Elsevier

Surgery

Volume 143, Issue 5, May 2008, Pages 658-666
Surgery

Original Communication
The platelet-lymphocyte ratio improves the predictive value of serum CA19-9 levels in determining patient selection for staging laparoscopy in suspected periampullary cancer

https://doi.org/10.1016/j.surg.2007.12.014Get rights and content

Background

The objective of this study was to identify whether the preoperative platelet-lymphocyte (P/L) ratio might improve the predictive value of CA19-9 levels in stratifying a patient group with suspected periampullary malignancy who do not require staging laparoscopy.

Methods

Patients with suspected periampullary cancer were identified from a prospectively maintained 10-year database. Only patients with resectable disease who underwent staging laparoscopy and subsequent laparotomy were included. Low-risk groups were stratified using a CA19-9 cutoff value of ≤ 150 kU/l (or ≤ 300 kU/l in patients with a concurrent bilirubin concentration > 35 μmol/l) and a P/L ratio value of ≤ 150.

Results

From 263 patients, preoperative CA19-9 levels and P/L ratios were available in 216 and 225 patients, respectively. The positive and negative predictive values for resectability, sensitivity, and specificity for CA19-9 levels ≤ 150kU/l were 83%, 36%, 51%, and 73%, respectively. For P/L ratios ≤ 150, these levels were 81%, 38%, 51%, and 72%, respectively. When combining the requirement for both CA19-9 levels and P/L ratios to be ≤ 150 (n = 38 out of 183), both positive predictive value (95%) and specificity (96%) were improved (Fisher exact test, P =.065 and P < .001, respectively); 21% of laparoscopies were avoidable when using these criteria. Increasing T stage (P = .005), vascular invasion (P < .001), perineural invasion (P = .008), and resection margin involvement (P < .001) were all associated with greater preoperative P/L ratios in resected periampullary adenocarcinoma (n = 204).

Conclusions

The preoperative P/L ratio reflects an index of tumor invasiveness and merits prospective evaluation as an adjunct to CA19-9 in determining the requirement for laparoscopic staging in patients with potentially resectable periampullary malignancy.

Section snippets

Material and methods

Details of all referrals between January 1997 and September 2006 with suspected pancreatic and periampullary malignancy were collected prospectively and maintained in a database. Patients undergoing contrast-enhanced computed tomography (CT) were identified to select patients with radiologically resectable disease. Decision-making regarding tumor resectability was undertaken during a weekly multidisciplinary team meeting. The principal CT criteria used to determine resectability were based on

Statistical analysis

Continuous data were described using the median and interquartile range (IQR) with 2-tailed Mann-Whitney U testing or Kruskal-Wallis testing for comparative analysis. Categorical data were analyzed using chi-squared (χ2) or Fisher exact. Receiver operating characteristic (ROC) curves were used to analyse whether serum CA19-9 levels or platelet-lymphocyte ratios conferred superior predictive information with regard to tumor resectability. Adjusted CA19-9 levels were calculated for these analyses

Results

A total of 1056 patients were recorded in the database during the study period; 675 patients were identified with CT resectable or borderline resectable pancreatic or periampullary tumors of whom 336 underwent staging laparoscopy. A total of 263 patients from this group went on to laparotomy with a resection rate of 72% (190/263). The median interval between laparoscopy and operation was 14 days (IQR, 7 to 28 days). The histologic diagnoses recorded in this group are shown in Table I. A total

Discussion

Laparoscopic staging has been demonstrated to influence decision-making regarding operative intervention in approximately 15% of patients with radiologically resectable periampullary malignancy.5, 22 Use of staging laparoscopy can minimize potentially unnecessary operative intervention in patients with locally advanced and metastatic disease missed by CT imaging and facilitate earlier administration of the most appropriate palliative therapy.23, 24, 25, 26 Although endoscopic ultrasonography

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    Supported by Cancer Research UK.

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