Studies have shown that the best opportunity for long-term survival in patients with pancreatic cancer (PC) is with surgical removal of the tumor during pancreaticoduodenectomy (PD).
To determine if patients are candidates for surgery, physicians rely on imaging technologies, such as endoscopic ultrasound (EUS) and computed tomography (CT), to determine the location and size of the tumor as well as its relation to surrounding structures. For example, if the mass is connected to a major blood vessel, it may be more difficult to safely resect the entire tumor. After surgery, doctors look for other features, such as positive margins (meaning that some cancer cells remain at the edge of the tissues removed) and positive lymph nodes (in which cells have spread beyond the immediate tissue to nearby nodes or glands), which indicate poorer survival rates. The study investigated EUS and CT accuracy in predicting margins and node status as well as the need for more extensive venous resection in patients undergoing pancreaticoduodenectomy.
A total of 107 patients with pancreatic head adenocarcinoma who underwent palliative or curative resection during the last five years were analyzed in the study, comparing preoperative imaging results to intraoperative findings and final pathology. Of the 61 patients who underwent potentially curative PD, 17 (28%) required mesenteric vein resection, a significant indicator of poor survival among PC patients. About one-fourth of patients (n=15) had an R0, LN-resection (a complete resection with clear margins, node-negative), 26 patients had an R0, LN+ (node-positive) resection, three had an R1, LN-resection (involved margins), and 17 had an R1, LN+ resection. Of the 46 unresectable patients, 26 had been estimated resectable by preoperative imaging.
The most significant predictor of unsuccessful R0 resection was superior mesenteric vein (SMV) involvement on CT (OR 0.29) and the only significant predictor of unresectability on CT was periportal adenopathy (OR 3.42). No imaging features predicting node-positivity or vein resection were statistically significant and adding EUS to CT did not improve the accuracy in predicting outcomes.
"We are continually trying to find better ways to choose which patients may benefit most from surgery versus other modalities, such as chemotherapy, particularly with pancreatic cancer, and this study gives us more information about how this staging process is influenced by the current state of the art in imaging," said Philip Bao, M.D., of Vanderbilt University Medical Center in Nashville, Tenn., and lead investigator of the study. "CT imaging appears to be the most valuable strategy to predict resectability of pancreatic cancer compared to endoscopic ultrasound, so we will continue to look at imaging quality to support our surgical procedures in order to improve overall survival."-American Gastroenterological Association
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