L. Bosonnet

'Preoperative platelet-lymphocyte ratio is an independent significant prognostic marker in resected pancreatic ductal adenocarcinoma'

BACKGROUND The objective of this study was to investigate whether the preoperative platelet-lymphocyte (P/L) ratio represents a significant prognostic index in resected pancreatic ductal adenocarcinoma. METHODS A total of 110 patients undergoing pancreatoduodenectomy for pancreatic ductal adenocarcinoma over a 10-year period were identified from a prospectively maintained database. RESULTS The preoperative P/L ratio was found to be a more significant prognostic marker (P < .001) than either the lymphocyte count (P = .007) or platelet count (P = .068) on univariate Cox survival analysis. The median overall survival in patients with a P/L ratio of 150 or less (n = 48) was 19.7 months, 13.7 months in those with a P/L ratio of 151 to 300 (n = 43), and 5.8 months in patients with a value of greater than 300 (n = 19) (log-rank, P = .006). The preoperative P/L ratio retained significance on multivariate analysis (P < .001), along with tumor size (P = .010) and lymph node ratio (P = .013). CONCLUSIONS The preoperative P/L ratio represents a significant independent prognostic index in patients of resected pancreatic adenocarcinoma.

Preoperative CA19-9 Levels and Lymph Node Ratio Are Independent Predictors of Survival in Patients with Resected Pancreatic Ductal Adenocarcinoma

Background: The aim of this study was to identify whether preoperative CA19-9 levels might represent an independent prognostic marker for overall survival in patients undergoing resection for pancreatic ductal adenocarcinoma, and to describe the relationship between CA19-9 and tumour histology. Methods: 109 patients who had a pancreatoduodenectomy for pancreatic ductal adenocarcinoma with recorded preoperative CA19-9 levels were identified from a prospectively maintained database (1997–2006). Multivariate analysis was conducted using a Cox proportional hazards model with continuous covariates where possible. Results: The median survival of 64 patients with a preoperative CA19-9 level >150 kU/l was 10.4 months while in 45 patients with a CA19-9 level ≤150 kU/l this was 22.1 months (corrected p = 0.012). Also significant on univariate analyses were overall lymph node status (p = 0.011), lymph node ratio (p = 0.003) and tumour diameter (p = 0.004). Preoperative CA19-9 levels >150 kU/l were associated with a larger, more poorly differentiated tumour along with an increased likelihood of a positive resection margin status (all p < 0.05). Preoperative CA19-9 levels (p = 0.030) and lymph node ratio (p = 0.042) emerged as independent predictors of survival on multivariate analysis. Conclusions: Preoperative CA19-9 levels and lymph node ratio were significant predictors of survival in resected pancreatic ductal adenocarcinoma.

Positron emission tomography does not add to computed tomography for the diagnosis and staging of pancreatic cancer.

Background: Positron emission tomography (PET) has been proposed for pancreatic cancer diagnosis and staging. Methods: 112 patients with suspected pancreatic cancer underwent 18F-fluoro-2-deoxy-D-glucose gamma camera PET and computed tomography (CT), of whom 62 also had laparoscopic ultrasonography and 70 underwent abdominal exploration for potential resection. The final diagnosis was malignancy in 78 and benign disease in 34 patients (25 with chronic pancreatitis). Results: The diagnostic sensitivity and specificity for PET were 73 and 60% compared to 89 and 65% for CT respectively (Cohen’s ĸ = 0.59). In 30 patients CT was equivocal with cancer in 14 and benign disease in 16. PET correctly diagnosed 13 of these patients (cancer in 6 and benign disease in 7), interpreted 4 as equivocal (cancer in 3 and benign disease in 1) but was incorrect in the remaining 13 patients (cancer in 5 and benign disease in 8). The sensitivity and specificity for detecting small volume metastatic disease were 20 and 94% for CT and 22 and 91% for PET, respectively. Conclusion: PET had a similar accuracy to that of CT for imaging pancreatic cancer but it did not provide any additional information in patients with equivocal CT findings and currently would seem of little benefit for the staging of pancreatic cancer.

Survival of patients with periampullary carcinoma is predicted by lymph node 8a but not by lymph node 16b1 status.

The aim of this study was to assess the impact of metastatic disease in lymph nodes 8a and 16b1 (as defined by the Japanese Pancreas Society) on survival in patients with periampullary malignancy.

The platelet-lymphocyte ratio improves the predictive value of serum CA19-9 levels in determining patient selection for staging laparoscopy in suspected periampullary cancer.

BACKGROUND The objective of this study was to identify whether the preoperative platelet-lymphocyte (P/L) ratio might improve the predictive value of CA19-9 levels in stratifying a patient group with suspected periampullary malignancy who do not require staging laparoscopy. METHODS Patients with suspected periampullary cancer were identified from a prospectively maintained 10-year database. Only patients with resectable disease who underwent staging laparoscopy and subsequent laparotomy were included. Low-risk groups were stratified using a CA19-9 cutoff value of < or = 150 kU/l (or < or = 300 kU/l in patients with a concurrent bilirubin concentration > 35 micromol/l) and a P/L ratio value of < or = 150. RESULTS From 263 patients, preoperative CA19-9 levels and P/L ratios were available in 216 and 225 patients, respectively. The positive and negative predictive values for resectability, sensitivity, and specificity for CA19-9 levels < or = 150 kU/l were 83%, 36%, 51%, and 73%, respectively. For P/L ratios < or = 150, these levels were 81%, 38%, 51%, and 72%, respectively. When combining the requirement for both CA19-9 levels and P/L ratios to be < or = 150 (n = 38 out of 183), both positive predictive value (95%) and specificity (96%) were improved (Fisher exact test, P =.065 and P < .001, respectively); 21% of laparoscopies were avoidable when using these criteria. Increasing T stage (P = .005), vascular invasion (P < .001), perineural invasion (P = .008), and resection margin involvement (P < .001) were all associated with greater preoperative P/L ratios in resected periampullary adenocarcinoma (n = 204). CONCLUSIONS The preoperative P/L ratio reflects an index of tumor invasiveness and merits prospective evaluation as an adjunct to CA19-9 in determining the requirement for laparoscopic staging in patients with potentially resectable periampullary malignancy.

Laparoscopy and Laparoscopic Ultrasound in the Evaluation of Pancreatic and Periampullary Tumours

Background and Aims: The pre-operative determination of resectability of pancreatic and peri-ampullary neoplasia assists the selection of patients for surgical or non-surgical treatment. This study investigated whether the addition of laparoscopy with laparoscopic ultrasound to dual-phase helical CT could improve the accuracy of assessment of resectability. Patients and Methods: Prospective study of 305 patients referred to a single unit for consideration of pancreatic resection who underwent dual-phase helical CT scanning ± laparoscopy with laparoscopic ultrasound. Data were collected on patient demographics, CT findings, assessment of operability, laparoscopic assessment (LA), surgical procedures and histology. Results: LA was undertaken in 239/305 patients, 190 of whom were considered CT resectable, and 49 CT unresectable. Of the 190 CT resectable patients, LA correctly identified unresectability in 28 (15%: metastases in 15; vascular encasement in 6; anaesthesia for laparoscopy found 7 unfit for major resection) and incorrectly in 2 (vascular encasement), but did not identify unresectability in 33; LA correctly confirmed resectability in the remainder (prediction improved, χ2 = 9.73, p < 0.01). Of the 49 CT unresectable patients, LA correctly identified resectability in 4, and incorrectly in 12, and correctly identified unresectability in the remaining 33. Sixty-six of the 305 patients did not undergo LA, of whom 23 underwent resection. Conclusion: When added to dual-phase helical CT, laparoscopy with laparoscopic ultrasound provides valuable information that significantly improves the selection of patients for surgical or non-surgical treatment.

Serum CA19-9 Measurement Increases the Effectiveness of Staging Laparoscopy in Patients with Suspected Pancreatic Malignancy

Background/Aims: Staging laparoscopy for suspected pancreatic neoplasia is not widely accepted due to its low yield. The aim of this study was to determine if serum carbohydrate antigen (CA19-9) levels could be used to improve the selection of patients for staging laparoscopy. Methods: The data from a prospectively collected database (1997–2004) with 159 patients who had computed tomography-predicted resectable disease and who had undergone laparoscopic staging were analysed to determine if a low preoperative CA19-9 level (≤150 kU/l, or ≤300 kU/l with a bilirubin >35 µmol/l) identified patients in whom laparoscopy was not useful. Results: The CA19-9 level was >150 kU/l in 96 patients of whom 75 (78%) were considered resectable following laparoscopic assessment. There were 63 patients with a CA19-9 ≤150 kU/l of whom 60 (95%) were considered resectable following laparoscopic assessment. The sensitivity, specificity, positive predictive value and negative predictive value for CA19-9 ≤150 kU/l in predicting that laparoscopic assessment would judge patients as resectable were 44, 88, 95 and 22%, respectively. A cut-off level of ≤300 kU/l in patients with a bilirubin >35 µmol/l produced values of 30, 94, 94 and 28%, respectively. By using CA19-9 ≤150 kU/l, laparoscopy could have been avoided in 40% of patients, increased to 55% of patients with adjustment for the presence of jaundice; concomitantly, the yield from laparoscopy would have been increased from 15 to 22 and 25%, respectively. Conclusion: Use of serum CA19-9 levels would increase the efficiency of laparoscopic staging in patients with suspected pancreatic malignancy.

Randomised Phase I/II trial assessing the safety and efficacy of radiolabelled anti-carcinoembryonic antigen I(131) KAb201 antibodies given intra-arterially or intravenously in patients with unresectable pancreatic adenocarcinoma.

BackgroundAdvanced pancreatic cancer has a poor prognosis, and the current standard of care (gemcitabine based chemotherapy) provides a small survival advantage. However the drawback is the accompanying systemic toxicity, which targeted treatments may overcome. This study aimed to evaluate the safety and tolerability of KAb201, an anti-carcinoembryonic antigen monoclonal antibody, labelled with I131 in pancreatic cancer (ISRCTN 16857581).MethodsPatients with histological/cytological proven inoperable adenocarcinoma of the head of pancreas were randomised to receive KAb 201 via either the intra-arterial or intravenous delivery route. The dose limiting toxicities within each group were determined. Patients were assessed for safety and efficacy and followed up until death.ResultsBetween February 2003 and July 2005, 25 patients were enrolled. Nineteen patients were randomised, 9 to the intravenous and 10 to the intra-arterial arms. In the intra-arterial arm, dose limiting toxicity was seen in 2/6 (33%) patients at 50 mCi whereas in the intravenous arm, dose limiting toxicity was noted in 1/6 patients at 50 mCi, but did not occur at 75 mCi (0/3).The overall response rate was 6% (1/18). Median overall survival was 5.2 months (95% confidence interval = 3.3 to 9 months), with no significant difference between the intravenous and intra-arterial arms (log rank test p = 0.79). One patient was still alive at the time of this analysis.ConclusionDose limiting toxicity for KAb201 with I131 by the intra-arterial route was 50 mCi, while dose limiting toxicity was not reached in the intravenous arm.

Double Resection for Patients with Pancreatic Cancer and a Second Primary Renal Cell Cancer

Background: Reports of synchronous or metachronous double kidney-pancreas cancers are very rare. Methods: We present 2 patients with renal cell carcinoma and synchronous (1 patient) or metachronous (1 patient) primary pancreatic ductal adenocarcinoma. The patients underwent resection for both cancer types with a worthwhile outcome. Results: The appearance of different primaries in an individual may indicate a genetic predisposition to different neoplasms. The study of double primary cancers is important because it might provide understanding of a shared genetic basis of different solid tumors. Conclusions: The association between these two cancers demands more detailed epidemiological and molecular investigation. From a clinical viewpoint a resectional policy is recommended.