- Email: [email protected]
High yield of occult metastases during staging laparoscopy for locally advanced pancreatic cancer
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Electronic Poster Abstracts
EP02C-044 NATURAL HISTORY AFTER LONGTERM FOLLOW UP OF NEUROENDOCRINE TUMORS (NETP), BASED ON THE DETECTION OF THE KI-67 AND PROLIFERATION CELL INDEX (PCI) OBTAINED BY EUS-FNA D. P. Morgado1, J. C. Ardengh2, F. R. Moraes2, D. P. Caetano2, M. B. Fortunato2, E. Taglieri2, O. Micelli-Neto2, A. A. Parada2, R. A. Anuar2, M. P. Moreira2 and V. R. Bastos2 1 Endoscopia, Hospital Ipiranga, Hospital 9 de Julho, and 2 Hospital 9 de Julho, Brazil NETP have been detected by the imaging methods. EUSFNA can obtain material for determining the Ki-67and PCI. These are an important tools to determine the prognostic factor, the treatment of a smaller NETP < 3.0 cm is controversial. Aim: Determine the natural history, importance of Ki-67 and PCI in patients with NETP 3,0 cm. Determine the management and assesses them in long-term follow-up. 29 with histologically proven NETP were followed by MRI, CT and/or EUS. 19 operated (G1) and 10 are assisted (G2). Well differentiated NETP (GI) in 93% and 2 7% well differentiated carcinoma (GII). There was no statistical difference between G1 and 2 regarding sex, mean age, symptons, and localization, In G1 and G2 EUS-FNA obtained a good material for immunohistochemical analysis in 18/19 (94.7%) and 9/10 (90%), and Ki-67, PCI was positive and <5% at 100% and 88.8%, respectively. After the average follow-up 35.7 months and average 4 imaging, G1 showed, perioperative death (5.2%), liver metastases (5.2%), reoperated 24 m after the first surgery and 89.6% well. G2: one had liver metastasis, four hypoglycaemic attacks (40%), one which follow-up 52 m and tumor growth of 1.4 to 2.5 cm opted for surgery (10%) and 5 (50%) are excellent, with PCI < 2%. Mean tumor growth rate was 0.25 cm/year. In selected patients conservative management of NETP 3.0 cm, symptomatic or not is safe. Obtaining material of the NETP by EUS-FNA and analysis of Ki-67 and the PCI are safe to determine the best approach to be imposed.
EP02C-046 WHEN WE NEED HEPATIC ARTERY RECONSTRUCTION AFTER CELIAC ARTERY RESECTION? V. Egorov1,2, R. Petrov3, N. Starostina4, T. Zhurenkova5, M. Petukhova6 and J. Zhurina3 1 Surgical Oncology, City Hospital # 5, 2Pirogov Russian National Research Medical University (RNRMU), 3City Hospital # 5, 4Moscow Clinical Scientific Centre, 5Vishnevsky Institute of Surgery, and 65th Moscow City Clinic, Russian Federation Aim: To study liver collateral arterial supply after temporary occlusion of the common (CHA), right gastroepiploic (RGEA) and accessory/replaced left hepatic arteries (a/ rLHA). Background: Distal pancreatectomy with celiac artery resection (DPCAR) is widely used for borderline-resectable
pancreatic cancer. It is believed that considerable reduction of the liver arterial supply after DPCAR may cause severe liver dysfunction and/or gallbladder necrosis. The necessity of arterial reconstruction is still debated. Patients and methods: arterial anatomy, diameters of CHA, proper hepatic (PHA), gastroduodenal(GDA) and pancreatoduodenal arteries (PDA) were registered before surgery in 107 consecutive patients with pancreatic body/ tail cancer (n32), gastric cancer with pancreatic involvement(n30) and liver tumors (n45) by CT. For DPCAR (n17) these data were obtained after surgery as well. Diameters of peripancreatic arteries and mean systolic blood velocity in hepatic arteries before and after CHA clamping were measured intraoperatively by Doppler ultrasound. Results: Classical arterial anatomy was identified in 67% and replaced right hepatic artery (rRHA) from the SMA in 12,2% of cases. Pulse had disappeared in 18 (17 %) cases after clamping of CHA, RGEA and aLHA/rLPA. Collateral arterial blood flow in the liver parenchyma was revealed in all cases. DPCAR led to increase of GDA, rRHA, PDA and RGEA blood flow in 0,9e2 times; visualization of PD arcades as a main and sole collateral way after DPCAR. Conclusion: Doppler ultrasound is a good modality for intraoperative assessment of liver arterial blood supply after DPCAR; Hepatic artery reconstruction may be necessary after DPCAR in case of disappearance of arterial Doppler signal upon the liver parenchima.
EP02C-047 HIGH YIELD OF OCCULT METASTASES DURING STAGING LAPAROSCOPY FOR LOCALLY ADVANCED PANCREATIC CANCER M. Suker1, B. Groot Koerkamp1, F. A. Eskens2, J. J. Nuyttens3 and C. H. J. van Eijck4 1 HPB Surgery, 2Oncology, 3Radiotherapy, and 4Erasmus Medical Center, Netherlands Introduction: Locally advanced pancreatic cancer (LAPC) is found in 40% of patients with pancreatic cancer. We looked for occult metastases during staging laparoscopy in patients with LAPC. Methods: Between January 2012 and August 2015 patients with pancreatic cancer underwent a 3 phase pancreas protocol CT. All patients with LAPC underwent a staging laparoscopy to exclude intrahepatic and peritoneal metastases. Univariate logistic regression analysis was conducted to predict metastasis found at laparoscopy. Preoperative risk factors for occult metastatic disease included gender, age, tumor size, and serum tumor markers (CEA and CA 19e9). Results: A total of 51 patients were included. The median overall survival was 17.8 months (95% CI 13.7e21.9) with a median follow-up of 12.6 months. During staging laparoscopy metastases were found in 9 patients (17.7%, 95% CI: 9.6%e30.2%). Five patients had liver and 4 peritoneal metastases. At logistic regression only serum CEA (p = 0.005) was a significant predictor for metastasis. Conclusions: The yield of staging laparoscopy for occult intrahepatic or peritoneal metastases was about 1 in 5 patients in this cohort. Finding these metastases has prognostic and therapeutic consequences for patients with
HPB 2016, 18 (S1), e1ee384
Electronic Poster Abstracts LAPC. Therefore staging laparoscopy should be a standard procedure for patients with LAPC.
EP02C-048 APPLICATION OF 3D PRINTING TECHNIQUE IN THE DIAGNOSIS AND TREATMENT FOR PANCREATIC AND PERIAMPULLARY NEOPLASMS C. -H. Fang Department of Hepatobiliary Surgery, ZhuJiang Hospital of Southern Medical University, China Introduction: Objective to study the value of 3D printing technique in the diagnosis and treatment for pancreatic and periampullary neoplasms. Methods: From March 2014 to April 2015, a total of 10 hospitalized patients with pancreatic or periampullary neoplasms in the Zhu Jiang Hospital of Southern Medical University were enrolled in the present study, all of them were examined with abdominal enhanced thin-slice CT scanning and the CT images were imported into Medical Image three Dimensional Visualization System (MI-3DVS) for 3D visualization. Standard Template Library (STL) file were exported for 3D printing preparation. Surgical planning and real-time guided operative were performed with 3D printing models. The operation time, intraoperative blood loss, intraoperative blood transfusions, the postoperative hospitalization time and the postoperative fellowup were observed. Results: The three dimensional visualization model of all the ten cases were obtained successfully. After completion of 3D printing model with the STL file, the high-fidelity tumor physical 3D printing models were obtained, stereoscopically displayed the location of tumors and adjacent vascular structure clearly. The operation time was 347 36 min, the intraoperative blood loss was 500 210 ml, intraoperative blood transfusion was 250 196 ml, the postoperative hospitalization time was 12.0 2.7 d. The negative surgery maigin was observed in all the 10 cases. There were no postoperative complications, postoperative follow-up was 5.8 3.7 month, tumor recurrence was not found. Conclusions: The 3D printing technique could facilitate to evaluate preoperative risk; ascertain critical anatomical structure, navigate surgical procedure in real time, improve the prognosis of the patients.
EP02C-049 CIRCULATING CELL FREE DNA LEVELS WHEN CONSIDERED IN ISOLATION HAVE LITTLE CLINICAL VALUE IN PATIENTS WITH PANCREATIC DUCTAL ADENOCARCINOMA COMPARED TO OTHER CHRONIC DISEASES M. Brand1, C. Dickens2, J. Omoshoro-Jones1, J. Devar1, G. Candy1, M. Smith1, R. Duarte2 and WITS HPB Research Group 1 Surgery, and 2University of the Witwatersrand, South Africa
HPB 2016, 18 (S1), e1ee384
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Background: Circulating cell free DNA (cfDNA) is being used as a novel prognostic prediction tumour biomarker in several malignancies, including pancreatic ductal adenocarcinoma (PDAC). However, cfDNA has also been shown to be elevated in various other non-malignant acute and chronic diseases. We hypothesised that cfDNA levels are not a useful clinical adjunct in patients with pancreatic disease. Methods: We compared cfDNA levels of chemotherapy naive patients with advanced PDAC, to patients with chronic pancreatitis (CP) as well as patients without pancreatic disease with either chronic critical limb ischaemia (CLI) or well controlled hypertension (HTN). cfDNA levels were determined using a diluted SYBR Gold Nucleic Acid Gel Stain, and using a flourimeter, fluorescence was measured at an emission wavelength of 535 nm and an excitation wavelength of 485 nm as per published protocols. Results: Age and gender matched black African participants were recruited. These included 49 PDAC’s, 24 CP’s, 21 CLI’s and 9 HTN’s. cfDNA levels were recorded and compared as follows: PDAC 497.3 411.5 ng/ml versus chronic pancreatitis 616.6 415.7 ng/ml (p-value = 1.000), versus chronic critical limb ischaemia 1085.0 517.3 ng/ ml(p-value < 0.01), versus controlled hypertensive patients 913.5 382.0 ng/ml(p-value = 0.057). cfDNA levels in PDAC participants alive after six months compared to those that died in the same time interval were 500.7 441.9 ng/ml vs 443.5 324.1 ng/ml(pvalue = 0.649). Conclusion: cfDNA levels were the highest in participants with a chronic inflammatory disease, they were not of prognostic value in determining survival in patients with advanced PDAC. cfDNA levels in isolation have little clinical value.
EP02C-050 PERIAMPULLARY CANCERS: FORMING CANCER SUBGROUPS BASED ON GENOMIC AND MOLECULAR PROFILES M. Chandrasegaram1, T. Price2, J. Samra3, J. Fawcett4 and N. Merrett5 1 The Prince Charles Hospital, 2Queen Elizabeth Hospital, 3 Royal North Shore Hospital, 4Princess Alexandra Hospital, and 5Bankstown Hospital, Australia Background: There is variation in the incidence of pancreatic, ampullary, biliary and duodenal cancers resected with a pancreaticoduodenectomy (PD). Pancreatic cancers represent the majority of cancers resected with a PD in most series. There are fundamental genomic and molecular differences in the four cancer subtypes. Methods: A literature review was performed to evaluate the incidence and proportions of periampullary cancers resected with a PD and their incidence of KRAS mutation. Results: Pancreatic cancers are the most subtype (56e 66%) followed by ampullary cancers (15e25%), cholangiocarcinomas (10e15%), and duodenal cancers (4e 6%). Surprisingly, ampullary cancers may represent the majority of cancers resected with a PD (50%) in Eastern series. Ampullary cancers can be further distinguished into two distinct subtypes, which are intestinal and
Electronic Poster Abstracts
EP02C-044 NATURAL HISTORY AFTER LONGTERM FOLLOW UP OF NEUROENDOCRINE TUMORS (NETP), BASED ON THE DETECTION OF THE KI-67 AND PROLIFERATION CELL INDEX (PCI) OBTAINED BY EUS-FNA D. P. Morgado1, J. C. Ardengh2, F. R. Moraes2, D. P. Caetano2, M. B. Fortunato2, E. Taglieri2, O. Micelli-Neto2, A. A. Parada2, R. A. Anuar2, M. P. Moreira2 and V. R. Bastos2 1 Endoscopia, Hospital Ipiranga, Hospital 9 de Julho, and 2 Hospital 9 de Julho, Brazil NETP have been detected by the imaging methods. EUSFNA can obtain material for determining the Ki-67and PCI. These are an important tools to determine the prognostic factor, the treatment of a smaller NETP < 3.0 cm is controversial. Aim: Determine the natural history, importance of Ki-67 and PCI in patients with NETP 3,0 cm. Determine the management and assesses them in long-term follow-up. 29 with histologically proven NETP were followed by MRI, CT and/or EUS. 19 operated (G1) and 10 are assisted (G2). Well differentiated NETP (GI) in 93% and 2 7% well differentiated carcinoma (GII). There was no statistical difference between G1 and 2 regarding sex, mean age, symptons, and localization, In G1 and G2 EUS-FNA obtained a good material for immunohistochemical analysis in 18/19 (94.7%) and 9/10 (90%), and Ki-67, PCI was positive and <5% at 100% and 88.8%, respectively. After the average follow-up 35.7 months and average 4 imaging, G1 showed, perioperative death (5.2%), liver metastases (5.2%), reoperated 24 m after the first surgery and 89.6% well. G2: one had liver metastasis, four hypoglycaemic attacks (40%), one which follow-up 52 m and tumor growth of 1.4 to 2.5 cm opted for surgery (10%) and 5 (50%) are excellent, with PCI < 2%. Mean tumor growth rate was 0.25 cm/year. In selected patients conservative management of NETP 3.0 cm, symptomatic or not is safe. Obtaining material of the NETP by EUS-FNA and analysis of Ki-67 and the PCI are safe to determine the best approach to be imposed.
EP02C-046 WHEN WE NEED HEPATIC ARTERY RECONSTRUCTION AFTER CELIAC ARTERY RESECTION? V. Egorov1,2, R. Petrov3, N. Starostina4, T. Zhurenkova5, M. Petukhova6 and J. Zhurina3 1 Surgical Oncology, City Hospital # 5, 2Pirogov Russian National Research Medical University (RNRMU), 3City Hospital # 5, 4Moscow Clinical Scientific Centre, 5Vishnevsky Institute of Surgery, and 65th Moscow City Clinic, Russian Federation Aim: To study liver collateral arterial supply after temporary occlusion of the common (CHA), right gastroepiploic (RGEA) and accessory/replaced left hepatic arteries (a/ rLHA). Background: Distal pancreatectomy with celiac artery resection (DPCAR) is widely used for borderline-resectable
pancreatic cancer. It is believed that considerable reduction of the liver arterial supply after DPCAR may cause severe liver dysfunction and/or gallbladder necrosis. The necessity of arterial reconstruction is still debated. Patients and methods: arterial anatomy, diameters of CHA, proper hepatic (PHA), gastroduodenal(GDA) and pancreatoduodenal arteries (PDA) were registered before surgery in 107 consecutive patients with pancreatic body/ tail cancer (n32), gastric cancer with pancreatic involvement(n30) and liver tumors (n45) by CT. For DPCAR (n17) these data were obtained after surgery as well. Diameters of peripancreatic arteries and mean systolic blood velocity in hepatic arteries before and after CHA clamping were measured intraoperatively by Doppler ultrasound. Results: Classical arterial anatomy was identified in 67% and replaced right hepatic artery (rRHA) from the SMA in 12,2% of cases. Pulse had disappeared in 18 (17 %) cases after clamping of CHA, RGEA and aLHA/rLPA. Collateral arterial blood flow in the liver parenchyma was revealed in all cases. DPCAR led to increase of GDA, rRHA, PDA and RGEA blood flow in 0,9e2 times; visualization of PD arcades as a main and sole collateral way after DPCAR. Conclusion: Doppler ultrasound is a good modality for intraoperative assessment of liver arterial blood supply after DPCAR; Hepatic artery reconstruction may be necessary after DPCAR in case of disappearance of arterial Doppler signal upon the liver parenchima.
EP02C-047 HIGH YIELD OF OCCULT METASTASES DURING STAGING LAPAROSCOPY FOR LOCALLY ADVANCED PANCREATIC CANCER M. Suker1, B. Groot Koerkamp1, F. A. Eskens2, J. J. Nuyttens3 and C. H. J. van Eijck4 1 HPB Surgery, 2Oncology, 3Radiotherapy, and 4Erasmus Medical Center, Netherlands Introduction: Locally advanced pancreatic cancer (LAPC) is found in 40% of patients with pancreatic cancer. We looked for occult metastases during staging laparoscopy in patients with LAPC. Methods: Between January 2012 and August 2015 patients with pancreatic cancer underwent a 3 phase pancreas protocol CT. All patients with LAPC underwent a staging laparoscopy to exclude intrahepatic and peritoneal metastases. Univariate logistic regression analysis was conducted to predict metastasis found at laparoscopy. Preoperative risk factors for occult metastatic disease included gender, age, tumor size, and serum tumor markers (CEA and CA 19e9). Results: A total of 51 patients were included. The median overall survival was 17.8 months (95% CI 13.7e21.9) with a median follow-up of 12.6 months. During staging laparoscopy metastases were found in 9 patients (17.7%, 95% CI: 9.6%e30.2%). Five patients had liver and 4 peritoneal metastases. At logistic regression only serum CEA (p = 0.005) was a significant predictor for metastasis. Conclusions: The yield of staging laparoscopy for occult intrahepatic or peritoneal metastases was about 1 in 5 patients in this cohort. Finding these metastases has prognostic and therapeutic consequences for patients with
HPB 2016, 18 (S1), e1ee384
Electronic Poster Abstracts LAPC. Therefore staging laparoscopy should be a standard procedure for patients with LAPC.
EP02C-048 APPLICATION OF 3D PRINTING TECHNIQUE IN THE DIAGNOSIS AND TREATMENT FOR PANCREATIC AND PERIAMPULLARY NEOPLASMS C. -H. Fang Department of Hepatobiliary Surgery, ZhuJiang Hospital of Southern Medical University, China Introduction: Objective to study the value of 3D printing technique in the diagnosis and treatment for pancreatic and periampullary neoplasms. Methods: From March 2014 to April 2015, a total of 10 hospitalized patients with pancreatic or periampullary neoplasms in the Zhu Jiang Hospital of Southern Medical University were enrolled in the present study, all of them were examined with abdominal enhanced thin-slice CT scanning and the CT images were imported into Medical Image three Dimensional Visualization System (MI-3DVS) for 3D visualization. Standard Template Library (STL) file were exported for 3D printing preparation. Surgical planning and real-time guided operative were performed with 3D printing models. The operation time, intraoperative blood loss, intraoperative blood transfusions, the postoperative hospitalization time and the postoperative fellowup were observed. Results: The three dimensional visualization model of all the ten cases were obtained successfully. After completion of 3D printing model with the STL file, the high-fidelity tumor physical 3D printing models were obtained, stereoscopically displayed the location of tumors and adjacent vascular structure clearly. The operation time was 347 36 min, the intraoperative blood loss was 500 210 ml, intraoperative blood transfusion was 250 196 ml, the postoperative hospitalization time was 12.0 2.7 d. The negative surgery maigin was observed in all the 10 cases. There were no postoperative complications, postoperative follow-up was 5.8 3.7 month, tumor recurrence was not found. Conclusions: The 3D printing technique could facilitate to evaluate preoperative risk; ascertain critical anatomical structure, navigate surgical procedure in real time, improve the prognosis of the patients.
EP02C-049 CIRCULATING CELL FREE DNA LEVELS WHEN CONSIDERED IN ISOLATION HAVE LITTLE CLINICAL VALUE IN PATIENTS WITH PANCREATIC DUCTAL ADENOCARCINOMA COMPARED TO OTHER CHRONIC DISEASES M. Brand1, C. Dickens2, J. Omoshoro-Jones1, J. Devar1, G. Candy1, M. Smith1, R. Duarte2 and WITS HPB Research Group 1 Surgery, and 2University of the Witwatersrand, South Africa
HPB 2016, 18 (S1), e1ee384
e357
Background: Circulating cell free DNA (cfDNA) is being used as a novel prognostic prediction tumour biomarker in several malignancies, including pancreatic ductal adenocarcinoma (PDAC). However, cfDNA has also been shown to be elevated in various other non-malignant acute and chronic diseases. We hypothesised that cfDNA levels are not a useful clinical adjunct in patients with pancreatic disease. Methods: We compared cfDNA levels of chemotherapy naive patients with advanced PDAC, to patients with chronic pancreatitis (CP) as well as patients without pancreatic disease with either chronic critical limb ischaemia (CLI) or well controlled hypertension (HTN). cfDNA levels were determined using a diluted SYBR Gold Nucleic Acid Gel Stain, and using a flourimeter, fluorescence was measured at an emission wavelength of 535 nm and an excitation wavelength of 485 nm as per published protocols. Results: Age and gender matched black African participants were recruited. These included 49 PDAC’s, 24 CP’s, 21 CLI’s and 9 HTN’s. cfDNA levels were recorded and compared as follows: PDAC 497.3 411.5 ng/ml versus chronic pancreatitis 616.6 415.7 ng/ml (p-value = 1.000), versus chronic critical limb ischaemia 1085.0 517.3 ng/ ml(p-value < 0.01), versus controlled hypertensive patients 913.5 382.0 ng/ml(p-value = 0.057). cfDNA levels in PDAC participants alive after six months compared to those that died in the same time interval were 500.7 441.9 ng/ml vs 443.5 324.1 ng/ml(pvalue = 0.649). Conclusion: cfDNA levels were the highest in participants with a chronic inflammatory disease, they were not of prognostic value in determining survival in patients with advanced PDAC. cfDNA levels in isolation have little clinical value.
EP02C-050 PERIAMPULLARY CANCERS: FORMING CANCER SUBGROUPS BASED ON GENOMIC AND MOLECULAR PROFILES M. Chandrasegaram1, T. Price2, J. Samra3, J. Fawcett4 and N. Merrett5 1 The Prince Charles Hospital, 2Queen Elizabeth Hospital, 3 Royal North Shore Hospital, 4Princess Alexandra Hospital, and 5Bankstown Hospital, Australia Background: There is variation in the incidence of pancreatic, ampullary, biliary and duodenal cancers resected with a pancreaticoduodenectomy (PD). Pancreatic cancers represent the majority of cancers resected with a PD in most series. There are fundamental genomic and molecular differences in the four cancer subtypes. Methods: A literature review was performed to evaluate the incidence and proportions of periampullary cancers resected with a PD and their incidence of KRAS mutation. Results: Pancreatic cancers are the most subtype (56e 66%) followed by ampullary cancers (15e25%), cholangiocarcinomas (10e15%), and duodenal cancers (4e 6%). Surprisingly, ampullary cancers may represent the majority of cancers resected with a PD (50%) in Eastern series. Ampullary cancers can be further distinguished into two distinct subtypes, which are intestinal and