Staging laparoscopy is used selectively at M. D. Anderson based on the understanding that it detects helical CT-occult disease in 4% to 15% of patients presenting with ostensibly localized pancreatic cancer (Pisters et al, 2001b). Routine staging laparoscopy is believed to be a relatively expensive, potentially morbid approach that has a relatively low rate of detection of CT-occult disease. However, in the absence of high-quality CT or in the presence of equivocal CT findings suggestive of metastatic disease, staging laparoscopy should be considered.
The criteria used to select patients for staging laparoscopy include the presence of (1) a small, low-density liver lesion or low-volume ascites suggestive of metastatic disease; (2) clinical features suggestive of more advanced disease—such as weight loss, pain, and compromised performance status—that appear to be out of proportion with the CT findings; or (3) a significant elevation in the serum CA19-9 level. With regard to the third criterion, it is difficult to assign a specific CA 19-9 level threshold at which there should be substantial concern about the possibility of occult metastatic disease. Analysis of large cohorts of patients has suggested that an elevation in the serum CA 19-9 level above 750 U/mL is associated with a high probability of locally advanced or metastatic disease (Tian et al, 1992). A threshold in the range of 500 U/mL to 1,000 U/mL therefore appears to be reasonable.
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