Staging for locally advanced pancreatic cancer.

AIM: To address the role of a dedicated radiologist and high quality CT scanning in staging of patients referred with suspected locally advanced pancreatic cancer. Furthermore, the value of laparoscopy in detecting CT-occult metastases in these patients was assessed. METHODS: In a prospective cohort study, 116 patients with suspected unresectable pancreatic cancer referred from peripheral hospitals (107) or our own gastroenterology department (9) were analysed. CT scans from referral centres were reviewed and in case of locally advanced disease or uncertain metastatic disease, patients underwent a laparoscopy to detect CT-occult metastases. Patients without metastases were offered 5-FU based chemoradiotherapy. RESULTS: After reviewing 107 abdominal CT scans from referral centres, 73 (68%) scans had to be repeated due to unacceptable quality. Locally advanced disease was confirmed in 59 (55%) patients and metastatic disease was found in 24 patients (22%). During laparoscopy, metastases were found in 24/68 (35%) patients with locally advanced disease on CT scan and metastases were confirmed in 3/5 (60%) with suspected metastases. Overall, only 46/116 (40%) patients with suspected unresectable disease appeared to have locally advanced pancreatic cancer after adequate staging including laparoscopy in our centre. CONCLUSION: Correct staging is difficult in patients with suspected locally advanced pancreatic cancer and should preferably be performed in centres with technically advanced equipment and experienced radiologists. Laparoscopy should be offered to patients before locoregional therapy.

Long-term survival after radical resection for pancreatic head and ampullary cancer: a potential role for the EGF-R.

BACKGROUND/AIM: Pancreatic cancer has a dismal prognosis. Ampullary cancer (defined as cancer of the ampulla of Vater or the distal common bile duct) has a better prognosis and is thought to be a biologically different tumor. The aim of this study was to find factors that could predict survival after radical (R-0) resection for pancreatic head and ampullary cancers. METHODS: We analyzed clinical and pathological data from 93 patients who underwent a true R-0 resection for pancreatic head or ampullary cancer. Furthermore, we performed a tissue microarray protein expression analysis for several growth factor receptors and oncogenes: HER-2, EGF-R, ER, PR, C-myc, p53, p16, RB-1, and chromogranin A as a neuroendocrine differentiation marker. RESULTS: Median survival (14 vs. 42 months) and time to recurrence (16 vs. 42 months) were significantly longer for ampullary than for pancreatic head cancers. Preoperative pain, perineural invasion, lymph node metastasis, and tumor differentiation grade are indicators of a poor survival. No differences in protein expression were found between groups, except for EGF-R which was expressed more in pancreatic head cancers (p = 0.026). CONCLUSIONS: Outcomes for ampullary cancers are better than for pancreatic head cancers. This different biological behavior can possibly be explained by differences in EGF-R expression.

Survival after surgical management of pancreatic adenocarcinoma: does curative and radical surgery truly exist?

Surgery for pancreatic cancer offers a low success rate but it provides the only likelihood of cure. Modern series show that, in experienced hands, the standard Whipple procedure is associated with a 5-year survival of 10%-20%, with a perioperative mortality rate of less than 5%. Most patients, however, will develop recurrent disease within 2 years after curative treatment. This occurs, usually, either at the site of resection or in the liver. This suggests the presence of micrometastases at the time of operation. Negative lymph nodes are the strongest predictor for long-term survival. Other predictors for a favourable outcome are tumour size, radical surgery and a histopathologically well-differentiated tumour. Adjuvant therapy has, so far, shown only modest results, with 5FU chemotherapy, to date, the only proven agent able to increase survival. Nowadays, the choice of therapy should be based on histopathological assessment of the tumour. Knowledge of the molecular basis of pancreatic cancer has led to various discoveries concerning its character and type. Well-known examples of genetic mutations in adenocarcinoma of the pancreas are k-ras, p53, p16, DPC4. Use of molecular diagnostics and markers in the assessment of tumour biology may, in future, reveal important subtypes of this type of tumour and may possibly predict the response to adjuvant therapy. Defining the subtypes of pancreatic cancer will, hopefully, lead to target-specific, less toxic and finally more effective therapies. Long-term survival is observed in only a very small group of patients, contradicting the published actuarial survival rates of 10%-45%. Assessment of clinical benefit from surgery and adjuvant therapy should, therefore, not only be based on actuarial survival but also on progression-free survival, actual survival, median survival and quality of life (QOL) indicators. Survival in surgical series is usually calculated by actuarial methods. If there is no information on the total number of patients and the number of actual survivors, and no clear definition of the subset of patients, actuarial survival curves can prove to be misleading. Proper assessment of QOL after surgery and adjuvant therapy is of the utmost importance, as improvements in survival rates have, so far, proved to be disappointing.

Flow profiles in the left anterior descending and the right coronary artery assessed by MR velocity quantification: effects of through-plane and in-plane motion of the heart.

PURPOSE: The purpose of this work was to compare the temporal profiles of volume flow in the left anterior descending artery (LAD) and the right coronary artery (RCA) and to assess the effect of through-plane and in-plane myocardial motion. METHOD: In eight healthy volunteers, MR phase-difference velocity quantification was applied with prospective ECG triggering, pixel size of 1.16 x 0.98 mm2 (LAD) or 1.25 x 0.98 mm2 (RCA), velocity sensitivity of 40 cm/s, and data acquisition time window of 64 ms for LAD (3 ky lines per heartbeat) and 24 ms for RCA. In-plane motion was measured from the magnitude images. RESULTS: In the LAD, systolic peak and mean flow values were 0.94+/-0.28 and 0.30 +/-0.22 ml/s, respectively. Diastolic peak and mean flows were 2.42+/-0.56 and 1.38+/-0.43 ml/s. The systolic to diastolic ratio was 0.37+/-0.12 for peak flow and 0.22+/-0.15 for mean flow. Mean flow through the cardiac cycle was 59.1+/-15.0 ml/min. In the RCA, systolic peak and mean flow values were 1.96+/-0.69 and 0.74+/-0.31 ml/s, respectively. Diastolic peak and mean flows were 1.80+/-0.53 and 0.83+/-0.20 ml/s. The systolic to diastolic ratio was 0.97+/-0.58 for peak flow and 0.85+/-0.39 for mean flow. Mean flow through the cardiac cycle was 38.4+/-10.8 ml/min. The in-plane velocity of the coronary artery cross-section was 6.4+/-1.8 cm/s for the LAD and 14.9 +/-4.0 cm/s for the RCA (given by peak values in diastole). CONCLUSION: It is confirmed noninvasively with MR that the LAD shows a predominantly diastolic flow, whereas the RCA shows about equal flow values in systole and diastole. Through-plane motion correction is required for assessing the true flow patterns. The in-plane velocities of the coronary artery cross-sections imply a maximum data acquisition time window, estimated at 58 ms for the LAD and at 23 ms for the RCA.