Thin-section contrast-enhanced computed tomography accurately predicts the resectability of malignant pancreatic neoplasms

Use of Diagnostic Laparoscopy and Peritoneal Washings for Pancreatic Cancer

Pancreatic adenocarcinoma is an aggressive malignancy that often presents with advanced disease. Accurate staging is essential for treatment planning and shared decision-making with patients. Staging laparoscopy is a minimally invasive procedure that can detect radiographically occult metastatic disease. Its routine use with the collection of peritoneal washings in patients with pancreatic cancer remains controversial. We, herein, review the current literature concerning staging laparoscopy and peritoneal washings in patients with pancreatic cancer.

Inter-reader agreement of pancreatic adenocarcinoma resectability assessment with photon counting versus energy integrating detector CT

PURPOSE

To compare the inter-reader agreement of pancreatic adenocarcinoma resectability assessment at pancreatic protocol photon-counting CT (PCCT) with conventional energy-integrating detector CT (EID-CT).

METHODS

A retrospective single institution database search identified all contrast-enhanced pancreatic mass protocol abdominal CT performed at an outpatient facility with both a PCCT and EID-CT from 4/11/2022 to 10/30/2022. Patients without pancreatic adenocarcinoma were excluded. Four fellowship-trained abdominal radiologists, blinded to CT type, independently assessed vascular tumor involvement (uninvolved, abuts ≤ 180°, encases > 180°; celiac, superior mesenteric artery (SMA), common hepatic artery (CHA), superior mesenteric vein (SMV), main portal vein), the presence/absence of metastases, overall tumor resectability (resectable, borderline resectable, locally advanced, metastatic), and diagnostic confidence. Fleiss's kappa was used to calculate inter-reader agreement. CTDIvol was recorded. Radiation dose metrics were compared with a two-sample t-test. A p < .05 indicated statistical significance.

RESULTS

145 patients (71 men, mean[SD] age: 66[9] years) were included. There was substantial inter-reader agreement, for celiac artery, SMA, and SMV involvement at PCCT (kappa = 0.61-0.69) versus moderate agreement at EID-CT (kappa = 0.56-0.59). CHA had substantial inter-reader agreement at both PCCT (kappa = 0.67) and EIDCT (kappa = 0.70). For metastasis identification, radiologists had substantial inter-reader agreement at PCCT (kappa = 0.78) versus moderate agreement at EID-CT (kappa = 0.56). CTDIvol for PCCT and EID-CT were 16.9[7.4]mGy and 29.8[26.6]mGy, respectively (p < .001).

CONCLUSION

There was substantial inter-reader agreement for involvement of 4/5 major peripancreatic vessels (celiac artery, SMA, CHA, and SMV) at PCCT compared with 2/5 for EID-CT. PCCT also afforded substantial inter-reader agreement for metastasis detection versus moderate agreement at EID-CT with statistically significant radiation dose reduction.

Surgical Treatment of Pancreatic Cancer: Currently Debated Topics on Vascular Resection

Vascular resections involving the superior mesenteric and portal veins (SMV-PV), celiac axis (CA), superior mesenteric artery (SMA) and hepatic artery (HA) have multiplied in recent years, raising the resection rate for pancreatic cancer (PDAC) and the related morbidity and mortality rates. While resection is generally accepted for resectable SMV-PV, the usefulness of associated arterial resection in borderline resectable (BRPC) and locally-advanced PDAC (LAPC) is much debated. Careful selection of splenic vein reconstruction is very important to prevent left-sided portal hypertension (LSPH). During distal pancreatectomy (DP), CA and common HA resection is largely accepted, while there is debate on the value of SMA and proper HA resection and reconstruction. Their resection is useless according to several reviews and meta-analyses, and some international societies, although some high-volume centers have reported good results. Short- and long-term reconstructed vessel patency varies with the type of reconstruction, the material used, and the surgeon's experience. Laparoscopic and robotic pancreaticoduodenectomy and DP are generally accepted if done by surgeons performing at least 10 such procedures annually. The usefulness of associated vascular resection remains highly controversial. Surgeons need to complete numerous minimally-invasive procedures to overcome the learning curve, and prevent an increase in complications and surgical mortality. Higher resectability rates and satisfactory long-term results have been reported after neoadjuvant therapy (NAT) for BRPC and LAPC requiring vascular resection. It is essential to select the most appropriate NAT for a given patient and to assess PDAC resectability preoperatively.

Development of a Customized Endoscopic Dual-Diffusing Optical Fiber Probe for Pancreatic Cancer Therapy: Toward Clinical Use

Objective: We developed a dual-diffusing optical fiber probe (DDOFP), capable of uniformly illuminating the anatomical structure of pancreatic duct for photodynamic therapy (PDT) of pancreatic cancer in clinical settings. Background: Optical fiber presents a unique route for pancreatic PDT by enabling access to the pancreatic duct. For effective pancreatic PDT, the optical fiber should produce a uniform illumination covering of the pancreatic duct, while maintaining its transmission property under thermomechanical stresses in surgical environments. Methods: The transmission profiles of DDOFP were measured using a charge-coupled device (CCD) camera at two directions: front-spherical and side-cylindrical areas of the optical fiber. We simulated the change in transmission property by curved tube structures using optically transparent phantom. DDOFP was integrated with 19-gauge needle catheter that is commercially used as an optical guide to treat pancreatic cancer. The temperature of DDOFP was measured at the end face using a thermistor probe in the bovine tissue, while delivering laser energy of over 200 and 500 J. Results: DDOFP was customized to secure the inner diameter of the 19-gauge needle catheter of 686 μm to be integrated as a clinical device. The round ball lens fiber tip minimized the back-burn effect caused by blood carbonization during surgery and induced front-spherical diffusion. DDOFP produced uniform light illumination with intensity difference of <10%. When DDOFP was bent with a small curvature <15 mm, the transmission intensity was consistent. Under high-power laser transmission, DDOFP was found to be robust to cracking or deformation. Conclusions: DDOFP was customized for pancreatic PDT with superior thermomechanical property and uniform light illumination at both the front-spherical and side-cylindrical areas. This is the smallest clinically available optical fiber per our knowledge and officially approved by the Korea Food and Drug Administration (item approval number: 17-516). DDOFP can contribute immensely toward the efficient delivery of pancreatic PDT and photothermal therapy.

The Role of Endoscopic Ultrasonography in the Diagnosis and Staging of Pancreatic Cancer

Pancreatic cancer is the fourth leading cause of cancer-related death and the second gastrointestinal cancer-related death in the United States. Early detection and accurate diagnosis and staging of pancreatic cancer are paramount in guiding treatment plans, as surgical resection can provide the only potential cure for this disease. The overall prognosis of pancreatic cancer is poor even in patients with resectable disease. The 5-year survival after surgical resection is ~10% in node-positive disease compared to ~30% in node-negative disease. The advancement of imaging studies and the multidisciplinary approach involving radiologists, gastroenterologists, advanced endoscopists, medical, radiation, and surgical oncologists have a major impact on the management of pancreatic cancer. Endoscopic ultrasonography is essential in the diagnosis by obtaining tissue (FNA or FNB) and in the loco-regional staging of the disease. The advancement in EUS techniques has made this modality a critical adjunct in the management process of pancreatic cancer. In this review article, we provide an overall description of the role of endoscopic ultrasonography in the diagnosis and staging of pancreatic cancer.

Curing pancreatic cancer

The distinct biology of pancreatic cancer with aggressive and early invasive tumor cells, a tumor promoting microenvironment, late diagnosis, and high therapy resistance poses major challenges on clinicians, researchers, and patients. In current clinical practice, a curative approach for pancreatic cancer can only be offered to a minority of patients and even for those patients, the long-term outcome is grim. This bitter combination will eventually let pancreatic cancer rise to the second leading cause of cancer-related mortalities. With surgery being the only curative option, complete tumor resection still remains the center of pancreatic cancer treatment. In recent years, new developments in neoadjuvant and adjuvant treatment have emerged. Together with improved perioperative care including complication management, an increasing number of patients have become eligible for tumor resection. Basic research aims to further increase these numbers by new methods of early detection, better tumor modelling and personalized treatment options. This review aims to summarize the current knowledge on clinical and biologic features, surgical and non-surgical treatment options, and the improved collaboration of clinicians and basic researchers in pancreatic cancer that will hopefully result in more successful ways of curing pancreatic cancer.

ESTRO IORT Task Force/ACROP recommendations for intraoperative radiation therapy in borderline-resected pancreatic cancer

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Radiation dose-escalation with intraoperative electron beam radiation therapy to the posterior resection margin and/or to residual disease is feasible with limited toxicity.

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Preoperative therapy prolongs the interval to surgery and IOERT, allowing an improved selection of patients who are candidates for local treatment intensification.

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Primary systemic therapy combined with chemoradiation allows to boost with IOERT in over 70% of patients with R0 surgical tumour beds.

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Median survival time ranges from 19 to 35 months in electron boosted patients.

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Overall survival at 5 years of over 30% is reported by contemporary expert IOERT institutions.

Radiation therapy (RT) is a valuable component of multimodal treatment for localized pancreatic cancer. Intraoperative radiation therapy (IORT) is a very precise RT modality to intensify the irradiation effect for cancer involving upper abdominal structures and organs, generally delivered with electrons (IOERT). Unresectable, borderline and resectable disease categories benefit from dose-escalated chemoradiation strategies in the context of active systemic therapy and potential radical surgery. Prolonged preoperative treatment may act as a filter for selecting patients with occult resistant metastatic disease. Encouraging survival rates have been documented in patients treated with preoperative chemoradiation followed by radical surgery and IOERT (>20 months median survival, >35% survival at 3 years). Intensive preoperative treatment, including induction chemotherapy followed by chemoradiation and an IOERT boost, appears to prolong long-term survival within the subset of patients who remain relapse-free for>2 years (>30 months median survival; >40% survival at 3 years). Improvement of local control through higher RT doses has an impact on the survival of patients with a lower tendency towards disease spread. IOERT is a well-accepted approach in the clinical scenario (maturity and reproducibility of results), and extremely accurate in terms of dose-deposition characteristics and normal tissue sparing. The technique can be adapted to systemic therapy and surgical progress. International guidelines (National Comprehensive Cancer Network or NCCN guidelines) currently recommend use of IOERT in cases of close surgical margins and residual disease. We hereby report the ESTRO/ACROP recommendations for performing IOERT in borderline-resectable pancreatic cancer.

ESTRO IORT Task Force/ACROP recommendations for intraoperative radiation therapy in unresected pancreatic cancer

Radiation therapy (RT) is a valuable component of multimodal treatment for localized pancreatic cancer. Intraoperative radiation therapy (IORT) is a very precise sub-component of RT that can intensify the irradiation effect for cancer involving an anatomically well-defined volume, generally delivered with electrons (IOERT). Unresectable disease categories benefit from dose-escalated chemoradiation strategies in the context of active systemic therapy and potential radical surgery. Prolonged preoperative treatment may act as a filter for selecting patients with occult resistant metastatic disease. Long-term survivors were observed among unresected patients treated with external beam RT and an IOERT boost (OS 6% at 3 years; 3% >5 years). Improvement of local control through higher RT doses has an impact on the survival of patients with a lower tendency towards disease spread. IOERT is a well-accepted asset in the clinical scenario (maturity and reproducibility of results, albeit of low official level of evidence) and extremely accurate in terms of dose-deposit characteristics and normal tissue sparing. It is a technique that can be integrated with systemic therapy and surgical progress. International guidelines (National Comprehensive Cancer Network or NCCN guidelines) currently recommend the use of IOERT in cases of close surgical margins and residual disease. We report the ESTRO/ACROP recommendations for performing IOERT in unresected pancreatic cancer.

FOLFIRINOX-based neoadjuvant chemoradiotherapy for borderline and locally advanced pancreatic cancer: A pilot study from a tertiary centre

BACKGROUND

Neoadjuvant chemoradiotherapy, potentially relevant to increase resection rate in pancreatic cancer, is still debated.

AIMS

To assess tolerance, resection rate and outcomes of patients with non-metastatic pancreatic ductal adenocarcinoma treated by concomitant chemoradiotherapy.

METHODS

This monocentric study included all consecutive patients treated from 2010 to 2014 for non-metastatic pancreatic adenocarcinoma. Chemotherapy was followed by chemoradiotherapy in operable patients, surgical resectability being assessed by CT-scan.

RESULTS

Seventy-nine patients were included: 41 patients had borderline and 38 locally advanced tumours. All patients were treated by chemotherapy (FOLFIRINOX), followed by chemoradiotherapy (median dose: 59 Gy, range 45-66 Gy) for 94% of patients. Thirty-seven patients (47%) could subsequently benefit from surgery with a complete R0 resection in 94% of cases, with a postoperative mortality of 5%. Median overall survival was 21.5 months (median follow-up: 48.8 months). Local control, overall and disease-free survival were significantly higher for patients who underwent resection compared to others, with 89.2% vs 59.5% (p = 0.01), 49.7 vs 17.4 months (p < 0.01) and 25.5 vs 9.2 months (p < 0.01), respectively.

CONCLUSION

Neoadjuvant treatment consisting of FOLFIRINOX chemotherapy followed by chemoradiotherapy is an efficient strategy for patients with borderline and locally advanced pancreatic cancer, resulting in a 43% rate of secondary complete surgical resection associated with high local control, overall and disease-free survival.

Definition and Management of Borderline Resectable Pancreatic Cancer

Patients with localized pancreatic ductal adenocarcinoma seek potentially curative treatment, but this group represents a spectrum of disease. Patients with borderline resectable primary tumors are a unique subset whose successful therapy requires a care team with expertise in medical care, imaging, surgery, medical oncology, and radiation oncology. This team must identify patients with borderline tumors then carefully prescribe and execute a combined treatment strategy with the highest possibility of cure. This article addresses the issues of clinical evaluation, imaging techniques, and criteria, as well as multidisciplinary treatment of patients with borderline resectable pancreatic ductal adenocarcinoma.

Diagnosis, Preoperative Evaluation, and Assessment of Resectability of Pancreatic and Periampullary Cancer

Periampullary region encircles a radius of 2 cm around the ampulla of Vater; accordingly, four distinct neoplasias with overlapping imaging features originate in the region. Each of these lesions has a different long-term prognosis; hence, imaging evaluation to characterize the lesion is important. Further certain specific features pertaining to the vascular invasion and systemic spread may decide about the treatment as well as surgical approach. An understanding of the advances in imaging and image processing technology as well as in the methods of image acquisition, for the purpose, is quite relevant towards etching out a rational pre-treatment evaluation protocol. Further, an evidence-based decision as to the choice of optimum modality for answering specific clinical question is of prime importance in achieving a reasonable post-treatment outcome. Pancreatic adenocarcinoma is the fourth most common cancer and a malignancy with one of the least 5-year survival rates (ranging from 6.8 to 15 % depending on peripancreatic extensions, dropping to 1.8 % for metastatic disease). A survival rate of 15-27 % can be achieved if the lesion is resectable but unfortunately, only 10-15 % of patients are eligible for resection. Cystic tumors of pancreas are a rarer variety of pancreatic neoplasia (5-15 % of pancreatic cysts and 1 % of all pancreatic cancers) which have a much better outcome and chances of resection. Being mostly incidentalomas, a timely differentiation of this lesion from the much more common pseudocyst (which would mandate a medical management and a different surgical protocol) is the key for curability. Lastly, the neuroendocrine tumors of pancreas are equally rare (1 % of all pancreatic tumors), but importantly due to associated clinical syndromes and their capability to metastasize early in the course of disease, a timely detection may hence be the key for successful treatment of these lesions. Imaging plays a vital role in the initial detection and characterization as well as in determination of resectability of each of these pancreatic neoplasias. Further, the differentiation of pancreatic head tumors from other periampullary neoplasias is important; the fact that most recurrences are as a result of surgical intervention in an otherwise inoperable disease while most treatment failures are due to improper characterization of the lesion is notable.

Efficacy of Neoadjuvant Versus Adjuvant Therapy for Resectable Pancreatic Adenocarcinoma: A Decision Analysis

BACKGROUND

Neoadjuvant therapy-based protocols for potentially resectable pancreatic adenocarcinoma (PAC) have not been directly compared with adjuvant protocols in large prospective randomized trials. This study aimed to compare the efficacy of neoadjuvant versus adjuvant therapy-based management by using a formal decision analytic model.

METHODS

A decision analytic model was created with a Markov process to compare neoadjuvant and adjuvant chemo- and/or chemoradiation therapy-based strategies for simulated cohorts of patients with potentially resectable PAC. Base-case probabilities were derived from the published data of 21 prospective phases 2 and 3 trials (3708 patients) between 1997 and 2014. The primary outcome measures determined in an intent-to-treat fashion were overall and quality-adjusted survival rates. One- and two-way sensitivity analyses were performed to assess the effects of model uncertainty on outcomes.

RESULTS

The median overall survival and 2-year survival rates for the patients in the standard adjuvant therapy arm of the study were 20 months and 42.2 % versus 22 months and 46.8 % for those in the neoadjuvant strategy arm. Quality-adjusted survival was 18.4 and 19.8 months, respectively. Sensitivity analysis demonstrated that when recurrence-free survival after completion of neoadjuvant therapy and resection is less than 13.9 months or when the rate for progression of disease precluding resection during neoadjuvant therapy is greater than 44 %, the neoadjuvant strategy is no longer the favored option.

CONCLUSIONS

The decision analytic model suggests that neoadjuvant therapy-based management improves the outcomes for patients with potentially resectable pancreatic cancer. However, the benefits in terms of overall and quality-adjusted survival are modest.

Inferior mesenteric vein serves as an alternative guide for transection of the pancreatic body during pancreaticoduodenectomy with concomitant vascular resection: a comparative study evaluating perioperative outcomes

BACKGROUND

Tumors of the pancreatic head often involve the superior mesenteric and portal veins. The purpose of this study was to assess perioperative outcomes after pancreaticoduodenectomy (PD) with concomitant vascular resection using the inferior mesenteric vein (IMV) as a guide for transection of the pancreatic body (Whipple at IMV, WATIMV).

METHODS

One hundred thirty-seven patients had segmental vein resection during PD between January 2006 and June 2013. Depending on whether the standard approach of creating a tunnel anterior to the mesenterico-portal vein (MPV) axis was achieved for pancreatic transection, patients were subjected to a standard PD with vein resection procedure (s-PD + VR, n = 75) or a modified procedure (m-PD + VR, n = 62). Within the m-PD + VR group, 28 patients underwent the WATIMV procedure, while 34 patients underwent the usual procedure of transection, or 'central pancreatectomy' (c-PD + VR).

RESULTS

The volume of intraoperative blood loss and the blood transfusion requirements were significantly greater, and the venous wall invasion and neural invasion frequency were significantly higher in the m-PD + VR group compared with the s-PD + VR group. There were no significant differences in the length of hospitalization, postoperative morbidity, and grades of complications between the two groups. Multivariate logistic regression identified intraoperative blood transfusion (P = 0.004) and vascular invasion (P = 0.008) as the predictors of postoperative morbidity. Further stratification of the entire cohort of 62 (45%) patients who underwent m-PD + VR showed a higher rate of negative resection margins (96.4%) in the WATIMV group compared with the c-PD + VR group (76.5%) (P = 0.06). The volume of intraoperative blood loss (P = 0.013), and intraoperative blood transfusion requirements (P = 0.07) were significantly greater in the c-PD + VR group compared with the WATIMV group. Furthermore, high intraoperative blood loss and tumor stage were predictive of a positive resection margin.

CONCLUSIONS

'Whipple at the IMV (WATIMV)' has comparable postoperative morbidity with standard PD + VR. If IMV runs into the splenic vein, it could serve as an alternative guide for transection of the pancreatic body during PD + VR.

Neoadjuvant strategies for pancreatic cancer

Pancreatic cancer (PC) is the fourth cause of cancer death in Western countries, the only chance for long term survival is an R0 surgical resection that is feasible in about 10%-20% of all cases. Five years cumulative survival is less than 5% and rises to 25% for radically resected patients. About 40% has locally advanced in PC either borderline resectable (BRPC) or unresectable locally advanced (LAPC). Since LAPC and BRPC have been recognized as a particular form of PC neoadjuvant therapy (NT) has increasingly became a valid treatment option. The aim of NT is to reach local control of disease but, also, it is recognized to convert about 40% of LAPC patients to R0 resectability, thus providing a significant improvement of prognosis for responding patients. Once R0 resection is achieved, survival is comparable to that of early stage PCs treated by upfront surgery. Thus it is crucial to look for a proper patient selection. Neoadjuvant strategies are multiples and include neoadjuvant chemotherapy (nCT), and the association of nCT with radiotherapy (nCRT) given as either a combination of a radio sensitizing drug as gemcitabine or capecitabine or and concomitant irradiation or as upfront nCT followed by nRT associated to a radio sensitizing drug. This latter seem to be most promising as it may select patients who do not go on disease progression during initial treatment and seem to have a better prognosis. The clinical relevance of nCRT may be enhanced by the application of higher active protocols as FOLFIRINOX.

Clinical evaluation, imaging studies, indications for cytologic study and preprocedural requirements for duct brushing studies and pancreatic fine-needle aspiration: The Papanicolaou Society of Cytopathology Guidelines

The Papanicolaou Society of Cytopathology has developed a set of guidelines for pancreaticobiliary cytology including indications for endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) biopsy, techniques for EUS-FNA, terminology and nomenclature to be used for pancreaticobiliary disease, ancillary testing and postbiopsy management. All documents are based on expertise of the authors, literature review, discussions of the draft document at national and international meetings and synthesis of online comments of the draft document. This document selectively presents the results of these discussions. This document summarizes recommendations for the clinical and imaging work-up of pancreatic and biliary tract lesions along with indications for cytologic study of these lesions. Prebrushing and FNA requirements are also discussed.

Clinical evaluation, imaging studies, indications for cytologic study, and preprocedural requirements for duct brushing studies and pancreatic FNA: the Papanicolaou Society of Cytopathology recommendations for pancreatic and biliary cytology

The Papanicolaou Society of Cytopathology has developed a set of guidelines for pancreaticobiliary cytology including indications for endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) biopsy, techniques for EUS-FNA, terminology and nomenclature to be used for pancreaticobiliary disease, ancillary testing, and post-biopsy management. All documents are based on expertise of the authors, literature review, discussions of the draft document at national and international meetings, and synthesis of online comments of the draft document. This document selectively presents the results of these discussions. This document summarizes recommendations for the clinical and imaging work-up of pancreatic and biliary tract lesions along with indications for cytologic study of these lesions. Prebrushing and FNA requirements are also discussed.

A multi-institutional phase 2 study of neoadjuvant gemcitabine and oxaliplatin with radiation therapy in patients with pancreatic cancer

BACKGROUND

The purpose of this study was to evaluate preoperative treatment with full-dose gemcitabine, oxaliplatin, and radiation therapy (RT) in patients with localized pancreatic cancer.

METHODS

Eligibility included confirmation of adenocarcinoma, resectable or borderline resectable disease, a performance status ≤2, and adequate organ function. Treatment consisted of two 28-day cycles of gemcitabine (1 g/m(2) over 30 minutes on days 1, 8, and 15) and oxaliplatin (85 mg/m(2) on days 1 and 15) with RT during cycle 1 (30 Gray [Gy] in 2-Gy fractions). Patients were evaluated for surgery after cycle 2. Patients who underwent resection received 2 cycles of adjuvant chemotherapy.

RESULTS

Sixty-eight evaluable patients received treatment at 4 centers. By central radiology review, 23 patients had resectable disease, 39 patients had borderline resectable disease, and 6 patients had unresectable disease. Sixty-six patients (97%) completed cycle 1 with RT, and 61 patients (90%) completed cycle 2. Grade ≥3 adverse events during preoperative therapy included neutropenia (32%), thrombocytopenia (25%), and biliary obstruction/cholangitis (14%). Forty-three patients underwent resection (63%), and complete (R0) resection was achieved in 36 of those 43 patients (84%). The median overall survival was 18.2 months (95% confidence interval, 13-26.9 months) for all patients, 27.1 months (95% confidence interval, 21.2-47.1 months) for those who underwent resection, and 10.9 months (95% confidence interval, 6.1-12.6 months) for those who did not undergo resection. A decrease in CA 19-9 level after neoadjuvant therapy was associated with R0 resection (P = .02), which resulted in a median survival of 34.6 months (95% confidence interval, 20.3-47.1 months). Fourteen patients (21%) are alive and disease free at a median follow-up of 31.4 months (range, 24-47.6 months).

CONCLUSIONS

Preoperative therapy with full-dose gemcitabine, oxaliplatin, and RT was feasible and resulted in a high percentage of R0 resections. The current results are particularly encouraging, because the majority of patients had borderline resectable disease.

Pancreatic surgery: beyond the traditional limits

Pancreatic cancer is one of the five leading causes of cancer death for both males and females in the western world. More than 85 % pancreatic tumors are of ductal origin but the incidence of cystic tumors such as intrapapillary mucinous tumors (IPMN) or mucinous cystic tumors (MCN) and other rare tumors is rising. Complete surgical resection of the tumor is the mainstay of any curative therapeutic approach, however, up to 40 % of patients with potentially resectable pancreatic cancer are not offered surgery. This is despite 5-year survival rates of up to 40 % or even higher in selected patients depending on tumor stage and histology. Standard procedures for pancreatic tumors include the Kausch-Whipple- or pylorus-preserving Whipple procedure, and the left lateral pancreatic resection (often with splenectomy), and usually include regional lymphadenectomy. More radical or extended pancreatic operations are becoming increasingly utilised however and we examine the data available for their role. These operations include major venous and arterial resection, multivisceral resections and surgery for metastatic disease, or palliative pancreatic resection. Portal vein resection for local infiltration with or without replacement graft is now well established and does not deleteriously affect perioperative morbidity or mortality. Arterial resection, however, though often technically feasible, has questionable oncologic impact, is not without risk and is usually reserved for isolated cases. The value of extended lymphadenectomy is frequently debated; the recent level I evidence demonstrates no advantage. Multivisceral resections, i.e. tumors, often in the tail of the pancreas, with invasion of the colon or stomach or other surrounding tissues, while associated with an increased morbidity and a longer hospital stay, do however show comparable mortality-and survival rates to those without such infiltration and therefore should be performed if technically feasible. Routine resection for metastatic disease however does not seem to show any advantage over palliative treatment but may be an option in selected patients with easily removable metastases. In conclusion pancreatic surgery beyond the traditional limits is established in tumors infiltration the venous system and may be a considered approach in selected patients with locally infiltrating pancreatic cancer or metastasis.

Liver blood supply after a modified Appleby procedure in classical and aberrant arterial anatomy

Reported here are two cases of a modified Appleby operation for borderline resectable ductal adenocarcinoma of the pancreatic body, in one of which a R0 distal resection was attended to by excision, not only of the celiac axis, but also of the common and left hepatic arteries in the presence of arterial anatomic variation Michels, type VIIIb. The possibility and avenues of the maintenance of the blood supply to the left hepatic lobe after surgical aggression of this kind are demonstrated employing computed tomography (CT) and 3-D CT angiography. Furthermore, both cases highlight all important worrisome aspects of pancreatic cancer resectability prediction.

Integration of radiation oncology with surgery as combined-modality treatment

Integration of surgery and radiation (external beam, EBRT; intraoperative, IORT) has become more routine for patients with locally advanced primary cancers and those with local-regional relapse. This article discusses patient selection and treatment from a more general perspective, followed by a discussion of patient selection and treatment factors in select disease sites (pancreas cancer, colorectal cancer, retroperitoneal soft-tissue sarcomas). Outcomes with combined modality treatment (surgery, EBRT alone or with concurrent chemotherapy, IORT) are discussed. The ultimate in contemporary integration of radiation and surgery is found in patients who are candidates for surgery plus both EBRT and IORT.

Effectiveness of combined endoscopic ultrasound-guided fine-needle aspiration biopsy and stenting in patients with suspected pancreatic cancer

BACKGROUND

Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) can be coupled with endoscopic retrograde cholangiopancreatography in the same setting when biliary and/or duodenal stenting are required.

AIMS

Our aim was to examine the effectiveness of EUS-FNA combined with stenting during the same session in patients with pancreatic cancer.

METHODS

Consecutive patients referred for EUS-FNA of a pancreatic mass with symptoms of biliary (±upper digestive) obstruction were included. Consecutive patients undergoing biliary and/or duodenal stenting without EUS-FNA during the same period were used as controls. Procedure-related complications were the primary outcome measure. Duration of the procedure, ability to achieve biliary/duodenal stenting, the yield of EUS-FNA, and clinical outcomes were evaluated.

RESULTS

A total of 122 patients underwent combined EUS-FNA and stenting and 68 underwent stenting alone (control group). In the combined group, histological proof of cancer was obtained in 88.52% at first EUS-FNA and 95.08% after a second EUS-FNA. Biliary stent placement was successful in 97.5 and 98% in the combined and the control groups, respectively. There was no statistical difference between the groups for length of stay after endoscopy and for procedure-related mortality and morbidity within 30 days. The median time from endoscopy to chemotherapy in the combined group was 12 days.

CONCLUSION

Combined EUS-FNA and biliary and/or duodenal stenting is feasible in almost all patients with suspected pancreatic cancer, with no additional hazard and a high histological yield.

Pancreatic Adenocarcinoma, version 2.2012: featured updates to the NCCN Guidelines

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Pancreatic Adenocarcinoma discuss the workup and management of tumors of the exocrine pancreas. These NCCN Guidelines Insights provide a summary and explanation of major changes to the 2012 NCCN Guidelines for Pancreatic Adenocarcinoma. The panel made 3 significant updates to the guidelines: 1) more detail was added regarding multiphase CT techniques for diagnosis and staging of pancreatic cancer, and pancreas protocol MRI was added as an emerging alternative to CT; 2) the use of a fluoropyrimidine plus oxaliplatin (e.g., 5-FU/leucovorin/oxaliplatin or capecitabine/oxaliplatin) was added as an acceptable chemotherapy combination for patients with advanced or metastatic disease and good performance status as a category 2B recommendation; and 3) the panel developed new recommendations concerning surgical technique and pathologic analysis and reporting.

Pancreatic Adenocarcinoma, version 2.2012: featured updates to the NCCN Guidelines

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Pancreatic Adenocarcinoma discuss the workup and management of tumors of the exocrine pancreas. These NCCN Guidelines Insights provide a summary and explanation of major changes to the 2012 NCCN Guidelines for Pancreatic Adenocarcinoma. The panel made 3 significant updates to the guidelines: 1) more detail was added regarding multiphase CT techniques for diagnosis and staging of pancreatic cancer, and pancreas protocol MRI was added as an emerging alternative to CT; 2) the use of a fluoropyrimidine plus oxaliplatin (e.g., 5-FU/leucovorin/oxaliplatin or capecitabine/oxaliplatin) was added as an acceptable chemotherapy combination for patients with advanced or metastatic disease and good performance status as a category 2B recommendation; and 3) the panel developed new recommendations concerning surgical technique and pathologic analysis and reporting.

Multimodality therapy offers a chance for cure in patients with pancreatic adenocarcinoma deemed unresectable at first operative exploration

BACKGROUND

Patients identified at surgical exploration with unresectable pancreatic ductal adenocarcinoma receive palliative, noncurative therapy. We hypothesized that accurate radiographic restaging, multimodality treatment, and advanced surgical technique can offer patients deemed unresectable at previous exploration the possibility for curative salvage pancreatectomy.

STUDY DESIGN

Review of a prospectively maintained pancreatic ductal adenocarcinoma database identified all patients (1990 to 2010) evaluated after being deemed unresectable at first exploration elsewhere. Referring hospitals were categorized per National Cancer Data Base criteria as academic, community, or international. Patients were restaged using objective imaging (CT) criteria and classified based on anatomic resectability. Clinicopathologic factors and cancer-related outcomes were assessed.

RESULTS

We evaluated 88 patients who underwent previously unsuccessful resection attempts at academic (n = 50), community (n = 25), and international (n = 13) centers. Radiographic restaging confirmed that 7 (8%) patient tumors were locally advanced and unresectable, but 81 (92%) were resectable (n = 61) or borderline resectable (n = 20). Using a surgery first (9%) or preoperative chemoradiation (91%) approach, successful reoperative pancreatectomy was performed in 66 (81%) patients, with 94% receiving R0 resections. Vascular resection/reconstruction was required in 30 (46%) patients and 50 (76%) required complex revision of previously created biliary/gastrointestinal bypass. The major complication rate was 20% and 3 (4.5%) patients died perioperatively. Median overall survival was 29.6 months for successfully resected patients vs 10.6 and 5.1 months (p < 0.0001) for those patients with locally advanced unresectable disease at initial referral or in whom metastatic disease developed before resection, respectively.

CONCLUSIONS

In this very selected cohort of high-risk patients, the majority had anatomically resectable tumors on restaging. Accurate radiographic restaging, a multimodality treatment strategy, and advanced surgical techniques can provide an opportunity for cure in a substantial proportion of select patients who were deemed unresectable at exploration.

Multimodality therapy offers a chance for cure in patients with pancreatic adenocarcinoma deemed unresectable at first operative exploration

BACKGROUND

Patients identified at surgical exploration with unresectable pancreatic ductal adenocarcinoma receive palliative, noncurative therapy. We hypothesized that accurate radiographic restaging, multimodality treatment, and advanced surgical technique can offer patients deemed unresectable at previous exploration the possibility for curative salvage pancreatectomy.

STUDY DESIGN

Review of a prospectively maintained pancreatic ductal adenocarcinoma database identified all patients (1990 to 2010) evaluated after being deemed unresectable at first exploration elsewhere. Referring hospitals were categorized per National Cancer Data Base criteria as academic, community, or international. Patients were restaged using objective imaging (CT) criteria and classified based on anatomic resectability. Clinicopathologic factors and cancer-related outcomes were assessed.

RESULTS

We evaluated 88 patients who underwent previously unsuccessful resection attempts at academic (n = 50), community (n = 25), and international (n = 13) centers. Radiographic restaging confirmed that 7 (8%) patient tumors were locally advanced and unresectable, but 81 (92%) were resectable (n = 61) or borderline resectable (n = 20). Using a surgery first (9%) or preoperative chemoradiation (91%) approach, successful reoperative pancreatectomy was performed in 66 (81%) patients, with 94% receiving R0 resections. Vascular resection/reconstruction was required in 30 (46%) patients and 50 (76%) required complex revision of previously created biliary/gastrointestinal bypass. The major complication rate was 20% and 3 (4.5%) patients died perioperatively. Median overall survival was 29.6 months for successfully resected patients vs 10.6 and 5.1 months (p < 0.0001) for those patients with locally advanced unresectable disease at initial referral or in whom metastatic disease developed before resection, respectively.

CONCLUSIONS

In this very selected cohort of high-risk patients, the majority had anatomically resectable tumors on restaging. Accurate radiographic restaging, a multimodality treatment strategy, and advanced surgical techniques can provide an opportunity for cure in a substantial proportion of select patients who were deemed unresectable at exploration.

The role of PET scanning in pancreatic cancer

The strength of functional imaging lies in its ability to detect malignant disease irrespective of lesion morphology. In this setting, 18FDG-PET can complement management by providing a more accurate diagnosis. When combined as an adjunct to CT, 18FDG-PET can increase the sensitivity, specificity, and accuracy for detecting a pancreatic malignancy, especially in patients in whom CT alone fails to identify a discrete mass or in whom biopsy results are indeterminate. This capability is accentuated with small lesions of the pancreas. 18FDG-PET is significantly more sensitive in detecting metastatic disease than conventional CT imaging. Moreover, 18FDG-PET is able to differentiate tumor response to therapy in the postoperative setting, and could potentially serve to monitor recurrence patterns in the setting of neoadjuvant or adjuvant chemoradiotherapy. Finally, as 18FDG-PET/CT fusion modalities become more widespread and technical advances in image acquisition progress, 18FDG-PET will continue to have an increasing role in the diagnosis, staging, and surveillance of pancreatic cancer, integrating anatomic information with functional imaging.

Adjuvant and neoadjuvant therapy in curable pancreatic cancer

Pancreatic cancer is the tenth most common cancer in the United States and the fourth leading cause of cancer death. Afflicting approximately 37,000 Americans yearly, more than 80% of patients are unresectable and, therefore, incurable at the time of their diagnosis. Although surgical resection offers the only opportunity for cure, it remains largely unsuccessful; most patients who are candidates for surgical resection relapse and die in fewer than 5 years. This mortality leaves a 5-year overall survival of about 4% for patients diagnosed with pancreatic cancer. Perhaps the most daunting realization for physicians involved in the management of this disease is the understanding that these numbers have not changed in more than 30 years. As surgery remains the foundation of curative therapy for pancreatic cancer, this article reviews the data on adjuvant chemotherapy and adjuvant chemotherapy with radiotherapy as efforts to boost cure rates.

Translational advances and novel therapies for pancreatic ductal adenocarcinoma: hope or hype?

Biological complexity, inaccessible anatomical location, nonspecific symptoms, lack of a screening biomarker, advanced disease at presentation and drug resistance epitomise pancreatic ductal adenocarcinoma (PDA) as a poor-prognosis, lethal disease. Twenty-five years of research (basic, translational and clinical) have barely made strides to improve survival, mainly because of a fundamental lack of knowledge of the biological processes initiating and propagating PDA. However, isolation of pancreas cancer stem cells or progenitors, whole-genome sequencing for driver mutations, advances in functional imaging, mechanistic dissection of the desmoplastic reaction and novel targeted therapies are likely to shed light on how best to treat PDA. Here we summarise current knowledge and areas where the field is advancing, and give our opinion on the research direction the field should be focusing on to better deliver promising therapies for our patients.

Medical management of pancreatic adenocarcinoma

Pancreatic cancer is the fourth leading cause of cancer death in the United States. In 2008, an estimated 34,290 people died from pancreatic cancer and 37,680 new cases were diagnosed. Despite modern treatment, 90% of patients die within 1 year of diagnosis. Pancreatectomy is still the only potentially curative approach, but most patients have incurable disease by the time they are diagnosed, and fewer than 20% are candidates for surgery. In the present paper the English-language literature addressing the medical management in pancreatic cancer was reviewed. Based on these data we will discuss the role of currently used chemotherapy and target therapy in pancreatic cancer, as well as perspectives of the emerging strategies that are arising in order to improve the outcomes of this complex disease.

Multidisciplinary approach to tumors of the pancreas and biliary tree

Tumors of the pancreas and biliary tree remain formidable challenges to patients and clinicians. These tumors elude early detection, rapidly spread locally and systemically, and frequently recur despite apparently complete resection. Cystic tumors of the pancreas, however, may represent a subset of patients who do not uniformly require aggressive resection, and a thoughtful, evidence-based approach to work-up allows for the rational application of surgical therapy. Increasing evidence supports treating patients who have pancreaticobiliary disease in a multidisciplinary setting.

Controversies in the management of borderline resectable proximal pancreatic adenocarcinoma with vascular involvement

Synchronous major vessel resection during pancreaticoduodenectomy (PD) for borderline resectable pancreatic adenocarcinoma remains controversial. In the 1970s, regional pancreatectomy advocated by Fortner was associated with unacceptably high morbidity and mortality rates, with no impact on long-term survival. With the establishment of a multidisciplinary approach, improvements in preoperative staging techniques, surgical expertise, and perioperative care reduced mortality rates and improved 5-year-survival rates are now achieved following resection in high-volume centres. Perioperative morbidity and mortality following PD with portal vein resection are comparable to standard PD, with reported 5-year-survival rates of up to 17%. Segmental resection and reconstruction of the common hepatic artery/proper hepatic artery (CHA/PHA) can be performed to achieve an R0 resection in selected patients with limited involvement of the CHA/PHA at the origin of the gastroduodenal artery (GDA). PD with concomitant major vessel resection for borderline resectable tumours should be performed when a margin-negative resection is anticipated at high-volume centres with expertise in complex pancreatic surgery. Where an incomplete (R1 or R2) resection is likely neoadjuvant treatment with systemic chemotherapy followed by chemoradiation as part of a clinical trial should be offered to all patients.

Retroperitoneal margin of the pancreaticoduodenectomy specimen: anatomic mapping for the surgical pathologist

Surgical margin status of the pancreaticoduodenectomy specimen is an independent predictor of survival in patients with pancreatic head cancer. Although most surgical pathologists are familiar with the protocols for grossing and evaluation of the various margins of the specimen, the currently prevailing definitions of the retroperitoneal surgical margin minimize the fact that this margin is actually a combination of surfaces of different anatomical structures. The unfamiliarity with its detailed anatomy often creates communication gaps when the pathologic findings are presented to other members of the multidisciplinary team. The following discussion is the collective opinion of hepato-pancreato-biliary pathologists in two tertiary care Canadian medical centers in this field. It describes the authors' proposed nomenclature and landmarks for anatomic mapping of the retroperitoneal margin of the pancreaticoduodenectomy resected specimen. Increasing familiarity with the subtleties of the retroperitoneal margin is expected to improve communication and sets the stage for future quality improvement initiatives and translational research in the multidisciplinary setting.

Adjuvant therapy for adenocarcinoma of the pancreas: analysis of reported trials and recommendations for future progress

The delivery of postoperative combined modality adjuvant therapy for completely resected pancreatic cancer was initially shown to be beneficial on the basis of a prospective, randomized trial published in 1985. Since then, oncologists have debated whether chemotherapy, chemoradiation, or both is optimal adjuvant therapy after pancreatectomy for ductal adenocarcinoma of the pancreas; no global consensus has emerged. Unfortunately, despite the completion of a number of subsequent randomized trials of adjuvant therapy since 1985, no further improvements in overall survival have materialized. This lack of progress is not simply the result of ineffective systemic therapies, but in part the result of poor trial design and calls for a more disciplined approach to the selection of patients for surgery, pathologic assessment of surgical resection margins, and postoperative (pretreatment) imaging. This is the only way to ensure that patients who receive adjuvant therapy are actually receiving therapy for radiographically occult possible microscopic disease, rather than therapy for incompletely resected locally advanced disease or early postoperative metastases. A critical analysis of completed adjuvant trials will be provided and a framework for the conduct of future trials of adjuvant therapy proposed.

CT and MR imaging of pancreatic cancer

Computed tomography (CT) and magnetic resonance imaging (MRI) are emerging noninvasive techniques for imaging of the pancreas. Based on multislice technology, CT enables multiplanar imaging of the pancreas (multislice-CT, MSCT) with a high contrast between vessels and parenchyma. In addition, MRI of the pancreas including the imaging of the lumina of the biliary tree and the pancreatic duct (magnetic resonance cholangiopancreaticography, MRCP) and the abdominal vessels (MR angiography, MRA) has become available for daily clinical practice in most hospitals. The addition of multiplanar and curved reformations may increase the sensitivity of CT and improves its agreement with surgical findings. Beyond abdominal MR imaging, techniques such as magnetic resonance cholangiopancreaticography (MRCP) and MR angiography should be integrated in the imaging protocol whenever possible.

Preoperative serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels for the evaluation of curability and resectability in patients with pancreatic adenocarcinoma

BACKGROUND PURPOSE

Although carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA 19-9) are the most studied serum tumor markers that have been evaluated for diagnosis and prognosis in patients with pancreatic cancer, little is known of the value of these markers for the prediction of curability and resectability.

METHODS

We retrospectively reviewed preoperative serum levels of CEA and CA 19-9 in 244 consecutive patients with pancreatic operations.

RESULTS

Although 159 pancreatic operations seemed "resectable", 93 of them were judged curative (R0) and the other 66 turned out to be noncurative (R1/2). The remaining 85 failed resection because of unexpected metastasis or locally advanced disease (LD), which was unresectable compared with levels in those patients without liver metastasis or LD. CEA levels were significantly higher in patients with liver metastasis and LD, while CA 19-9 levels were correlated with liver and peritoneal metastases. When both markers were negative, curative (R0) and respectable (R0 + R1/2) operation were performed in 70% and 85% of patients, respectively. Logistic regression analysis indicated that under conditions where both CEA and CA 19-9 were negative, the odds ratios for curative and respectable operations were 4.43 and 3.58, respectively.

CONCLUSIONS

Our data suggest that combined preoperative CEA and CA 19-9 levels are suitable for assessing expected curability and resectability in patients with pancreatic cancer.

Locally advanced pancreatic cancer: a review

It is anticipated that there will be 37,170 new cases of pancreatic cancer diagnosed in the United States this year, resulting in approximately 33,370 deaths from the disease. Approximately 40% of these patients will present with locally advanced, non-metastatic disease. Treatment regimens that incorporate conventional radiation therapy for local tumor control, and chemotherapy to prevent distant failure in this metastasis-prone malignancy, are the current standard of care. A number of clinical studies have been undertaken to establish the optimal definitive chemoradiation treatment in this setting. Other potential treatment strategies include chemoradiation incorporating novel chemotherapeutic agents, intraoperative radiation therapy, brachytherapy, and the integration of combined therapies that utilize targeted molecular agents. This review summarizes the current status, controversies, and future prospects for the treatment of locally advanced pancreatic cancer.

Guidelines for the Surgical Management of Pancreatic Adenocarcinoma

Pancreaticoduodenectomy remains the most formidable operative procedure for the surgical treatment of gastrointestinal malignancy. Improved outcomes after the Whipple procedure have been attributed to better preoperative patient selection, advances in three-dimensional radiographic imaging, and regionalization of referrals to high-volume, tertiary care centers. Despite these advances, morbidity and mortality after pancreaticoduodenectomy are not insignificant and the overall prognosis following resection for adenocarcinoma of the pancreas remains poor. Improvements in endoscopic decompression of malignant biliary obstruction have decreased the need for palliative bypass operations and have focused current surgical issues on ways to improve clinical outcomes following potentially curative resections. Controversies such as whether or not to perform extended lymph node dissections, and standard versus pylorus-preserving resections have been addressed by randomized, prospective clinical trials. Major venous resections secondary to local tumor extension are now performed without an increase in morbidity or mortality and with survival rates comparable to standard resections. This has led to even more aggressive resections following neoadjuvant therapy for lesions previously considered unresectable and now perhaps better categorized as borderline resectable. The impact of surgical specialization and regionalization of referrals to tertiary care centers is evident in markedly improved perioperative mortality rates. This article will attempt to describe current guidelines for the preoperative, intraoperative, and postoperative management of patients with localized pancreatic adenocarcinoma.

Endoscopic palliation of pancreatic cancer

Endoscopic approaches have revolutionized the palliation of advanced pancreatic cancer. The ideal management consists of a multidisciplinary approach involving surgeons, endoscopists, radiologists, and oncologists. Concurrent advances in the fields of interventional radiology and laparoscopic surgical oncology should be readdressed and directly compared with endoscopic approaches in randomized controlled trials. Exciting novel endoscopic techniques are being developed and evaluated; however, these approaches require further validation with randomized clinical trials to determine the safety and efficacy when compared with more traditional approaches.

The role of positron emission tomography in the management of pancreatic cancer

The role of positron emission tomography (PET) and PET/computed tomography (CT) in the assessment of a patient presenting with cancer of the pancreas is discussed in the overall context of the management of this condition. The clinical limitations persist, with many patients presenting late with unresectable disease and poor prospects for novel drug therapies. PET and PET/CT are best at diagnosing and staging but are relatively inefficient in the detection of nodal disease. The detection of late disease manifestations such as metastatic spread is often of little clinical consequence. PET/CT may be considered as a first-line imaging investigation but evidence for this approach needs to accrue. Overall detection sensitivity at diagnosis varies between 90% and 95% and specificity from 82% to 100%, whereas for staging, sensitivity data vary from 61% to 100% and specificity data from 67% to 100%.

Predicting unresectability in pancreatic cancer patients: the additive effects of CT and endoscopic ultrasound

BACKGROUND

A standardized method for predicting unresectability in pancreatic cancer has not been defined. We propose a system using CT and endoscopic ultrasound (EUS) to assess patients for unresectable pancreatic cancers.

METHODS

Radiologic and surgical data from 101 patients who underwent exploration/resection for pancreatic cancer were reviewed. Chi-squares were used to identify five factors significantly correlated with unresectability, which were incorporated into a scoring system (one point for each factor).

RESULTS

The resectability rates were 84, 56, and 10% for patients with scores of 0, 1, and 2, respectively. All four patients with three risk factors for unresectability had unresectable tumors. The most accurate results were achieved in patients evaluated with both CT and EUS.

DISCUSSION

This scoring system stratifies pancreatic cancer patients into three groups: (1) patients with a score of zero (likely to undergo successful resection), (2) patients with a score of one (likely to benefit from laparoscopic staging prior to attempting resection), and (3) patients with a score of two or higher (low probability of successful resection, who may be better served by neoadjuvant therapy).

MDCT of pancreatic adenocarcinoma: optimal imaging phases and multiplanar reformatted imaging

OBJECTIVE

The objective of our study was to evaluate the individual contributions of arterial, pancreatic parenchymal, and portal venous phase (PVP) images and the utility of coronal and sagittal multiplanar reformatted (MPR) images in the assessment of pancreatic adenocarcinoma using triple-phase MDCT.

MATERIALS AND METHODS

Thirty-one patients with and 35 patients without pancreatic adenocarcinoma underwent triple-phase MDCT. Three radiologists independently attempted to detect pancreatic adenocarcinoma and assess local extension using the MDCT images in five sessions. The first three sessions involved sets of images obtained in arterial phase, pancreatic parenchymal phase, and PVP separately and respectively. In the fourth session, a combination of axial images from all phases was evaluated. During the fifth session, radiologists had access to coronal and sagittal MPR images together with the axial images obtained in all phases. Results were compared with surgical findings using receiver operating characteristic (ROC) analysis and kappa statistics.

RESULTS

Regarding tumor detection, the image set composed of coronal and sagittal MPR images and of axial images obtained in all phases had a significantly higher value for the area under the ROC curve (A(Z), 0.98 +/- 0.01) than the other image sets and yielded the highest sensitivity (93.5%). The sensitivity of the arterial phase image set (80.6%) was significantly lower than that of all other image sets. Whereas the image set composed of coronal and sagittal MPR images and axial images obtained in all phases yielded the highest kappa values for all local extension factors evaluated, the image set composed of only arterial phase images yielded the lowest kappa values for almost all of the factors.

CONCLUSION

A combination of pancreatic parenchymal phase and PVP imaging is necessary and efficient for the assessment of pancreatic adenocarcinoma. The addition of coronal and sagittal MPR images increased the performance of MDCT, especially in the evaluation of local extension.

Current treatment strategies for pancreatic cancer in the elderly

Pancreatic cancer, which is responsible for >90% of exocrine pancreatic tumours, is typically a disease of the elderly (> or =70 years of age). However, older patients are less likely to be staged than younger patients despite having a worse overall 5-year survival rate than their younger counterparts. Various radiological, ultrasonographic and endoscopic investigations are used not only as diagnostic tools but also to accurately stage the cancer for possible surgery. Many patients with pancreatic cancer have mutations of the K-ras oncogene, and various tumour suppressor genes are also inactivated. Pancreas resection can be performed in elderly resectable patients without excess mortality, even in those >80 years of age. However, treatment for locally advanced, unresectable and metastatic pancreatic cancer is palliative. Fluorouracil-based chemoradiation for locally advanced or unresectable cancer, and gemcitabine for patients with metastatic disease, can result in clinical benefits. Placement of a stent in the biliary tract has been shown to improve symptoms of obstructive jaundice or ascites, as well as quality of life. As molecular targets are identified, interventions with targeted specific agents may improve tumour control. However, further studies will be needed to demonstrate whether or not various agents targeting signal transduction pathways or nuclear transcription factors are useful for elderly patients with advanced pancreatic cancer.

Clinical implications of combined portal vein resection as a palliative procedure in patients undergoing pancreaticoduodenectomy for pancreatic head carcinoma

BACKGROUND

The clinical implications of combined portal vein resections are controversial.

METHODS

One-hundred and forty-nine consecutive patients underwent macroscopically curative pancreatectomies for pancreatic head carcinoma between January 1, 1996 and December 31, 2004. Portal vein resection was performed in 86 patients (58%). Data on surgical mortality, morbidity, perioperative outcome, pathological factors, initial recurrence site, and survival were retrospectively compared between the patients with and without portal vein resection.

RESULTS

The incidence of postoperative pancreatic fistula was lower among patients who underwent portal vein resection. The median survival period was 14 months for the portal vein resection group and 35 months for the non-portal vein resection group, respectively. Combined portal vein resection was a significant predictor of poor survival using a multivariate analysis. Portal vein resection was strongly associated with larger tumor size, the degree of retropancreatic tissue invasion, the presence of extrapancreatic nerve plexus invasion, lymph node metastases, and positive cancer infiltration at the surgical margins.

CONCLUSIONS

Portal vein resection at the time of pancreaticoduodenectomy can be safely performed. However, most of patients requiring portal vein resection do not achieve a potentially curative resection or a favorable survival term. As a result, the aggressive application and the strict selection of portal vein resection might reduce the incidence of positive surgical margins, enabling long-term survival in patients who do not require portal vein resection.

Pancreas: optimal scan delay for contrast-enhanced multi-detector row CT

PURPOSE

To prospectively determine optimal scan delays for multiphasic contrast medium-enhanced imaging of the pancreas with multi-detector row computed tomography (CT).

MATERIALS AND METHODS

This study was approved by an institutional review committee, and patients gave written informed consent. One hundred ninety-one patients underwent three-phase CT of the pancreas after receiving intravenous contrast medium with a fixed duration injection of 30 seconds. Patients were prospectively assigned among four groups with scan delays of 25, 45, and 65 seconds (group 1); 30, 50, and 70 seconds (group 2); 35, 55, and 75 seconds (group 3); and 40, 60, and 80 seconds (group 4). Mean CT numbers of abdominal aorta, spleen, pancreatic parenchyma, superior mesenteric artery and vein, splenic vein, and hepatic parenchyma were measured, and increases in contrast enhancement on enhanced images were assessed. Qualitative analysis was performed with a four-point scale.

RESULTS

Abdominal aorta and superior mesenteric artery enhanced at a mean of 35 seconds from the start of injection (both P < .001). Pancreatic parenchyma enhanced most intensely at 35-45 seconds (P < .001) with a peak enhancement at the mean of 40 seconds. Liver parenchyma enhanced most intensely at 55-65 seconds with a peak at 60 seconds (P < .001). The mean time to peak enhancement was 45 seconds for the splenic vein and 55 seconds for the superior mesenteric vein. Qualitative results were in good agreement with quantitative results (both P < .001).

CONCLUSION

With the injection protocol used in this study, optimal scan delays for imaging the pancreas were 30-35 seconds for the abdominal aorta and the superior mesenteric artery, 35-45 seconds for the pancreas, 45 seconds for the splenic vein, and 55 seconds or later for the liver.