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Clinical Usefulness of Staging Laparoscopy in Patients With Biliary Tract Cancer Following Criteria Based on Inflammation-Based Prognostic Scores and Tumor Markers
Kenta Shinozaki*, Tetsuo Ajiki, Taku Matsumoto, Masayuki Akita, Tadahiro Goto, Sadaki Asari, Hirochika Toyama, Masahiro Kido, Takumi Fukumoto, Yonson Ku
Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
Background Biliary tract cancers still have a poor prognosis. Although the most promising therapy is complete resection of the disease, many patients are unresectable at the time of diagnosis. The advances of medical imaging technologies have enabled us to understand the details of the disease preoperatively. But detecting small liver metastasis and peritoneal dissemination is still difficult, and quite a few patients are found to be unresectable during surgical exploration. Staging laparoscopy is widely performed in patients with gastric cancer, pancreatic cancer, and ovarian cancer. However, only a few studies on staging laparoscopy in patients with biliary tract cancer have been reported.
Methods The medical records of patients with biliary tract cancer who underwent open surgery between January 2008 and June 2014 were retrospectively reviewed. The patients were divided into two groups: a resected (R) group and an exploratory laparotomy (EL) group. Preoperative inflammation-based prognostic scores-including neutrophil-lymphocyte ratio (NLR), modified Glasgow Prognostic Score (mGPS) and prognostic nutrition index (PNI)-and tumor markers-including carcinoembryonic antigen (CEA) and carbohydrate antigen19-9 (CA19-9)-were compared between the two groups. We designed a novel score for the selection criteria of staging laparoscopy. We scored 1 for each CEA > 7ng/ml, NLR > 3, CA19-9 > 255U/ml, and mGPS >= B and summed up the scores for each patients. The total scores ranged from 0 to 4.
Results A total of 236 patients were enrolled in this study. The tumor locations were 39 intrahepatic bile duct, 55 perihilar bile duct, 55 distal bile duct, 50 gallbladder, 37 papilla of Vater. Twenty six (11%) patients finally underwent exploratory laparotomy (EL group). The unresectable factors in the EL group were liver metastasis (7 patients), abdominal disseminations (9 patients), distant lymph node metastasis (4 patients), and local advanced or widely spread disease (6 patients). Only 29% of the liver metastases and 50% of the distant lymph node metastases were diagnosed by preoperative imaging studies. CEA, NLR, and mGPS grade were significantly higher in the EL group. The averages of the total scores in the EL and R groups were 2.03 and 0.95, respectively. When the CEA > 7ng/ml and/or the total score >= 3 were considered positive indicators, the sensitivity, the specificity, and the positive predictive value for detecting EL patients were 53.8%, 89.5%, and 38.8%, respectively. If we had performed staging laparotomy according to this criterion, the rate of exploratory laparotomy would have decreased from 11% to 5.1%.
Conclusion Staging laparoscopy in patients with biliary tract cancer according to the criteria based on inflammation-based prognostic scores and tumor markers might be useful in reducing invasive exploratory laparotomy.
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