Impact of centralization of pancreatoduodenectomy on reported radical resections rates in a nationwide pathology database

BACKGROUND

Centralization of a pancreatoduodenectomy (PD) leads to a lower post-operative mortality, but is unclear whether it also leads to improved radical (R0) or overall resection rates.

METHODS

Between 2004 and 2009, pathology reports of 1736 PDs for pancreatic and peri-ampullary neoplasms from a nationwide pathology database were analysed. Pre-malignant lesions were excluded. High-volume hospitals were defined as performing ≥ 20 PDs annually. The relationship between R0 resections, PD-volume trends, quality of pathology reports and hospital volume was analysed.

RESULTS

During the study period, the number of hospitals performing PDs decreased from 39 to 23. High-volume hospitals reported more R0 resections in the pancreatic head and distal bile duct tumours than low-volume hospitals (60% versus 54%, P = 0.035) although they operated on more advanced (T3/T4) tumours (72% versus 58%, P < 0.001). The number of PDs increased from 258 in 2004 to 394 in 2009 which was partly explained by increased overall resection rates of pancreatic head and distal bile duct tumours (11.2% in 2004 versus 17.5% in 2009, P < 0.001). The overall reported R0 resection rate of pancreatic head and distal bile duct tumours increased (6% in 2004 versus 11% in 2009, P < 0.001). Pathology reports of low-volume hospitals lacked more data including tumour stage (25% versus 15%, P < 0.001).

CONCLUSIONS

Centralization of PD was associated with both higher resection rates and more reported R0 resections. The impact of this finding on overall survival should be further assessed.

Aberrant methylation of the 5' CpG island of TSLC1 is common in pancreatic ductal adenocarcinoma and is first manifest in high-grade PanlNs

The recently identified tumor-suppressor gene TSLC1 on chromosome 11q23.2 is frequently inactivated in human non-small cell lung adenocarcinoma by DNA methylation-associated silencing. The aim of this study was to determine if TSLC1 is inactivated in adenocarcinoma of the pancreas. We analyzed 17 pancreatic cancer cell lines, 91 primary pancreatic adenocarcinoma, 46 pancreatic intraepithelial (PanIN) precursor lesions and 15 microscopically normal pancreata for methylation of the 5' CpG island of the TSLC1 gene through methylation-specific PCR. We observed 5' CpG methylation of TSLC1 in 4 of 17 cell lines (24%). In each cell line the aberrant methylation was associated with loss of TSLC1 expression by RT-PCR that was reversible after treatment with the DNA methyl-transferase inhibitor 5-aza-2'- deoxycytidine. Furthermore, we observed that TSLC1 was methylated in 25 of 91 primary pancreatic adenocarcinomas (27%), and in 2 of 7 highgrade PanIN-3 lesions (29%), but not in low-grade PanIN (0 of 9 PanlN-2 and 0 of 30 PanIN-1) lesions or in normal pancreata (n=15). We conclude that epigenetic silencing of TSLC1 expression through 5' CpG island associated methylation is common in pancreatic adenocarcinoma and is a late event in pancreatic neoplastic development.

Phenotype and cancer risk of various polyposis syndromes

The gastrointestinal polyposis syndromes are disorders with multiple intestinal polyps. Three of these disorders, familial adenomatous polyposis, Peutz-Jeghers syndrome and juvenile polyposis are associated with increased risk of colorectal as well as extracolonic cancers. A description of the phenotype and associated cancer risk is provided for each.

Early gastric stump cancer: macroscopic and microscopic appearance

Six cases of early gastric stump cancer are presented. The clinical data and macroscopic and microscopic features are described in detail. All the early cancers were located near the gastro-enterostoma. All the carcinomas were of the intestinal type in accordance with Lauren's criteria, and of type II in accordance with the classification of the Japanese Gastroenterological Society. Two carcinomas were multicentric. No metastases were found. In 4 patients no suspicious lesion was found at the site of the carcinoma, stressing the importance of routine multiple biopsies even when no abnormalities are present. In 4 patients, severe dysplasia was found simultaneously with or prior to the carcinoma in one of the stomal biopsies, stressing the significance of severe dysplasia as a morphological marker for cancer. In addition, dysplastic changes were found surrounding the carcinoma in all the surgical specimens. All the patients are well and alive at least 4 years after resection of the carcinoma. All the carcinomas were found more than 20 years after the initial gastric operation. Early detection of gastric stump cancer is readily possible. Early gastric stump carcinoma has a good prognosis. Surveillance of gastric stump cancer can be intensified by identification of postgastrectomy patients with dysplastic mucosal alterations. Severe dysplasia in particular is a dependable marker for cancer.