Agnė Kavaliauskaitė¹

¹Lithuanian University of Health Sciences, Academy of Medicine, Kaunas, Lithuania

Abstract

Pancreatic cancer (PC) is an intractable malignancy which more often occurs in more developed countries.  PC has high mortality and morbidity rate, is fourth leading cause of cancer death worldwide. Symptoms depend on the localisation of the tumor, but there are no specific symptoms and that leads to late diagnosis. Carbohydrate 19-9 antigen (Ca 19-9) is the only marker used in clinical practice, but there are other biomarkers for earlier diagnosis at the research levels. The standard for PC diagnosis and staging is multi-detector computed tomography (MDCT). Surgical resection is the only potentially curative treatment for PC. Two main surgical methods are pacreaticoduodenectomy for tumors of the head of the pancreas and distal pancreatectomy for tumors localised in the tail or body of the pancreas. Minimally invasive surgery use is increasing, however, so far it does not have many advantages over open surgery.

Keywords: pancreatic cancer, biomarkers, cancerseek, pancreaticoduodenectomy.

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Medical Sciences 2021 Vol. 9 (2), p. 129-139

Pancreatic cancer: diagnostics and surgical treatment. Is

there anything new?

Agnė Kavaliauskaitė

1

1

Lithuanian University of Health Sciences, Academy of Medicine, Kaunas, Lithuania

Abstract

Pancreatic cancer (PC) is an intractable malignancy which more often occurs in more developed

countries. PC has high mortality and morbidity rate, is fourth leading cause of cancer death worldwide.

Symptoms depend on the localisation of the tumor, but there are no specific symptoms and that leads to

late diagnosis. Carbohydrate 19-9 antigen (Ca 19-9) is the only marker used in clinical practice, but there

are other biomarkers for earlier diagnosis at the research levels. The standard for PC diagnosis and staging

is multi-detector computed tomography (MDCT). Surgical resection is the only potentially curative

treatment for PC. Two main surgical methods are pacreaticoduodenectomy for tumors of the head of the

pancreas and distal pancreatectomy for tumors localised in the tail or body of the pancreas. Minimally

invasive surgery use is increasing, however, so far it does not have many advantages over open surgery.

Keywords: pancreatic cancer, biomarkers, cancerseek, pancreaticoduodenectomy.

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130

1. Introduction

Pancreatic cancer (PC) is an intractable

malignancy which more often occurs in higher-

income countries. Pancreatic tumors are divided

into two main groups: adenocarcinoma (90% of

cases) and pancreatic endocrine tumors which

are less common (less than 5%) [1, 2]. PC ranks

11th place among men's most common

malignancies and, respectively, 12th place

among women [3]. It is the fourth leading cause

of cancer deaths worldwide. Approximately

57,600 new cases of PC and around 47,050

deaths were expected in 2020 in the USA [4]. The

risk of developing of PC correlates with age: the

majority of patients are older than 40 - 45 years

and at diagnosis mean age is 70 years [5, 6].

Other risk factors include smoking, type 2

diabetes, high body mass index, family history,

long-term alcohol use and chronic pancreatitis [1,

5, 7, 8]. The larger amounts of cases are

diagnosed at advanced stages of PC when lymph

nodes and other organs are already affected. The

prognosis of 5-year survival rate is

approximately 6% [8]. That shows how

important it is to increase diagnostic and

treatment abilities to reach greater survival rate.

The purpose of this literature review is to

summarize the main diagnostic and surgical

treatment methods and to review the latest

diagnostic findings.

2. Diagnostics

2.1. Symptoms

This section will review the symptoms

caused by pancreatic adenocarcinoma (PAC), as

it is, as mentioned earlier, the most common

pancreatic tumor. In addition, the onset of initial

symptoms depends on the location of the tumor.

About two-thirds of PACs are localized in the

head of the pancreas, about 20% in the body or

tail and the rest involves whole organ [9-11].

However, the symptoms are nonspecific. The

most frequent symptoms associate with

constitutional syndrome: weight loss, anorexia,

asthenia and cachexia [12]. The second most

common symptom is abdominal pain. Tumors

located in the head cause symptoms of the biliary

tree obstruction as jaundice, pruritus, dark urine

and pale stools [9, 10]. PACs in the body or tail

of the pancreas rarely cause symptoms of

obstruction. Patients commonly have such

symptoms as pain in the epigastrium or back,

early satiety, dyspepsia and weight loss [13]. The

sudden onset of type 2 diabetes, which is hardly

treated with medications in patients older than 50

years, may be a sign of PC [14]. The distribution

of frequency of symptoms described in literature

is shown in Table 1.

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Table 1. Frequency of symptoms.

Symptom

Frequency

Weight loss

85 – 92%

Asthenia

86%

Anorexia

64 – 83%

Jaundice

56 – 82%

Abdominal pain

72 – 79%

Epigastric pain

71%

Dark urine

59 – 63%

Pale stool

62%

Nausea

43 – 51%

Back pain

49%

Diarrhea

44%

Weakness

35 – 42%

Vomiting

33 – 37%

2.2. Physical examination

Findings of physical examination also

vary and depend on localisation of the tumor. The

examination in early stages of the PAC is usually

normal, without any changes. Biliary tract

obstruction with jaundice, abdominal pain and

cachexia occur in advanced stages of PAC

located in the head of the pancreas [9, 15].

Enlarged, nontender gallbladder may be felt

during palpation of the abdomen. Courvoisier’s

sign (painless jaundice and enlarged gallbladder)

is quite specific (83 – 90%), but rare and only 26

– 55% sensitive, because most commonly pain

also occurs [9, 15, 16]. Other findings include

hepatomegaly, palpable mass at pancreas

projection, enlarged supraclavicular (Virchow’s

node) or other lymph nodes and superficial

migrantory thrombophlebitis (Trousseau’s sign)

[15 – 17]. Pancreatic panniculitis, known as

nodular fat necrosis, manifestation in lower

extremities is rare (up to 3%), but possible

finding with acinar cell variant of PC [18].

2.3. Laboratory findings

Serum aspartate aminotransferase

(AST), alanine aminotransferase (ALT), alkaline

phosphatase and bilirubin tests have to be

performed for patients who have developed

jaundice, epigastric pain to assess for cholestasis

[11, 19]. Also, for patients with epigastric pain, a

test of serum lipase is important for

differentiation with acute pancreatitis.

The aforementioned laboratory analytes

may show changes induced by pancreatic cancer

but are not specific. More specific is serum tumor

marker carbohydrate 19-9 antigen (Ca 19-9). Ca

19-9 can be an additional factor in confirming the

diagnosis in symptomatic patients or in helping

to predict (1) tumor resectability (serum level <

200 U/ml – resectable tumor, >1000 U/ml –

probably metastatic PC), (2) treatment efficacy

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[20, 21]. However, literature sources provide that

sensitivity and specificity of this cancer marker

are only 50 – 81% and 82 – 90%, respectively, in

symptomatic patients making it unreliable for the

diagnosis or screening [13, 20, 21]. Also, there is

a possibility for (1) false negative results in

patients with a Lewis negative genotype, when

Ca19-9 cannot be expressed (about 10% of the

population) or (2) false positive results in cases

of diabetes mellitus, chronic pancreatitis,

cirrhosis, cholestasis and etc. [20, 22].

2.4. Imaging

First imaging test for patients with

symptoms of PC is typically a transabdominal

ultrasound (TUS), because of its low cost and

high accessibility. TUS has high sensitivity and

specificity of 88% and 94%, respectively for

tumors larger than 3cm [11, 13, 23]. However,

there are less sensitivity and specificity in smaller

tumors. The standard for PC diagnosis and

staging is multi-detector computed tomography

(MDCT) which involves arterial, late and venous

phases cross-sectional imaging [9]. MDCT is

sufficient to detect pancreatic mass and

metastases, is quite fast and more accessible than

magnetic resonance imaging (MRI). Otherwise,

MRI is as sensitive and specific as MDCT and is

an alternative for people with allergy to contrast

media. Also, it can detect isoattenuating

pancreatic lesions, which are not or poorly

visible at MDCT [9, 20, 23]. Endoscopic

ultrasonography (EUS) should be performed if

no lesions of the pancreas are visualized using

imaging methods mentioned above and high

suspicion of PC remains. This method excels by

higher sensitivity of 80% detectioning small

cancers (<1 cm) compared with MDCT and MRI

[24, 25]. Fine needle aspiration (FNA) biopsy

could be done during EUS. It is indicated for

patients with unresectable tumor for decision on

further treatment. As Robert Freelove and Anne

D. Walling say, biopsy for resectable cancer is

not necessary and patients can undergo surgery

without preoperative histological conformation

[13]. Another method is endoscopic retrograde

cholangiopancreatography (ERCP), which is

used to relieve cholestasis due to tumor

obstruction by placing biliary stent. Also, forceps

biopsy or brush cytology can be performed

during the ERCP for histological diagnosis, but

its sensitivity is lower than FNA biopsy’s.

However, bile duct stenting before CT scanning

is not recommended, because it can cause

inflammatory changes or artifacts and mask the

tumor [11, 13, 20]. Magnetic resonance

cholangiopancreatography (MRCP) can replace

ERCP for patients with gastric outlet or duodenal

stenosis [11, 26]. 18-Fluorodeoxyglucose

positron emission tomography (FDG-PET) can

also be used for early detection and staging, but

in the literature this method is still very

controversial and not included in the systematic

staging of PCA [20, 27]. The distribution of

sensitivity and specificity of imaging modalities

found in the literature is shown in Table 2.

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Table 2. Sensitivity and specificity of imaging modalities for the diagnosis of PCA.

Imaging method

Sensitivity

Specificity

TUS

83 – 90%

87 – 99%

MDCT

89 – 97%

79 – 93%

MRI

88 – 96%

82 – 94%

EUS

87 – 94%

81 – 91%

ERCP

70 – 92%

94 – 96%

MRCP

84 – 91%

94 – 97%

FDG-PET

85 – 96%

54 – 84%

TUS – transabdominal ultrasound, MDCT – multi-detector computed tomography, MRI – magnetic

resonance imaging, EUS – endoscopic ultrasonography, ERCP – endoscopic retrograde

cholangiopancreatography, MRCP – magnetic resonance cholangiopancreatography, FDG-PET – 18-

Fluorodeoxyglucose positron emission tomography.

2.5. New ways of biomarkers using

As mentioned above, Ca 19-9 is the

only clinically used protein biomarker for PAC

diagnosis. Though there are several studies who

tested other biomarkers. One of them is

carcinoembryonic antigen (CEA), which is found

in serum of 30 – 60% of patients with PC [22,

28]. Sensitivity and specificity of CEA alone are

of 45% and 75%, respectively. Ca 19-9 and CEA

when used together increase specificity to 84%

but decrease sensitivity to 37% [29]. Darragh P.

O’Brien and co-authors in their study established

that cancer antigen 125 (Ca 125) and Ca 19-9

combined together gave sensitivity and

specificity of 56,7% and 90,6%, respectively, but

there was no significant difference by using Ca

19-9 alone [30]. Also, CEA and Ca 125

biomarkers are one of the solutions for Lewis

negative patients with PCA [31]. Another

promising marker is macrophage inhibitory

cytokine 1 which, as mentioned in literature,

shows better differentiation between healthy

patients and patients with resectable PAC

comparing to Ca 19-9. Other prognostic

biomarkers are osteopontin (OPN) and matrix

metalloprotease which spread to the bloodstream

because of PAC fibrotic stroma remodulation.

Literature sources mention that the sensitivity

and specificity of these markers are similar to Ca

19-9 and high levels associates with poor

survival [22].

New blood test, called CancerSEEK, for

early cancer detection was presented in 2018. It

can detect eight most common human cancers

types including cancer of pancreas [32, 33]. Tests

consist of a combination of genetic marker -

circulating tumor DNA (ctDNA) and eight

protein markers (Ca 125, CEA, Ca 19-9,

prolactin, hepatocyte growth factor, OPN,

myeloperoxidase). A test could detect about 81%

of PC, its sensitivity for PC is about 72%,

specificity – 99% [34]. However, there is still a

possibility for false positive results for

individuals with comorbidities which can

increase protein markers levels [33]. Also, as

Alain R Thierry says, there is a possibility of

overdiagnosis and overtreatment, because this

test cannot predict the tumor’s growing rate and

foresee possible tumor’s changes [32]. This test

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looks very promising, but needs further

investigation in larger, more various population.

3. Treatment

Surgical resection is the only potentially

curative treatment for PAC. However, only 15-

20% of patients can undergo this treatment

because of late diagnosis of the disease [13, 35].

According to NCCN guidelines, tumors are

resectable if there is no arterial tumor contact

including celiax axis (CA), superior mesenteric

aretry (SMA), common hepatic artery (CHA).

Also, resectable tumors are with no contact with

the superior mesenteric vein (SMV), portal vein

(PV) or if there is <180

o

contact without vein

contour irregularity. Borderline resectability is

possible for solid tumor contact with CHA

without extension to CA or hepatic artery

bifurcation; solid tumor contact with the SMA of

<180

o

; solid tumor contact with variant arterial

anatomy; solid tumor contact with the CA <180

o

or >180

o

without involvement of the aorta.

Furthermore, borderline resection can be applied

for solid tumor contact with the inferior vena

cava or solid tumor contact with SMV/PV of

>180

o

,

contact of <180

o

with contour irregularity

of the vein or thrombosis of the vein but with

suitable complete resection and vein

reconstruction [36]. Resectable tumors of the

head of the pancreas account for 20%, of the

body and tail accounts for 5%. To achieve R0

resection is the main goal of the surgery [37, 38].

For PAC localized in the head of the

pancreas the standard operation is

pancreaticoduodenectomy (PD), also known as

Whipple procedure [9]. It involves resection of

pancreatic head, gallbladder, common bile duct,

duodenum, part of jejunum and partial

gastrectomy [9, 35]. There are some modified

methods: pylorus-preserving PD to avoid

postoperative dumping or subtotal stomach-

preserving PD to preserve more stomach. One

study found that patients who underwent

stomach-preserving PD lived longer than patients

who undergo PD or pylorus-preserving PD [39].

Also, there are two ways to reconstruct the

integrity of the digestive tract after PD by

anastomosing left part of pancreas to jejunum or

stomach. However, there is no difference

between these procedures [40]. Vascular

resection has not been extensively studied, but in

literature there are promising outcomes described

for venous resection (VR) comparing to arterial

resection. PD with VR comparing to PD alone

has similar mortality rates, however PD with VR

is associated with increased operative time and

blood loss [41, 42].

Distal pancreatectomy with

splenectomy is a typical surgery for tumors in the

tail or body of the pancreas. However, as

mentioned above, tumors in this localization are

diagnosed only in advanced stages because they

do not cause obstruction of the common bile

duct, there are no early symptoms, so total

resection of tumor is rare [35].

With the development of medicine, the

use of minimally invasive surgeries for the

treatment of pancreatic tumors has also

increased. Laparoscopic or robotic-assisted

pancreatectomy can also be performed. Patients

who underwent laparoscopic PD comparing to

those who underwent open PD have had shorter

hospital stays, less blood loss and better survival

rate of 3-5 years, postoperative complications

rate was the same [43, 44]. Robotic PD results in

longer operation duration, less blood loss and

more lymph nodes harvested than open PD [45].

In the literature sources there was no significant

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difference between robotic and laparoscopic

methods [46]. All in all, further research is

required to evaluate advantages of minimally

invasive treatment.

4. Conclusion

Pancreatic cancer is a global problem

due to its late diagnosis and poor 5-year survival

rate. MDCT remains the main diagnostic

method. However, there are promising findings

in biomarkers, but further studies must be

conducted. Surgical treatment is the only

potentially curative treatment, but available just

to a small portion of patients. Resectability is

determined by special criteria.

Pancreaticoduodenectomy is a standard

operation for resectable tumors in the head of

pancreas, distal pancreatectomy for – tumors in

the body or tail of pancreas. The use of minimally

invasive surgeries is increasing, because these

operations result in less blood loss, shorter

hospital stays, but there are no significant

differences in complications, mortality and

survivance rates comparing to open surgeries.

Further studies must be conducted for treatment.

5. References:

1. Rawla P, Sunkara T, Gaduputi V.

Epidemiology of Pancreatic Cancer: Global

Trends, Etiology and Risk Factors. World J

Oncol 2019;10(1):10-27.

doi:10.14740/wjon1166.

2. Manuel Hidalgo, Stefano Cascinu, Jörg

Kleeff, Roberto Labianca, J.-Matthias Löhr,

John Neoptolemos et al. Addressing the

challenges of pancreatic cancer: Future

directions for improving outcomes.

Pancreatology 2015; 8-18.

doi.org/10.1016/j.pan.2014.10.001.

3. Bray F, Ferlay J, Soerjomataram I, Siegel

RL, Torre LA, Jemal A. Global Cancer

Statistics 2018: GLOBOCAN estimates of

incidence and mortality worldwide for 36

cancers in 185 countries. CA Cancer J Clin

2018; 394-424.

https://doi.org/10.3322/caac.21492.

4. Rebecca L. Siegel, Kimberly D. Miller,

Ahmedin Jemal. Cancer statistics, 2020. CA

Cancer J Clin 2020; 70: 7-30.

https://doi.org/10.3322/caac.21590.

5. Vedat Goral. Pancreatic Cancer:

Pathogenesis and Diagnosis. Asian Pac J

Cancer Prev, 2015; 16(14): 5619-5624.

6. American Cancer Society. Pancreatic

Cancer Risk Factors. June 9, 2020.

Available form:

https://www.cancer.org/cancer/pancreatic-

cancer/causes-risks-prevention/risk-

factors.html [Accessed December 11, 2020].

7. Jonathan D Mizrahi, Risi Surana, Prof Juan

W Valle, Rachna T Shroff. Pancreatic

Cancer. Lancet 2020; 2008-2020.

https://doi.org/10.1016/S0140-

6736(20)30974-0.

8. Ilic M, Ilic I. Epidemiology of pancreatic

cancer. World J Gastroenterol. 2016;

22(44): 9694-9705.

doi:10.3748/wjg.v22.i44.9694.

9. Maria Syl D. De La Cruz, Alisa P. Young,

Mack T. Ruffin. Diagnosis and Management

of Pancreatic Cancer. Am Fam Physician

2014; 89(8): 626-632.

10. Avo Artinyan, Perry A. Soriano, Christina

Prendergast, Tracey Low, Joshua D.I.

Ellenhorn, Joseph Kim. The anatomic

location of pancreatic cancer is a prognostic

factor for survival. HPB 2008; 10(5): 371-

376.

Journal of Medical Sciences. Mar 30, 2021 - Volume 9 | Issue 2. Electronic - ISSN: 2345-0592

136

https://doi.org/10.1080/1365182080229123

3.

11. Carlos Fernandez-del Castillo. Clinical

manifestations, diagnosis, and staging of

exocrine pancreatic cancer. UpToDate,

2020. Available from: https://www-

uptodate-

com.ezproxy.dbazes.lsmuni.lt/contents/clini

cal-manifestations-diagnosis-and-staging-

of-exocrine-pancreatic-cancer.

12. Porta, M., Fabregat, X., Malats, N. et

al. Exocrine pancreatic cancer: Symptoms at

presentation and their relation to tumour site

and stage. Clin Transl Oncol, 2005; 7: 189–

197. https://doi-

org.ezproxy.dbazes.lsmuni.lt/10.1007/BF02

712816

13. Robert Freelove, Anne D. Walling.

Pancreatic Cancer. Diagnosis and

Management. Am Fam Physician 2006; 73

(3): 485-492.

14. Margaret A. Tempero, J. pablo Arnoletti,

Stephen Behrman, Edgar Ben-Josef, Al B.

Benson, Jordan D. Berlin. Pancreatic

Adenocarcinoma. J Natl Compr Canc Netw

2010; 8(9): 972-1017.

https://doi.org/10.6004/jnccn.2010.0073.

15. Giambelluca Dario, Dimarco Mariangela,

Salvaggio Giuseppe, Midiri Massimo. The

Courvoisier’s sign. Abdominal Radiology

2019; 44: 1185-1186. DOI:10.1007/s00261-

018-1881-9.

16. Rowan Hillson. Pancreatitis, pancreatic

cancer, and diabetes. Practical Diabetes

2016; 33: 77-78.

https://doi.org/10.1002/pdi.2006

17. Cinthya S. Yabar, Jordan M. Winter.

Pancreatic Cancer: A Review.

Gastroenterology Clinics of North America

2016; 45(3): 429-445.

https://doi.org/10.1016/j.gtc.2016.04.003.

18. Rongioletti F, Caputo V. Pancreatic

panniculitis. G Ital Dermatol Venereol 2013;

148(4): 419-25.

19. Namita Roy-Chowdhury, Jayanta Roy-

Chowdhury. Diagnostic approach to the

adult with jaundice or asymptomatic

hyperbilirubinemia. UpToDate, 2020.

Available from: https://www-uptodate-

com.ezproxy.dbazes.lsmuni.lt/contents/diag

nostic-approach-to-the-adult-with-jaundice-

or-asymptomatic-hyperbilirubinemia.

20. Cindy Neuzillet, Sébastien Gaujoux,

Nicolas Williet, Jean-Baptiste Bachet,

Lucile Bauguion, Laurianne Colson Durand

et al. Pancreatic cancer: French clinical

practice guidelines for diagnosis, treatment

and follow-up (SNFGE, FFCD, GERCOR,

UNICANCER, SFCD, SFED, SFRO,

ACHBT, AFC). Digestive and Liver Disease

2018; 50(12): 1257-1271.

https://doi.org/10.1016/j.dld.2018.08.008.

21. Umashankar K Ballehaninna, Ronald S

Chamberlain. The clinical utility of serum

CA 19-9 in the diagnosis, prognosis and

management of pancreatic adenocarcinoma:

An evidence based appraisal. Journal of

Gastrointestinal Oncology 2012; 3(2).

22. Andrii Khomiak, Marius Brunner,

Maximilian Kordes, Stina Lindblad, Rainer

Christoph Miksch, Daniel Ohlund et al.

Recent Discoveries of Diagnostic,

Prognostic and Predictive Biomarkers for

Pancreatic Cancer 2020; 12(11): 3234.

https://doi.org/10.3390/cancers12113234.

23. James Toft, William J. Hadden, Jerome M.

Laurence, Vincent Lam, Lawrence Yuen,

Anna Janssen et al. Imaging modalities in

Journal of Medical Sciences. Mar 30, 2021 - Volume 9 | Issue 2. Electronic - ISSN: 2345-0592

137

the diagnosis of pancreatic adenocarcinoma:

A systematic review and meta-analysis of

sensitivity, specificity and diagnostic

accuracy. European Journal of Radiology

2017; 92: 17-23.

https://doi.org/10.1016/j.ejrad.2017.04.009.

24. Kitano, M., Yoshida, T., Itonaga, M. et

al. Impact of endoscopic ultrasonography on

diagnosis of pancreatic cancer. J

Gastroenterol 2019; 54: 19–32.

https://doi.org/10.1007/s00535-018-1519-2.

25. Harmsen FR, Domagk D, Dietrich CF,

Hocke M. Discriminating chronic

pancreatitis from pancreatic cancer:

Contrast-enhanced EUS and multidetector

computed tomography in direct

comparison. Endosc Ultrasound 2018; 7(6):

395-403. doi:10.4103/eus.eus_24_18.

26. Henning Ernst Adamek, Joerg Albert,

Hermann Breer, Mathias Weitz, Dieter

Schilling, Juergen Ferdinand Riemann.

Pancreatic cancer detection with magnetic

resonance cholangiopancreatography and

endoscopic retrograde

cholangiopancreatography: a prospective

controlled study. Lancet 2000; 356: 190-

193. https://doi.org/10.1016/S0140-

6736(00)02479-X.

27. Ippei Matsumoto, Sachiyo Shirakawa,

Makoto Shinzeki, Sadaki Asari, Tadahiro

Goto, Tetsuo Ajiki et al. 18-

Fluorodeoxyglucose Positron Emission

Tomography Does Not Aid in Diagnosis of

Pancreatic Ductal Adenocarcinoma. Clinical

Gastroenterology and Hepatology 2013;

11(6) : 712-718.

https://doi.org/10.1016/j.cgh.2012.12.033.

28. Meng Q, Shi S, Liang C, et al. Diagnostic

and prognostic value of carcinoembryonic

antigen in pancreatic cancer: a systematic

review and meta-analysis. Onco Targets

Ther 2017; 10: 4591-4598.

doi:10.2147/OTT.S145708.

29. X.G. Ni, X.F. Bai, Y.L. Mao, Y.F. Shao, J.X.

Wu, Y. Shan et al. The clinical value of

serum CEA, CA19-9, and CA242 in the

diagnosis and prognosis of pancreatic

cancer.European Journal of Surgical

Oncology 2005; 31: 164-169.

https://doi.org/10.1016/j.ejso.2004.09.007.

30. Darragh P. O’Brien, Neomal S.

Sandanayake, Claire Jenkinson, Aleksandra

Gentry-Maharay, Sophia Apostolidou,

Evangelia-Ourania Fourkala et al. Serum

CA19-9 Is Significantly Upregulated up To

2 Years before Diagnosis with Pancreatic

Cancer: Implications for Early Disease

Detection. Clin Cancer Res 2015; 21: 622-

631. doi:10.1158/1078-0432.CCR-14-0365.

31. Luo Guopei, Liu Chen, Guo Meng, Cheng

He, Lu Yu, Jin Kaizhou et al. Potential

Biomarkers in Lewis Negative Patients With

Pancreatic Cancer. Annals of Surgery 2017;

265: 800-805. doi:

10.1097/SLA.0000000000001741.

32. Alain R Thierry. A Step Closer to Cancer

Screening by Blood Test. Clinical

Chemistry 2018; 64: 1420–1422. https://doi-

org.ezproxy.dbazes.lsmuni.lt/10.1373/clinc

hem.2018.287847.

33. Killock, D. CancerSEEK and destroy — a

blood test for early cancer detection. Nat Rev

Clin Oncol 2018; 15: 133. https://doi-

org.ezproxy.dbazes.lsmuni.lt/10.1038/nrcli

nonc.2018.21.

34. Joshua D. Cohen, Lu Li, Yuxuan Wang,

Christopher Thoburn, Bahman Afsari,

Ludmila Danilova. Detection and

Journal of Medical Sciences. Mar 30, 2021 - Volume 9 | Issue 2. Electronic - ISSN: 2345-0592

138

localization of surgically resectable cancers

with a multi-analyte blood test. Science

2018; 359: 926-930. DOI:

10.1126/science.aar3247.

35. Carlos Fernandez-del Castillo, Ramon E

Jimenez. Overview of surgery in the

treatment of exocrine pancreatic cancer and

prognosis. UpToDate, 2020. Available

from: https://www-uptodate-

com.ezproxy.dbazes.lsmuni.lt/contents/over

view-of-surgery-in-the-treatment-of-

exocrine-pancreatic-cancer-and-prognosis.

36. Margaret A. Tempero, Mokenge P. Malafa,

Mahmoud Al-Hawary, Horacio Asbun,

Andrew Bain, Stephen W. Behrman et al.

Pancreatic Adenocarcinoma, Version

2.2017. Journal of the National

Comprehensive Cancer Network 2017; 15:

1028-1061.

37. M. Ducreux, A. Sa. Cuhna, C. Caramella, T.

Conroy, A. Hollebecque, P. Burtin. Cancer

of the pancreas: ESMO Clinical Practice

Guidelines for diagnosis, treatment and

follow-up. Annals of Oncology 2015; 26:56-

68.

38. McGuigan A, Kelly P, Turkington RC,

Jones C, Coleman HG, McCain RS.

Pancreatic cancer: A review of clinical

diagnosis, epidemiology, treatment and

outcomes. World J Gastroenterol 2018;

24(43): 4846-4861.

doi:10.3748/wjg.v24.i43.4846.

39. Fujii T, Kanda M, Kodera Y, Nagai S, Sahin

TT, Hayashi M et al. Preservation of the

pyloric ring has little value in surgery for

pancreatic head cancer: a comparative study

comparing three surgical procedures. Ann

Surg Oncol 2012;19(1): 176-83. doi:

10.1245/s10434-011-1901-2.

40. Cheng Y, Briarava M, Lai M, Wang X, Tu

B, Cheng N et al. Pancreaticojejunostomy

versus pancreaticogastrostomy

reconstruction for the prevention of

postoperative pancreatic fistula following

pancreaticoduodenectomy. Cochrane

Database Syst Rev 2017; 9(9): CD012257.

doi: 10.1002/14651858.CD012257.pub2.

41. Yu XZ, Li J, Fu DL, Di Y, Yang F, Hao SJ

et al. Benefit from synchronous portal-

superior mesenteric vein resection during

pancreaticoduodenectomy for cancer: a

meta-analysis. Eur J Surg Oncol. 2014;

40(4): 371-8. doi:

10.1016/j.ejso.2014.01.010.

42. Joal D. Beane, Michael G. House, Susan C.

Pitt, Ben Zarzaur, E. Molly Kilbane, Bruce

L. Hall et al. Pancreatoduodenectomy with

venous or arterial resection: a NSQIP

propensity score analysis. HPB 2017;19:

254-263.

https://doi.org/10.1016/j.hpb.2016.11.013.

43. Ke Chen, Yucheng Zhou, Weiwei Jin,

Qicong Zhu, Chao Lu, Nan Niu et al.

Laparoscopic pancreaticoduodenectomy

versus open pancreaticoduodenectomy for

pancreatic ductal adenocarcinoma:

oncologic outcomes and long‐term survival.

Surgical Endoscopy 2020; 34: 1948-1958.

44. Zhang Hang, Guo Xingjun, Xia Jia, Zhu

Feng, Shen Ming, Wang Xin et al.

Comparison of Totally 3-Dimensional

Laparoscopic Pancreaticoduodenectomy

and Open Pancreaticoduodenectomy.

Pancreas 2018; 47: 592-600. doi:

10.1097/MPA.0000000000001036.

45. Shin-E Wang, Bor-Uei Shyr, Shih-Chin

Chen, Yi-Ming Shyr. Comparison between

robotic and open pancreaticoduodenectomy

Journal of Medical Sciences. Mar 30, 2021 - Volume 9 | Issue 2. Electronic - ISSN: 2345-0592

139

with modified Blumgart

pancreaticojejunostomy: A propensity

score–matched study. Surgery 2018; 164:

1162-1167.

https://doi.org/10.1016/j.surg.2018.06.031.

46. Nassour, I., Wang, S.C., Porembka, M.R. et

al. Robotic Versus Laparoscopic

Pancreaticoduodenectomy: a NSQIP

Analysis. J Gastrointest Surg 2017; 21:

1784–1792. https://doi.org/10.1007/s11605-

017-3543-6.