Oncology/endocrine
The Use of Adjusted Preoperative CA 19-9 to Predict the Recurrence of Resectable Pancreatic Cancer

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Background

Despite the usefulness of CA 19-9 in the diagnosis and prognosis of pancreatic cancer, cholestasis can falsely elevate CA 19-9 levels, which contributes to limited clinical utility in patients with biliary obstruction. This study was designed to evaluate the usefulness of adjusted preoperative CA 19-9 levels in predicting a prognosis of pancreatic cancer.

Methods

The available medical records of patients with resected pancreatic cancer from January 1990 to June 2005 were retrospectively viewed at Yonsei Medical Center, Seoul, Korea. The adjusted CA 19-9 value was obtained by dividing the serum CA 19-9 level by the values of serum bilirubin in case of bilirubin ≳2 mg/dL. Disease-free survival was evaluated according to the adjusted preoperative CA 19-9 value.

Results

Sixty-one patients were investigated. Their adjusted preoperative CA 19-9 values were significantly different from the actual baseline CA 19-9 value (129.4 ± 225.2 U/mL, versus 442.1 ± 645.5 U/mL, P < 0.0001). On univariate analysis, peripancreatic microscopic invasion (P = 0.0142), lymphovascular invasion (P = 0.0038), and adjusted preoperative CA 19-9 ≥ 50 U/mL (P = 0.0049) were predictive factors for cancer recurrence after curative resection. Adjusted preoperative CA 19-9 ≥ 50 U/mL (Exp (B) = 2.097, P = 0.027) was an independent predictive factor in multivariate analysis.

Conclusions

The adjusted preoperative CA 19-9 value can predict the risk of recurrence after curative resection of pancreatic cancer. Interpreting the preoperative CA 19-9 value adjusted to the serum bilirubin values seems to be more reasonable in evaluating prognosis of pancreatic cancer.

Introduction

Pancreatic adenocarcinoma may be one of the most devastating diagnoses for patients and their families. Prognosis remains dismal, and only a few patients can be surgical candidates due to locally advanced disease and distant metastasis at the time of diagnosis. Overall, 5-y survival is less than 5%, and only 10 to 20% of patients who undergo resection have long-term survival [1]. Moreover, even after curative surgery, 50 to 80% of patients experience local recurrence, and more than 50% develop distant metastasis, especially to the liver [2].

CA 19-9, initially described as a colorectal cancer marker, was later found to be associated with pancreatic cancer. Normally, low levels of CA 19-9 can be expressed in healthy individuals (<40 U/mL). Using CA 19-9 for the diagnosis and prognosis of patients with pancreatic cancer has been evaluated [3]; however, diagnostic utility is limited in occasional cases. Elevated CA 19-9 levels can occur not only in several cancers, including pancreatic, hepatocellular, colorectal, and ovarian neoplasms, but also in benign, pathologic conditions, such as pancreatitis and choledocholithiasis [4].

Several studies have evaluated the correlation between high levels of CA 19-9 and advanced pancreatic disease, as well as between recurrence and postoperative CA 19-9 levels [5, 6, 7]. We investigated whether preoperative CA 19-9 levels, adjusted to total bilirubin levels, can be used as a predictive factor for disease-free survival in patients undergoing surgery for pancreatic ductal adenocarcinoma.

Section snippets

Patients and Methods

This was a retrospective study of patients who underwent surgical resection for pancreatic ductal adenocarcinoma from January 1990 to June 2005, at Yonsei Medical Center, Seoul, Korea. Data, including preoperative CA 19-9 levels and recurrence information, were obtained from a review of medical records. We controlled for bilirubin levels, as increased cholestasis falsely elevates CA 19-9 levels, likely a result of the decreased capacity of a cholestatic liver to degrade and excrete CA 19-9 [8, 9

Patient Demographics

During the study period, 102 patients underwent curative resection for pancreatic ductal adenocarcinoma. Among them, 61 patients had available medical records with data on both preoperative CA 19-9 levels and recurrence data. Of these patients, 39 were male and 22 were female, with a mean age of 60 y. General characteristics are listed in Table 1. The adjusted CA 19-9 levels were determined, as has been previously described. The adjusted CA 19-9 levels (mean ± SD, 129.4 ± 225.2 U/mL) were

Discussion

Pancreatic adenocarcinoma is the most devastating malignancy despite recent improvements in surgical and postoperative management. The overall survival rate is less than 5%, and even cumulative survival after resection is between 3.4 and 25% [11, 12, 13, 14]. In addition, recurrence and distant metastasis are common after resection. According to our data, the mean survival rate of patients with resectable pancreatic cancer was only 39.6 mo, and the 5-y survival rate was only 16.4%. Due to these

Conclusions

Adjusted preoperative CA 19-9 levels could predict the recurrence risk (disease-free survival) in patients with resectable pancreatic cancer. Our study suggests another clinical value of serum CA 19-9 in pancreatic cancer patients. In addition, when considering CA 19-9 biological properties and biliary excretion, the adjusted levels appear to be more reasonable than the actual levels of CA 19-9 in evaluating prognosis. We recommend that a well-designed prospective study to evaluate the

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