High serum CA 19-9 but not tumor size should select patients for staging laparoscopy in radiological resectable pancreas head and peri-ampullary cancer

doi:10.1016/j.ejso.2014.09.006

European Journal of Surgical Oncology (EJSO)

Volume 41, Issue 2, February 2015, Pages 265-269

https://doi.org/10.1016/j.ejso.2014.09.006 Get rights and content

Abstract

Background

The objective of this study was to validate current recommendations for the selective use of staging laparoscopy in patients with radiological resectable pancreas head and peri-ampullary tumors.

Methods

Data from a prospectively collected database (2007–2013) of 136 patients with peri-pancreatic head cancer were analyzed.

Results

Over a 6 year time period, 136 patients were evaluated, 126 patients were deemed radiological resectable and underwent laparotomy and 10 patients were characterized radiological unresectable. There were 111 patients with pancreas head resection and 15 without resection (8 due to extensive vascular involvement and 3 due to peritoneal/liver metastases). The sensitivity, specificity, PPV and NPV of pre-operative radiological imaging in determining unresectability due to liver/peritoneal metastases were 42%, 100%, 100% and 94.7% respectively. There was a significant difference in CA 19-9 values between metastatic and non-metastatic disease (p = 0.020). ROC curve analysis calculated the optimal CA 19-9 cutoff point for predicting metastasis at 215.37 U/ml with a sensitivity of 72.7%, a specificity of 58.3%, PPV of 15.1% and NPV of 95.5%. Tumor diameter was not a significant factor in predicting resectability. Laparoscopy would have been useful in only 5.3% of patients in the present series.

Conclusion

High CA 19-9 values (>215 U/ml) and not tumor size should select patients with radiological resectable peri-pancreatic cancer for staging laparoscopy.

Introduction

Most of the patients with pancreas cancer present with metastatic disease (∼60%) and only 10% have local disease and about 30% have regional disease.1, 2 Detection of metastatic disease is critical because it prevents the patient from undergoing unnecessary surgery as even exploratory laparotomy has high morbidity (up to 30%)³ and also allows for endoscopic/minimally invasive palliation.

The role of laparoscopic assessment (laparoscopy with or without intra-operative ultrasound) in the pre-operative staging in suspected peri-pancreatic head malignancy is controversial. With improvements in multi-detector computed tomography and Magnetic Resonance Imaging, the number of patients benefiting from pre-operative laparoscopy is reduced to 6–16% in the last 10 years.4, 5, 6 Current recommendations are for a selective use in patients with pancreas head tumors > 3 cm and with CA 19-9 values >100 U/ml.⁷

The aim of this study was to validate the above recommendations in a contemporary cohort of patients with pancreas head/peri-ampullary cancer who were considered radiological resectable, using the indirect assessment method.

Section snippets

Patients and methods

The present study is based on the STARD (Standards for Reporting of Diagnostic accuracy) recommendations.

From 2007 to 2013, consecutive patients who met radiological criteria for potentially resectable peri-pancreatic head tumors were identified from the prospective departmental HPB cancer database. Each tumor was characterized as resectable, marginally resectable or unresectable on the basis of CT/MRI findings. The majority of patients had internal multi-detector CT scanning. Patients with

Results

A flow chart of the study is shown in Fig. 1. Over a 6 year time period, 136 patients with pancreas head and/or peri-ampullary tumors were referred and evaluated.

Pre-operative imaging studies reveal radiographically resectable tumors in 126 patients (92.6%) who underwent laparotomy with curative intent. These included 10 (7.9%) patients with equivocal radiological findings for resectability. There were 10 patients (8%) who were deemed radiological unresectable (5 due to vascular involvement and

Discussion

We found that laparoscopy is indicated only in patients with a CA 19-9 >215 U/ml and that a peri-pancreatic head tumor diameter >3 cm in not an indication for staging laparoscopy if the patient has radiological resectable disease. Only 5.3% of patients would have theoretically benefited from staging laparoscopy in the current series.

No level I data for the value of laparoscopic staging exist. A recent meta-analysis of 2827 patients found the yield of staging laparoscopy for pancreatic and

Conflict of interest statement

The authors declare no conflicts of interest.

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^☆: Part of the study was presented at the 14th World Congress of Endoscopic Surgery, Paris 25-28/06/2014.

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High serum CA 19-9 but not tumor size should select patients for staging laparoscopy in radiological resectable pancreas head and peri-ampullary cancer☆

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Patients and methods

Results

Discussion

Conflict of interest statement

Surgery

J Gastrointest Surg

J Am Coll Surg

Eur J Surg Oncol

HPB

J Gastrointest Surg

J Gastrointest Surg

Pancreatic cancer in the general population: improvements in survival over the last decade

J Gastrointest Surg