Surgical palliation of pancreatic cancer. Cancer J. 2012;18:577-583. [PMID: 23187845 DOI: 10.1097/ppo.0b013e3182797dfe]

Advances in Endoscopic Ultrasound in Pancreatic Cancer Screening, Diagnosis, and Palliative Care

Pancreatic cancer is a highly aggressive malignancy with a profoundly poor prognosis. Clinically, the condition most frequently manifests with symptoms including painless jaundice, abdominal discomfort, and back pain. Early diagnosis and the implementation of effective therapeutic strategies are critical for improving patient survival outcomes. However, merely 10-20% of patients are diagnosed at an early stage, with the majority presenting at advanced stages, often with metastasis. Consequently, early detection and intervention are crucial for enhancing prognosis. The widespread adoption of endoscopic ultrasonography (EUS) technology in recent years has significantly enhanced the diagnostic accuracy for pancreatic space-occupying lesions. EUS is increasingly recognized for its pivotal role in alleviating malignant biliary obstruction (MBO), gastric outlet obstruction (GOO), and refractory pain in advanced pancreatic cancer. This article aims to provide an overall review of the current applications of EUS in the diagnosis and treatment of pancreatic cancer, exploring its advantages and limitations in early screening, diagnosis, and palliative care. Furthermore, this review explores potential future directions in the field, aiming to provide valuable insights to inform and enhance the clinical management of pancreatic cancer.

Aborted pancreatoduodenectomy after extensive vascular dissection in patients with pancreatic cancer: a word of caution

BACKGROUND

Difficulties in distinguishing fibrosis from tumor in borderline and locally advanced pancreatic adenocarcinoma (PDAC) justify surgical exploration to assess resectability. This issue is especially relevant after neoadjuvant treatments (NAT) prior to pancreaticoduodenectomy (PD) although outcomes of aborted PD are unknown.

OBJECTIVES

This study aimed to evaluate early outcomes after aborted PD in patients with PDAC.

METHODS

Data were collected over a ten-year period, in three University Hospitals in France. Perioperative patient management was similar. The causes of intraoperative PD abortions were recorded, and outcomes of patients who underwent early (metastases, carcinomatosis) and late (following extensive vascular dissection) PD abortion were compared.

RESULTS

Of 774 PD for PDAC, 131 (17%) were aborted. 97 (74%) patients underwent early PD abortion due to carcinomatosis (n = 14; 14%), liver metastases (n = 32; 33%), aortocaval lymph node invasion (n = 28; 29%) and massive vascular extension (n = 23; 24%). Late PD abortion occurred after extensive vascular dissection in 34 (26%) patients due to invasion of the common hepatic (n = 16; 47%), superior mesenteric (n = 5; 15%) and right hepatic (n = 1; 3%) arteries and nonreconstructable venous invasion (n = 12; 35%). Patients who underwent late PD abortion had higher rates of overall morbidity (n = 22; 65% vs n = 27; 28%, p = 0.0001), severe complications (n = 14; 41% vs n = 11; 11%, p = 0.0005), mortality (n = 4; 12% vs n = 0; 0%, p = 0.003). They also had higher rates of delayed gastric emptying (n = 11; 32% vs n = 6; 6%, p = 0.0003), deep space infections (n = 10; 29% vs n = 7; 7%, p = 0.002), wound infections (n = 5; 15% vs n = 4; 4%, p = 0.05), and bleeding (n = 8; 24% vs n = 0; 0%, p < 0.0001).

CONCLUSION

Aborted PD after extensive vascular dissection has high morbidity and mortality rates. Appropriate information and counseling should be delivered to patients with borderline/locally advanced PDAC considered for PD.

Therapeutic Endoscopic Ultrasound for Complications of Pancreatic Cancer

Progression of pancreatic adenocarcinoma can result in disease complications such as biliary obstruction and gastric outlet obstruction. The recent advances in endoscopic ultrasound (EUS) have transformed EUS from a purely diagnostic technology to a therapeutic modality, particularly with the development of lumen-apposing metal stents. In terms of biliary drainage, EUS-guided choledochoduodenostomy and EUS-guided hepaticogastrostomy offer safe and effective techniques when conventional transpapillary stent placement via ERCP fails or is not possible. If these modalities are not feasible, EUS-guided gallbladder drainage offers yet another salvage technique when the cystic duct is non-involved by the cancer. Lastly, EUS-guided gastroenterostomy allows for an effective bypass treatment for cases of gastric outlet obstruction that enables patients to resume eating within several days. Future randomized studies comparing these techniques to current standard-of-care options are warranted to firmly establish therapeutic EUS procedures within the treatment algorithm for this challenging disease.

Morbidity and Mortality of Non-pancreatectomy operations for pancreatic cancer: An ACS-NSQIP analysis

BACKGROUND

Patients with pancreas cancer may undergo palliative gastrointestinal or biliary bypass. Recent comparisons of post-operative outcomes following such procedures are lacking.

METHODS

We analyzed patients undergoing exploration, gastrojejunostomy, biliary bypass or double bypass for pancreatic cancer using data from the 2005-2019 American College of Surgeons National Surgical Quality Improvement Program. We compared 30-day mortality and complications across procedures and over time periods (2005-10, 2011-14, 2015-19) using multivariable regression models. Factors associated with postoperative mortality were identified.

RESULTS

Of 43,525 patients undergoing surgery with a postoperative diagnosis of pancreatic cancer, 5572 met inclusion criteria. Palliative operations included 1037 gastrojejunostomies, 792 biliary bypasses, 650 double bypasses, and 3093 explorations. The proportion of biliary and double bypass procedures decreased from 2005-10 to 2015-19. Gastrojejunostomy had higher 30-day mortality rate (11.5%) than other operations (p < 0.001). Adjusted 30-day mortality rates remained stable over time (7.8% vs 6.3%, p = 0.095), while rates of serious complications decreased over time (23.2% vs 17.1%, p < 0.001).

CONCLUSIONS

Palliative bypass for pancreatic cancer has not become safer over time, and 30-day mortality and complications remain high.

Palliative Therapies in Metastatic Pancreatic Cancer: Does Medicaid Expansion Make a Difference?

BACKGROUND

The aim of this study was to evaluate the impact of medicaid expansion (ME) on receipt of palliative therapies in metastatic pancreatic cancer patients.

PATIENTS AND METHODS

A difference-in-differences (DID) approach was used to analyze patients with metastatic pancreatic cancer identified from the National Cancer Database diagnosed during two time periods: pre-expansion (2010-2012) and post-expansion (2014-2016). Patients diagnosed while residing in ME states were compared with those in non-ME states. Multivariable logistic regression was used to identify predictors of receipt of palliative therapies.

RESULTS

Of 87,738 patients overall, 7483(18.1%) received palliative therapies in the pre-expansion, while 10,211(21.5%) received palliative therapies in the post-expansion period. In the pre-expansion period, treatment at a high-volume facility (HVF) (odds ratio [OR] 1.10, 95% confidence interval [CI] 1.02-1.18) and non-west geographic location were predictive of increased palliative therapies. In the post-expansion period, treatment at an HVF (OR 1.09, 95% CI 1.02-1.16), geographic location, and living in an ME state at the time of diagnosis (OR 1.14, 95% CI 1.06-1.22) were predictive of increased palliative therapies. Older age, highest quartile median income (zip-code based), and treatment at a nonacademic facility were independently associated with decreased palliative therapies in both periods. DID analysis demonstrated that patients with metastatic pancreatic cancer living in ME states had increased receipt of palliative therapies relative to those in non-ME states (DID = 2.68, p < 0.001).

CONCLUSIONS

The overall utilization of palliative therapies in metastatic pancreatic cancer is low. Multiple sociodemographic disparities exist in the receipt of palliative therapies. ME is associated with increased receipt of palliative therapies in patients with metastatic pancreatic cancer.

Evaluation and Management of Malignant Biliary Obstruction

There is no reason to be pollyannaish when approaching patients with malignant biliary obstruction (MBO). Although technology has allowed refining diagnosis and resectability of cancers causing biliary obstruction, outcomes have not improved significantly. The previous preponderant place of surgical procedures now is replaced by endoluminal and percutaneous techniques for the management of symptoms of MBO. Because quantity of life often is the primary and sole outcome for evaluation of various interventions, the main focus of patient quality of life may be erroneously deemphasized. Lagging behind scientific advances are the availability of palliative care services and studies of patient-related outcomes.

Malignant obstructive jaundice: approaches to minimally invasive biliary decompression

Modern approaches to surgical treatment of malignant obstructive jaundice are reviewed in the article. The advantages and disadvantages of various types of minimally invasive biliary decompression are emphasized.

Cystatin F as a key family 2 cystatin subunit and prognostic biomarker for early‑stage pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal malignancies, and early diagnosis and assessment may enhance the quality of life and survival of patients. The prognostic value of key family 2 cystatins subunit in PDAC patients remains unknown. The potential molecular roles of family 2 cystatins and related pathways were investigated using bioinformatics analysis. The relationship of family 2 cystatin expression levels and clinical outcomes of 112 patients with early-stage PDAC were evaluated via univariate and combined survival analysis. A prognostic nomogram model was also constructed and gene set enrichment analysis was performed to investigate potential pathways in PDAC. The pathways, interaction networks, and Gene Ontology term analysis of the cystatin gene family were analyzed in the present study. Cystatin F (CST7) was identified as the key subunit of family 2 cystatins in survival analysis. PDAC patients who harbored a higher expression level of CST7 had a lower risk in overall survival (adjusted HR_OS=0.44, 95% CI=0.25-0.77, P=0.004) and a longer survival time in various subgroups. The prognostic nomogram indicated that the CST7 expression model effectively predicted the outcomes of patients with early-stage PDAC (predictive ability >0.75). In the gene set enrichment analysis, it was revealed that CST7 expression may be involved in immune regulation and be associated with cell adhesion. CST7 could be a useful biomarker for the prognostic prediction of early-stage PDAC after pancreaticoduodenectomy.

Trends in the Utilization of Life-Sustaining Procedures and Palliative Care Consultation Among Dying Patients With Advanced Chronic Pancreas Illnesses in US Hospitals: 2005 to 2014

AIM

Pancreas cancer continues to carry a poor prognosis. Hospitalized patients with advanced chronic pancreatic illnesses increasingly receive palliative care due to its perceived clinical benefits. Meanwhile, a growing proportion of elderly patients are reportedly receiving life-sustaining procedures. Temporal trends in the utilization of life-sustaining procedures and palliative care consultation among dying patients with advanced chronic pancreatic illnesses in US hospitals were examined.

METHODS AND MATERIALS

A serial, cross-sectional analysis was carried out using the National Inpatient Sample Database. Decedents 18 years and older with a principal diagnosis of pancreas cancer or other advanced chronic pancreatic illnesses from 2005 through 2014. The compound annual growth rates (CAGRs) and Cochrane-Armitage correction of χ² statistic were used. The receipt of life-sustaining systemic procedures, intra-abdominal local procedures and surgeries, and palliative care consultation were examined. Multilevel multivariate logistic regressions were performed to examine the association of various procedures with the utilization of palliative care consultation.

RESULTS

Among 77 394 183 hospitalizations, 29 515 patients were examined. The CAGRs of systemic procedures, intra-abdominal procedures, surgeries, and palliative care were -4.19% (P = .008), 2.17%, -1.40%, and 14.03% (P < .001), respectively. The receipt of systemic procedures (odds ratio [OR] = 2.40, 95% confidence interval [CI], 2.08-2.74), local intra-abdominal procedures (OR = 1.46, 95% CI, 1.27-1.70), and surgeries (OR = 2.51, 95% CI, 2.07-3.05) was associated with palliative care consultation (Ps < .001).

CONCLUSIONS

Among adults with pancreatic cancer or other advanced chronic pancreatic illnesses in the US hospitals from 2005 to 2014, the utilization of life-sustaining systemic procedures decreased while the prevalence of palliative care consultation increased.

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.

Roux-en-Y duodenojejunostomy improves gastric emptying in experimental obstruction of the distal duodenum

Introduction

We undertook a comparative survey of gastric emptying (GE) kinetics after two variants of bypass surgery for upper bowel obstruction.

Material & methods

In 10 dogs with experimental upper bowel obstruction, five were randomized to obtain gastrojejunal anastomosis (GA), and the other five received Roux-en-Y duodenojejunal anastomosis (DA). Duplicate scintigraphic measurements of GE of a solid meal were accomplished in every animal before surgery and during the early (2–3 weeks), medium (3 months), and late (6 months) post-operative period. The GE curves were fitted with a power-exponential function to derive the GE half time T½, and the curve shape parameter S.

Results

Early after surgery T½ slightly decreased by -18±21 min in the DA group and lengthened by 91±37 min in the GA group (p = 0.042). In both groups an increase in the S parameter was found then. In either group T½ gradually declined towards the basal value during the medium and late post-operative period. On the other hand, net differences relative to the basal situation in the S values appeared to be positive in the GA group (0.32±0.11 at 3 months; 0.64±0.19 at six months), and negative in the DA group (-0.30±0.09 at 3 months; -0.01±0.20 at six months). Hence a statistically significant contrast was found between those differences: p = 0.0022 at 3 months, and p = 0.045 at six months after the surgery.

Conclusion

Roux-en-Y duodenojejunal anastomosis appears to be superior to the classical gastrojejunal anastomosis while restoring patency of the gastrointestinal passage in the case of upper bowel obstruction.

EUS-Guided Transluminal Interventions

The role of endoscopic ultrasound (EUS) has transitioned from a diagnostic to a therapeutic one over the past 40 years. With the advent of curvilinear array echoendoscopes in the 1990s with an accessory channel, multiple tools and devices have been developed and used for a variety of transluminal interventions. EUS provides a viable option and is becoming the procedure of choice for many interventions, including bile and pancreatic duct drainage, guiding angiotherapy, pancreatic fluid collection management, gallbladder drainage, and creating a gastrojejunostomy. Although reports demonstrate the technical success of these interventions, there is tremendous study heterogeneity and a relative lack of controlled randomized trials, which may limit our understanding of their role and utility. Furthermore, adverse events are relatively common and occasionally severe. Despite the limitations, available data strongly indicate the efficacy of EUS interventions when performed by well-trained endosonographers in carefully selected patients and managed in a multidisciplinary setting.

Utilization and trends in palliative therapy for stage IV pancreatic adenocarcinoma patients: a U.S. population-based study

BACKGROUND

Pancreatic adenocarcinoma is an aggressive malignancy, with most patients diagnosed with advanced or metastatic disease. Palliative therapies comprise an important, but underutilized, aspect of care. This aim of this study was to characterize the trends, factors, and outcomes associated with utilization of palliative therapies.

METHODS

Patients with stage IV pancreatic adenocarcinoma from the 2003-2011 U.S. National Cancer Database were identified and stratified by receipt of palliative therapy. Linear regression, multivariable logistic regression, and survival analyses using multivariate proportional hazards models were performed.

RESULTS

Sixty-eight thousand and seventy-five patients with stage IV disease were identified, of which only 11,449 (16.8%) underwent designated palliative therapy. The majority received systemic chemotherapy (37.2%), followed by surgery (19.0%), pain management alone (15.3%), radiation (8.1%), referral alone (11.7%), or a combination thereof (8.7%). Utilization of palliative therapies increased from 12.9% in 2003 to 19.2% in 2011 (P<0.001). Patients were less likely to undergo palliation when older than 60 (OR 0.89, P<0.001), or of black or Hispanic race (OR 0.83, P<0.001; OR 0.80, P<0.001, respectively, vs. Caucasians). Presence of comorbidities increased the use of palliative therapy (OR 1.16 per comorbidity, P<0.001). Survival was improved in those receiving palliative systemic chemotherapy (HR 0.55, P<0.001) and palliative surgery (HR 0.94, P<0.001), although this may be due to selection bias.

CONCLUSIONS

Despite the continued dismal prognosis of pancreatic cancer, palliation of symptoms remains underutilized in this country, particularly in non-Caucasian, older patients. Increased awareness of palliative options may help increase its utilization.

Overuse of surgery in patients with pancreatic cancer. A nationwide analysis in Italy

BACKGROUND

According to current guidelines, pancreatic cancer patients should be strictly selected for surgery, either palliative or resective.

METHODS

Population-based study, including all patients undergoing surgery for pancreatic cancer in Italy between 2010 and 2012. Hospitals were divided into five volume groups (quintiles), to search for differences among volume categories.

RESULTS

There were 544 hospitals performing 10 936 pancreatic cancer operations. The probability of undergoing palliative/explorative surgery was inversely related to volume, being 24.4% in very high-volume hospitals and 62.5% in very low-volume centres (adjusted OR 5.175). Contrarily, the resection rate in patients without metastases decreased from 86.9% to 46.1% (adjusted OR 7.429). As for resections, the mortality of non-resective surgery was inversely related to volume (p < 0.001). Surprisingly, mortality of non-resective surgery was higher than that for resections (8.2% vs. 6.7%; p < 0.01). Approximately 9% of all resections were performed on patients with distant metastases, irrespective of hospital volume group. The excess cost for the National Health System from surgery overuse was estimated at 12.5 million euro.

DISCUSSION

Discrepancies between guidelines on pancreatic cancer treatment and surgical practice were observed. An overuse of surgery was detected, with serious clinical and economic consequences.

Validation of biomarkers that complement CA19.9 in detecting early pancreatic cancer

PURPOSE

Pancreatic ductal adenocarcinoma (PDAC) is a significant cause of cancer mortality. Carbohydrate antigen 19.9 (CA19.9), the only tumor marker available to detect and monitor PDAC, is not sufficiently sensitive and specific to consistently differentiate early cancer from benign disease. In this study, we aimed to validate recently discovered serum protein biomarkers for the early detection of PDAC and ultimately develop a biomarker panel that could discriminate PDAC from other benign disease better than the existing marker CA19.9.

PATIENTS AND METHODS

We performed a retrospective blinded evaluation of 400 serum samples collected from individuals recruited on a consecutive basis. The sample population consisted of 250 individuals with PDAC at various stages, 130 individuals with benign conditions and 20 healthy individuals. The serum levels of each biomarker were determined by ELISAs or automated immunoassay.

RESULTS

By randomly splitting matched samples into a training (n = 186) and validation (n = 214) set, we were able to develop and validate a biomarker panel consisting of CA19.9, CA125, and LAMC2 that significantly improved the performance of CA19.9 alone. Improved discrimination was observed in the validation set between all PDAC and benign conditions (AUCCA19.9 = 0.80 vs. AUCCA19.9+CA125+LAMC2 = 0.87; P < 0.005) as well as between early-stage PDAC and benign conditions (AUCCA19.9 = 0.69 vs. AUCCA19.9+CA125+LAMC2 = 0.76; P < 0.05) and between early-stage PDAC and chronic pancreatitis (CP; AUCCA19.9 = 0.59 vs. AUCCA19.9+CA125+LAMC2 = 0.74; P < 0.05).

CONCLUSIONS

The data demonstrate that a serum protein biomarker panel consisting of CA125, CA19.9, and LAMC2 is able to significantly improve upon the performance of CA19.9 alone in detecting PDAC.