FORT LAUDERDALE, Fla--Clinicians now have at their disposal more accurate
staging technologies for pancreatic cancer than were available in the past.
The appropriate roles of these technologies, particularly endoscopic
ultrasound (EUS) and laparoscopy, engendered the most controversy among
the panel members charged with creating preliminary practice guidelines
on pancreatic cancer for the National Comprehensive Cancer Network (NCCN),
panel chair Margaret Tempero, MD, said in an interview.
The various staging modalities provide different types of information
and also differ with regard to cost and invas-iveness, said Dr. Tempero,
of the University of Nebraska Medical Center. She presented the pancreatic
cancer guidelines at the NCCN's second annual conference.
Consequently, she anticipates that the panel's recommendations about
the use of staging technologies in various situations will change as the
guidelines undergo review by the NCCN institutions.
The pancreatic cancer practice guidelines, developed by a nine-member
multidisciplinary panel , consist of seven distinct paths for the workup
and treatment of patients with ductal adenocarcinoma. The decision of which
path should be followed for a particular patient rests primarily on the
resectability status of the cancer and whether there is evidence of metastatic
disease. Both of these determinations hinge on accurate staging.
NCCN Pancreatic Cancer Practice Guidelines Panel
Margaret Tempero, MD
Al Benson, MD
John L. Cameron, MD
Ephraim S. Casper, MD
John Hoffman, MD
Ted Lawrence, MD
Ted Martin, MD
Cornelius McGinn, MD
Christopher Willett, MD
Since definitions of resectability and unresectability are not clear
in the literature, the panel developed its own criteria, and although these
are fairly noncon-troversial, the yardsticks for borderline resectability
may provoke some debate, Dr. Tempero said.
The panel deems lesions in either the head or body of the pancreas borderline
resectable when there is bilateral or severe unilateral superior mesenteric
vein or portal impingement, tumor abutment on the superior mesenteric artery,
gastroduodenal artery encasement up to the origin at the hepatic artery,
or direct invasion into the transverse colon.
For lesions in the tail of the pancreas, extension into the adrenal
gland, kidney, or colon is characterized as borderline resectable.
Which Staging Tests to Use When?
The crux of the controversy over staging technologies is which test
or tests to use when, Dr. Tempero said.
To determine resectability in the patient who presents with a mass in
the head of the pancreas and who is not jaundiced, the panel recommends
spiral (helical) CT. If the scan indicates that the mass is potentially
resectable, the patient should undergo a laparotomy, and, if that confirms
the CT findings, the resection should be completed.
The guidelines do not require a preop-erative biopsy prior to laparotomy.
"Because of one of the histologic hallmarks of pancreatic cancer,
ie, associated desmo-plasia, preoperative biopsies can often be misleading,"
Dr. Tempero noted. Thus, if a biopsy is taken in a desmoplastic area of
the pancreas in a patient who actually has an adenocarcinoma, the cancer
may go undetected.
If findings on spiral CT indicate that a mass is borderline resectable,
the panel recommends the use of endoscopic ultrasound (EUS) (coupled with
a transgas-tric biopsy) to ascertain whether that mass is truly resectable.
A number of studies have suggested that EUS is a far better staging
tool than conventional ultrasound or CT, Dr. Tempero said. "However,
we recognize that EUS is an operator-dependent modality. And even within
our own NCCN institutions, we have not yet determined that all institutions
have dedicated personnel who are skilled in this procedure."
If EUS findings indicate that the borderline lesion is, indeed, resectable,
the committee advocates the use of laparos-copy rather than laparotomy
to determine whether metastases are present.
"The reason for this is that many of these patients with borderline
lesions will have peritoneal studding or other evidence of metastatic disease
that would not have been apparent on the CT scan," Dr. Tempero said.
"And so, it was the panel's feeling that, by doing a preop-erative
laparoscopy, you would be able to spare some of these patients from undergoing