Should High Serum Ca 19-9 Levels Preclude Surgery in Patients with Resectable Pancreatic Head Adenocarcinoma?
Olivier Turrini1, C. Max Schmidt*1,2, Jose a. Moreno1, Purvi Parikh1, Michael House1, Nicholas J. Zyromski1,2, Attila Nakeeb1, Thomas J. Howard1, Henry a. Pitt1, Keith D. Lillemoe1
1Surgery, Indiana University School of Medicine, Indianapolis, IN; 2Surgery, Richard L Roudebush VAMC, Indianapolis, IN
An elevated serum CA 19-9 in patients with pancreatic adenocarcinoma (PA) has been associated with a poor prognosis. This study was conducted to assess the outcome of patients with resectable pancreatic head adenocarcinoma associated with high serum CA 19-9 levels. Methods: From 2000-2007, 344 patients underwent pancreaticoduodenectomy for resectable PA. Standard preoperative staging included dual-phase helical CT scanning +/- endoscopic ultrasound. Fifty-three patients (elevated group) had preoperatively elevated serum CA 19-9 levels (>400 IU/ml) after correction for obstructive jaundice. Of these, 27 patients had high levels (400-899 IU/ml (HL)) and 26 patients had very high levels >900 IU/ml (VHL). Patients with a serum bilirubin of > 2 mg/dL at the time of serum CA 19-9 measurement were excluded. Serum CA 19-9 levels were re-measured after surgery and before adjuvant treatment. Fifty patients with normal preoperative serum CA 19-9 levels (<37 IU/ml) comprised the control group. Results: Both median survival (22 mos, vs. 15 mos, p= 0.02) and overall 3-year survival (32% vs. 14%, p= 0.03) were significantly longer in the control group (n= 50) compared to the elevated group (n= 53). There was no significant differences in the median survival or overall 3-year survival rates between patients with HL and VHL. Seven patients in the elevated group (4 HL and 3 VHL) are still alive after a mean follow-up of 34 months. Patients in the elevated group who normalized their serum CA 19-9 levels after resection (n= 11) had a survival equivalent to patients in the control group. Conclusions: Patients with resectable PA and high preoperative serum CA 19-9 levels have equivalent perioperative morbidity and mortality but a shorter survival compared to patients with normal preoperative serum CA 19-9 levels. Patients who normalized their serum CA 19-9 levels after resection, however, had equivalent survival to patients with normal pre-operative serum CA 19-9 levels. Pre-operative serum CA 19-9 level, by itself, should not preclude resection in patients who have undergone careful preoperative staging.
| Group | n | age (yr) | † CA 19-9 (IU/ml)* | T (cm) | R0 (%) | N1 (%) | Morbidity (%) | Mortality |
| Control | 50 | 64.4 | 33.5 | 2.8 | 41 (82) | 29 (58) | 18 (36) | 0 |
| Elevated | 53 | 65.9 | 1756 | 3.1 | 40 (76) | 39 (73) | 15 (28) | 0 |
(†preoperative value; T: tumor size; N1: positives lymph nodes; *p <0.05 control vs elevated groups)
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