Pancreatic cancer: Minimally invasive treatments and possible links to GI diseases

Randomized Trial Comparing EUS and Surgery for Pancreatic Pseudocyst Drainage (Abstract #354)

Endoscopic ultrasound (EUS) is as effective as surgery in treating pancreatic pseudocysts while also being less expensive, less invasive and less painful than surgery, according to a new study. Pancreatic pseudocysts develop in approximately 10 percent of patients with pancreatitis, a painful condition in which the pancreas is inflamed, causing abdominal pain, nausea and vomiting.

Pseudocysts can block the intestines or stomach preventing food from being digested, and, because of their size, they increase pressure in the abdomen, causing pain. Typically, pseudocysts are treated by surgery in which the pseudocyst is opened and attached to the stomach so that the fluid can be drained into the stomach.

EUS is a new technology that represents an alternative to surgery by using an ultrasound at the tip of an endoscope which is passed into the stomach and is used to locate the pseudocyst on the outside of the stomach. Through a small incision and the use of stent, the pseudocyst can be drained into the stomach without the incision on the skin's surface, which is required with surgery. Previous research has shown that pseudocysts could be managed by EUS, however, the treatment outcomes compared to traditional surgery was unknown.

Shyam Varadarajulu, MD, and fellow researchers at the University of Alabama at Birmingham School of Medicine studied 36 patients over a 30-month period who had undergone EUS to treat pancreatic pseudocysts. They found that EUS is as effective as surgery and, because the procedure is less invasive than surgery, patients experienced no pain or scarring, and shorter length of stay in the hospital following the procedure (two days after EUS compared with six days after surgery). Researchers found no difference in the rate of recurrence of pseudocysts between EUS and surgery. EUS is also less costly than surgery ($8,195 compared with $22,475 for surgery).

"Our results show the effectiveness of EUS in treating pseudocysts and indicate that an investment in the development of better devices for performing this procedure would be worthwhile," said Dr. Varadarajulu. "Not only do patients have a better experience overall, but the cost to the health-care system is significantly lower using EUS."

Dr. Varadarajulu will present these data on Monday, May 3 at 3:50 p.m. CT in Ballroom C, Ernest N. Morial Convention Center.

Inflammatory Bowel Disease and Pancreatic Cancer: A Prospective Cohort Study (Abstract #252)

Researchers at the University of Utah have discovered a potential link between pancreatic cancer and inflammatory bowel disease (IBD), a disease that afflicts one in 500 Americans.

Investigators had previously observed that pancreatic cancer seemed to occur more frequently in patients and family members of patients with IBD, so researchers examined data from the NCI's Surveillance Epidemiology and End Results (SEER) database in conjunction with the Utah cancer registry. They looked at a retrospective, population-based cohort study of 2,877 adult patients over a 10-year period.

Their findings substantiated up to a six-fold increased risk of pancreatic cancer in patients with certain forms of IBD, which investigators say suggests a possible hereditary link between IBD and pancreatic neoplasia. They added that because few risk factors have been identified for the development of pancreatic malignancy -- making current screening attempts mostly ineffectual -- these results have potential implications for the early identification of patients with pancreatic cancer and may translate to improvements in survival similar to other forms of cancer where early screening has been employed successfully.

"Given a diagnosis of inflammatory bowel disease, specialized populations may benefit from efforts aimed at early detection where surgical intervention may offer a hope of long-term survival," said Jason Schwartz, MD, assistant professor of surgery, the University of Utah. "The survival rate for this cancer is currently very low, mostly because the tumor is discovered extremely late in its course."

Previous reports have examined the association between IBD and various other malignancies, but this study is the first to examine standardized incidence rates of IBD and pancreatic cancer, which is an estimate of the occurrence of cancer in a population relative to a larger comparison population designated as "normal" or "average."

Dr. Schwartz cautioned that people should not conclude that all patients with IBD will develop pancreatic cancer; more studies are needed to examine whether an increased risk of pancreatic cancer exists in extended family pedigrees of patients with IBD. If an increased predilection for pancreatic cancer exists in these family members, future studies will also focus on identification of the mode of inheritance as well as attempts to identify "susceptibility genes" that put patients at increased risk. He added that other studies may examine the utility of various screening modalities in susceptible populations.

Dr. Schwartz will present these data on Sunday, May 2 at 4:30 p.m. CT in 388-390, Ernest N. Morial Convention Center.

Intra-Abdominal Fat Predicts Survival in Pancreatic Cancer (Abstract #W1681)

A new study shows intra-abdominal fat can predict a pancreatic cancer patient's chances of survival. Researchers at the Michael E. DeBakey VA Medical Center (MEDVAMC) and Baylor College of Medicine (BCM) found that the more visceral fat, or fat located inside the belly, the worse a patient's chances for survival.

"Obesity is known to increase the risk of numerous types of cancer, including colon, breast, prostate, and endometrial and it is thought it is related to hormones or chemicals produced by fat," said David H. Berger, MD, MHCM, co-author of the paper, MEDVAMC Operative Care Line Executive, and professor of surgery at BCM. "However, our study determined that the location of the fat is the key to survival rates."

Dr. Berger and Courtney Balentine, MD, co-author of the paper and a fellow in surgical research at BCM, sought to determine if patients with central obesity had poorer chances of survival from pancreatic cancer. Typically, body mass index (BMI) is used to determine whether a patient is overweight or obese. BMI is a common measurement that uses a person's height and weight to formulate a measure of overweight or obesity.

"We have known that central obesity produces different hormones and chemicals than other types of obesity, and that these hormones are likely to stimulate cancer cells," said Dr. Balentine. "We wanted to determine the benefits of examining not only if a patient is obese, but where that fat is distributed."

Using CT scans of 61 patients, the researchers measured the distance between the back of the kidney and the abdominal wall to determine the amount of visceral fat in the patient. They found that the more intra-abdominal fat a patient had, the worse his or her prognosis. Patients were divided into four groups based on the amount of intra-abdominal fat. The best outcomes were seen in patients with the least intra-abdominal fat. Those with more fat had between a 30 percent and 400 percent increase in mortality.

Dr. Balentine will present these data on Wednesday, May 5 at 8 a.m. CT in Hall F, Ernest N. Morial Convention Center.

Image-Guided Stereotactic Radiosurgery for Locally Advanced Pancreatic Adenocarcinoma Results of First 85 Patients (Abstract #317)

New research from Sinai Hospital in Baltimore, MD, has found that locally advanced pancreatic cancer can be successfully controlled with stereotactic radiosurgery (SRS) which delivers beams of concentrated radiation to tumors with extreme accuracy and is administered non-invasively in outpatient settings.

Pancreatic cancer is extremely difficult to treat because it is not as sensitive to chemotherapy as other GI and body tumors. Surgery is available for about five to ten percent of diagnoses of locally advanced pancreatic cancer, but more often, radiation and chemotherapy are the two most common treatments.

Investigators, led by Mukund Didolkar, MD, director of surgical oncology, Sinai Hospital, and associate professor department of surgery, Johns Hopkins University School of Medicine, treated 85 patients with locally advanced and recurrent pancreatic adenocarcinoma with pancreatic SRS from February 2004 through August 2009. Patients were given SRS therapy with real time monitoring by CT scan over two to five days. The real-time monitoring allowed a more exact delivery of radiation adjusted for the motion of respiration. Following SRS treatment, patients received systemic chemotherapy to help control the spread of disease to other areas.

Patients experienced a local tumor control rate of 91.7 percent. Five patients experienced progression of the disease and three did not continue with follow-up. Survival time observed thus far is higher than with conventional radiation therapy. Most patients achieved mean survival over 11 months, compared with survival of five to eight months with other available treatments for patients with advanced pancreatic cancer with unresectable tumors.

In addition to increased survival, SRS has many advantages over currently recommended treatments for locally advanced, unresectable pancreatic cancers. SRS is delivered in three portions over two to five days, rather than conventional radiation therapy delivered over six to eight weeks, and patients experience less recovery time and an immediate return to normal activity. Conventional radiation therapy also exposes surrounding organs to high levels of radiation and its side effects.

"Stereotactic radiosurgery might be considered a substitute for surgery for patients with locally advanced pancreatic cancer," said Dr. Didolkar. "We have seen very encouraging results for this treatment in patients with inoperable pancreatic cancer."

Study results need to be replicated in larger centers to confirm the results.

Dr. Didolkar will present these data on Monday, May 3 at 11 a.m. CT in 244-245, Ernest N. Morial Convention Center.

Digestive Disease Week® 2010 (DDW®) is the largest international gathering of physicians, researchers and academics in the fields of gastroenterology, hepatology, endoscopy and gastrointestinal surgery. Jointly sponsored by the American Association for the Study of Liver Diseases, the AGA Institute, the American Society for Gastrointestinal Endoscopy and the Society for Surgery of the Alimentary Tract, DDW takes place May 1 -- May 5, 2010 in New Orleans, LA. The meeting showcases more than 5,000 abstracts and hundreds of lectures on the latest advances in GI research, medicine and technology.