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ABSTRACT: The impact of the number of lymph node (LN) evaluated pathologically on accurate staging is unknown. Our primary aim was to determine a minimum number of evaluated LN needed to provide accurate staging of pancreatic cancer.
Four hundred ninety-nine patients underwent a curative pancreatectomy for pancreatic adenocarcinoma cancer from 1981-2007. The probability of understaging a patient as N0 was estimated based on the number of LN evaluated. The prognostic value of LN ratio (LNR) was assessed.
Survival for node-negative (pN0) patients with <11 LN examined was worse than for pN0 patients with ≥11 LNs with a hazard ratio (95 % CI) of 1.33 (1.1-1.7, p = 0.01) with 3-year survivals of 32 vs. 50%, respectively. Three-year survival for pN1 patients with <11 nodes evaluated was similar to pN1 patients with ≥11 nodes (25 vs. 30%). LNR ≥ 0.17 predicted worse survival with hazard ratio of 1.76 (1.3-2.4, p = 0.001) than LNR < 0.17; 3-year survivals were 37 vs. 19%.
Patients with "N0" disease with <11 LN evaluated pathologically have worse survival, suggesting that metastatic nodes were missed by evaluating too few nodes. For pN1 patients, LNR stratifies survival of patient cohorts more accurately. Adequate staging of pancreatic cancer requires pathologic evaluation of ≥11 LNs.
Journal of Gastrointestinal Surgery 03/2012; 16(5):920-6. · 2.83 Impact Factor
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Travis E Grotz,
David Nagorney,
John Donohue,
Florencia Que,
Michael Kendrick, Michael Farnell,
Scott Harmsen,
David Mulligan,
Justin Nguyen,
Charles Rosen,
Kaye M Reid-Lombardo
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ABSTRACT: Hepatic epithelioid haemangioendothelioma (HEH) is a rare vascular neoplasm with unpredictable clinical behaviour.
To compare overall survival (OS) and disease-free survival (DFS) between liver resection (LR) and orthotopic liver transplantation (OLT) for the treatment of HEH.
Retrospective review of 30 patients with HEH treated at Mayo Clinic during 1984 and 2007.
Median age was 46 years with a female predominance of 2:1. Treatment included LR (n= 11), OLT (n= 11), chemotherapy (n= 5) and no treatment (n= 3). LR was associated with a 1-, 3- and 5-year OS of 100%, 86% and 86% and a DFS of 78%, 62% and 62%, respectively. OLT was associated with a 1-, 3- and 5-year OS of 91%, 73% and 73% and a DFS 64%, 46% and 46%, respectively. Metastases were present in 37% of patients but did not significantly affect OS. Important predictors of a favourable OS and DFS were largest tumour ≤ 10 cm and multifocal disease with ≤ 10 nodules.
LR and OLT achieve comparable results in the treatment of HEH. LR is appropriate for patients with resectable disease and favourable prognostic factors. OLT is appropriate for patients with unresectable disease and possibly those with unfavourable prognostic factors. Metastases may not be a contraindication to surgical treatment.
HPB 10/2010; 12(8):546-53. · 1.60 Impact Factor
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ABSTRACT: Preoperative serum values of CA 19-9 have been reported to be associated with survival in patients undergoing resection of pancreatic adenocarcinoma.
Preoperative CA 19-9 levels are associated with margin and/or lymph node status in patients undergoing pancreatoduodenectomy for pancreatic carcinoma.
We conducted a review of 143 patients undergoing pancreatoduodenectomy for pancreatic adenocarcinoma from July 2001 through April 2006 at our institution. Preoperative serum values of CA 19-9 and total bilirubin, pathologic findings, and survival were analyzed. A cutoff value for CA 19-9 (120 U/ml) was determined using a Cox proportional hazards model for survival.
Overall survival at 1, 3, and 5 years for patients with CA 19-9 < or = 120 U/ml was 76%, 41%, and 31%, respectively, versus 64%, 17%, and 10% for patients with CA 19-9 > 120 U/ml (p = 0.002). CA 19-9 > 120 U/ml was not associated, however, with a greater chance of an R1 or R2 resection (p = 0.86), tumor involving the SMA margin (p = 0.88), tumor at the portal vein groove (p = 0.14), or lymph node metastases (p = 0.89).
Our findings do not support a cutoff value for CA 19-9 that is associated with margin or lymph node involvement. Preoperative CA 19-9 < or = 120 U/ml is, however, associated with increased overall and recurrence-free survival.
Journal of Gastrointestinal Surgery 09/2009; 13(11):2050-8. · 2.83 Impact Factor
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ABSTRACT: Less than 5% of patients diagnosed with exocrine pancreas cancer live to be long-term survivors (5+ years after diagnosis). As a result, few studies have focused on these patients' cumulative, cancer-related morbidity and late mortality. This descriptive study was undertaken to explore such issues.
One thousand eight hundred thirty consecutive patients who had exocrine pancreas cancer had been seen at the Mayo Clinic between 1995 and 2001 and who had well-documented evidence of having lived for 5+ years were the focus of this study.
Only 85 patients (4.6%) met all the above criteria. These patients had a median age of 65 years with a slight female predominance (53%). Eighty-one (95%) were treated with surgery, 42 (49%) with chemotherapy, and 41 (48%) with radiation. Cumulative morbidity included one or more subsequent surgeries in 17 patients (20%), one or more major infections in 14 (16%), diabetes in 39 (45%), depression in 16 (19%), and a second malignancy in 17 (20%). Twenty-nine patients were deceased at the time of this report; 15 (18%) died from recurrent pancreas cancer more than 5 years after their original diagnosis.
Long-term survivors of exocrine pancreas cancer confront notable rates of cumulative morbidity, which include subsequent major surgeries, major infections, diabetes, depression, and second malignancies, as well as late deaths from pancreas cancer itself.
Journal of Gastrointestinal Cancer 09/2009; 40(1-2):46-50.
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ABSTRACT: Pancreatic cancer recurs in most patients after resection with curative intent. Recurrence is particularly common in patients with extrapancreatic neural invasion (EPNI), the presence of which correlates with poor prognosis. Macroscopic EPNI may be detected with conventional noninvasive imaging and endoscopic ultrasound (EUS) imaging, but microscopic EPNI has required postoperative pathologic examination of surgical specimens. We report the preoperative diagnosis of cancer infiltration into celiac ganglia. We hypothesized that microscopic pancreatic cancer metastasis to neural ganglia can be detected by EUS-guided biopsy examination.
We performed a retrospective review of patients with pancreatic cancer undergoing EUS in whom celiac ganglia were sampled to exclude malignant infiltration.
Six patients with pancreatic cancer underwent EUS-guided fine-needle aspiration or trucut biopsy examination of presumed celiac ganglia. Metastatic cancer was found in ganglia of 2 patients. Specimen review identified adenocarcinoma and neural tissue in the absence of lymphocytes. At laparoscopy, 1 of the 2 patients with positive celiac biopsy specimens also had several unexpected peritoneal metastatic deposits. The other patient was considered to have locally advanced unresectable disease. Both patients are receiving supportive care.
EPNI may be shown preoperatively in patients with pancreatic cancer using EUS-guided sampling of celiac ganglia. A preoperative diagnosis of EPNI has the potential to improve staging accuracy and patient outcomes.
Clinical Gastroenterology and Hepatology 01/2007; 4(12):1479-82. · 5.63 Impact Factor
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ABSTRACT: Hepatic resection for hepatocellular carcinoma (HCC) in patients with cirrhosis is generally recommended for patients with Child-Turcotte-Pugh (CTP) Class A liver disease and early tumor stage. The Model for End-Stage Liver Disease (MELD) has been shown to accurately predict survival in patients with cirrhosis, but whether MELD is useful for selection of patients with cirrhosis for hepatic resection is unknown. We examined whether MELD was predictive of perioperative mortality and correlated MELD with other potential clinicopathologic factors to overall survival in patients with cirrhosis undergoing hepatic resection for HCC. A retrospective chart review was undertaken of patients with HCC and cirrhosis undergoing hepatic resection between 1993 and 2003. Eighty-two patients (62 men, 20 women; mean age, 62 years) were identified. Forty-five patients had MELD score > or =9 (range, 9-15) and CTP score ranged from 5 to 9 points. Fifty-nine patients underwent minor (<3 segments) hepatic resections (MELD < or =8, n = 29; MELD > or =9, n = 30) and 23 underwent major (> or =3 segments) hepatic resections (MELD < or =8, n = 8; MELD > or =9, n = 15). Perioperative mortality rate was 16%. MELD score < or =8 was associated with no perioperative mortality versus 29% for patients with an MELD score > or =9 (P < 0.01). Multivariate analysis demonstrated that MELD score > or =9 (P < 0.01), clinical tumor symptoms (P < 0.01), and ASA score (P = 0.046) are independent predictors of perioperative mortality. Multivariate analysis showed MELD > or =9 (P < 0.01), tumor size >5 cm (P < 0.01), high tumor grade (P = 0.03), and absence of tumor capsule (P < 0.01) as independent predictors of decreased long-term survival. MELD score was a strong predictor of both perioperative mortality and long-term survival in patients with cirrhosis undergoing hepatic resection for HCC. In patients with cirrhosis, hepatic resection (minor or major) for HCC is recommended if the MELD score is < or =8. In patients with MELD score > or =9, other treatment modalities should be considered.
Journal of Gastrointestinal Surgery 12/2005; 9(9):1207-15; discussion 1215. · 2.83 Impact Factor
