Current surgical therapy for carcinoma of the pancreas

Gamma knife combined with high-intensity focused ultrasound for treatment of locally advanced pancreatic carcinoma

AIM: To evaluate the safety and effectiveness of high-intensity focused ultrasound (HIFU) following gamma knife for treating locally advanced pancreatic cancer.

METHODS: Sixty-eight patients with locally advanced pancreatic cancer were randomly divided into two groups to receive either simple radiotherapy (group A; n = 33) or HIFU following gamma knife (group B; n = 35). The patients underwent contrast-enhanced computed tomography (CT) scans and CA199 tests 1, 2, 3 mo after treatment and every 3 mo thereafter during a total of 36 mo of follow-up. Short-term and long-term effects were observed after treatment, and survival curve analysis was performed.

RESULTS: The rate of clinical benefit response was significantly lower in group A than in group B (87.88% vs 94.29%, χ² = 4.001, (P = 0.045 < 0.05); the median survival time was significantly shorter in group A than in group B (12.00 mo vs 26.00 mo, P < 0.05); the average survival time was significantly shorter in group A than in group B (18.01 mo vs 22.99 mo, (P = 0.040 < 0.05). All the patients in the two groups completed the treatment smoothly as planned, and no serious complications such as pancreatic leakage, skin burns, viscera perforation and radioactive enteritis occurred.

CONCLUSION: Gamma knife combined with HIFU therapy may be a safe and effective method for the treatment of locally advanced pancreatic cancer.

CT-guided 125I seed interstitial implantation combined with gemcitabine/cisplatin chemotherapy for treatment of locally advanced pancreatic carcinoma

AIM: To explore the clinical efficacy of computed tomography (CT)-guided ¹²⁵I seed interstitial implantation combined with the gemcitabine and cisplatin (GP) chemotherapy regimen for the treatment of locally advanced pancreatic carcinoma.

METHODS: Eighty-eight patients with unresectable locally advanced pancreatic carcinoma (LAPC) were randomly divided into two groups: A (n = 54; 125I seed implantation + chemotherapy) and B (chemotherapy alone). CT-guided ¹²⁵I seed interstitial implantation was performed under local anaesthesia. Chemotherapy was given 10-14 d after surgery. The chemotherapy protocol was gemcitabine 1000 mg/m², d1, 8, + cisplatin 75 mg/m² d1-4 every 21 d. After four cycles of chemotherapy, the curative effect was assessed. Contrast-enhanced CT scanning and CA199 test were performed 1, 2, and 3 mo after treatment, and thereafter every 3 mo during a follow-up period of 30 mo.

RESULTS: The rate of clinical benefit and mean survival time were significantly higher in group A than in group B (P < 0.05 for both). No serious complications such as pancreatic leakage, bleeding, visceral perforation and grade Ⅳ bone marrow suppression were observed in either group.

CONCLUSION: CT-guided ¹²⁵I seed interstitial implantation combined with GP chemotherapy is safe and effective in the treatment of locally advanced pancreatic cancinoma.

A new approach for evaluating the resectability of pancreatic and periampullary neoplasms

OBJECTIVE

To establish a new standard for assessing the resectability of pancreatic and periampullary tumors by the Medical Image Three-Dimensional Visualization System (MI-3DVS).

METHODS

Eighty cases of pancreatic and periampullary tumors were examined. The 64-slice multidetector CT (64-MDCT) images and patient data were processed by MI-3DVS. The main elements examined by MI-3DVS included tumor shape, size, and location; distribution of related vessels; luminal morphology of large vessels; distribution and morphology of the small peripancreatic veins; morphology, degree of dilation, and obstructive sites of bile and pancreatic ducts. Based on vascular characteristics of MI-3DVS findings, the cases were classified into five types. Type I and II were resectable, type III were potentially resectable or resectable with combined vascular resection and reconstruction, and type IV and V were unresectable. The outcome was then compared with corresponding CT angiography (CTA) analysis and actual surgical observations.

RESULTS

Among the 80 cases, MI-3DVS indicated that 60 were resectable and the remaining 20 were not. In contrast, CTA indicated 50 resectable cases and 30 unresectable cases. For 57 cases of pancreatic ductal carcinomas and all 80 cases periampullary tumors, MI-3DVS assessment yielded a positive predictive value of 100%, negative predictive value of 100%, a sensitivity of 100%, a specificity of 100%, and an accuracy of 100%. While CTA generated corresponding values of 96%, 60%, 80%, 90%, 82.5%. The overall differences between the two methods were significant (P < 0.05).

CONCLUSION

The new classification system is able to reliably assess the resectability of pancreatic and periampullary tumors.

Staging cancer of the pancreas

Pancreatic carcinoma is the fourth cause of death from cancer in the United States, with a survival rate at 5 years of less than 5%. About 60% of tumors originate at the head of the pancreas, 15% in the body, 5% in the tail; 20% are diffuse within the pancreas. This article discusses the imaging and staging of pancreatic cancer.

Innovations in Treating the Elderly Who Have Biliary and Pancreatic Disease

Many diseases of the biliary tract and pancreas preferentially effect the elderly. Recent innovations in the evaluation and management of these disorders have directly impacted the lives of many seniors. Improved outcomes of pancreatic surgery is a good example of a positive impact in quality of life, especially when these surgeries are performed in centers of excellence. Evaluation and treatment strategies are presented for complicated calculous biliary disease, pancreatic carcinoma, and pancreatic cystic neoplasms.

Impact of polyunsaturated fatty acids on hepato-pancreatic prostaglandin and leukotriene concentration in ductal pancreatic cancer -- is there a correlation to tumour growth and liver metastasis?

Type and composition of polyunsaturated fatty acids (PUFAs) are suspected to play an important role in carcinogenesis. Thus we investigated the effects of n-3, n-6 and n-9 PUFAs on tumour growth, liver metastasis and concentration of prostaglandins (PG) and leukotrienes (LT) in experimental ductal pancreatic adenocarcinoma. Ninety male hamsters were randomised into six groups (Gr.) (n=15). While Gr. 1-3 were healthy control groups, Gr. 4-6 weekly received subcutaneous injections of 10mg N-nitrosobis-2-oxypropylamine (BOP)/kg body weight for 12 weeks in order to induce ductal pancreatic adenocarcinoma. Between week 1 and 16 all animals were fed with a standard diet with a raw fat content of 2.9%. In week 17 Gr. 1-6 were allocated to three types of diets: Gr. 1: standard high fat (=SHF diet, rich in n-6 PUFAs)/Gr. 2: FISH-OIL (rich in n-3 PUFAs)/Gr. 3: SMOF (=mixture of n-3, n-6 and n-9 PUFAs)/Gr. 4: BOP+SHF/Gr. 5: BOP+SMOF/Gr. 6: BOP+FISH-OIL. After 32 weeks all animals were sacrificed and pancreas as well as liver were analysed histologically. Furthermore pancreatic and hepatic concentrations of prostaglandins (PGF1alpha, PGE(2)) and LT were measured. FISH-OIL decreased number of macroscopically visible pancreatic tumours (Gr. 4-6: 54.5% vs. 45.5% vs. 9.1%, P<0.05) as well as incidence of liver metastasis (Gr. 4-6: 90.9% vs. 72.7% vs. 36.4%, P<0.05). Furthermore concentration of PGF(1)(alpha), PGE(2) and LT were significantly increased in pancreatic carcinoma compared to tumour-free tissue. Moreover levels of PGF(1)(alpha) and PGE(2) were higher in liver metastasis than in extrametastatic hepatic tissue. However, in Gr. 6 (FISH-OIL) intrametastatic concentration of LT was significantly lower than in non-metastatic hepatic tissue as well as in Gr. 4 and Gr. 5. FISH-OIL decreased number of visible pancreatic tumours and incidence of histological proven liver metastasis. This effect might be caused by a decrease of intrametastatic concentration of LT compared to extrametastatic hepatic tissue.

Diagnostic value of curved multiplanar reformatted images in multislice CT for the detection of resectable pancreatic ductal adenocarcinoma

The purpose of this study was to assess the usefulness of curved multiplanar reformatted (MPR) images obtained by multislice CT for the depiction of the main pancreatic duct (MPD) and detection of resectable pancreatic ductal adenocarcinoma. This study included 28 patients with pancreatic carcinoma (size range 12-40 mm) and 22 without. Curved MPR images with 0.5-mm continuous slices were generated along the long axis of the pancreas from pancreatic-phase images with a 0.5- or 1-mm slice thickness. Seven blinded readers independently interpreted three sets of images (axial images, curved MPR images, and both axial and curved MPR images) in scrolling mode. The depiction of the MPD and the diagnostic performance for the detection of carcinoma were statistically compared among these images. MPR images were significantly superior to axial images in depicting the MPD, and the use of both axial and MPR images resulted in further significant improvements. For the detection of carcinoma, MPR images were equivalent to axial images, and the diagnostic performance was significantly improved by the use of both axial and MPR images. High-resolution curved MPR images can improve the depiction of the MPD and the diagnostic performance for the detection of carcinoma compared with axial images alone.

Does enteral nutrition of dietary polyunsaturated fatty acids promote oxidative stress and tumour growth in ductal pancreatic cancer? Experimental trial in Syrian Hamster

BACKGROUND

Type and composition of dietary fat intake is supposed to play an important role in carcinogenesis. Thus we investigated the effects of n-3, n-6 and n-9 polyunsaturated fatty acids (PUFA) on oxidative stress (lipidperoxidation) and tumour growth in ductal pancreatic cancer.

METHODS

Ninety male hamsters were randomized into 6 groups (gr.) (n=15) and allocated to 3 main dietary categories: gr. 1 and 2 received a standard high fat diet (SHF, rich in n-6 PUFA), while gr. 3 and 4 were fed with a diet containing a mixture of n-3, n-6 and n-9 PUFA (SMOF) and gr. 5 and 6 had free access to a diet rich in n-3 PUFA (FISH-OIL). Gr. 1, 3 and 5 received weekly subcutaneous (s.c.) injections of 10 mg N-nitrosobis-2-oxypropylamine (BOP)/kg body weight in order to induce ductal pancreatic adenocarcinoma. Healthy control gr. 2, 4 and 6 were treated with 0.5 ml 0.9% sodium chloride s.c. After 32 weeks all animals were sacrificed. Removed pancreata were weighed and analysed histologically and biochemically. Activities of glutathionperoxidase (GSH-Px), superoxiddismutase (SOD) and levels of lipidperoxidation were measured in samples of pancreatic carcinoma as well as in tumour-free pancreatic tissue.

RESULTS

While different diets did not significantly alter the overall incidence of histologically proven pancreatic adenocarcinoma, the number of macroscopically visible tumours was decreased in the FISH-OIL-gr.

CONCLUSION

Different diets did not significantly influence the incidence of histologically proven pancreatic adenocarcinoma. However, administration of a diet rich in n-3 PUFA (FISH-OIL) resulted in a decrease of macroscopically visible tumours, thus indicating its beneficial effects in respect to attenuation of tumour growth.

Weight stabilisation is associated with improved survival duration and quality of life in unresectable pancreatic cancer

BACKGROUND & AIMS

Cancer-induced weight loss is associated with poor outcomes and is common in pancreatic cancer. The aims were to determine whether stabilising weight loss for patients with unresectable pancreatic cancer was associated with improved survival and quality of life (QoL) and to identify determinants of weight stabilisation.

METHODS

A post hoc analysis was performed using data from 107 patients in a multicentre trial. Patients were categorised as weight losing (> 1 kg lost) or weight stable (< or = 1 kg lost) after an 8 week nutrition intervention period. Group survival duration (Kaplan Meier) and QoL (EORTC QLQ-C30) were compared. Predictors of weight stability were determined using logistic regression analysis.

RESULTS

Patients with weight stabilisation survived longer from baseline (log rank test 5.53, P = 0.019). They also reported higher QoL scores (P = 0.037) and a greater mean energy intake (P <0.001) at Week 8 than those who continued to lose weight. The absence of nausea and vomiting (OR 6.5, P =0.010) and female gender (OR 5.2, P = 0.020) were independent determinants of weight stabilisation.

CONCLUSIONS

Weight stabilisation over an 8 week period in weight-losing patients with unresectable pancreatic cancer was associated with improved survival duration and QoL.

Different radiogenic effects on microcirculation in healthy pancreas and in pancreatic carcinoma of the rat

OBJECTIVE

To compare the radiogenic effects on microcirculation in healthy and malignant pancreatic tissue.

SUMMARY BACKGROUND DATA

Vascular injury is an important effect of radiotherapy, which has been suggested for antiangiogenic tumor therapy.

METHODS

An established model of duct-like pancreatic cancer (DSL6A) was used. Investigation was performed in 12 healthy and 24 tumor-bearing Lewis rats. The tumors were locally irradiated with 15 Gy in 12 animals 4 weeks after intraperitoneal inoculation. Additionally, local radiation of the normal pancreas was performed in six healthy animals. Intravital microscopy of tumor and normal pancreatic microcirculation was performed 5 days after radiation. Relevant parameters were erythrocyte velocity and functional vessel density. Tumor apoptosis and the fraction of vital tumor cells were estimated histologically 5 and 12 days after radiation.

RESULTS

Local radiation with 15 Gy caused a pronounced impairment of blood flow and functional capillary density in the normal pancreas 5 days after radiation, while the tumor blood flow was not significantly changed. A significant reduction in the fraction of vital tumor cells and a significant increase in tumor apoptosis were observed 12 days after radiation.

CONCLUSIONS

Local radiation impairs blood flow in healthy pancreas but not in pancreatic cancer tissue. Tumor cell death is the leading consequence of radiation injury in malignant pancreatic tissue without affecting the vascular system of the tumor. The authors conclude that external beam radiation does not appear to be a useful adjunct for a vascular-targeted therapy in pancreatic carcinoma but causes distinct hypoperfusion in the healthy pancreas.

Angiogenesis inhibition with TNP-470, 2-methoxyestradiol, and paclitaxel in experimental pancreatic carcinoma

INTRODUCTION

Inhibition of tumor angiogenesis is a novel therapeutic modality for various malignancies.

AIM

To investigate the effect of different antiangiogenic agents (TNP-470, 2-methoxyestradiol, and paclitaxel) on growth and neovascularization of experimental pancreatic cancer.

METHODOLOGY

In 25 male Lewis rats, tumor induction was achieved by orthotopic and subcutaneous tumor fragment implantation of ductlike pancreatic cancer DSL6A. Four weeks after tumor implantation, the animals were randomly treated with TNP-470, 2-methoxyestradiol, or paclitaxel. After 2 weeks of antiangiogenic therapy, total tumor volume, vital tumor surface, vascular density, and apoptosis were measured.

RESULTS

Total tumor volume and vital tumor surface were not significantly different in any of the treatment groups. Similarly, vascular density and apoptosis were not altered by treatment with the various angiogenesis inhibitors at the specific doses used.

CONCLUSION

We conclude that in contrast to many earlier studies, angiogenesis inhibition by a single-drug application and by the doses used in the present model did not reveal a favorable therapeutic effect on pancreatic cancer DSL6A. The combination of different angiogenesis inhibitors or higher doses might be more effective.

Multivariate statistical analysis of clinicopathologic factors influencing survival of patients with bile duct carcinoma

AIM: To evaluate the influence of various clinicopathologic factors on survival of patients with bile duct carcinoma after curative resection.

METHODS: A retrospective analysis was made for 86 cases of bile duct carcinoma treated from January 1981 to September 1995. Fifteen clinicopathologic factors possibly influencing survival were selected. Independent variables were first analyzed by univariate methods. Survival for variable was estimated by the method of Kaplan and Meier. The variables that were statistically significant by univariate analysis were included in a multivariate analysis, which were confirmed using the Cox stepwise proportion hazard model with the help of SPSS 10.0 for Windows software.

RESULTS: The overall cumulative survival rate was 72.6% at 1 year, 32.4% at 3 years, and 18.7% at 5 years. The results of univariate analysis showed that the major significant prognostic factors influencing survival of these patients were histological type of lesion, lymph node metastasis, pancreatic invasion, duodenal invasion, perineural invasion, macroscopic vessel involvement, resected surgical margin and depth of cancer invasion (P = 0.02, 0.02, 0.004, 0.005, 0.01, 0.43, 0.03 and 0.04). Age, sex, location of tumor, size of tumor, macroscopic type of lesions, hepatic metastasis, and hepatic invasion were not significantly associated with prognosis (P > 0.05). Pancreatic invasion, perineural invasion and lymph node metastases were the three most important prognostic factors by multivariate analysis using the Cox proportional hazards model.

CONCLUSION: Pancreatic invasion, perineural invasion and lymph node metastases are the most important prognostic factors for bile duct carcinoma after curative resection.

Surgical palliation in advanced disease: recent developments

Despite many valuable technical innovations for the relief of suffering in advanced disease over the past few years, only recently have surgical oncologists attempted to more clearly define palliation. Previous definitions have been misleading, creating confusion about the merits of surgery in many situations and difficulty in posing questions for future prospective clinical trials. This report outlines recent progress in identifying and refining a philosophy of palliative surgery that would align it with the consensus of nonsurgical opinion summarized by the 1990 World Health Organization definition of palliative care and the emerging consensus among the medical specialties in the United States concerning principles of care at the end of life. Selected controversies and recent innovations, as well as guidelines for palliative surgery, are discussed.

Pancreatic surgery

Recent advances have been made in both laparoscopic and endoscopic techniques for diagnosing and treating pancreatic neoplasms. These advances are reviewed. In addition to the traditional methods of pancreatic resection (eg, standard Whipple and pylorus-preserving Whipple), several other techniques have been described and are discussed (eg, median pancreatectomy and extended pancreatectomy). The morbidity and mortality rates of pancreatic operations have diminished, but significant complications still occur (eg, delayed gastric emptying, pancreatic fistula, and biliary strictures). These are discussed. In managing acute and chronic pancreatitis, less invasive and more conservative approaches are being advocated.