Bile duct angulation and tumor vascularity are useful radiographic features for differentiating pancreatic head cancer and intrapancreatic bile duct cancer

Preoperative prognostic stratification and prediction of long-term outcomes after pancreatoduodenectomy for distal cholangiocarcinoma

BACKGROUND

Patients with distal cholangiocarcinoma (DCC) frequently receive adjuvant chemotherapy in preoperative and postoperative settings, but prediction of prognostic risk at the time of treatment selection remains challenging.

METHODS

This single-center retrospective study enrolled DCC patients who underwent initial pancreatoduodenectomy (PD) between 2009 and 2022. Preoperative clinical parameters were collected, and Cox regression analysis was used to identify risk factors for overall survival (OS).

RESULTS

Among 170 patients examined, the median tumor depth was 10 mm, and 37 % of the patients were diagnosed with pT3. Overall, 46 % of patients had lymph node metastasis. The median and 5-year OS was 58.2 months and 50 %, respectively. Multivariate analysis revealed tumor size on computed tomography (CT) ≥15 mm and main pancreatic duct (MPD) dilatation (≥3 mm) as independent risk factors for OS among various preoperative parameters; the prognosis was stratified based on these two parameters. Patients with one risk factor had similar outcomes (5-year OS: 39 %) to pStage IIB DCC (pT2N1 or pT3), while those with two risk factors had a prognosis akin to pStage IIIA (pN2), with a high early recurrence rate of 64 % (5-year OS: 8 %). Among non-risk group patients with low carbohydrate antigen (CA)19-9 levels (<37 U/mL), the prognosis was comparable (5-year OS: 72 %) to those with pStage I DCC.

CONCLUSION

A simple stratification approach was developed to predict long-term postoperative outcomes. To improve poor prognosis, intensive therapy, including neoadjuvant chemotherapy, should be considered for patients with two risk factors.

Extrahepatic Distal Cholangiocarcinoma vs. Pancreatic Ductal Adenocarcinoma: Histology and Molecular Profiling for Differential Diagnosis and Treatment

Pancreatic ductal adenocarcinoma (PDAC) and distal cholangiocarcinoma (dCCA) are very aggressive tumors with a high mortality rate. Pancreas and distal bile ducts share a common embryonic development. Hence, PDAC and dCCA exhibit similar histological features that make a differential diagnosis during routine diagnostic practice challenging. However, there are also significant differences, with potential clinical implications. Even if PDAC and dCCA are generally associated with poor survival, patients with dCCA seem to present a better prognosis. Moreover, although precision oncology-based approaches are still limited in both entities, their most important targets are different and include alterations affecting BRCA1/2 and related genes in PDAC, as well as HER2 amplification in dCCA. Along this line, microsatellite instability represents a potential contact point in terms of tailored treatments, but its prevalence is very low in both tumor types. This review aims at defining the most important similarities and differences in terms of clinicopathological and molecular features between these two entities, also discussing the main theranostic implications derived from this challenging differential diagnosis.

Clinical Utility of Bile Duct Axis Deviation for Differential Diagnosis Between Pancreatic Head Cancer and Bile Duct Cancer

BACKGROUNDS

Differential diagnosis between pancreatic head cancer (PHC) and intrapancreatic bile duct cancer (BDC) is important, but no clinical standard has been established. Here we examine the diagnostic utility of bile duct axis deviation and other clinical factors for this differential diagnosis.

METHODS

This study enrolled patients who underwent pancreaticoduodenectomy for PHC or BDC at our center between 2009 and 2016. PHCs in groove or uncinate portions were excluded from analysis. From contrast-enhanced computed tomography images, the bile duct angle (BDA) was measured using three points: the junction of intrahepatic bile ducts, upper pancreatic edge, and Vater papilla. Logistic regression was performed to evaluate the diagnostic performance of BDA and other clinical factors for differential diagnosis.

RESULTS

During the study period, 22 PHCs and 31 BDCs were resected. The combination of BDA ≤ 130°, main pancreatic duct diameter ≥ 4.3 mm, and absence of jaundice predicted PHC rather than BDC with an area under the curve of the receiver-operator characteristics curve of .856 (95% confidence interval, .766-.947).

CONCLUSION

Clinical findings of larger bile duct axis deviation, main pancreatic duct dilation, and the absence of jaundice may be useful for distinguishing PHC from BDC.