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Preoperative Pain in Pancreas Cancer: A Predictor of Perineural Invasion?
Rosalie Carr*, Alexandra M. Roch, Nicholas J. Zyromski, Andrea Jester, Eugene P. Ceppa, Attila Nakeeb, C. Max Schmidt, Michael G. House
General Surgery, Indiana University, Indianapolis, IN
Introduction:
Perineural invasion is characteristic of pancreatic adenocarcinoma biology and is present in the majority of resected pathologic specimens. While perineural invasion is a proven negative prognostic factor, its clinical manifestations have not been studied. The purpose of this study was to understand the relationships between preoperative pain, cancer stage, and histopathologic perinerual invasion in patients with pancreatic adenocarcinoma.
Methods:
Chemotherapy naïve patients undergoing resection for pancreatic adenocarcinoma from 2012 to 2014 completed a previously validated Brief Pain Inventory (BPI) survey, for preoperative clinical pain scoring. Scores were grouped according to severity or degree of interference with daily life that was further subdivided into degree of interference with daily activity and mood. Patients were subdivided into those with no pain (BPI score 0), low pain (BPI 1-5), and high pain (BPI 6-10). Preoperative pain was correlated with tumor location, cancer stage, perineural and lymphovascular invasion, lymph node status, lymph node positive ratio, and margin status.
Results:
Fifty two patients were included in this prospective study. Clinical and pathologic differences between patients with and without perineural invasion are indicated in the table. Preoperative pain was not associated with cancer stages, nodal status, node positive ratio, margin status, or tumor location.
In the subgroup of pancreatic head cancers, pain interference with daily life was associated with absence of perineural invasion (none= 33%, low= 17%, and high= 50%) versus presence of perineural invasion (none= 19%, low= 70%, and high= 11%; p=0.02). Patients with stage I cancer had higher pain interference scores (none= 0%, low= 40%, and high= 60%) than those with stage II cancer (none= 24%, low= 66%, and high= 11%; p=0.02).
Conclusions:
Preoperative pain does not predict the presence of perineural invasion or other pathologic prognostic factors. Higher pain scores in pancreatic head cancers correlated with absence of perineural invasion and early cancer stage. Preoperative pain as a prognostic factor deserves further investigation in larger prospective studies.
Perineural invasion versus no perineural invasion
| Variables | Perineural Invasion
n=43 | No perineural invasion
n=9 | p values | | Age | 64 years | 69 years | 0.2 | | Gender | 67% male | 56% male | 0.7 | | Total pain score | 2.2 | 2.5 | 0.5 | | Pain severity | 1.9 | 2.0 | 0.5 | | Pain interference | 2.3 | 2.7 | 0.5 | | Pain interference with activity | 2.5 | 2.8 | 0.6 | | Pain interference with affect | 2.2 | 2.7 | 0.1 | | Opioid use | 54% yes | 67% yes | 0.7 |
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