术前影像学检查评估胰腺肿瘤可切除性的价值

目的 探讨胰腺癌可切除性的术前评估.方法 通过回顾性分析患者术前的CT、MRI、MRCP等影像学资料,对1990年6月至2006年6月间115例胰腺癌患者进行术前可切除性评估.结果 本组115例,有29例术前判断为无法切除,86例可切除;术中实际行胰十二指肠切除术的病例为78例,未能手术切除的病例为37例.CT等影像学检查术前判断肿瘤可切除的阳性预测值为87.2%(75/86),阴性预测值为89.7%(26/29),准确性为87.8%(101/115).结论 胰腺癌术前可切除性判断,既可提高手术切除率,降低手术风险,减少术后并发症及病死率;同时可避免不必要的手术给患者带来的侵害,提高患者的生活质量.     

术前影像学检查评估胰腺肿瘤可切除性的价值

目的探讨胰腺癌可切除性的术前评估。方法通过回顾性分析患者术前的CT、MRI、MRCP等影像学资料,对1990年6月至2006年6月间115例胰腺癌患者进行术前可切除性评估。结果本组115例,有29例术前判断为无法切除,86例可切除;术中实际行胰十二指肠切除术的病例为78例,未能手术切除的病例为37例。CT等影像学检查术前判断肿瘤可切除的阳性预测值为87.2%（75/86）,阴性预测值为89.7%（26/29）,准确性为87.8%（101/115）。结论胰腺癌术前可切除性判断,既可提高手术切除率,降低手术风险,减少术后并发症及病死率;同时可避免不必要的手术给患者带来的侵害,提高患者的生活质量。     

Induction chemotherapy in pancreatic cancer: CA 19-9 may predict resectability and survival

BackgroundPreoperative/Neoadjuvant treatment (NT) is increasingly used in unresectable pancreatic cancer (PDAC). However, ∼40% of patients cannot be resected after NT and reliable preoperative response evaluation is currently lacking. We investigated CA 19-9 levels and their dynamics during NT for prediction of resectability and survival.MethodsWe screened our institution's database for patients who underwent exploration or resection after NT with gemcitabine-based therapy (GEM) or FOLFIRINOX (FOL). Pre- and post-NT CA 19-9, resection rate and survival were analyzed.ResultsOf 318 patients 165 (51.9%) were resected and 153 (48.1%) received exploration. In the FOL group (n = 103; 32.4%), a post-NT CA 19-9 cutoff at 91.8 U/ml had a sensitivity of 75.0% and a specificity of 76.9% for completing resection with an AUC of 0.783 in the ROC analysis (95% CI: 0.692–0.874; p < 0.001. PPV: 84.2%, NPV: 65.2%). Resected patients above the cutoff did not benefit from resection. Post-NT CA 19-9 <91.8 U/ml (OR 11.63, p < 0.001) and CA 19-9 ratio of <0.4 (OR 5.77, p = 0.001) were independent predictors for resectability in FOL patients.DiscussionCA 19-9 levels after neoadjuvant treatment with FOLFIRINOX predict resectability and survival of PDAC more accurately than dynamic values and should be incorporated into response evaluation and surgical decision-making.     

70岁及以上不可切除的胰腺癌患者生存因素分析

目的 探讨影响70岁及以上不可切除的胰腺癌患者生存的相关因素.方法 总结57例70岁及以上的晚期胰腺癌住院患者的临床资料,分析性别、年龄、既往糖尿病史、胆道疾病史、吸烟史、化疗、放疗、美国东部肿瘤协作组(Eastern Collaborative Oncology Group,ECOG)评分、肿瘤标志物癌胚抗原(carcinoembroynic antigen,CEA)和CA199升高情况等对总生存的影响.结果 性别、行为状态、化疗、放疗与生存密切相关.男性和女性比较,中位生存期分别为(10.7±5.4)个月和(5.5±2.3)个月,P=0.000;ECOG评分0～1分和≥2分比较,中位生存期分别为(10.1±5.8)个月和(7.3±3.8)个月,P=0.040;未接受化疗组和接受化疗组比较,中位生存期分别为(7.8±5.3)个月和(11.5±5.0)个月,P=0.038;未接受放疗组和接受放疗组比较,中位生存期分别为(8.9±5.4)个月和(13.7±3.8)个月,P=0.048;差异均有统计学意义.胰腺癌总的中位生存期为8.9个月,1年生存率为28.1%.结论 70岁及以上老年人胰腺癌的预后与性别、行为状态、化疗和放疗相关.对于不可切除但行为状态好的老年胰腺癌患可以考虑化疗,部分患者甚至可以考虑联合放疗.     

70岁及以上不可切除的胰腺癌患者生存因素分析

Objective To explore the effect of related factors on survival of patients with unresectable pancreatic cancer aged 70 years and over. Methods Fifty-seven patients with unresectable locally advanced or metastatic pancreatic cancer aged 70 years and over were enrolled.Their survival time were analyzed with SPSS 13.0 by taking account of gender, age, smoking history,alcohol history, pancreatic disease history, diabetes mellitus history, Eastern Collaborative Oncology Group (ECOG) scoring, chemotherapy, radiotherapy, CEA and CA199 levels. Results Gender,ECOG scoring, chemotherapy and radiotherapy had relationship with overall survival. The median survival time was 8.9 months and one-year survival rate was 28.1%. The median survival was (10.7±5.4) months in male group and (5.5±2.3) months in female group (P=0.000). The median survival was(10.1±5.8) months in patients with ECOG 0～1 group and(7.3±3.8)months in patients with ECOG 2 group (P=0.040). The median survival was(7.76±5.27) months in nochemotherapy group and(11.5±5.0)months in chemotherapy group (P=0.038). The median survival was(8.87±5.36)months in no radiotherapy group and (13.7±3.8) months in radiotherapy group (P=0.048). Conclusions The patients who have better ECOG performance status and receive chemotherapy or radiotherapy show better survival.     

70岁及以上不可切除的胰腺癌患者生存因素分析

Objective To explore the effect of related factors on survival of patients with unresectable pancreatic cancer aged 70 years and over. Methods Fifty-seven patients with unresectable locally advanced or metastatic pancreatic cancer aged 70 years and over were enrolled.Their survival time were analyzed with SPSS 13.0 by taking account of gender, age, smoking history,alcohol history, pancreatic disease history, diabetes mellitus history, Eastern Collaborative Oncology Group (ECOG) scoring, chemotherapy, radiotherapy, CEA and CA199 levels. Results Gender,ECOG scoring, chemotherapy and radiotherapy had relationship with overall survival. The median survival time was 8.9 months and one-year survival rate was 28.1%. The median survival was (10.7±5.4) months in male group and (5.5±2.3) months in female group (P=0.000). The median survival was(10.1±5.8) months in patients with ECOG 0～1 group and(7.3±3.8)months in patients with ECOG 2 group (P=0.040). The median survival was(7.76±5.27) months in nochemotherapy group and(11.5±5.0)months in chemotherapy group (P=0.038). The median survival was(8.87±5.36)months in no radiotherapy group and (13.7±3.8) months in radiotherapy group (P=0.048). Conclusions The patients who have better ECOG performance status and receive chemotherapy or radiotherapy show better survival.     

与胰腺癌神经浸润相关的临床因素分析

目的 观察胰腺癌的神经浸润状况,分析与其相关的临床因素.方法 回顾性分析73例胰腺癌患者的神经浸润状况,分析神经浸润与肿瘤临床病理特征及患者生存率之间的关系.结果 73例中38例(52.1％)有神经浸润,其中6例(15.8％)为单纯胰内神经浸润,32例(84.2％)为胰内、胰外神经均浸润.神经浸润与患者性别、年龄及肿瘤病理类型、分化程度、大小、淋巴结转移均无关(P值均＞0.05),而与腹痛、脉管浸润、肿瘤组织表皮生长因子受体(EGFR)及血管内皮生长因子(VEGF)表达均显著相关(P值均＜0.01).有神经浸润患者的中位生存时间为8个月,显著短于无神经浸润患者的13个月(x2=4.69,P=0.030).结论 胰腺癌的神经浸润发生率较高,可引起明显腹痛,其与脉管浸润及肿瘤组织EGFR和VEGF表达相关,是影响胰腺癌患者术后生存率的因素之一.     

The impact of extent of pancreatic and venous resection on survival for patients with pancreatic cancer

BackgroundBorderline resectable pancreatic cancer may require extended resections in order to achieve tumor-free margins, especially in the case of up-front resections, but it is important to know the limits of surgical therapy in this disease. This study aimed to investigate the impact of extent of pancreatic and venous resection on short- and long-term outcomes in patients with pancreatic adenocarcinoma (PDAC).MethodsThis was a retrospective study from a prospectively maintained database of pancreatic resections for PDAC. Short- and long-term outcomes were analyzed in patients having borderline resectable PDAC submitted to up-front total pancreatectomy (TP) or pancreaticoduodenectomy (PD) with simultaneous portal vein (PV) and/or superior mesenteric vein (SMV) resection. Venous resections were carried out as tangential venous resection (TVR) or segmental venous resection (SVR). Patients were divided into 4 groups: (1) PD + TVR, (2) PD + SVR, (3) TP + TVR, (4) TP + SVR. Uni- and multivariate Cox regression analysis were performed to identify factors associated with survival.ResultsNinety-nine patients were submitted to simultaneous pancreatic and venous resection for PDAC. Among them, 25 were submitted to PD + TVR (25.3%), 12 to PD + SVR (12.1%), 23 to TP + TVR (23.2%), and 39 to TP + SVR (39.4%). Overall, major morbidity (Clavien-Dindo grade ≥ IIIA) was 26.3%. Thirty- and 90-day mortality were 3% and 11.1%, respectively. There were no significant differences among groups in terms of short-term outcomes. Median overall survival of patients submitted to PD + TVR was significantly higher than those to TP+SVR (29.5 vs 7.9 months, P = 0.001). Multivariate analysis identified TP (HR = 2.11; 95% CI: 1.31–3.44; P = 0.002) and SVR (HR = 2.01; 95% CI: 1.27–3.15; P = 0.003) as the only independent prognostic factors for overall survival.ConclusionsUp-front TP associated to SVR was predictive of worse survival in borderline resectable PDAC. Perioperative treatments in high-risk surgical groups may improve such poor outcomes.     

多层螺旋CT对胰腺癌血管侵犯的可切除性评价标准探讨

目的 探讨不同标准对胰腺癌血管侵犯的判断作用.方法 回顾性分析经手术证实的56例胰腺癌MSCT图像,对胰腺周围5支大血管分别按照Loyer等、Lu等及长海医院标准评价各支血管的侵犯程度及肿瘤可切除性.以手术结果 为金标准,统计各标准评价的准确性,并计算其与手术间的Kappa系数.结果 Loyer等分型标准判断肿瘤可切除性的正确率、敏感性、特异性、阳性预测值、阴性预测值分别为86.79%、86.27%、86.90%、59.46%和96.60%,Kappa系数为0.623;Lu等分级法判断肿瘤可切除性的正确率、敏感性、特异性、阳性预测值、阴性预测值分别为93.21%、84.31%、95.20%、79.63%和96.46%,Kappa系数为0.777;长海医院标准判断肿瘤可切除性的正确率、敏感性、特异性、阳性预测值、阴性预测值分别为95.36%、84.31%、97.82%、89.58%和96.55%,Kappa系数为0.841.结论 长海医院标准对胰腺癌血管侵犯的评价是切实可行的.     

The impact of different metastatic patterns on survival in patients with pancreatic cancer

BackgroundThe aims of this study were to compare the metastatic patterns of pancreatic ductal adenocarcinoma (PDAC) of head and body/tail and to determine the prognostic factors.MethodsData of metastatic PDAC (MPC) between 2004 and 2015 from the Surveillance, Epidemiology and End Results (SEER) database was extracted and analyzed. The correlation analyses of metastatic patterns were also conducted. Multivariate Cox regression analyses were used to analyze prognosis.ResultsA total of 27470 eligible MPC patients were collected from SEER database. Patients in the head group had a higher proportion of single-metastasis while those in the body/tail group had a higher proportion of two-site metastases. Similar distributions of metastatic sites were observed in cases with single-metastasis between two groups. Patients with liver and peritoneum metastases in the head group had significantly higher overall survival (OS) rates than those in the body/tail group. Also, the OS rates stratified by varied tumor sites did not differ significantly in patients with bone, brain, and lung metastases. Chemotherapy could prolong survival in almost all MPC patients while radiotherapy or surgery could only benefit certain types of metastases. Tumor site, therapy and vascular invasion were independent prognostic factors of OS in MPC patients.ConclusionsMPC of the head and body/tail presented with different metastatic patterns. Chemotherapy benefited patients with metastases while surgery and radiotherapy could only prolong survival in patients with liver and peritoneum metastases. Our findings may provide more details for the precise management of patients with MPC in clinical practice.     

EUS diagnosis of vascular invasion in pancreatic cancer: surgical and histologic correlates

BACKGROUND: Endoscopic ultrasound (EUS) has been compared to intraoperative surgical palpation for diagnosis of vascular invasion by pancreatic cancer. This study compares EUS with vascular resection and histologic evidence of vascular invasion in resected pancreatic masses. METHODS: All patients with solid pancreatic masses who underwent both preoperative EUS and surgery at 1 hospital over a 7 year period were identified. The relationship of pancreatic masses to adjacent vessels was prospectively assessed by EUS. EUS findings were compared to surgical and pathology gold standards. "Vascular adherence" was defined as tumor adherence requiring vascular resection during surgery, and "vascular invasion" as histologic invasion of vessel wall by tumor. RESULTS: 30 of 68 patients were resectable. Among these 30, vascular adherence was present in 8, including 18% of patients with an intact echoplane between tumor and adjacent vessels at EUS, 29% of those with loss of echoplane alone, and 50% of those with additional EUS features of vascular involvement. Vascular invasion was present in 4, including 12% of patients with an intact echoplane, 0% of those with loss of echoplane alone, and 33% of those with additional EUS features. Sensitivity, specificity, PPV, and NPV of EUS were 63%, 64%, 43% and 80% for vascular adherence and 50% 58%, 28% and 82% for vascular invasion. NPV rose to 90% for vascular adherence if only the portal confluence vessels were considered. CONCLUSIONS: EUS has poor sensitivity, specificity, and positive predictive value for diagnosis of venous involvement by pancreatic cancer.     

Relationship between DNA ploidy and survival in patients with exocrine pancreatic cancer

The DNA ploidy of pancreatic cancer tissue from paraffin blocks was measured by flow cytometry in 46 patients whose disease had been detected and treated with surgery. Lymph node involvement was observed at the time of diagnosis in 36% of patients with diploid tumors and in 79% of patients with aneuploid tumors (p = 0.017), but no clear relation to metastasis could be observed (p = 0.201). The S-phase fraction (SPF) was significantly higher in aneuploid than in diploid tumors (p = 0.007). All patients who underwent radical surgery had diploid DNA content and SPF below the median (11.5%). Seven patients with a diploid tumor (32%) and none of the aneuploid cases survived 1 year. Over the 1-year period, in order of importance, the type of treatment (p less than 0.001), DNA ploidy (p = 0.004), tumor size (p = 0.0046), and lymph node status (p = 0.027) predicted survival. Aneuploidy showed a significant association with decreased cumulative survival (p = 0.015), and a suggestive relationship with SPF was found. The results suggest that DNA ploidy of pancreatic cancer can be used in dividing the patients into different prognostic groups. The value of the detection of aneuploidy, however, is limited, because diploid pancreatic cancers are also generally rapidly fatal.     

Biological and conditional factors should be included when defining criteria for resectability for patients with pancreatic cancer

BackgroundThis study aimed to evaluate novel resectability criteria for pancreatic ductal adenocarcinoma (PDAC) proposed by the International Association of Pancreatology (IAP) by comparing them with the National Comprehensive Cancer Network (NCCN) guidelines.Methods369 patients who underwent upfront surgery for PDAC were retrospectively analyzed. Overall survival (OS) of each group as defined by either of the guidelines were compared and preoperative prognostic factors for OS were identified.ResultsBased on the IAP-criteria, 157 patients were classified as resectable (R), 192 as borderline resectable (BR) and 20 as unresectable (UR), with the median survival time (MST) of 40 months, 17 and 11, respectively. In contrast to the NCCN-criteria, BR demonstrated significantly better OS than UR (P = 0.023) under the IAP-criteria. Performance status ≥2 (hazard ratio [HR]: 2.47, P = 0.014) and lymph node metastasis suspected by imaging (HR: 1.55, P = 0.003) were identified as independent prognostic factors by the multivariate analysis along with portal or arterial invasion, while carbohydrate antigen 19-9 ≥ 500 U/ml was not (HR: 1.23, P = 0.190).ConclusionThe IAP-criteria, which includes biological and conditional factors, resulted in superior separation of survival curves stratified by the resectablity when compared with the NCCN-criteria.     

Power Doppler ultrasonography for the assessment of vascular invasion by pancreatic cancer

Aim: To investigate the diagnostic accuracy of power Doppler ultrasonography (US) in assessing the vascular invasion by pancreatic cancer. Methods: A prospective study of 40 consecutive patients with pancreatic cancer (head 35, body 5) was performed. All patients underwent surgery. The relationships between tumor and each vessel were classified into four types according to the closest circumferential contact of the tumor with the vessel. A type 0 indicated no contact; type 1 indicated less than one third contact; type 2 indicated one third to 99% contact, and type 3 indicated encasement. Vascular invasion was diagnosed in types 2 and 3. The diagnostic accuracy was evaluated in the portal vein and in the splanchnic arteries (celiac artery, common hepatic artery, and superior mesenteric artery). The power Doppler US findings were confirmed by the operative findings. The results of power Doppler US were compared with those of CT scan and angiography. Results: Portal vein invasion was confirmed in resected specimens in 23 cases and by operative findings in 5 cases. For the diagnosis of portal vein invasion, sensitivity, specificity, and overall accuracy of power Doppler US were, respectively, 79.3, 90.9, and 82.5%. The respective values were 79.3, 100, and 85% for CT and 72.4, 81.8, and 75% for angiography. For the diagnosis of arterial invasion, sensitivity, specificity, and overall accuracy of power Doppler US were 80, 92, and 90%, respectively. The corresponding values were 47, 88, and 73% for CT and 47, 100, and 80% for angiography. Conclusion: Power Doppler US proved to be useful for the diagnosis of vascular invasion by pancreatic cancer.