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HPB : the Official Journal of the... Jul 2016Hepatic-artery and para-aortic lymph node metastases (LNM) may be detected during surgical exploration for pancreatic (PDAC) or periampullary cancer. Some surgeons will... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Hepatic-artery and para-aortic lymph node metastases (LNM) may be detected during surgical exploration for pancreatic (PDAC) or periampullary cancer. Some surgeons will continue the resection while others abort the exploration.
METHODS
A systematic search was performed in PubMed, EMBASE and Cochrane Library for studies investigating survival in patients with intra-operatively detected hepatic-artery or para-aortic LNM. Survival was stratified for node positive (N1) disease.
RESULTS
After screening 3088 studies, 13 studies with 2045 patients undergoing pancreatoduodenectomy were included. No study reported survival data after detection of LNM and aborted surgical exploration. In 110 patients with hepatic-artery LNM, median survival ranged between 7 and 17 months. Estimated pooled mean survival in 84 patients with hepatic-artery LNM was 15 [95%CI 12-18] months (13 months in PDAC), compared to 19 [16-22] months in 270 patients with N1-disease without hepatic-artery LNM (p = 0.020). In 192 patients with para-aortic LNM, median survival ranged between 5 and 32 months. Estimated pooled mean survival in 169 patients with para-aortic LNM was 13 [8-17] months (11 months in PDAC), compared to 17 (6-27) months in 506 patients with N1-disease without para-aortic LNM (p < 0.001). Data on the impact of (neo)adjuvant therapy on survival were lacking.
CONCLUSION
Survival after pancreatoduodenectomy in patients with intra-operatively detected hepatic-artery and especially para-aortic LNM is inferior to patients undergoing pancreatoduodenectomy with other N1 disease. It remains unclear what the consequence of this should be since data on (neo-)adjuvant therapy and survival after aborted exploration are lacking.
Topics: Ampulla of Vater; Carcinoma, Pancreatic Ductal; Common Bile Duct Neoplasms; Hepatic Artery; Humans; Kaplan-Meier Estimate; Lymph Node Excision; Lymphatic Metastasis; Neoplasm Staging; Pancreatic Neoplasms; Pancreaticoduodenectomy; Predictive Value of Tests; Risk Factors; Treatment Outcome
PubMed: 27346135
DOI: 10.1016/j.hpb.2016.05.001 -
European Journal of Gastroenterology &... Feb 2016The aim of the study was to investigate the prognostic role of extranodal extension (ENE) of lymph node metastasis in adenocarcinoma of the pancreas (PDAC) and papilla... (Meta-Analysis)
Meta-Analysis Review
The aim of the study was to investigate the prognostic role of extranodal extension (ENE) of lymph node metastasis in adenocarcinoma of the pancreas (PDAC) and papilla [cancer of the papilla of Vater (CPV)]. A PubMed and SCOPUS search from database inception until 5 January 2015 without language restrictions was conducted. Eligible were prospective studies reporting data on prognostic parameters in individuals with PDAC and/or CPV, comparing participants with the presence of ENE (ENE+) with those with intranodal extension (ENE-). Data were summarized using risk ratios for number of deaths/recurrences and hazard ratios for time-dependent risk related to ENE+, adjusted for potential confounders. ENE was found to be very common in these tumors (up to about 60% in both N1-PDAC and CPV), leading to a significant increased risk for all-cause mortality [risk ratio=1.20; 95% confidence interval (CI): 1.06-1.35, P=0.003, I(2)=44%; hazard ratio=1.415, 95% CI: 1.215-1.650, P<0.0001, I(2)=0%] and recurrence of disease (risk ratio=1.20, 95% CI: 1.03-1.40, P=0.02, I(2)=0%). On the basis of our results, in PDAC and CPV, ENE should be considered mandatorily from the gross sampling and pathology report to the oncologic staging and therapeutic approach.
Topics: Adenocarcinoma; Ampulla of Vater; Common Bile Duct Neoplasms; Disease Progression; Disease-Free Survival; Humans; Lymph Nodes; Lymphatic Metastasis; Neoplasm Recurrence, Local; Odds Ratio; Pancreatic Neoplasms; Predictive Value of Tests; Risk Factors; Time Factors; Treatment Outcome
PubMed: 26566063
DOI: 10.1097/MEG.0000000000000520 -
World Journal of Surgical Oncology Jan 2014Metastases from breast cancer cause the frequent involvement of lung, bone, liver, and brain, while the occurrence of metastases to the gastrointestinal tract is rare,... (Review)
Review
BACKGROUND
Metastases from breast cancer cause the frequent involvement of lung, bone, liver, and brain, while the occurrence of metastases to the gastrointestinal tract is rare, and more frequently discovered after a primary diagnosis of breast cancer. Solitary pancreatic metastases from breast cancer, without widespread disease, are actually unusual, and only 19 cases have been previously described; truly exceptional is a solitary pancreatic metastasis becoming evident together with the primary breast cancer.
CASE PRESENTATION
A 68-year-old woman reported general fatigue, lethargy, and jaundice. Abdominal ultrasound (US) and magnetic resonance imaging (MRI) showed an ampulloma of Vater's papilla; moreover, a neoplastic nodule in the left breast was diagnosed. She underwent surgery for both breast cancer and ampulloma of Vater's papilla. Pathological examination of pancreatic specimen, however, did not confirm primary carcinoma of the duodenal papilla, but showed a metastatic involvement of pancreas from lobular breast cancer. Immunohistochemistry has been essential to confirm the origin of the malignancy: hormone receptors and mammaglobin were expressed in both the primary breast tumor and the pancreatic metastasis.
CONCLUSIONS
This is one of the few reported cases in literature of an isolated and synchronous pancreatic metastasis from breast cancer, where the definitive diagnosis was obtained only after surgery. We discuss the controversies in this diagnosis and the choice of correct treatment. The surgical resection of solitary metastases can be performed in the absence of disseminated disease.
Topics: Aged; Breast Neoplasms; Carcinoma, Lobular; Combined Modality Therapy; Female; Humans; Pancreatic Neoplasms; Prognosis
PubMed: 24387226
DOI: 10.1186/1477-7819-12-2 -
HPB : the Official Journal of the... Nov 2013Ampullary adenocarcinoma is considered to have a better prognosis than either pancreatic or bile duct adenocarcinoma. Pancreaticoduodenectomy is associated with... (Review)
Review
BACKGROUND
Ampullary adenocarcinoma is considered to have a better prognosis than either pancreatic or bile duct adenocarcinoma. Pancreaticoduodenectomy is associated with significant mortality and morbidity. Some recent publications have advocated the use of endoscopic papillectomy for the treatment of early ampullary adenocarcinoma. This article reviews investigations and surgical treatment options of ampullary tumours.
METHODS
A systematic review of English-language articles was carried out using an electronic search of the Ovid MEDLINE (from 1996 onwards), PubMed and Cochrane Database of Systematic Reviews databases to identify studies related to the investigation and management of ampullary tumours.
RESULTS
Distinguishing between ampullary adenoma and adenocarcinoma is challenging given the inaccuracy of endoscopic biopsy, for which high false negative rates of 25-50% have been reported. Endoscopic ultrasound is the most accurate method for local staging of ampullary lesions, but distinguishing between T1 and T2 adenocarcinomas is difficult. Lymph node metastasis occurs early in the disease process; it is lowest for T1 tumours, but the risk is still high at 8-45%. Case reports of successful endoscopic resection and transduodenal ampullectomy of T1 adenocarcinomas have been published, but their duration of follow-up is limited.
CONCLUSIONS
Optimal staging should be used to distinguish between ampullary adenoma and adenocarcinoma. Pancreaticoduodenectomy remains the treatment of choice for all ampullary adenocarcinomas.
Topics: Adenocarcinoma; Ampulla of Vater; Biopsy; Cholangiopancreatography, Endoscopic Retrograde; Common Bile Duct Neoplasms; Endosonography; Humans; Image-Guided Biopsy
PubMed: 23458317
DOI: 10.1111/hpb.12038 -
European Journal of Gastroenterology &... Jun 2012Duodenal intussusception is a rare entity. To date, only a few cases have been reported in the literature. In this report, a case of duodenal intussusception due to an... (Review)
Review
Duodenal intussusception is a rare entity. To date, only a few cases have been reported in the literature. In this report, a case of duodenal intussusception due to an unusual tumor was presented and the clinical features of this entity were discussed. A 42-year-old man with Peutz-Jeghers syndrome presented with epigastric pain, vomiting, and severe anemia. Computed tomography scan revealed synchronous duodenojejunal and jejunojejunal intussusceptions. An emergency laparotomy revealed a polypoid mass originating from the lateral wall of the descending duodenum with intussusception of the distal duodenum. Histological examination demonstrated a poorly differentiated neuroendocrine carcinoma with muscularis infiltration, vascular invasion, and a Ki-67 index of 20%. A comprehensive literature search revealed 44 English reports that provided adequate descriptions of an additional 47 such cases. Clinical presentation was usually chronic and nonspecific. Diagnostic modalities included ultrasonography, upper gastrointestinal series, computed tomography, and endoscopy. Five patients were due to a non-neoplastic lesion; however, the other 43 patients were secondary to a tumor, benign in 35 cases and malignant in eight cases. Only one patient was treated by endoscopic polypectomy, whereas the remaining underwent open surgeries. Duodenal intussusception is a challenging condition due to its rarity and nonspecific presentation. It should be considered in the differential diagnosis of gastric outlet obstruction, upper gastrointestinal bleeding, pancreatitis, and obstructive jaundice.
Topics: Adult; Carcinoma, Neuroendocrine; Diagnosis, Differential; Duodenal Diseases; Duodenal Neoplasms; Humans; Intussusception; Male; Peutz-Jeghers Syndrome
PubMed: 22356785
DOI: 10.1097/MEG.0b013e328351c1df -
Diseases of the Colon and Rectum Nov 2007This study was designed to review safety and efficacy of strictureplasty for Crohn's disease. (Meta-Analysis)
Meta-Analysis Review
PURPOSE
This study was designed to review safety and efficacy of strictureplasty for Crohn's disease.
METHODS
A literature search was performed to identify studies published between 1975 and 2005 that reported the outcome of strictureplasty. Systematic review was performed on the following subjects separately: 1) overall experience of strictureplasty; 2) postoperative complications; 3) postoperative recurrence and site of recurrence; 4) factors affecting postoperative complications and recurrence; 5) short-bowel syndrome; and 6) cancer risk. Meta-analysis of recurrence rate after strictureplasty was performed by using random-effect model and meta-regressive techniques.
RESULTS
A total of 1,112 patients who underwent 3,259 strictureplasties (Heineke-Mikulicz, 81 percent; Finney, 10 percent; side-to-side isoperistaltic, 5 percent) were identified. The sites of strictureplasty were jejunum and/or ileum (94 percent), previous anastomosis (4 percent), duodenum (1 percent), and colon (1 percent). After jejunoileal strictureplasty, including ileocolonic strictureplasty, septic complications (leak/fistula/abscess) occurred in 4 percent of patients. Overall surgical recurrence was 23 percent (95 percent confidence interval, 17-30 percent). Using meta-regressive analysis, the five-year recurrence rate after strictureplasty was 28 percent. In 90 percent of patients, recurrence occurred at nonstrictureplasty sites, and the site-specific recurrence rate was 3 percent. Two patients developed adenocarcinoma at the site of previous jejunoileal strictureplasty. The experience of duodenal or colonic strictureplasty was limited.
CONCLUSIONS
Strictureplasty is a safe and effective procedure for jejunoileal Crohn's disease, including ileocolonic recurrence, and it has the advantage of protecting against further small bowel loss. However, the place for strictureplasty is less well defined in duodenal and colonic diseases.
Topics: Adenocarcinoma; Anastomosis, Surgical; Colonic Neoplasms; Crohn Disease; Digestive System Surgical Procedures; Humans; Ileum; Jejunum; Recurrence; Short Bowel Syndrome; Treatment Outcome
PubMed: 17762967
DOI: 10.1007/s10350-007-0279-5 -
Gastrointestinal Endoscopy May 2007Vascular invasion (VI) in a patient with pancreatic or periampullary cancers precludes surgery and indicates a poor prognosis. Published data on the accuracy of EUS in... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Vascular invasion (VI) in a patient with pancreatic or periampullary cancers precludes surgery and indicates a poor prognosis. Published data on the accuracy of EUS in diagnosing VI is varied.
OBJECTIVE
The aim of this meta-analysis was to evaluate the accuracy of EUS in diagnosing VI in patients with pancreatic and periampullary cancers.
DESIGN
Data from EUS studies were pooled according to the Mantel-Haenszel and DerSimonian Laird methods.
PATIENTS
EUS studies in which VI was confirmed by surgery or angiography were selected.
INTERVENTIONS
EUS.
MAIN OUTCOME MEASURES
Pooled estimates of sensitivity, specificity, likelihood ratios, and diagnostic odds ratio of EUS.
RESULTS
Data were extracted from 29 studies (N = 1308) that met the inclusion criteria. The pooled sensitivity of EUS in diagnosing VI was 73% (95% CI, 68.8-76.9) and the pooled specificity was 90.2% (95% CI, 87.9-92.2). The positive likelihood ratio for diagnosing VI by EUS was 9.1 (95% CI, 4.6-17.9) and the negative likelihood ratio was 0.3 (95% CI, 0.2-0.5). Diagnostic odds ratio, the odds of having VI in positive as compared with negative EUS studies, was 40.1 (95% CI, 16.1-99.9). The P value for chi(2) heterogeneity for all the pooled estimates was >.05.
CONCLUSIONS
Although EUS is the best noninvasive test to diagnose VI in pancreatic and periampullary cancers, this meta-analysis showed that the specificity (90%) is high but the sensitivity (73%) is not as high as suggested. Further refinements in EUS technologies and interpretation may improve the sensitivity for detecting VI.
Topics: Adenocarcinoma; Ampulla of Vater; Biopsy, Fine-Needle; Common Bile Duct Neoplasms; Endosonography; Humans; Neoplasm Invasiveness; Pancreatic Neoplasms; Prognosis; Reproducibility of Results; Sensitivity and Specificity; Vascular Neoplasms
PubMed: 17350008
DOI: 10.1016/j.gie.2006.08.028 -
Endoscopy Jul 2004A swift and aggressive diagnostic and therapeutic approach is advisable when managing submucosal or polypoid lesions in the duodenum, since it is not possible to... (Review)
Review
A swift and aggressive diagnostic and therapeutic approach is advisable when managing submucosal or polypoid lesions in the duodenum, since it is not possible to distinguish small, benign, and unremarkable duodenal growths macroscopically from malignant tumors such as carcinoids. This paper presents a systematic review of the published literature listed in Medline, focusing on the results after endoscopic treatment of duodenal carcinoids during the last 15 years; on the biological behavior of duodenal carcinoids; and on the endoscopic appearance of duodenal carcinoids. Endoscopic ultrasonography (EUS) is extremely useful in the diagnostic and preoperative work-up. The results indicate that endoscopic removal of duodenal carcinoids smaller than 1 cm that are located outside the periampullary region, with no EUS signs of invasion of the muscularis propria, is a safe, patient-friendly, adequate, and effective treatment.
Topics: Carcinoid Tumor; Duodenal Neoplasms; Duodenoscopy; Endosonography; Humans
PubMed: 15243891
DOI: 10.1055/s-2004-814539