HPB
DOI:10.1111/hpb.12158
LETTER TO THE EDITOR
Jaundice in resected pancreatic cancer patients
Sir, We enjoyed the article by Strasberg et al. emphasizing the use of jaundice as a prognostic biomarker in patients with resected adenocarcinoma of the pancreas.1 In our attempt to validate these authors’ findings in our own cohort2 of 124 patients resected for pancreatic cancer, we found median survival amounted to 28.5 months in patients without jaundice and 17.9 months in those with jaundice. This difference was not statistically significant, but the findings of Strasberg et al.1 have been validated by other groups.3 Following the approach used by Strasberg et al.,1 we found tumour size, alkaline phosphatase level, tumour–node– metastasis (TNM) stage, grading and margin status to be significant prognostic factors in univariate analyses. When all factors were entered in a multivariate model, grading and margin status remained significant. The prognostic effect of jaundice – when present1,3 – is apparently independent of local obstruction (i.e. tumour size, stenting and nodal status), which suggests the presence of at least some underlying metabolic differences in the liver and/or tumour cells.4 The study by Strasberg et al.1 raises another important question. Tumour–node–metastasis staging is probably the most important factor in choosing treatment options and predicting outcome (e.g. determining resectability).5 However, both our own analysis and that of Strasberg et al.1 demonstrate larger effect sizes of other factors, such as grading after resection. Did Strasberg et al.1 include TNM staging in their analyses? The finding that preoperative jaundice status outperforms postoperative staging in
HPB 2014, 16, 195
predicting outcome would emphasize the clinical relevance of jaundice as a prognostic biomarker. Fenja M. Feld & Jochen K. Lennerz Institute of Pathology, University of Ulm, Ulm, Germany E-mail: [email protected]
References 1. Strasberg SM, Gao F, Sanford D, Linehan DC, Hawkins WG, Fields R et al. (2013) Jaundice: an important, poorly recognized risk factor for diminished survival in patients with adenocarcinoma of the head of the pancreas. HPB 15:245–324. 2. Schmid J, Glatzel MC, Welke C, Kornmann M, Kleger A, Barth TFE et al. (2013) Absence of FLICE-inhibitory protein (c-FLIP) is a novel independent prognostic marker for very short survival in ductal pancreatic adenocarcinoma. Pancreas (in press). 3. Lee SR, Kim HO, Son BH, Yoo CH, Shin JH. (2013) Prognostic factors associated with longterm survival and recurrence in pancreatic adenocarcinoma. Hepatogastroenterology 60:358–362. 4. Son J, Lyssiotis CA, Ying H, Wang X, Hua S, Ligorio M et al. (2013) Glutamine supports pancreatic cancer growth through a KRAS-regulated metabolic pathway. Nature 496:101–105. 5. National Comprehensive Cancer Network. (2013) NCCN Guidelines Version 1. Pancreatic Adenocarcinoma. Available at www.nccn.org (last accessed 8 May 2013).
© 2014 International Hepato-Pancreato-Biliary Association
DOI:10.1111/hpb.12158
LETTER TO THE EDITOR
Jaundice in resected pancreatic cancer patients
Sir, We enjoyed the article by Strasberg et al. emphasizing the use of jaundice as a prognostic biomarker in patients with resected adenocarcinoma of the pancreas.1 In our attempt to validate these authors’ findings in our own cohort2 of 124 patients resected for pancreatic cancer, we found median survival amounted to 28.5 months in patients without jaundice and 17.9 months in those with jaundice. This difference was not statistically significant, but the findings of Strasberg et al.1 have been validated by other groups.3 Following the approach used by Strasberg et al.,1 we found tumour size, alkaline phosphatase level, tumour–node– metastasis (TNM) stage, grading and margin status to be significant prognostic factors in univariate analyses. When all factors were entered in a multivariate model, grading and margin status remained significant. The prognostic effect of jaundice – when present1,3 – is apparently independent of local obstruction (i.e. tumour size, stenting and nodal status), which suggests the presence of at least some underlying metabolic differences in the liver and/or tumour cells.4 The study by Strasberg et al.1 raises another important question. Tumour–node–metastasis staging is probably the most important factor in choosing treatment options and predicting outcome (e.g. determining resectability).5 However, both our own analysis and that of Strasberg et al.1 demonstrate larger effect sizes of other factors, such as grading after resection. Did Strasberg et al.1 include TNM staging in their analyses? The finding that preoperative jaundice status outperforms postoperative staging in
HPB 2014, 16, 195
predicting outcome would emphasize the clinical relevance of jaundice as a prognostic biomarker. Fenja M. Feld & Jochen K. Lennerz Institute of Pathology, University of Ulm, Ulm, Germany E-mail: [email protected]
References 1. Strasberg SM, Gao F, Sanford D, Linehan DC, Hawkins WG, Fields R et al. (2013) Jaundice: an important, poorly recognized risk factor for diminished survival in patients with adenocarcinoma of the head of the pancreas. HPB 15:245–324. 2. Schmid J, Glatzel MC, Welke C, Kornmann M, Kleger A, Barth TFE et al. (2013) Absence of FLICE-inhibitory protein (c-FLIP) is a novel independent prognostic marker for very short survival in ductal pancreatic adenocarcinoma. Pancreas (in press). 3. Lee SR, Kim HO, Son BH, Yoo CH, Shin JH. (2013) Prognostic factors associated with longterm survival and recurrence in pancreatic adenocarcinoma. Hepatogastroenterology 60:358–362. 4. Son J, Lyssiotis CA, Ying H, Wang X, Hua S, Ligorio M et al. (2013) Glutamine supports pancreatic cancer growth through a KRAS-regulated metabolic pathway. Nature 496:101–105. 5. National Comprehensive Cancer Network. (2013) NCCN Guidelines Version 1. Pancreatic Adenocarcinoma. Available at www.nccn.org (last accessed 8 May 2013).
© 2014 International Hepato-Pancreato-Biliary Association
