Should Patients with Locally Advanced Pancreatic Adenocarcinoma Undergo Laparoscopic Staging Prior to Initiation of Chemoradiation?
Abstracts
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Introduction: Pancreatic adenocarcinoma remains a lethal disease with the majority of patients presenting at an advanced stage precluding resection. Locally advanced disease is commonly treated with combined modality therapy. However, the ability of noninvasive imaging modalities such as CT and MRI to determine the presence of metastatic disease has not been examined. The aim of this study was to examine our prospectively accrued experience with laparoscopic staging to determine the incidence of metastatic disease in patients with locally advanced pancreatic cancer who were otherwise considered eligible for chemoradiation therapy. Methods: Between 1994-2000, 100 consecutive patients undergoing staging laparoscopy with radiologic evidence of unresectable locally advanced pancreatic cancer were identified from a prospective database. All patients were without detectable metastatic disease on preoperative contrast-enhanced, thin cut helical CT or contrast-enhanced MRI. The operative and pathology reports were reviewed, and the presence or absence of metastatic disease confirmed. Results: With a median age of 64 years (38-84), there were 53 men and 47 women. The disease site was the pancreatic head in 69 cases and in the body or tail in 31 cases. Radiologic assessment of nonresectability was due to celiac and/or hepatic artery encasement in 37 patients and portal vein, superior mesenteric vein or arterial encasement in 63 cases. Laparoscopy identified 37 (37%) patients with metastatic disease. Peritoneal disease was noted in 12 cases, liver metastasis in 18 cases, and 7 patients had both. Median tumor size was determined radiologically to be 4.0 cm for both the locally advanced alone group and for those with metastatic disease. Patients with metastatic disease had a reduced median survival compared to those with locally advanced disease (7 vs 9 months). Conclusion: Contemporary imaging modalities failed to detect metastatic disease in 37% of patients who were considered to have locally advanced pancreatic cancer and thus were candidates for combined modality chemoradiation. This study suggests that patients considered for chemoradiation for locally advanced pancreatic cancer should be staged at operation prior to initiating therapy. This approach will achieve considerable economic and quality of life benefits, and avoid inappropriate use of ineffective local therapies. |
