|Year : 2016 | Volume
| Issue : 3 | Page : 545-548
Clinical value of serum CA19-9 levels in evaluating resectability of pancreatic carcinoma
Alaa A Elsesi, Asem F Moustafa, Mostafa H Elmarakby
General Surgery Department, Faculty of Medicine, Menofia University, Menofia, Egypt
|Date of Submission||11-Jan-2015|
|Date of Acceptance||04-May-2015|
|Date of Web Publication||23-Jan-2017|
Mostafa H Elmarakby
General Surgery Department, Faculty of Medicine, Menofia University, Menofia
Source of Support: None, Conflict of Interest: None
Serum CA19-9 is a tumor marker with high sensitivity to pancreatic cancer. It is considered an easy, cheap, fast, and noninvasive tool in the diagnosis and monitoring of cancer pancreas, which is one of the medical problems that has high morbidity and mortality rates.
The aim of this study was to evaluate the clinical value of serum CA19-9 levels in predicting the resectability of pancreatic carcinoma, provided the tumor is resectable on computer tomography basis.
Patients and methods
In this retrospective study, serum CA19-9 levels were evaluated in 48 patients with pancreatic cancer in whom there was a possibility of resection on the basis of imaging. The patients were presented and treated at Menoufia University Hospitals and Damanhour Oncology Center during the period from January 2012 to December 2014.
Resectable pancreatic cancer was detected in 38 (79.2%) patients and unresectable pancreatic cancer was detected in 10 (20.8%) patients. CA19-9 gave positive results (>39 U/ml) in 43 (89.6%) patients. The cutoff value of CA19-9 was 439.15 U/ml.
Conclusion and recommendations
Preoperative CA19-9 serum level is a useful marker in further evaluating the resectability of pancreatic cancer. Significantly increased serum level of CA19-9 can be regarded as an ancillary parameter for unresectable pancreatic cancer. CA19-9 level in combination with computer tomography has higher sensitivity in the determination of the resectability of pancreatic cancer and thereby benefits in avoiding unnecessary laparotomy and prevents its morbidity.
Keywords: pancreatic carcinoma, resectability, tumor marker CA19-9
|How to cite this article:|
Elsesi AA, Moustafa AF, Elmarakby MH. Clinical value of serum CA19-9 levels in evaluating resectability of pancreatic carcinoma. Menoufia Med J 2016;29:545-8
|How to cite this URL:|
Elsesi AA, Moustafa AF, Elmarakby MH. Clinical value of serum CA19-9 levels in evaluating resectability of pancreatic carcinoma. Menoufia Med J [serial online] 2016 [cited 2020 Aug 15];29:545-8. Available from: http://www.mmj.eg.net/text.asp?2016/29/3/545/198697
| Introduction|| |
The prognosis of pancreatic cancer is extremely poor and its early diagnosis is difficult , . Surgical resection offers the best chance of cure  . However, local vascular involvement and nodal and distant metastases are frequently found at the time of diagnosis, thus losing the opportunity of operation  . At present, the best way for preoperative staging of pancreatic cancer is bolus contrast and triple-phase helical computed tomography, which have been shown to be almost 100% accurate in predicting unresectable disease , . However, ∼25-50% of patients with resectable disease on computed tomography are found to have unresectable lesions at laparotomy  .
CA19-9 is the most widely used pancreatic cancer serum marker. Serum CA19-9 level has been shown to correlate with the node metastasis (TNM) staging and tumor size in patients with pancreatic cancer. However, little is known about the value of serum CA19-9 level in evaluating the resectability of pancreatic carcinoma  . It may also be elevated in other conditions such as cholangiocarcinoma and chronic pancreatitis  .
Receiver-operating characteristic (ROC) curve has been widely accepted as the standard method for describing and comparing the accuracy of medical diagnostic tests , . ROC curve is an efficient way to display and assess the predictive value of cutoff points. In this study, we evaluated the clinical value of serum CA19-9 level in predicting the resectability of pancreatic carcinoma based on ROC curve analysis.
| Patients and methods|| |
We retrospectively reviewed the clinical and imaging data, including preoperative CA19-9 level, in 48 patients with pancreatic cancer who underwent laparotomy at Menoufia University Hospitals and Damanhour Oncology Center from January 2012 to December 2014. Pancreatic carcinoma was histologically confirmed. Resectability of pancreatic cancer was evaluated at least with preoperative bolus contrast and triple-phase helical computer tomography scan.
Resectability was defined as a tumor limited to the pancreas with no invasion of the superior mesenteric artery and vein, portal vein, and metastases (celiac lymph, peritoneum or liver). Serum levels of CA19-9 and total serum bilirubin levels were measured before surgery (normal: 0-39 U/ml for CA19-9; 1.1-38 moI/l for total bilirubin).
Differences between groups were detected using the Wilcoxon 2-sample test. Serum CA19-9 levels were used to plot the ROC curve and calculate the area under the curve. We chose the point closest to the upper left-hand corner of the graph as the cutoff point. A P value less than 0.05 was considered statistically significant.
| Results|| |
Of the 48 patients, 16 were male and 32 were female, with a mean age of 55 years (range 15-85 years). The pancreatic tumor was confined to the head, body, and tail of the pancreas in 34, 12, and two patients, respectively.
Thirty-four patients underwent pancreaticoduodenectomy, two patients underwent distal pancreatectomy, two patients underwent total pancreatectomy, and 10 patients underwent only exploratory laparotomy and biopsy. The general characteristics of the patients are listed in [Table 1].
The distribution of preoperative serum CA19-9 levels is shown in [Figure 1]. The median preoperative serum CA19-9 level in patients with unresectable tumor (1000.63 U/ml) was five-fold higher compared with that in patients with resectable tumor (184.3 U/ml). The difference between the two groups was highly significant (P < 0.001).
This great difference in serum CA19-9 levels suggests a direct relation to resectability of pancreatic carcinoma , .
When the cutoff value of CA19-9 was 439.15 U/ml, only four cases with CA19-9 more than that level had resectable tumor, and two cases of the irresectable group had CA19-9 less than cutoff level.
| Discussion|| |
Pancreatic cancer is one of the most common causes of cancer-related death. The overall 5-year survival rate ranges from 0.4 to 4%, the lowest for any cancer , . Early diagnosis of pancreatic cancer is difficult because its early symptoms are usually nonspecific. Local vascular involvement and nodal and distant metastases are frequently found at the time of diagnosis  . Recently, considerable improvements in radiological imaging have made it possible to limit surgery for patients who will benefit , . The current methods of choice for diagnosing and staging pancreatic cancer are thin section, contrast-enhanced, and triple-phase helical computed tomography , . However, ∼25-50% of patients with resectable disease on computed tomography are found to have unresectable lesions at laparotomy , . Although MRI is increasingly used in the evaluation of pancreatic tumor, it was reported that it offers no significant diagnostic advantage over computed tomography  . Endoscopic retrograde cholangiopancreatography is more controversial for patients with a mass on computer tomography  . B-mode ultrasonography is operator-dependent and may be inaccurate due to factors such as large body habitus, presence of ascites, or overlying bowel gases. Therefore, we should find other ways to further evaluate the resectability of pancreatic cancer.
CA19-9 is a tumor-associated antigen, initially described by Koprowski et al.  . The sensitivity and specificity of CA19-9 for the diagnosis of pancreatic cancer are higher than those of CEA, CA50, and CA242 , . CA19-9 has become a predominant tumor marker for the diagnosis of pancreatic adenocarcinoma. It was reported that CA19-9 level is useful in the diagnosis and prognosis of pancreatic cancer , . However, little is known about the value of serum CA19-9 levels in evaluating the resectability of pancreatic carcinoma  . This study was conducted to determine whether preoperative serum CAI 9-9 is a useful marker for evaluating the resectability of pancreatic cancer.
In the present study, the differences between patients with resectable and unresectable pancreatic cancer were highly significant (P < 0.001), suggesting that the preoperative serum CA19-9 level is an efficient marker for evaluating the resectability of pancreatic carcinoma. The cutoff value of CA19-9 was 439.15 U/ml, as obtained from the point closest to the upper left-hand corner of the graph, indicating that increased serum levels of CA19-9 (>439.15 U/ml) can be regarded as an ancillary parameter for the unresectable pancreatic cancers  . Pancreatic cancer was resectable only in four patients whose preoperative serum CA19-9 level was over 439.15 U/ml.
Kilic et al.  , in a study including 51 patients reported that the cutoff value of CA19-9 was 256.4 U/ml. Their results are similar to our data, but the cutoff value was lower than that in our study (256.4 vs. 439.15 U/ml). The discrepancy may be due to the sample size and the unadjusted CA19-9 level based on bilirubin level. In conclusion, a preoperative serum CAI 9-9 level is a useful marker for evaluating the resectability of pancreatic cancer. Increased serum levels of CA19-9 (>439.15 U/ml) can be regarded as an ancillary parameter for unresectable pancreatic cancer.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Jemal A, Siegel R, Ward E, Hao Y, Xu J, Murray T, Thun MJ. Cancer statistics, 2008. CA Cancer J Clin 2008; 58 (2)
Wang L, Yang GH, Lu XH, Huang ZJ, Li H. Pancreatic cancer mortality in China (1991-2000). World J Gastroenterol 2003; 9 (8)
AM El-Gendia, S El-Gendib. Influence of standardized histopathological workup on reporting of the resection margin status in pancreatic head cancer. Egypt J Surg 2014; 33
Warshaw AL, Fernández-del Castillo C. Pancreatic carcinoma. N Engl J Med 1992; 326 (7)
Tamm EP, Silverman PM, Charnsangavej C, Evans DB. Diagnosis, staging, and surveillance of pancreatic cancer. Am J Roentgenol 2003; 180 (5)
Wakabayashi H, Nishiyama Y, Otani T, Sano T, Yachida S, Okano K, et al
. Role of 18
F-fluorodeoxyglucose positron emission tomography imaging in surgery for pancreatic cancer. World J Gastroenterol 2008; 14 (1)
Pisters PW, Lee JE, Vauthey JN, Chamsangavej C, Evans DB. Laparoscopy in the staging of pancreatic cancer. Br J Surg 2001; 88
Koopmann J, Rosenzweig CN, Zhang Z, Canto MI, Brown DA, Hunter M, et al
. Serum markers in patients with resectable pancreatic adenocarcinoma: macrophage inhibitory cytokine 1 versus CA19-9. Clin Cancer Res 2006; 12 (2)
I Baghdady, F Fouad, M Sayed, A Shoaib, Y Salah, E Elshayeb, A EfatHasan. Serum markers for the early detection of hepatocellular carcinoma in patients with chronic viral hepatitis. Menoufia Med J 2014; 27
Zou KH, O'Malley AJ, Mauri L. Receiver-operating 23 characteristic analysis for evaluating diagnostic tests and predictive models. Circulation 2007; 115
Waller SD, Sinuff T. Studies reporting ROC curves of diagnostic and prediction data can be incorporated into 24 meta-analyses using corresponding odds ratios. J Clin Epidemiol 2007; 60
Altman DG, Bland JM. Diagnostic tests 2: predictive values. BMJ 1994; 309 (6947)
Altman DG, Bland JM. Diagnostic tests 3: receiver operating characteristic plots. BMJ 1994; 309 (6948)
Jemal A, Murray T, Samuels A, Ghafoor A, Ward E, Thun MJ. Cancer statistics, 2003. CA Cancer J Clin 2003; 53 (1)
Pappas S, Federle MP, Lokshin AE, Zeh HJ III. Early detection and staging of adenocarcinoma of the pancreas. Gastroenterol Clin North Am 2007; 36 (2)
Takhar AS, Palaniappan P, Dhingsa R, Lobo DN. Recent developments in diagnosis of pancreatic cancer. BMJ 2004; 329 (7467)
Misek DE, Patwa TH, Lubman DM, Simeone DM, Patwa TH, et al
. Early detection and biomarkers in pancreatic cancer. J Natl Compr Canc Netw 2007; 5 (10)
Delbeke D, Pinson CW. Pancreatic tumors: role of imaging 29 in the diagnosis, staging, and treatment. J Hepatobiliary Pancreat Surg 2004; 11
Sahani DV, Shah ZK, Catalano OA, Boland GW, Brugge WR. Radiology of pancreatic adenocarcinoma: current status of imaging. J Gastroenterol Hepatol 2008; 23 (1)
Karmazanovsky G, Fedorov V, Kubyshkin V, Kotchatkov A. Pancreatic head cancer: accuracy of CT in determination of resectability. Abdom Imaging 2005; 30 (4)
Hanbidge AE. Cancer of the pancreas; the best image for early detection-CT, MRI, PET or US? Can J Castroenterol 2002; 16
Andersson R, Vagianos CE, Williamson RC. Preoperative staging and evaluation of resectability in pancreatic ductal adenocarcinoma. HPB (Oxford) 2004; 6 (1)
Koprowski H, Steplewski Z, Mitchell K, Herlyn M, Herlyn D, Fuhrer P. Colorectal carcinoma antigens detected by hybridoma antibodies. Somatic Cell Genet 1979; 5 (6)
Wu X, Lu XH, Xu T, Qian JM, Zhao P, Guo XZ, et al
. The diagnostic value of serum carcinoma markers, fecal K-ras and p53 gene mutation in pancreatic cancers. Zhonghua Nei Ke Za Zhi 2005; 44 (10)
Okusaka T, Okada S, Sato T, Wakasugi H, Saisho H, Furuse J, et al
. Tumor markers in evaluating the response to radiotherapy in unresectable pancreatic cancer. Hepatogastroenterology 1998; 45 (21)
Kang CM, Kim JY, Choi GH, Kim KS, Choi JS, Lee WJ, Kim BR. The use of adjusted preoperative CA 19-9 to predict the recurrence of resectable pancreatic cancer. J Surg Res 2007; 140 (1)
Zhao JZ, Wu BH. Clinical significance of CA19-9 in diagnosis of digestive tract tumors. China Nati J New Gastroenterol 1997; 3
Schlieman MG, Ho HS, Bold RJ. Utility of tumor markers in determining resectability of pancreatic cancer. Arch Surg 2003; 138 (9)
: 951-955. discussion 955-956.
Zakowski L, Seibert C, VanEyck S. Evidence-based medicine: answering questions of diagnosis. Clin Med Res 2004; 2 (1)
Kiliç M, Göçmen E, Tez M, Ertan T, Keskek M, Koç M. Value of preoperative serum CA 19-9 levels in predicting resectability for pancreatic cancer. Can J Surg 2006; 49 (4)