for pancreatic cancer.

METHODS

We queried the National Surgical Quality Improvement Program for patients with pancreas cancer (2005-2013) and compared groups who underwent DLAP, exploratory laparotomy (XLAP), pancreas resection (RSXN) or therapeutic bypass (THBP). We compared demographics, comorbidities, postoperative complications, 30-day mortality (Chi-square P < 0.05) and trends over time (R² 0-1).

RESULTS

We identified 17,138 patients (RSXN 81.8%, XLAP 16.5%, THBP 8.2%, and DLAP 12.9%), with some having multiple CPT codes. Only 10.3% (n = 1432) of RSXN patients underwent DLAP prior to resection. XLAP occurred in 49.5% of non-RSXN patients, of whom 67.1% had no other operation. The percentage of patients undergoing RSXN increased 20.3% over time (R² 0.81), while DLAP decreased 52.6% (R² 0.92). XLAP patients without other operations decreased from 4.2 to 2.4%, although not linearly (R² 0.31). Only 10.3% of XLAP had a diagnostic laparoscopy as well, leaving nearly 90% of these patients with an exploratory laparotomy without RSXN or THBP.

DISCUSSION

Diagnostic laparoscopy for pancreas malignancy is becoming less common but could benefit a subset of patients who undergo open exploration without resection or therapeutic bypass.

Palliative therapy in pancreatic cancer-palliative surgery

Pancreatic cancer is a highly lethal disease with a dismal prognosis. It will probably become the second leading cause of cancer-related death within the next decade in Western countries. Over 80% of patients undergo palliative treatment for unresectable pancreatic cancer due to locally advanced disease or metastases. Those patients often develop gastric outlet obstruction (GOO), obstructive jaundice and pain during the course of their disease. Symptoms such as vomiting, anorexia, pruritus and jaundice will impact the quality of life (QOL) and could delay the administration of the chemotherapy. Palliative therapy in pancreatic cancer aims to relieve the symptoms durably and to improve the QOL. Palliative surgery was traditionally considered as a gold standard with the "double by-pass" including biliary-digestive and gastro-jejunal anastomosis. However, since the development of endoscopic stenting and minimally invasive surgery, the choice of the best modalities remains debated. While there is still a place for surgical gastrojejunostomy (GJ) in case of duodenal or GOO, endoscopic biliary stenting during endoscopic retrograde cholangiopancreatography (ERCP) is now accepted as the gold standard in case of obstructive jaundice. In pain management, endoscopic ultrasound guided or percutaneous celiac plexus neurolysis is recommended. The selection of the best technique should consider the effectiveness and the morbidity of the treatment, the performance status of the patient and the disease stage. While endoscopic stenting is associated with earlier recovery and shorter length of stay, recurrence of symptoms and reintervention are less frequent after palliative surgery. Finally, controversy exists on whether to perform prophylactic palliative surgery in the absence of symptoms when unresectable disease is discovered during surgical exploration.

Current role of palliative interventions in advanced pancreatic cancer

Pancreatic adenocarcinoma is the third leading cause of cancer death in the United States. Unfortunately, at diagnosis, most patients are not candidates for curative resection. Surgical palliation, a procedure performed with the intention of relieving symptoms or improving quality of life, comes to the forefront of management. This article reviews the palliative management of unresectable pancreatic cancer, including obstructive jaundice, duodenal obstruction and pain control with celiac plexus block. Although surgical bypasses for both biliary and duodenal obstructions usually achieve good technical success, they result in considerable perioperative morbidity and mortality, even when performed laparoscopically. The effectiveness of self-expanding metal stents for biliary drainage is excellent with low morbidity. Surgical gastrojejunostomy for duodenal obstruction appears to be best for patients with a life expectancy of greater than 2 mo while endoscopic stenting has been shown to be feasible with good symptom relief in those with a shorter life expectancy. Regardless of the palliative procedure performed, all physicians involved must be adequately trained in end of life management to ensure the best possible care for patients.

The development of fluorescence guided surgery for pancreatic cancer: from bench to clinic

INTRODUCTION

Surgeons face major challenges in achieving curative R0 resection for pancreatic cancers. When the lesion is localized, they must appropriately visualize the tumor, determine appropriate resection margins, and ensure complete tumor clearance. Real-time surgical navigation using fluorescence-guidance has enhanced the ability of surgeons to see the tumor and has the potential to assist in achieving more oncologically complete resections. When there is metastatic disease, fluorescence enhancement can help detect these lesions and prevent unnecessary and futile surgeries. Areas covered: This article reviews different approaches for delivery of a fluorescence signal, their pre-clinical and clinical developments for fluorescence guided surgery, the advantages/challenges of each, and their potential for advancements in the future. Expert commentary: A variety of molecular imaging techniques are available for delivering tumor-specific fluorescence signals. Significant advancements have been made in the past 10 years due to the large body of literature on targeted therapies and this has translated into rapid developments of tumor-specific probes.

Photodynamic diagnosis of peritoneal metastasis in human pancreatic cancer using 5-aminolevulinic acid during staging laparoscopy

Peritoneal metastasis is an important prognostic factor for pancreatic cancer. The present study evaluated the possibility of diagnosing peritoneal metastasis by a photodynamic diagnosis using 5-aminolevulinic acid (5-ALA-PDD). In vitro, protoporphyrin IX (PpIX) accumulation was examined in the AsPC-1-GFP cell line following 5-ALA hydrochloride administration. In vivo, AsPC-1-GFP cells were injected into the peritoneal cavities of mice. Three weeks later 5-ALA hydrochloride was intraperitoneally administered to the mice. The peritoneal nodules were observed under fluorescence excitation. A total of 34 patients were enrolled in the present study who were clinically diagnosed with pancreatic malignancy. 5-ALA hydrochloride was orally administered to the patients prior to surgery. During the operation the abdominal cavity was observed under white light and fluorescence. In vitro and in vivo, it was confirmed that PpIX-induced red fluorescence. In 9 patients peritoneal nodules suspected to be peritoneal metastasis were observed under white light. In 4 of the 9 patients nodules were detected on the basis of the fluorescence images. Fluorescent nodules were histopathologically diagnosed as metastatic. In the present study it was confirmed that 5-ALA-PDD holds promise for the rapid diagnosis of peritoneal metastasis in patients with pancreatic cancer.

Laparoscopic gastrojejunostomy for gastric outlet obstruction in patients with unresectable hepatopancreatobiliary cancers: A personal series and systematic review of the literature

The major symptoms of advanced hepatopancreatic-biliary cancer are biliary obstruction, pain and gastric outlet obstruction (GOO). For obstructive jaundice, surgical treatment should de consider in recurrent stent complications. The role of surgery for pain relief is marginal nowadays. On the last, there is no consensus for treatment of malignant GOO. Endoscopic duodenal stents are associated with shorter length of stay and faster relief to oral intake with more recurrent symptoms. Surgical gastrojejunostomy shows better long-term results and lower re-intervention rates, but there are limited data about laparoscopic approach. We performed a systematic review of the literature, according PRISMA guidelines, to search for articles on laparoscopic gastrojejunostomy for malignant GOO treatment. We also report our personal series, from 2009 to 2017. A review of the literature suggests that there is no standardized surgical technique either standardized outcomes to report. Most of the studies are case series, so level of evidence is low. Decision-making must consider medical condition, nutritional status, quality of life and life expectancy. Evaluation of the patient and multidisciplinary expertise are required to select appropriate approach. Given the limited studies and the difficulty to perform prospective controlled trials, no study can answer all the complexities of malignant GOO and more outcome data is needed.

Diagnostic accuracy of laparoscopy following computed tomography (CT) scanning for assessing the resectability with curative intent in pancreatic and periampullary cancer

BACKGROUND

Surgical resection is the only potentially curative treatment for pancreatic and periampullary cancer. A considerable proportion of patients undergo unnecessary laparotomy because of underestimation of the extent of the cancer on computed tomography (CT) scanning. Laparoscopy can detect metastases not visualised on CT scanning, enabling better assessment of the spread of cancer (staging of cancer). This is an update to a previous Cochrane Review published in 2013 evaluating the role of diagnostic laparoscopy in assessing the resectability with curative intent in people with pancreatic and periampullary cancer.

OBJECTIVES

To determine the diagnostic accuracy of diagnostic laparoscopy performed as an add-on test to CT scanning in the assessment of curative resectability in pancreatic and periampullary cancer.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed, EMBASE via OvidSP (from inception to 15 May 2016), and Science Citation Index Expanded (from 1980 to 15 May 2016).

SELECTION CRITERIA

We included diagnostic accuracy studies of diagnostic laparoscopy in people with potentially resectable pancreatic and periampullary cancer on CT scan, where confirmation of liver or peritoneal involvement was by histopathological examination of suspicious (liver or peritoneal) lesions obtained at diagnostic laparoscopy or laparotomy. We accepted any criteria of resectability used in the studies. We included studies irrespective of language, publication status, or study design (prospective or retrospective). We excluded case-control studies.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed data extraction and quality assessment using the QUADAS-2 tool. The specificity of diagnostic laparoscopy in all studies was 1 because there were no false positives since laparoscopy and the reference standard are one and the same if histological examination after diagnostic laparoscopy is positive. The sensitivities were therefore meta-analysed using a univariate random-effects logistic regression model. The probability of unresectability in people who had a negative laparoscopy (post-test probability for people with a negative test result) was calculated using the median probability of unresectability (pre-test probability) from the included studies, and the negative likelihood ratio derived from the model (specificity of 1 assumed). The difference between the pre-test and post-test probabilities gave the overall added value of diagnostic laparoscopy compared to the standard practice of CT scan staging alone.

MAIN RESULTS

We included 16 studies with a total of 1146 participants in the meta-analysis. Only one study including 52 participants had a low risk of bias and low applicability concern in the patient selection domain. The median pre-test probability of unresectable disease after CT scanning across studies was 41.4% (that is 41 out of 100 participants who had resectable cancer after CT scan were found to have unresectable disease on laparotomy). The summary sensitivity of diagnostic laparoscopy was 64.4% (95% confidence interval (CI) 50.1% to 76.6%). Assuming a pre-test probability of 41.4%, the post-test probability of unresectable disease for participants with a negative test result was 0.20 (95% CI 0.15 to 0.27). This indicates that if a person is said to have resectable disease after diagnostic laparoscopy and CT scan, there is a 20% probability that their cancer will be unresectable compared to a 41% probability for those receiving CT alone.A subgroup analysis of people with pancreatic cancer gave a summary sensitivity of 67.9% (95% CI 41.1% to 86.5%). The post-test probability of unresectable disease after being considered resectable on both CT and diagnostic laparoscopy was 18% compared to 40.0% for those receiving CT alone.

AUTHORS' CONCLUSIONS

Diagnostic laparoscopy may decrease the rate of unnecessary laparotomy in people with pancreatic and periampullary cancer found to have resectable disease on CT scan. On average, using diagnostic laparoscopy with biopsy and histopathological confirmation of suspicious lesions prior to laparotomy would avoid 21 unnecessary laparotomies in 100 people in whom resection of cancer with curative intent is planned.

A Pilot Study Evaluating Serum MMP7 as a Preoperative Prognostic Marker for Pancreatic Ductal Adenocarcinoma Patients

BACKGROUND

Current preoperative risk stratification modalities for pancreatic ductal adenocarcinoma (PDA) patients are inadequate. Elevated serum matrix metalloproteinase 7 (MMP7) is associated with metastatic PDA. We evaluated preoperative MMP7 level as a prognostic marker in patients with resectable PDA.

METHODS

From a prospectively maintained database, we identified PDA patients who underwent operation with curative intent from 2004 to 2008 and had serum collected preoperatively. MMP7 was measured by enzyme-linked immunosorbent assay. Patients were defined as having advanced disease if they were found to be unresectable at the time of operation or had nodal involvement on final pathology.

RESULTS

Preoperative serum samples were available for 134 patients. Using a cutoff of 13.5 ng/mL, MMP7 was highly predictive for advanced disease. For patients who underwent R0 resection, MMP7 > 13.5 ng/mL was strongly associated with N1 status, T3/T4 stage, moderate/poor differentiation, and perineural invasion. The median recurrence-free survival was 5.0 months in patients with MMP7 > 13.5 ng/mL versus 9.9 months for patients with lower values (P = 0.004).

CONCLUSIONS

Very elevated serum MMP7 was highly predictive of unresectable disease and nodal involvement despite favorable preoperative cross-sectional imaging. MMP7 should be further evaluated as a biomarker to risk-stratify PDA patients prior to operation.

Diagnostic Laparoscopy with Ultrasound Still Has a Role in the Staging of Pancreatic Cancer: A Systematic Review of the Literature

Background. The reported incidence of noncurative laparotomies for pancreatic cancer using standard imaging (SI) techniques for staging remains high. The objectives of this study are to determine the diagnostic accuracy of diagnostic laparoscopy with ultrasound (DLUS) in assessing resectability of pancreatic tumors. Study Design. We systematically searched the literature for prospective studies investigating the accuracy of DLUS in determining resectability of pancreatic tumors. Results. 104 studies were initially identified and 19 prospective studies (1,573 patients) were included. DLUS correctly predicted resectability in 79% compared to 55% for SI. DLUS prevented noncurative laparotomies in 33%. Of those, the most frequent DLUS findings precluding resection were liver metastases, vascular involvement, and peritoneal metastases. DLUS had a morbidity rate of 0.8% with no mortalities. DLUS remained superior to SI when analyzing studies published only in the last five years (100% versus 81%), enrolling patients after the year 2000 (74% versus 58%), or comparing DLUS to modern multidimensional CT (100% versus 78%). Conclusion. DLUS seems to still have a role in the preoperative staging of pancreatic cancer. With its ability to detect liver metastases, vascular involvement, and peritoneal metastases, the use of DLUS leads to less noncurative laparotomies.

A wait-and-see strategy with subsequent self-expanding metal stent on demand is superior to prophylactic bypass surgery for unresectable periampullary cancer

BACKGROUND

A patient with unresectable periampullary malignancy found at laparotomy has traditionally received a prophylactic double bypass (biliary and duodenal), associated with considerable morbidity. With modern endoscopic treatments, surgical bypass has become questionable. This study aims to compare the two strategies. Sahlgrenska University Hospital (SU) performs a double bypass (DoB) routinely, and Skåne University Hospital Lund (SUL) secures biliary drainage endoscopically and treats only symptomatic duodenal obstruction (Wait and See, WaS).

METHOD

Between 2004 and 2013, 73 patients from SU and 70 from SUL were retrospectively identified. Demographics, tumour-related factors and postoperative outcomes during the remaining lifetime were noted.

RESULTS

The DoB group had significantly more complications (67% vs. 31%, p = 0.00002) and longer hospital stay (14 vs. 8 days, p = 0.001) than the WaS-group. The two groups had similar proportion of patients in need of readmission. The DoB patients and the WaS patients with metallic biliary stents were comparable regarding their need of re-interventions and hospitalisation due to biliary obstruction. Surgical duodenal bypass did not prevent future duodenal obstructions.

CONCLUSION

Patients with unresectable periampullary malignancies can safely be managed with endoscopic drainage on demand and with lower morbidity and shorter hospital stay than with surgical prophylactic bypass.

miRNAs As Diagnostic and Prognostic Biomarkers in Pancreatic Ductal Adenocarcinoma and Its Precursor Lesions: A Review

Pancreatic ductal adenocarcinoma (PDAC), a rare but lethal tumor, is difficult to diagnose without performing an invasive procedure. miRNAs are known to be deregulated in PDAC patients, and recent studies have shown that they can be used as diagnostic and prognostic of the disease. The detection of miRNAs in samples acquired through minimally or noninvasive procedures, such as serum, plasma, and saliva, can have a positive impact on the clinical management of these patients. This article is a comprehensive review of the major studies that have evaluated the expression of miRNAs as biomarkers in pancreatic cancer and its premalignant lesions.

PET/CT Fusion Scan Prevents Futile Laparotomy in Early Stage Pancreatic Cancer

BACKGROUND

Surgical resection with negative margins is the only curative approach for pancreatic cancer. A paucity of data exists in using PET/CT scan as staging workup in resectable pancreatic cancer. The aim of this study is to determine if PET/CT prevents futile laparotomy by detecting occult metastatic disease in patients with resectable or borderline resectable pancreatic cancer.

METHODS

Patients were included using institutional PET/CT data base incorporating National Oncologic PET Registry with diagnosis of resectable or borderline resectable pancreatic cancer from 2005 to 2012. Clinical, radiographic, and pathologic characteristics were evaluated. The impact of PET/CT on patient management was estimated by calculating the percentage of patients whose treatment plan was altered secondary to PET/CT.

RESULTS

We identified 285 patients with early stage pancreatic cancer who received PET/CT as part of initial staging workup. Upon initial workup (CT + EUS), 62% of patients were considered resectable, and 38% were borderline resectable. Addition of PET/CT scan changed the management in 10.9% (n = 31) of the patients (95% CI, 8%-15%). Metastatic lesions were confirmed with biopsy in 19 patients (61%). The proportion of change in treatment plan was significantly higher in patients who were initially considered to have borderline resectable compared with resectable malignancy (17% vs 7%, P = 0.019). In 199 patients who underwent surgery, 18.1% (n = 36) were found to have metastatic disease intraoperatively.

CONCLUSIONS

PET/CT helped improve detection of occult metastases, ultimately sparing these patients a potentially unnecessary surgery. The role of PET/CT scan should be validated in prospective study.

A wait-and-see strategy with subsequent self-expanding metal stent on demand is superior to prophylactic bypass surgery for unresectable periampullary cancer

BACKGROUND

A patient with unresectable periampullary malignancy found at laparotomy has traditionally received a prophylactic double bypass (biliary and duodenal), associated with considerable morbidity. With modern endoscopic treatments, a surgical bypass has become questionable. This study aims to compare the two strategies. Sahlgrenska University Hospital (SU) performs a double bypass (DoB) routinely, and Skåne University Hospital Lund (SUL) secures biliary drainage endoscopically and treats only symptomatic duodenal obstruction (Wait and See, WaS).

METHOD

Between 2004 and 2013, 73 patients from SU and 70 from SUL were retrospectively identified. Demographics, tumour-related factors and post-operative outcomes during the remaining lifetime of the patients were noted.

RESULTS

The DoB group had significantly more complications (67% versus 31%, P = 0.00002) and a longer hospital stay (14 versus 8 days, P = 0.001) than the WaS group. The two groups had a similar proportion of patients in need of readmission. The DoB patients and the WaS patients with metallic biliary stents were comparable regarding their need of re-interventions and hospitalization as a result of biliary obstruction. A surgical duodenal bypass did not prevent future duodenal obstructions.

CONCLUSION

Patients with unresectable periampullary malignancies can safely be managed with endoscopic drainage on demand and with a lower morbidity and a shorter hospital stay than with a surgical prophylactic bypass.

Cost-effectiveness of diagnostic laparoscopy for assessing resectability in pancreatic and periampullary cancer

Background

Surgical resection is the only curative treatment for pancreatic and periampullary cancer, but many patients undergo unnecessary laparotomy because tumours can be understaged by computerised tomography (CT). A recent Cochrane review found diagnostic laparoscopy can decrease unnecessary laparotomy. We compared the cost-effectiveness of diagnostic laparoscopy prior to laparotomy versus direct laparotomy in patients with pancreatic and periampullary cancer with resectable disease based on CT scanning.

Method

Model based cost-utility analysis estimating mean costs and quality-adjusted life years (QALYs) per patient from the perspective of the UK National Health Service. A decision tree model was constructed using probabilities, outcomes and cost data from published sources. One-way and probabilistic sensitivity analyses were undertaken.

Results

When laparotomy following diagnostic laparoscopy occurred in a subsequent admission, diagnostic laparoscopy incurred similar mean costs per patient to direct laparotomy (£7470 versus £7480); diagnostic laparoscopy costs (£995) were offset by avoiding unnecessary laparotomy costs. Diagnostic laparoscopy produced significantly more mean QALYs per patient than direct laparotomy (0.346 versus 0.337). Results were sensitive to the accuracy of diagnostic laparoscopy and the probability that disease was unresectable. Diagnostic laparoscopy had 63 to 66% probability of being cost-effective at a maximum willingness to pay for a QALY of £20 000 to £30 000. When laparotomy was undertaken in the same admission as diagnostic laparoscopy the mean cost per patient of diagnostic laparoscopy increased to £8224.

Conclusions

Diagnostic laparoscopy prior to laparotomy in patients with CT-resectable cancer appears to be cost-effective in pancreatic cancer (but not in periampullary cancer), when laparotomy following diagnostic laparoscopy occurs in a subsequent admission.

Electronic supplementary material

The online version of this article (doi:10.1186/s12876-015-0270-x) contains supplementary material, which is available to authorized users.

Diagnostic laparoscopy should be performed before definitive resection for pancreatic cancer: a financial argument

OBJECTIVES

Laparoscopy is recommended to detect radiographically occult metastases in patients with pancreatic cancer before curative resection. This study was conducted to test the hypothesis that diagnostic laparoscopy (DL) is cost-effective in patients undergoing curative resection with or without neoadjuvant therapy (NAT).

METHODS

Decision tree modelling compared routine DL with exploratory laparotomy (ExLap) at the time of curative resection in resectable cancer treated with surgery first, (SF) and borderline resectable cancer treated with NAT. Costs (US$) from the payer's perspective, quality-adjusted life months (QALMs) and incremental cost-effectiveness ratios (ICERs) were calculated. Base case estimates and multi-way sensitivity analyses were performed. Willingness to pay (WtP) was US$4166/QALM (or US$50,000/quality-adjusted life year).

RESULTS

Base case costs were US$34,921 for ExLap and US$33,442 for DL in SF patients, and US$39,633 for ExLap and US$39,713 for DL in NAT patients. Routine DL is the dominant (preferred) strategy in both treatment types: it allows for cost reductions of US$10,695/QALM in SF and US$4158/QALM in NAT patients.

CONCLUSIONS

The present analysis supports the cost-effectiveness of routine DL before curative resection in pancreatic cancer patients treated with either SF or NAT.

McGill Brisbane Symptom Score for patients with resectable pancreatic head adenocarcinoma

AIM: To evaluate the ability of the McGill Brisbane Symptom Score (MBSS) to predict survival in resectable pancreatic head adenocarcinoma (PHA) patients.

METHODS: All PHA patients (n = 83) undergoing pancreaticoduodenectomy at the McGill University Health Center, Quebec between 1/2001-1/2010 were evaluated. Data related to patient and cancer characteristics, MBSS variables, and treatment were collected; univariable and multivariable survival analyses were performed. We obtained complete follow-up until February 2011 in all patients through the database of the provincial health insurance plan of Quebec. The unique health insurance numbers of these patients were used to retrieve information from this database which captures all billable clinical encounters, and ensures 100% actual survival data.

RESULTS: Median survival was 23 mo overall: 45 mo for patients with low MBSS, 17 mo for high MBSS (P = 0.005). At twelve months survival was 83.3% (95%CI: 66.6-92.1) vs 58.1% (95%CI: 42.1-71.2) in those with low vs high MBSS, and24 mo survival was 63.8% (95%CI: 45.9-77.1) and 34.0% (95%CI: 20.2-48.2) respectively. In the multivariate Cox model (stratified by chemotherapy), after addition of clinically meaningful covariates, MBSS was the variable with the strongest association with survival (HR = 2.63; P = 0.001). Adjuvant chemotherapy interacted with MBSS category such that only high MBSS patients accrued a benefit. In univariate analysis we found a lower mortality in high MBSS but not low MBSS patients receiving adjuvant chemotherapy. This interaction variable, on Cox model, resulted in an adjusted mortality HR for the high MBSS (compared to low MBSS) of 4.14 (95%CI: 1.48-11.64) without chemotherapy and 2.11 (95%CI: 1.06-4.17) with chemotherapy.

CONCLUSION: The MBSS is a simple prognostic tool for resectable PHA. Preoperative categorization of patients according to the MBSS allows effective stratification of patients to guide therapy.

Staging laparoscopy in pancreatic cancer: a potential role for advanced laparoscopic techniques

BACKGROUND

The role of staging laparoscopy in pancreatic cancer in the age of high-resolution CT scans is under debate. This study's aim is to evaluate the efficacy of staging laparoscopy in this disease.

STUDY DESIGN

A retrospective cohort study was conducted evaluating patients who underwent operative treatment for radiographic stage I to III pancreatic cancer between July 2003 and October 2012. Radiographic follow-up was 94% at 6 months.

RESULTS

Of 274 patients who met inclusion criteria, 136 underwent staging laparoscopy, which identified radiographic occult distant metastases in 2% (3 of 136). However, subsequent laparotomy identified an additional 9% (12 of 136) harboring distant metastases in regions not visualized on standard staging laparoscopy; specifically, the posterior liver surface, paraduodenal retroperitoneum, proximal jejunal mesentery, and lesser sac. The remaining 138 patients underwent initial staging laparotomy, which showed similar results identifying radiographic occult distant disease in 11% (15 of 138). Within 6 months after the operation, peritoneal or subcapsular liver metastases developed in an additional 6% (15 of 257)-disease that potentially could have been diagnosed at the time of operation-providing a false-negative rate of 88% for staging laparoscopy compared with 36% for staging laparotomy.

CONCLUSIONS

Despite the availability of high-resolution CT scans, occult distant metastases can still be found in 11% of patients during the operation. In the absence of reliable risk factors to predict distant metastases, staging laparoscopy should be offered to all patients with radiographic localized disease. However, the results favor extended laparoscopic staging with evaluation of the posterior liver surface, mobilization of the duodenum, evaluation of the proximal jejunal mesentery, and visualization of the lesser sac.

Diagnostic accuracy of laparoscopy following computed tomography (CT) scanning for assessing the resectability with curative intent in pancreatic and periampullary cancer

BACKGROUND

Surgical resection is the only potentially curative treatment for pancreatic and periampullary cancer. A considerable proportion of patients undergo unnecessary laparotomy because of underestimation of the extent of the cancer on computed tomography (CT) scanning. Laparoscopy can detect metastases not visualised on CT scanning, enabling better assessment of the spread of cancer (staging of cancer). There has been no systematic review or meta-analysis assessing the role of diagnostic laparoscopy in assessing the resectability with curative intent in patients with pancreatic and periampullary cancer.

OBJECTIVES

To determine the diagnostic accuracy of diagnostic laparoscopy performed as an add-on test to CT scanning in the assessment of curative resectability in pancreatic and periampullary cancer.

SEARCH METHODS

We searched the Cochrane Register of Diagnostic Test Accuracy Studies, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed, EMBASE via OvidSP (from inception to 13 September 2012), and Science Citation Index Expanded (from 1980 to 13 September 2012).

SELECTION CRITERIA

We included diagnostic accuracy studies of diagnostic laparoscopy in patients with potentially resectable pancreatic and periampullary cancer on CT scan, where confirmation of liver or peritoneal involvement was by histopathological examination of suspicious (liver or peritoneal) lesions obtained at diagnostic laparoscopy or laparotomy. We accepted any criteria of resectability used in the studies. We included studies irrespective of language, publication status, or study design (prospective or retrospective). We excluded case-control studies.

DATA COLLECTION AND ANALYSIS

Two authors independently performed data extraction and quality assessment using the QUADAS-2 tool. The specificity of diagnostic laparoscopy in all studies was 1 because there were no false positives since laparoscopy and the reference standard are one and the same if histological examination after diagnostic laparoscopy is positive. Therefore, the sensitivities were meta-analysed using a univariate random-effects logistic regression model. The probability of unresectability in patients who had a negative laparoscopy (post-test probability for patients with a negative test result) was calculated using the median probability of unresectability (pre-test probability) from the included studies and the negative likelihood ratio derived from the model (specificity of 1 assumed). The difference between the pre-test and post-test probabilities gave the overall added value of diagnostic laparoscopy compared to the standard practice of CT scan staging alone.

MAIN RESULTS

Fifteen studies with a total of 1015 patients were included in the meta-analysis. Only one study including 52 patients had a low risk of bias and low applicability concern in the patient selection domain. The median pre-test probability of unresectable disease after CT scanning across studies was 40.3% (that is 40 out of 100 patients who had resectable cancer after CT scan were found to have unresectable disease on laparotomy). The summary sensitivity of diagnostic laparoscopy was 68.7% (95% CI 54.3% to 80.2%). Assuming a pre-test probability of 40.3%, the post-test probability of unresectable disease for patients with a negative test result was 0.17 (95% CI 0.12 to 0.24). This indicates that if a patient is said to have resectable disease after diagnostic laparoscopy and CT scan, there is a 17% probability that their cancer will be unresectable compared to a 40% probability for those receiving CT alone.A subgroup analysis of patients with pancreatic cancer gave a summary sensitivity of 67.9% (95% CI 41.1% to 86.5%). The post-test probability of unresectable disease after being considered resectable on both CT and diagnostic laparoscopy was 18% compared to 40% for those receiving CT alone.

AUTHORS' CONCLUSIONS

Diagnostic laparoscopy may decrease the rate of unnecessary laparotomy in patients with pancreatic and periampullary cancer found to have resectable disease on CT scan. On average, using diagnostic laparoscopy with biopsy and histopathological confirmation of suspicious lesions prior to laparotomy would avoid 23 unnecessary laparotomies in 100 patients in whom resection of cancer with curative intent is planned.

Laparoscopic staging in hilar cholangiocarcinoma: Is it still justified?

Radical resection remains the only potential curative therapy for hilar cholangiocarcinoma (HCCA). The aim of staging laparoscopic (SL) is to identify patients with previously undetected advanced disease who will not benefit from surgical palliation and therefore avoid unnecessary laparotomies. The accuracy of non-invasive imaging techniques has significantly improved during the last years. As a consequence, the diagnostic yield of SL of biliary tract malignancy should have decreased proportionally. At the same time, some authors have recently questioned the value of laparoscopic ultrasound (LUS) as a complement of SL. In this setting, the precise role of SL and LUS in the preoperative workup of HCCA remains unclear. As it seems undoubtedly clear that its efficacy has decreased in the last decades, there is a general consensus that the universal use of SL shouldn't be recommended anymore; SL should be performed only in selected patients with higher risk of holding unresectable disease (T2/T3 or Bismuth type 3/4 and patients with suspicion of metastases). It would also be recommended in patients with potentially resectable disease who would need preoperative invasive procedures. Finally, SL should be performed preceding laparotomy in one session. Further studies on the benefit of SL and LUS in this subset of HCCA patients are warranted.

Somatostatin analogues for pancreatic surgery

BACKGROUND

Pancreatic resections are associated with high morbidity (30% to 60%) and mortality (5%). Synthetic analogues of somatostatin are advocated by some surgeons to reduce complications following pancreatic surgery; however, their use is controversial.

OBJECTIVES

To determine whether prophylactic somatostatin analogues should be used routinely in pancreatic surgery.

SEARCH METHODS

We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 1), MEDLINE, EMBASE and Science Citation Index Expanded to February 2013.

SELECTION CRITERIA

We included randomised controlled trials comparing prophylactic somatostatin or one of its analogues versus no drug or placebo during pancreatic surgery (irrespective of language or publication status).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and independently extracted data. We analysed data with both the fixed-effect and random-effects models using Review Manager (RevMan). We calculated the risk ratio (RR), mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals (CI) based on an intention-to-treat or available case analysis. When it was not possible to perform either of the above, we performed a per protocol analysis.

MAIN RESULTS

We identified 21 trials (19 trials of high risk of bias) involving 2348 people. There was no significant difference in the perioperative mortality (RR 0.80; 95% CI 0.56 to 1.16; n = 2210) or the number of people with drug-related adverse effects between the two groups (RR 2.09; 95% CI 0.83 to 5.24; n = 1199). Quality of life was not reported in any of the trials. The overall number of participants with postoperative complications was significantly lower in the somatostatin analogue group (RR 0.70; 95% CI 0.61 to 0.80; n = 1903) but there was no significant difference in the re-operation rate (RR 1.26; 95% CI 0.58 to 2.70; n = 687) or hospital stay (MD -1.29 days; 95% CI -2.60 to 0.03; n = 1314) between the groups. The incidence of pancreatic fistula was lower in the somatostatin analogue group (RR 0.66; 95% CI 0.55 to 0.79; n = 2206). The proportion of these fistulas that were clinically significant was not mentioned in most trials. On inclusion of trials that clearly distinguished clinically significant fistulas, there was no significant difference between the two groups (RR 0.69; 95% CI 0.38 to 1.28; n = 292).

AUTHORS' CONCLUSIONS

Somatostatin analogues may reduce perioperative complications but do not reduce perioperative mortality. Further adequately powered trials with low risk of bias are necessary. Based on the current available evidence, somatostatin and its analogues are recommended for routine use in people undergoing pancreatic resection.

Prophylactic gastrojejunostomy for unresectable periampullary carcinoma

BACKGROUND

The role of prophylactic gastrojejunostomy in patients with unresectable periampullary cancer is controversial.

OBJECTIVES

To determine whether prophylactic gastrojejunostomy should be performed routinely in patients with unresectable periampullary cancer.

SEARCH METHODS

For the initial version of this review, we searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, issue 3), MEDLINE, EMBASE and Science Citation Index Expanded until April 2010. Literature searches were re-run in August 2012.

SELECTION CRITERIA

We included randomised controlled trials comparing prophylactic gastrojejunostomy versus no gastrojejunostomy in patients with unresectable periampullary cancer (irrespective of language or publication status).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and independently extracted data. We analysed data with both the fixed-effect and the random-effects models using Review Manager (RevMan). We calculated the hazard ratio (HR), risk ratio (RR), and mean difference (MD) with 95% confidence intervals (CI) based on an intention-to-treat or available case analysis.

MAIN RESULTS

We identified two trials (of high risk of bias) involving 152 patients randomised to gastrojejunostomy (80 patients) and no gastrojejunostomy (72 patients). In both trials, patients were found to be unresectable during exploratory laparotomy. Most of the patients also underwent biliary-enteric drainage. There was no evidence of difference in the overall survival (HR 1.02; 95% CI 0.84 to 1.25), peri-operative mortality or morbidity, quality of life, or hospital stay (MD 0.97 days; 95%CI -0.18 to 2.12) between the two groups. The proportion of patients who developed long-term gastric outlet obstruction was significantly lower in the prophylactic gastrojejunostomy group (2/80; 2.5%) compared with no gastrojejunostomy group (20/72; 27.8%) (RR 0.10; 95%CI 0.03 to 0.37). The operating time was significantly longer in the gastrojejunostomy group compared with no gastrojejunostomy group (MD 45.00 minutes; 95%CI 21.39 to 68.61).

AUTHORS' CONCLUSIONS

Routine prophylactic gastrojejunostomy is indicated in patients with unresectable periampullary cancer undergoing exploratory laparotomy (with or without hepaticojejunostomy).

[Resectability evaluation in pancreatic cancer]

Accurate staging of pancreatic cancer is essential in order to select patients, which are candidates for curative resection. Multidetector computed tomography is the best imaging for determination of pancreatic cancer loco regional and distal resectability. Endoscopic ultra sonography has complementary role in small tumours. It can guide regional lymph node puncture for accurate staging. Magnetic resonance with MR angiography can be helpful in determining vascular respectability of pancreatic cancer. The use of laparoscopy with laparoscopic ultrasound has been increased last years in order to avoid unnecessary laparotomy. Positron emission tomography may be useful tool for diagnosing occult metastatic disease. It is still in evaluation.

Molecular pathology of pancreatic cancer: from bench-to-bedside translation

Pancreatic ductal adenocarcinoma (referred here as pancreatic cancer) is a lethal disease with the worst prognosis among all solid tumors. Surgical resection represents the only hope for cure but it is possible only in patients that present with local disease (about 20% of cases). Whether dismal prognosis of pancreatic cancer is a result of late diagnosis or early dissemination to distant organ is still a debate. Moreover, this disease shows an intrinsic chemotherapeutic resistance that has been mainly ascribed to the presence of a dense stromal reaction that significantly impairs drugs delivery. Clinical management of pancreatic cancer patients relies on few molecular markers (e.g., the diagnostic marker CA19-9) that, however, present several limitations to their use. The clinical usefulness of somatic alterations in well-characterized genes (such as KRAS and TP53), whose detection is technically feasible in different biological samples, has been extensively investigated leading to inconsistent results. Furthermore, none of the candidate molecular markers identified in recent years has shown an appropriate clinical performance and therefore none is routinely used. This depicts a scenario where the identification of novel and effective clinical biomarkers is mandatory. Very recent genome-wide comprehensive studies have shed light on the high degree of genetic complexity and heterogeneity of the pancreatic cancers. Although far from being introduced into the clinical settings, results from those studies are expected to change definitively the perspective through which we look at the clinical management of pancreatic cancer patients towards a personalized cancer medicine.

Multimodality imaging of pancreatic ductal adenocarcinoma: a review of the literature

BACKGROUND

Accurate pre-operative imaging in pancreatic cancer helps avoid unsuccessful surgical explorations and forewarns surgeons regarding aberrant anatomy. This review aimed to determine the role of current imaging modalities in the diagnosis and determination of resectability of pancreatic and peri-ampullary adenocarcinomas.

METHODS

A systematic search of the scientific literature was carried out using EMBASE, PubMed/MEDLINE and the Cochrane Central Register of Controlled Trials for the years 1990 to 2011 to obtain access to all publications, especially randomized controlled trials, reporting on the diagnostic accuracy of ultrasonography, multi-detector computed tomography (MDCT), magnetic resonance imaging (MRI), endoscopic ultrasonography (EUS) or positron emission tomography (PET)-computed tomography (CT) and the evaluation of resectability of pancreatic and peri-ampullary adenocarcinomas.

RESULTS

Based on 66 articles analysed in the review, MDCT and MRI/MRCP have comparable sensitivity and specificity rates for diagnosis and staging of pancreatic cancers. EUS offers the best sensitivity and specificity rates for lesions <2 cm. Improved staging has been noted when PET-CT scans are added to pre-operative evaluation.

CONCLUSIONS

MDCT with angiography or MRI/MRCP should constitute the first imaging modality in suspected pancreatic adenocarcinomas. EUS is recommended for assessing lesions not clearly detected, but suspected, on CT/MRI and in tumours considered 'borderline resectable' on MDCT to assess vascular involvement. PET-CT in locally advanced lesions will help rule out distant metastases.

Preoperative therapies for resectable and borderline resectable pancreatic cancer

In the era of multidetector high quality CT imaging, it is feasible and critical to use objective criteria to define resectable pancreatic cancer. This allows accurate pretreatment staging and the development of stage-specific therapy. Tumors of borderline resectability have emerged as a distinct subset and the definition has been expanded in the last few years. Borderline resectable tumors are defined as those with tumor abutment of <180degrees (< 50%) of the SMA or celiac axis, short segment abutment or encasement of the common hepatic artery typically at the gastroduodenal artery origin, SMV-PV abutment with impingement and narrowing or segmental venous occlusion with sufficient venous flow above and below the occlusion to allow an option for venous reconstruction. Most of the patients whose cancer meet these CT criteria are candidates for preoperative systemic chemotherapy followed by chemoradiation since they are at a high risk for margin positive resection with upfront surgery. Patients whose imaging studies show radiographic stability or regression proceed to pancreaticoduodenectomy (or pancreatectomy) and this may require vascular resection and reconstruction. Prospective biomarker and functional imaging enriched studies are warranted to determine the best overall treatment strategy for these patients.

Current surgical management of pancreatic cancer

En bloc resection is the treatment of choice for localized pancreatic cancer. While the perioperative mortality associated with resection is low, it still carries a significant morbidity rate of up to 50% in certain high-risk subsets of patients. With advances in perioperative care, radical resection with inclusion of adjacent vascular structure to achieve negative margin status can be performed with comparable mortality and morbidity in high-volume centers. Early results with the use of minimally invasive technique in pancreatic surgery are promising. Recent data on perioperative care to decrease morbidity with pancreatic surgery will also be discussed.

Somatostatin analogues for pancreatic surgery

BACKGROUND

Pancreatic resections are associated with high morbidity (30% to 60%) and mortality (5%). Synthetic analogues of somatostatin are advocated by some surgeons to reduce complications following pancreatic surgery, however their use is controversial.

OBJECTIVES

To determine whether prophylactic somatostatin analogues should be used routinely in pancreatic surgery.

SEARCH METHODS

We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 12), MEDLINE, EMBASE and Science Citation Index Expanded to December 2011.

SELECTION CRITERIA

We included randomised controlled trials comparing prophylactic somatostatin or one of its analogues versus no drug or placebo during pancreatic surgery (irrespective of language or publication status).

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trials for inclusion and independently extracted data. We analysed data with both the fixed-effect and random-effects models using Review Manager (RevMan). We calculated the risk ratio (RR), mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals (CI) based on an intention-to-treat or available case analysis. When it was not possible to perform either of the above, we performed per protocol analysis.

MAIN RESULTS

We identified 19 trials (17 trials of high risk of bias) involving 2245 patients. There was no significant difference in the perioperative mortality (RR 0.80; 95% CI 0.56 to 1.16; N = 2210) or the number of patients with drug-related adverse effects between the two groups (RR 2.09; 95% CI 0.83 to 5.24; N = 1199). Quality of life was not reported in any of the trials. The overall number of patients with postoperative complications was significantly lower in the somatostatin analogue group (RR 0.69; 95% CI 0.60 to 0.79; N = 1858) but there was no significant difference in the re-operation rate (RR 1.26; 95% CI 0.58 to 2.70; N = 687) or hospital stay (MD -1.04 days; 95% CI -2.54 to 0.46; N = 1269) between the groups. The incidence of pancreatic fistula was lower in the somatostatin analogue group (RR 0.63; 95% CI 0.52 to 0.77; N = 2161). The proportion of these fistulas that were clinically significant was not mentioned in most trials. On inclusion of trials that clearly distinguished clinically significant fistulas, there was no significant difference between the two groups (RR 0.69; 95% CI 0.34 to 1.41; N = 247).

AUTHORS' CONCLUSIONS

Somatostatin analogues may reduce perioperative complications but do not reduce perioperative mortality. Further adequately powered trials with low risk of bias are necessary. Based on the current available evidence, somatostatin and its analogues are recommended for routine use in patients undergoing pancreatic resection.

Staging laparoscopy for proximal pancreatic cancer in a magnetic resonance imaging-driven practice: what's it worth?

BACKGROUND

Preoperative imaging is often inadequate in excluding unresectable pancreatic cancer. Accordingly, many groups employ staging laparoscopy (SL), although none have evaluated SL after preoperative magnetic resonance imaging (MRI). We performed a retrospective, indirect cost-effectiveness analysis of SL after MRI for pancreatic head lesions.

METHODS

All MRI scans administered for proximal pancreatic cancer between 2004 and 2008 were reviewed and the clinical course of each patient determined. We queried our billing database to render average total costs for all inpatients with proximal pancreatic cancer who underwent pancreaticoduodenectomy, palliative bypass or an endoscopic stenting procedure. We then performed an indirect evaluation of the cost of routine SL.

RESULTS

The average costs of hospitalization for patients undergoing pancreaticoduodenectomy, open palliative bypass and endoscopic palliation were: US$26, 122.43, US$21, 957.18 and US$11, 304.00, respectively. The calculated cost of SL without laparotomy was US$2966.25 or US$1538.61 prior to laparotomy. The calculated cost of treating unresectable disease by outpatient laparoscopy followed by endoscopy was US$5943.17. Routine SL would increase our costs by US$76, 967.46 (3.6%).

CONCLUSIONS

Staging laparoscopy becomes cost-effective by diverting unresectable patients from operative to endoscopic palliation. Given the paucity of missed metastases on MRI, the yield of SL is marginal and its cost-effectiveness is poor. Future studies should address the utility of SL by both examining this issue prospectively and investigating the cost-effectiveness of endoscopic vs. surgical palliation in a manner that takes account of survival and quality of life data.

Selective use of staging laparoscopy based on carbohydrate antigen 19-9 level and tumor size in patients with radiographically defined potentially or borderline resectable pancreatic cancer

OBJECTIVE

The aims of this study were to verify whether the selective use of staging laparoscopy can prevent unnecessary laparotomy and to find a surrogate marker for surgical unresectability in patients with potentially or borderline resectable pancreatic cancer.

METHODS

Group A consisted of consecutive 33 patients evaluated between 2005 and 2006 and who directly underwent open laparotomy for planned surgical resection. Group B consisted of consecutive 61 patients evaluated between 2007 and 2009 and of whom 16 patients (26%) had a staging laparoscopy due to the presence of high-risk markers of unresectability defined as carbohydrate antigen 19-9 level 150 U/mL or greater and tumor size 30 mm or greater.

RESULTS

The frequency of unnecessary laparotomies for occult distant organ metastasis was significantly different between groups A and B (18% and 3%, respectively; P = 0.021). Of 16 patients who underwent staging laparoscopy in group B, 5 patients (31%) had occult metastases. The multivariate analysis showed that the presence of high-risk markers and extrapancreatic plexus invasion on multidetector-row computed tomography were significant independent risk factors for unresectability.

CONCLUSIONS

The presence of high-risk markers was associated with surgical unresectability in patients with potentially or borderline resectable pancreatic cancer. The selective use of staging laparoscopy decreased the frequency of unnecessary laparotomy by detecting minute metastases.

Serum biomarkers for improved diagnostic of pancreatic cancer: a current overview

PURPOSE

Complete resection constitutes the only curative approach in pancreatic cancer but is possible only in a minority of patients due to advanced stages upon diagnosis. Consequently, early detection is crucial for curative treatment. Clinical routine still lacks efficient, non-invasive screening assays, and 80-90% of pancreatic carcinomas are detected at unresectable stages. A wide range of serum proteins have been in the focus of intensive search for biomarkers specific for pancreatic cancer. This article will give an overview on serum biomarkers with screening potential for pancreatic malignancy.

DESIGN AND METHODS

PUBMED database was searched for articles, and 43 manuscripts were selected that provided data regarding biomarkers used, type of assay, study population, sample cohort quality and diagnostic performance.

RESULTS

Superior values for diagnostic performance were shown for MIC-1, PAM4, OPN, HSP27, TPS, TSGF, and CAM17.1 as individual markers. Panels of biomarkers comprised CA 19-9, MCSF, CEA, SAA, Haptoglobin, TSGF, CA 242, and HSP27. Individually or in concerted form, sensitivity and specificity ranged from 77 to 100% and 84-100%, respectively.

CONCLUSIONS

While the above named markers show high screening potential for pancreatic cancer, standardized validation studies using multiplex assays are required to pave the way for clinical routine application.

Prophylactic gastrojejunostomy for unresectable periampullary carcinoma

BACKGROUND

The role of prophylactic gastrojejunostomy in patients with unresectable periampullary cancer is controversial.

OBJECTIVES

To determine whether prophylactic gastrojejunostomy should be performed routinely in patients with unresectable periampullary cancer.

SEARCH STRATEGY

We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, issue 3), MEDLINE, EMBASE and Science Citation Index Expanded until April 2010.

SELECTION CRITERIA

We included randomised controlled trials comparing prophylactic gastrojejunostomy versus no gastrojejunostomy in patients with unresectable periampullary cancer (irrespective of language or publication status).

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trials for inclusion and independently extracted data. We analysed data with both the fixed-effect and the random-effects models using Review Manager (RevMan). We calculated the hazard ratio (HR), risk ratio (RR), or mean difference (MD) with 95% confidence intervals (CI) based on an intention-to-treat or available case analysis.

MAIN RESULTS

We identified two trials (of high risk of bias) involving 152 patients randomised to gastrojejunostomy (80 patients) and no gastrojejunostomy (72 patients). In both trials, patients were found to be unresectable during exploratory laparotomy. Most of the patients also underwent biliary-enteric drainage. There was no evidence of difference in the overall survival (HR 1.02; 95% CI 0.84 to 1.25), peri-operative mortality or morbidity, quality of life, or hospital stay (MD 0.97 days; 95%CI -0.18 to 2.12) between the two groups. The proportion of patients who developed long term gastric outlet obstruction was significantly lower in the prophylactic gastrojejunostomy group (2/80; 2.5%) compared with no gastrojejunostomy group (20/72; 27.8%) (RR 0.10; 95%CI 0.03 to 0.37). The operating time was significantly longer in the gastrojejunostomy group compared with no gastrojejunostomy group (MD 45.00 minutes; 95%CI 21.39 to 68.61).

AUTHORS' CONCLUSIONS

Routine prophylactic gastrojejunostomy is indicated in patients with unresectable periampullary cancer undergoing exploratory laparotomy (with or without hepaticojejunostomy).

Is there still a role for laparoscopy combined with laparoscopic ultrasonography in the staging of pancreatic cancer?

PURPOSE

This study was designed to compare our laparoscopic ultrasonography (LUS) experience in the resectability evaluation of pancreatic or periampullary cancers (PAC) in two different periods: before and after the introduction of multidetector CT (MDCT).

METHODS

We prospectively enrolled 104 CT-resectable patients with PAC. During Step 1 (1995-1999), we performed LUS on all patients, whereas during Step 2 (2002-2007), LUS was performed selectively according to Pisters' criteria.

RESULTS

LUS was satisfactorily performed in all cases. At Step 1 accuracy of LUS in predicting pancreatic resectability was high (96%) but it was markedly lower in a subgroup of patients with close contact between tumor and portal vein (sensibility of 57%). At Step 2, selective LUS was performed on 9 of 64 patients (14%). LUS confirmed the MDCT finding of unresectability in 8 of 9 cases, and allowed curative resection in 1 case. Only 1 of 55 of the patients who did not undergo LUS would have benefited from the procedure. The yield of LUS decreased from 45% before to 1.8% after MDCT.

CONCLUSIONS

In resectable-MDCT patients, routine LUS is unjustified. However, in doubtful MDCT cases, LUS has yet a good yield. In the event of close vascular contact, neither MDCT nor LUS seem to be conclusive, and laparotomy is still the only solution.