Laparoscopy with Laparoscopic Ultrasonography in the TNM Staging of Pancreatic Carcinoma

Abstract

A prospective study was performed comparing laparoscopy with laparoscopic ultrasonography (LapUS), transabdominal ultrasonography (USS), computed tomography (CT), and selective visceral angiography with portal phase venography (SVA) for the assessment of resectability in 50 patients with pancreatic or periampullary cancer. The results were stratified by TNM stages. Tumor unresectability was demonstrated in 36 patients (72%). The sensitivity of LapUS for demonstrating the index lesion was 96%. Laparoscopic ultrasonography failed to predict factors precluding resection by T stage in six patients, and there were no significant differences in the ability of any modality to predict local resectability (predictive value 58-73%). Laparoscopic ultrasonography did not overestimate T stage and was significantly more specific for assessing unresectability compared with USS (100% vs. 64%, p<0.05) and CT (100% vs. 47%, p<0.005). No imaging investigation was able to assess the N stage accurately. Metastases were confirmed in 16 patients (32%), with LapUS proving significantly more sensitive than USS (94% vs. 29%, p<0.001) and CT (94% vs. 33%, p<0.005). The addition of LapUS to the laparoscopic examination did not change the M stage in any patient, as all metastases were superficially located. Laparoscopy with LapUS was the most reliable method for assessing overall tumour resectability and was significantly more predictive than CT (97% vs. 79%, p<0.005). These results confirm that laparoscopy is indispensable for detecting occult intraabdominal metastases. LapUS reliably predicts tumor unresectability, offsetting the tendency of USS and CT to overestimate T stage. Methods of accurate N staging remain elusive, and the use of routine SVA is not justified.

Prospective Comparison of Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography in the Preoperative Assessment of Masses in the Pancreatic Head

“…We are convinced that the preoperative differentiation between benign and malignant lymph nodes in populations like ours cannot accurately be done without cytology or histology, and puncture under EUS guidance is possibly the most promising tool [37, 38, 39]. The roles of preoperative laparoscopy and laparoscopic ultrasonography are still discussed controversially, but their major diagnostic impact seems to be prediction of tumor unresectability and detection of liver metastases or peritoneal carcinomatosis, whereas the accuracy in lymph node staging is also disappointing [40, 41, 42]. …”

Refining the role of laparoscopy and laparoscopic ultrasound in the staging of presumed pancreatic head and ampullary tumours

“…The technique for laparoscopic ultrasound has been previously described (John et al, 1999). Laparoscopy was performed under general anaesthesia and if metastatic disease was identified laparoscopic ultrasound was not performed routinely.…”

“…Vascular invasion was indicated if there was (a) obliteration or thrombosis of the vein; (b) a fixed stenosis of the vessel wall; (c) loss of the hyperechoic vessel -tumour interface with encroachment of hypoechoic tumour to the vessel margin; (d) vessel encasement by tumour encirclement and rigidity; (e) presence of tumour within the vessel lumen (John et al, 1999) (Figure 1). The accuracy of this technique has previously been validated from this unit (John et al, 1995).…”

“…Laparoscopy with the addition of laparoscopic ultrasound has previously been shown to be an effective tool in the staging of pancreatic cancer (John et al, 1995) being more predictive of resectability than abdominal computed tomography (John et al, 1999). Palliative surgery does not increase the duration of survival compared to endoscopic stenting (Taylor et al, 2000), however, operative bypass offers longer palliation of symptoms.…”

Laparoscopic Pancreatic Surgery

“…Studies comparing laparoscopy and laparoscopic ultrasound with radiological staging modalities have produced controversial results. However, several studies have found that laparoscopy and laparoscopic ultrasound are more accurate than contrastenhanced CT at determining T stage (John et al, 1999;Doran et al, 2004).…”