review of literature on clinical pancreatology - The Pancreapedia

the optimal combination <strong>of</strong> preoperative studies to accurately identify resectable patients.Therefore, it was conducted a statewide <strong>review</strong> <strong>of</strong> all patients with surgically managedpancreatic cancer from 1996 to 2003 using data from the Oregon State Cancer Registry,augmented with clinical information from primary medical record <strong>review</strong>. It was documentedthe use <strong>of</strong> all staging modalities, including CT, endoscopic ultrasonography, andlaparoscopy. Primary outcomes included resection with curative intent. The associationbetween staging modalities, clinical features, and resection was measured using amultivariate logistic regression model. There were 298 patients from 24 hospitals who metthe eligibility criteria. Patients were staged using a combination <strong>of</strong> CT (98 %), laparoscopy(29 %), and endoscopic ultrasonography (32 %). The overall proportion <strong>of</strong> patients who wentto surgical exploration and were resected was 87 percent. Of patients undergoing diagnosticlaparoscopy, metastatic disease that precluded resection was discovered in 24 (28 %). Forpatients who underwent diagnostic laparoscopy and were not resected, vascular invasionwas the most common determinant <strong>of</strong> unresectability (57 %). In multivariate analysis,preoperative weight loss and surgeon decision to use laparoscopy predicted unresectabilityat laparotomy. This population-based study demonstrates that surgeons appear to uselaparoscopy in a subset <strong>of</strong> patients at high risk for metastatic disease. The combination <strong>of</strong>current staging techniques is associated with a high proportion <strong>of</strong> resectability for patientstaken to surgical exploration. With current imaging modalities, selective application <strong>of</strong>laparoscopy with a dual-phase CT scan as the cornerstone <strong>of</strong> staging is a sound clinicalapproach to evaluate pancreatic cancer patients for potential resectability [413].Prognostic factorsThe purpose <strong>of</strong> one study was to determine the operative indications for pancreatic cancerwith paraaortic lymph node metastases (node 16+). Between 1981 and 2007, 335 patientswith pancreatic cancer including 45 node 16) patients underwent extended radical surgery.Although there was no significant difference in survival between the node 16+ patients andthe unresectable cases, there were some long-term survivors among the node 16+ patients.Multivariate analysis <strong>of</strong> the node 16+ patients identified age (59 years or younger), tumorsize (>4 cm), and pathologically confirmed portal invasion (pPV+) as independent prognosticfactors. The survival <strong>of</strong> node 16+ patients without these factors was significantly better thanthe unresectable cases. The survival <strong>of</strong> patients with only 1 metastatic paraaortic lymph nodealso was significantly better than the unresectable cases, and tended to be better than thosewith more than 2 metastatic nodes. It was concluded that node 16 + pancreatic cancerpatients with age 60 years or older, tumor size 4 cm or less, and pPV- may benefit fromresection [414].Pancreatic cancer diagnosing and stagingAlgorithmTo develop an algorithmic approach to the diagnosis <strong>of</strong> pancreatic neoplasms that simplifiestheir pathologic evaluation it was <strong>review</strong>ed <strong>literature</strong> related to the classification <strong>of</strong> pancreaticneoplasms on the basis <strong>of</strong> their gross, histologic, and immunohistochemical features. Byusing a series <strong>of</strong> dichotomous decisions, the differential diagnosis <strong>of</strong> a pancreatic neoplasmcan be narrowed, and in cases <strong>of</strong> the more common neoplasms, accurate classification canbe achieved [415].Tumor markersAggressive growth and metastases <strong>of</strong> pancreatic cancer are the result <strong>of</strong> basement