Diagnostic Laparoscopy Prior to Neoadjuvant Therapy in Pancreatic Cancer Is High Yield: an Analysis of Outcomes and Costs

Peng, June S.; Mino, Jeffrey; Monteiro, Rosebel; Morris‐Stiff, Gareth; Ali, Noaman; Wey, Jane; El‐Hayek, Kevin; Walsh, R. Matthew; Chalikonda, Sricharan

doi:10.1007/s11605-017-3470-6

Cited by 24 publications

(18 citation statements)

References 26 publications

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“…A small percentage of patients will never make it to the operating room, often because of a combination of drainage-related complications (eg, cholangitis or pancreatitis) and frailty. Moreover, about 20% of radiographically BRPC patients will never undergo resection because of occult metastatic disease at staging laparoscopy or unexpected LAPC during surgical exploration (61,62). Finally, most adjuvant trials require a complete macroscopic resection, a CA 19-9 level below 180 U/ mL, and full recovery from surgery within 12 weeks after resection.…”

Section: Resection and R0 Resection Ratesmentioning

confidence: 99%

Neoadjuvant FOLFIRINOX in patients with (borderline) resectable pancreatic cancer: A systematic review and patient-level meta-analysis.

Janssen

Buettner

Suker

et al. 2018

JCO

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Background: FOLFIRINOX is a standard treatment for metastatic pancreatic cancer patients. The effectiveness of neoadjuvant FOLFIRINOX in patients with borderline resectable pancreatic cancer (BRPC) remains debated. Methods: We performed a systematic review and patient-level meta-analysis on neoadjuvant FOLFIRINOX in patients with BRPC. Studies with BRPC patients who received FOLFIRINOX as first-line neoadjuvant treatment were included. The primary endpoint was overall survival (OS), and secondary endpoints were progression-free survival, resection rate, R0 resection rate, and grade III-IV adverse events. Patient-level survival outcomes were obtained from authors of the included studies and analyzed using the Kaplan-Meier method. Results: We included 24 studies (8 prospective, 16 retrospective), comprising 313 (38.1%) BRPC patients treated with FOLFIRINOX. Most studies (n ¼ 20) presented intention-to-treat results. The median number of administered neoadjuvant FOLFIRINOX cycles ranged from 4 to 9. The resection rate was 67.8% (95% confidence interval [CI] ¼ 60.1% to 74.6%), and the R0-resection rate was 83.9% (95% CI ¼ 76.8% to 89.1%). The median OS varied from 11.0 to 34.2 months across studies. Patientlevel survival data were obtained for 20 studies representing 283 BRPC patients. The patient-level median OS was 22.2 months (95% CI ¼ 18.8 to 25.6 months), and patient-level median progression-free survival was 18.0 months (95% CI ¼ 14.5 to 21.5 months). Pooled event rates for grade III-IV adverse events were highest for neutropenia (17.5 per 100 patients, 95% CI ¼ 10.3% to 28.3%), diarrhea (11.1 per 100 patients, 95% CI ¼ 8.6 to 14.3), and fatigue (10.8 per 100 patients, 95% CI ¼ 8.1 to 14.2). No deaths were attributed to FOLFIRINOX.

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Section: Resection and R0 Resection Ratesmentioning

confidence: 99%

Neoadjuvant FOLFIRINOX in patients with (borderline) resectable pancreatic cancer: A systematic review and patient-level meta-analysis.

Janssen

Buettner

Suker

et al. 2018

JCO

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“…Tumor size and increased carbohydrate antigen 19‐9 (CA 19‐9) values have been previously associated with OMD . Diagnostic laparoscopy is routinely utilized in certain institutions for the assessment of possible disseminated abdominal disease and prevention of unnecessary laparotomy . However, utilization of diagnostic laparoscopy in all patients is time‐consuming and costly, especially due to the limited sensitivity in identifying small metastases in the posterior liver surface and the visceral peritoneum of the small bowel …”

Section: Introductionmentioning

confidence: 99%

“…5,[10][11][12][13] Diagnostic laparoscopy is routinely utilized in certain institutions for the assessment of possible disseminated abdominal disease and prevention of unnecessary laparotomy. 14,15 However, utilization of diagnostic laparoscopy in all patients is timeconsuming and costly, especially due to the limited sensitivity in identifying small metastases in the posterior liver surface and the visceral peritoneum of the small bowel. 16 We retrospectively reviewed all explored patients with radiographically resectable PDAC within the past 10 years, to address an important question for patient care: what are the contemporary incidence and the associated risk factors for OMD.…”

Section: Introductionmentioning

confidence: 99%

Incidence and risk factors for abdominal occult metastatic disease in patients with pancreatic adenocarcinoma

Gemenetzis

Groot

Blair

et al. 2018

Journal of Surgical Oncology

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Background The incidence of occult metastatic disease (OMD) in pancreatic ductal adenocarcinoma (PDAC) and associated risk factors are largely unknown. Methods We identified all patients with PDAC, who had an aborted oncologic operation due to OMD within a 10‐year period. The cases were matched to a cohort of resected PDAC patients on a 1:3 ratio, based on age and sex, for comparison of preoperative clinical characteristics and potential risk factors for OMD. Results In the studied period, 117 patients with OMD were identified in 1423 pancreatectomies performed for PDAC (8%). Liver metastases were the most common finding (79%) followed by peritoneal implants (16%). When compared with non‐OMD cases, patients with OMD presented more often with abdominal pain (P < 0.001), and higher preoperative carbohydrate antigen 19‐9 (CA 19‐9) values ( P = 0.007). Additionally, indeterminate liver lesions on preoperative computed tomography (CT) were identified in 40% of OMD versus 17% of non‐OMD patients ( P < 0.001). Multivariable analysis distinguished four independent predictors for OMD: indeterminate lesions on preoperative CT, tumor size > 30 mm, abdominal pain, and preoperative CA 19‐9 > 192 U/mL. Conclusions Occurrence of OMD in PDAC accounts for 8% of cases. Preoperative CA 19‐9 > 192 U/mL, primary tumor size > 30 mm, and identification of indeterminate lesions in preoperative CT may indicate the need for diagnostic laparoscopy.

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“…There are still a number of cases that were determined to be non-resectable after staging laparoscopy, particularly in borderline resectable cases. Peng et al [37] found that still up to 25% of cases were found to be non-resectable in borderline resectable cases. The reason for including both resectable and borderline resectable cases in our study was to demonstrate the increased yield for staging laparoscopy especially in borderline resectable cases.…”

Section: Limitationsmentioning

confidence: 99%

The Role of Staging Laparoscopy in Resectable and Borderline Resectable Pancreatic Cancer: A Systematic Review and Meta-Analysis

O’Connor

Sulistijo

et al. 2018

Dig Surg

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Aim: The study aimed to determine the additional value of staging laparoscopy in patients with pancreatic cancer deemed potentially resectable based on computed tomography imaging. Methods: A systematic literature search was performed using MEDLINE and the Cochrane Register of Controlled Trials (January 1995 to June 2017). Primary outcome measures were the overall yield and sensitivity to detect non-resectable disease. Quality of studies was assessed with the Newcastle-Ottawa Scale. Results: From 156 records, 15 studies including 2,776 patients met the inclusion criteria. In 12 studies, reporting outcomes on 1,756 patients with resectable disease after standard imaging, 350 (20%, range 14–38%) cases of non-resectable cancer were detected with staging laparoscopy. In 3 studies on 242 patients with locally advanced disease after standard imaging, staging laparoscopy detected metastases in 86 patients (36%). The failure rate of staging laparoscopy to detect non-resectable disease was 5% (64 of 1,406). Conclusion: Staging laparoscopy reduces the non-therapeutic laparotomy rate, and in locally advanced or borderline resectable disease, staging laparoscopy could more accurately select patients for neoadjuvant protocols.

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Diagnostic Laparoscopy Prior to Neoadjuvant Therapy in Pancreatic Cancer Is High Yield: an Analysis of Outcomes and Costs

Abstract: SDL prior to NAT is a useful adjunct to CT to diagnose occult metastatic disease in BRPC.

Cited by 24 publications

References 26 publications

Neoadjuvant FOLFIRINOX in patients with (borderline) resectable pancreatic cancer: A systematic review and patient-level meta-analysis.

Neoadjuvant FOLFIRINOX in patients with (borderline) resectable pancreatic cancer: A systematic review and patient-level meta-analysis.

Incidence and risk factors for abdominal occult metastatic disease in patients with pancreatic adenocarcinoma

The Role of Staging Laparoscopy in Resectable and Borderline Resectable Pancreatic Cancer: A Systematic Review and Meta-Analysis

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