Review of radiological classifications of pancreatic cancer with peripancreatic vessel invasion: are new grading criteria required?

Portomesenteric venous contact ≤180° and overall survival in resectable head and body pancreatic adenocarcinoma treated with upfront surgery

INTRODUCTION

Upfront surgery is the standard of care for resectable pancreatic cancer, defined as the absence of or ≤180° tumour contact with the portal/superior mesenteric vein. We hypothesized that portomesenteric venous tumour contact is prognostically unfavourable and aimed to assess whether it is associated with poorer survival compared with no venous contact in resectable head and body pancreatic cancer.

METHODS

This single-centre retrospective study included patients undergoing upfront surgery for resectable head and body pancreatic cancer in 2010-2020 at Umeå University Hospital, Sweden. No venous contact was compared with portomesenteric venous contact of ≤180° based on preoperative imaging. Overall survival on an intention-to-treat basis was compared with Kaplan-Meier curves, a log-rank test and Cox proportional hazards models.

RESULTS

The final study cohort included 39 patients with portomesenteric venous tumour contact and 144 patients without venous tumour contact. Patients with venous tumour contact had a median overall survival of 15.3 months compared to 23.0 months (log rank P = 0.059). Portomesenteric venous tumour contact was an independent negative prognostic factor for survival in the multivariable Cox model (HR 1.68; 95% CI 1.11-2.55, P = 0.014) and was associated with higher rates of microscopically non-radical resections (R1) (50% vs 26.1%, P = 0.012) and pathological lymph node metastasis (76.7% vs 56.8%, P = 0.012). There was no difference in adjuvant chemotherapy receipt or postoperative complications between the groups.

CONCLUSIONS

Portomesenteric venous tumour contact is associated with poorer overall survival and higher rates of R1 resections and lymph node metastasis in patients with resectable head and body pancreatic cancer treated with upfront surgery.

The Usefulness of Elastin Staining to Detect Vascular Invasion in Cancer

Tumor prognosis hinges on accurate cancer staging, a pivotal process influenced by the identification of lymphovascular invasion (LVI), i.e., blood vessel and lymphatic vessel invasion. Protocols by the College of American Pathologists (CAP) and the World Health Organization (WHO) have been established to assess LVI in various tumor types, including, but not limited to, breast cancer, colorectal cancer (CRC), pancreatic exocrine tumors, and thyroid carcinomas. The CAP refers to blood vessel invasion as "angioinvasion" (vascular invasion) to differentiate it from lymphatic vessel invasion (lymphatic invasion). For clarity, the latter terms will be used throughout this review. The presence of lymphatic and/or vascular invasion has emerged as a pivotal prognostic factor; therefore, its accurate identification is crucial not only for staging but also for providing the patient with an honest understanding of his/her prognosis. Given the prognostic importance of the correct identification of LVI, specific staining techniques are employed to distinguish lymphatic vessel invasion from angioinvasion and to differentiate true LVI from artifact. These encompass hematoxylin and eosin (H&E) staining, elastic staining, Factor VIII staining, Ulex europaeus I agglutinin staining, CD31, CD34, D2-40, ERG, and D2-40 (podoplanin) immunohistochemical (IHC) stains among others. Based on a review of numerous publications regarding the efficacy of various methods for LVI detection, elastin staining demonstrated superior accuracy and prognostic value, allowing for more targeted treatment strategies. The clinical significance of accurately detecting LVI cannot be overstated, as it is strongly linked to higher cancer-related mortality and an increased risk of tumor recurrence. This review aims to examine the existing literature on the use of elastin stains in the detection of vascular invasion among different types of tumors and its prognostic value.

Utility of Dark-Blood Dual-Energy CT Images for Predicting Vascular Involvement and R0 Resection in Patients With Pancreatic Cancer

BACKGROUND. Current CT criteria for assessing vascular involvement by pancreatic ductal adenocarcinoma (PDAC) use circumferential contact as an indirect indicator. Dark-blood images derived from dual-energy CT (DECT) provide high lumen-to-wall contrast and may aid assessment. OBJECTIVE. The purpose of this study was to compare the diagnostic performance of 55-keV virtual monoenergetic images (VMIs) assessed using NCCN criteria with that of dark-blood images assessed using wall-based criteria for predicting vascular involvement and surgical resection that achieves microscopically negative margins (i.e., R0 resection) in patients with PDAC who undergo contrast-enhanced DECT. METHODS. This retrospective study included 109 patients (mean age, 62.6 ± 8.8 [SD] years; 66 men, 43 women) with histologically confirmed PDAC who underwent pancreatic parenchymal and portal venous phase DECT within 4 weeks before surgery (including PDAC resection in 73 patients) between July 2020 and June 2022. Dark-blood images were derived using a two-material decomposition algorithm. Two radiologists independently reviewed 55-keV VMIs and dark-blood images in separate sessions to evaluate celiac artery, common hepatic artery, superior mesenteric artery, portal vein, and superior mesenteric vein involvement; a third radiologist resolved discrepancies. On 55-keV VMIs, vessel relationships were classified as no contact, abutment (≤ 180° contact), or encasement (> 180° contact). On dark-blood images, vessel walls were categorized as intact circumferentially, irregular, or discontinuous. Tumor resectability status was classified on the basis of vessel relationships. Surgical observation served as the reference for vascular involvement. Margin status was determined for resected tumors. RESULTS. Across the five vessels, for predicting vascular involvement, abutment or encasement on 55-keV VMIs had sensitivity of 100.0% (all vessels) and specificity of 66.2-92.9%, and an irregular or discontinuous wall on dark-blood images had sensitivity of 80.0-100.0% and specificity of 88.2-98.0%. Specificity was higher for an irregular or discontinuous wall than for abutment or encasement for all vessels (all p < .05); sensitivity was not different for any vessel (all p > .05). Resectable disease classified by dark-blood images, compared with resectable disease classified by 55-keV VMIs, showed no difference in sensitivity (89.5% vs 78.9%, p = .33) but showed higher specificity (75.9% vs 59.3%, p = .01) for predicting R0 resection. CONCLUSION. Dark-blood images showed higher diagnostic performance than 55-keV VMIs for predicting vascular involvement and R0 resection in patients with PDAC. CLINICAL IMPACT. Dark-blood images may aid decisions regarding neoadjuvant therapy and surgical planning for PDAC.

Predictive nomogram based on serum tumor markers and clinicopathological features for stratifying lymph node metastasis in breast cancer

BACKGROUND

This study was aimed to establish the nomogram to predict patients' axillary node status by using patients' clinicopathological and tumor characteristic factors.

METHODS

A total of 705 patients with breast cancer were enrolled in this study. All patients were randomly divided into a training group and a validation group. Univariate and multivariate ordered logistic regression were used to determine the predictive ability of each variable. A nomogram was performed based on the factors selected from logistic regression results. Receiver operating characteristic curve (ROC) analysis, calibration plots and decision curve analysis (DCA) were used to evaluate the discriminative ability and accuracy of the models.

RESULTS

Logistic regression analysis demonstrated that CEA, CA125, CA153, tumor size, vascular-invasion, calcification, and tumor grade were independent prognostic factors for positive ALNs. Integrating all the predictive factors, a nomogram was successfully developed and validated. The C-indexes of the nomogram for prediction of no ALN metastasis, positive ALN, and four and more ALN metastasis were 0.826, 0.706, and 0.855 in training group and 0.836, 0.731, and 0.897 in validation group. Furthermore, calibration plots and DCA demonstrated a satisfactory performance of our nomogram.

CONCLUSION

We successfully construct and validate the nomogram to predict patients' axillary node status by using patients' clinicopathological and tumor characteristic factors.

Current trends in the diagnosis of pancreatic cancer

Pancreatic ductal adenocarcinoma (PDAC) is a dreaded malignancy with a dismal 5-year survival rate despite maximal efforts on optimizing treatment strategies. Currently, early detection is considered to be the most effective way to improve survival as radical resection is the only potential cure. PDAC is often divided into four categories based on the extent of disease: resectable, borderline resectable, locally advanced, and metastatic. Unfortunately, the majority of patients are diagnosed with locally advanced or metastatic disease, which renders them ineligible for curative resection. This is mainly due to the lack of or vague symptoms while the disease is still localized, although appropriate utilization and prompt availability of adequate diagnostic tools is also critical given the aggressive nature of the disease. A cost-effective biomarker with high specificity and sensitivity allowing early detection of PDAC without the need for advanced or invasive methods is still not available. This leaves the diagnosis dependent on radiodiagnostic methods or endoscopic ultrasound. Here we summarize the latest epidemiological data, risk factors, clinical manifestation, and current diagnostic trends and implications of PDAC focusing on serum biomarkers and imaging modalities. Additionally, up-to-date management and therapeutic algorithms are outlined.

Screening for pancreatic cancer: a review for general clinicians

Pancreatic cancer (PC) is an exceptionally lethal malignancy with increasing incidence and mortality worldwide. One of the principal challenges in the treatment of PC is that the diagnosis is usually made at a late stage when potentially curative surgical resection is no longer an option. General clinicians including internists and family physicians are well positioned to identify high-risk individuals and refer them to centers with expertise in PC screening and treatment where screening modalities can be employed. Here, we provide an up-to-date review of PC precursor lesions, epidemiology, and risk factors to empower the general clinician to recognize high-risk patients and employ risk reduction strategies. We also review current screening guidelines and modalities and preview progress that is being made to improve screening tests and biomarkers. It is our hope that this review article will empower the general clinician to understand which patients need to be screened for PC, strategies that may be used to reduce PC risk, and which screening modalities are available in order to diminish the lethality of PC.

CT texture analysis for the presurgical prediction of superior mesenteric-portal vein invasion in pancreatic ductal adenocarcinoma: comparison with CT imaging features

AIM

To investigate the value of computed tomography (CT) texture analysis (TA) and imaging features for evaluating suspected surgical superior mesenteric-portal vein (SMPV) invasion in patients with pancreatic ductal adenocarcinoma (PDAC).

MATERIALS AND METHODS

Fifty-four patients with PDAC in the pancreatic head or uncinate process with suspected SMPV involvement were analysed retrospectively. SMPV invasion status was identified by surgical exploration. For each patient, 396 texture features were extracted on pretreatment CT. Non-parametric tests and minimum redundancy maximum relevance were used for feature selection. A CTTA model was constructed using multivariate logistic regression, and the area under the receiver operating characteristic (AUROC) of the model was calculated. Two reviewers evaluated qualitative imaging features independently for SMPV invasion and interobserver agreement was investigated. The diagnostic performance of the imaging features and the CTTA model for SMPV invasion was compared using the McNemar test.

RESULTS

Of the 54 patients with PDAC, SMPV invasion was detected in 23 (42.6%). The CTTA model yielded an AUROC of 0.88 (95% confidence interval, 0.76-0.97) and achieved significantly higher specificity (0.90) than the two reviewers (0.61 and 0.65; p=0.027 and 0.043). Interobserver agreement was moderate between the two reviewers (κ = 0.517). Of the 13 cases with disagreement between the two reviewers, 11 cases were predicted accurately by the CTTA model.

CONCLUSION

CTTA can predict suspected SMPV invasion in PDAC and may be a beneficial addition for qualitative imaging evaluation.

Surgical management and pathological assessment of pancreatoduodenectomy with venous resection: an international survey among surgeons and pathologists

BACKGROUND

The aim of this survey was to gain insights in the current surgical management and pathological assessment of pancreatoduodenectomy with portal-superior mesenteric vein resection (VR).

METHODS

A systematic literature search was performed to identify international expert surgeons (N = 150) and pathologists (N = 40) who published relevant studies between 2009 and 2019. These experts and Dutch surgeons (N = 17) and pathologists (N = 20) were approached to complete an online survey.

RESULTS

Overall, 76 (46%) surgeons and 37 (62%) pathologists completed the survey. Most surgeons (71%) estimated that preoperative imaging corresponded correctly with intraoperative findings of venous involvement in 50-75% of patients. An increased complication risk following VR was expected by 55% of surgeons, mainly after Type 4 (segmental resection-venous conduit anastomosis). Most surgeons (61%) preferred Type 3 (segmental resection-primary anastomosis). Most surgeons (75%) always perform the VR themselves. Standard postoperative imaging for patency control was performed by 54% of surgeons and 39% adjusted thromboprophylaxis following VR. Most pathologists (76%) always assessed tumor infiltration in the resected vein and only 54% of pathologists always assess the resection margins of the vein itself. Variation in assessment of tumor infiltration depth was observed.

CONCLUSION

This international survey showed variation in the surgical management and pathological assessment of pancreatoduodenectomy with venous involvement. This highlights the lack of evidence and emphasizes the need for research on imaging modalities to improve patient selection for VR, surgical techniques, postoperative management and standardization of the pathological assessment.

Preoperative prediction of futile surgery in patients with radiologically resectable or borderline resectable pancreatic adenocarcinoma

BACKGROUND AND AIM

The aim of this study is to identify the predictive factors for futile surgery in patients with radiologically resectable or borderline resectable pancreatic cancer and to develop a prediction model.

METHODS

This retrospective study included patients who underwent pancreatic surgery for pancreatic cancer between 2006 and 2017. To identify independent risk factors for futile surgery, logistic regression and random forest analyses were performed in the training cohort, based on which a nomogram was established. The predictive accuracy and discriminative ability of the nomogram were validated in the validation cohort.

RESULTS

Of 389 patients who underwent pancreatic surgery, the laparotomy was futile in 40 patients (10.3%). In the training cohort, the univariate and multivariate logistic regression analyses revealed that serum carbohydrate antigen 19-9 level of ≥ 150 U/mL (P = 0.003), the presence of suspicious lymph node (P = 0.013), and more extensive peripancreatic tumor infiltration (P < 0.001) were independent predictive factors for futile surgery. The bootstrap-corrected concordance index of the nomogram was high in the training cohort, 0.826 with a 95% confidence interval of 0.745-0.907. This model also showed a good discriminative performance in the validation cohort, with a concordance index of 0.831.

CONCLUSIONS

We established and validated a novel nomogram that predicts the risk of futile surgery due to occult distant metastasis in patients with radiologically resectable or borderline resectable pancreatic cancer.

[Diagnosis and treatment of pancreatic head cancer followed by mesenteric-portal vein invasion]

AIM

To evaluate the outcomes of pancreaticoduodenectomy with mesenteric-portal vein resection for pancreatic head cancer.

MATERIAL AND METHODS

Retrospective analysis included 124 patients with pancreatic head cancer for the period 2010-2017. Mesenteric-portal vein (MPV) invasion was diagnosed in 37 (29.8%) patients, tumor contact with superior mesenteric artery as a borderline resectable state was noted in 11 cases. All patients underwent pancreaticoduodenectomy with mesenteric-portal vein resection.

RESULTS

Vein invasion was histologically confirmed in 19 (51.3%) out of 37 patients. At the same time, arterial invasion was absent in 11 patients with a borderline resectable tumor. CT-associated overdiagnosis of venous wall invasion was 6.4%, intraoperative overdiagnosis - 87.5%. R0-resection was achieved in 88.5% after conventional pancreaticoduodenectomy and in 78.4% after pancreaticoduodenectomy followed by MPV resection. Median survival was 17 months, 2-year survival - 41%. Among 11 patients with a borderline resectable tumor median survival was 11 months. Pancreaticoduodenectomy without vein resection was followed by 2-year survival near 68.1%. Differences were significant (p=0.02).

CONCLUSION

Pancreaticoduodenectomy followed by MPV resection as the first stage of combined treatment of pancreatic head cancer is absolutely justified if circumferential involvement of the vein and contact with superior mesenteric artery or celiac trunk do not exceed 50%. Vein resection can provide R0-surgery in these cases.

Preoperative prediction of peripancreatic vein invasion by pancreatic head cancer

Background

Pancreatic adenocarcinoma is often diagnosed at an advanced stage when adjacent vascular invasion is present. Accurate evaluation of presence of vascular invasion can help guide therapy. The aim of this study was to construct a nomogram for preoperative prediction of peripancreatic vein invasion in patients with pancreatic head cancer.

Study design

Data of patients with carcinoma head of pancreas and suspected peripancreatic invasion (n = 247) who underwent pancreatic resection with venous reconstruction between January 2012 and January 2017 at four academic institutions were retrospectively analyzed. Univariate and multivariate analyses were used to identify independent risk factors for vein invasion from among demographic, biological, conditional host-related, and anatomical data. A predictive nomogram was constructed based on the identified independent risk factors.

Results

The nomogram was constructed using data from 181 patients while the validation cohort consisted of 66 patients. Length of tumor contact (P = 0.031), circumferential vein involvement (P = 0.048), and venous contour abnormalities (P = 0.001) were independent predictors of venous invasion. The C-index of the model in predicting venous invasion was 0.963 for the external validation cohort. Patients could be assigned into low- (< 50%), intermediate- (50–90%), and high-risk (> 90%) groups based on the nomogram to facilitate personalized management.

Conclusions

Vein invasion by pancreatic head cancer is mainly associated with anatomical factors. The nomogram for prediction of vein invasion was found to be practicable.

Electronic supplementary material

The online version of this article (10.1186/s40644-018-0179-z) contains supplementary material, which is available to authorized users.

A preoperative nomogram predicts prognosis of up front resectable patients with pancreatic head cancer and suspected venous invasion

BACKGROUND

Pancreatic head adenocarcinoma is commonly diagnosed at an advanced stage when adjacent vascular invasion is present. This study aimed to establish a preoperative prognostic nomogram for patients who underwent attempted curative resectional surgery for pancreatic head cancer with suspected peripancreatic venous invasion.

METHODS

Data on all consecutive patients were retrospectively collected from 2012 to 2016 at four academic institutions. The demographic and radiological parameters were analyzed using univariate and multivariate Cox regression analyses. The final nomogram was established using the concordance Harrell's C-indices and calibration curves from data obtained in three institutions and validated in the cohort of patients coming from the fourth institution.

RESULTS

The nomogram was constructed using data from 178 patients while the validation cohort consisted of 61 patients. Age, length of tumor contact, peripancreatic venous abnormalities and lymph node staging were independent factors of overall survival. The nomogram showed good probabilities of survival on calibration curves. The C-index of the model in predicting overall survival (OS) was 0.824 for the validation cohort.

CONCLUSIONS

The nomogram accurately predicted OS in patients with pancreatic head cancer with suspected peripancreatic venous invasion after attempted curative pancreatic resectional surgery.

Clinical significance of defining borderline resectable pancreatic cancer

Since the introduction of the concept of borderline resectable pancreatic cancer (BRPC), various definitions of this disease entity have been suggested. However, there are several obstacles in defining this disease category. The current diagnostic criteria of BRPC mainly focuses on its expanded 'technical resectability'; however, they are difficult to interpret because of their ambiguity using potential subjective or arbitrary terminology, In addition, limitations in current imaging technology and a lack of evidence in radiological-pathological-clinical correlation make it difficult to refine the criteria. On the other hand, neoadjuvant treatment is usually applied to increase the R0 resection rate of BRPC focusing on the 'oncological curability'. However, evidence is needed concerning the effect of neoadjuvant treatment by quality-controlled prospective randomized clinical trials based on a standardized radiologic and pathologic reporting system. In conclusion, there are two aspects in the current concept of BRPC, which are technical resectability and oncological curability. Although the recent evolution of surgical techniques is expanding the scope of technical resectability, it should not be overlooked that the disease entity must be defined based on the evidence of oncological curability.