Radiologic Resectability Assessment in Pancreatic Cancer

Abstract

Complete tumor resection is still the only potentially curative therapy option for patients with ductal adenocarcinoma of the pancreas. Surgical exploration is the gold standard for the determination of tumor resectability. Radiological resectability assessment is of great importance because many clearly unresectable cases can be identified preoperatively and it became essential for surgical planning. The evolving surgical and radiological techniques demand a continuous reappraisal of radiological criteria in resectability assessment. In the following, the criteria for resection planning are described along with surgical management and the role of radiology in some innovative surgical concepts is explained.

Citation Format:

• Denecke T, Grieser C, Neuhaus P et al. Radiologic Resectability Assessment in Pancreatic Cancer. Fortschr Röntgenstr 2014; 186: 23 – 29

Zusammenfassung

Für Patienten mit duktalem Adenokarzinom des Pankreas stellt die vollständige Tumorresektion nach wie vor die einzige potenziell kurative Therapieoption dar. Zur Klärung ob eine Tumorresektion möglich ist gilt die chirurgische Exploration als Goldstandard. Die radiologische Einschätzung der Resektabilität vor der Operation ist von entscheidender Bedeutung, da sie viele eindeutig irresektable Fälle präoperativ identifizieren kann und zur Planung des chirurgischen Eingriffs unverzichtbar geworden ist. Die Weiterentwicklungen chirurgischer Techniken und bildgebender Methoden verlangen eine kontinuierliche Neubewertung der Kriterien für eine Einschätzung der Resektabilität anhand radiologischer Diagnostik. Im Folgenden werden die Kriterien für die Resektionsplanung und das chirurgische Vorgehen beschrieben sowie die Rolle der Radiologie bei einigen innovativen chirurgischen Therapiekonzepten erläutert.

Key words

pancreas - CT - MR imaging - resectability - cancer - staging

• References

• 1 Ferlay J, Shin HR, Bray F et al. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer 2010; 127: 2893-2917
• 2 Bahra M, Neumann U. Surgical techniques for resectable pancreatic cancer. Recent Results Cancer Res 2008; 177: 29-38
• 3 Barugola G, Partelli S, Marcucci S et al. Resectable pancreatic cancer: who really benefits from resection?. Ann Surg Oncol 2009; 16: 3316-3322
• 4 Walter J, Nier A, Rose T et al. Palliative partial pancreaticoduodenectomy impairs quality of life compared to bypass surgery in patients with advanced adenocarcinoma of the pancreatic head. Eur J Surg Oncol 2011; 37: 798-804
• 5 Grenacher L, Klauss M, Dukic L et al. Hochauflösende Bildgebung beim Pankreaskarzinom: Prospektiver Vergleich von MRT und 4-Zeilen-Spiral-CT. Fortschr Röntgenstr 2004; 176: 1624-1633
• 6 Buerke B, Heiundel W, Wessling J. Differenzialdiagnose und radiologisches Management von zystischen Tumoren des Pankreas. Fortschr Röntgenstr 2010; 182: 852-860
• 7 Grieser C, Heine G, Steffen IG et al. Morphological Analysis and Differentiation of Benign Cystic Neoplasms of the Pancreas Using Computed Tomography and Magnetic Resonance Imaging. Fortschr Röntgenstr 2012; [Epub ahead of print]
• 8 Hartwig W, Hackert T, Hinz U et al. Multivisceral resection for pancreatic malignancies: risk-analysis and long-term outcome. Ann Surg 2009; 250: 81-87
• 9 Fletcher JG, Wiersema MJ, Farrell MA et al. Pancreatic malignancy: value of arterial, pancreatic, and hepatic phase imaging with multi-detector row CT. Radiology 2003; 229: 81-90
• 10 Koelblinger C, Ba-Ssalamah A, Goetzinger P et al. Gadobenate dimeglumine-enhanced 3.0-T MR imaging versus multiphasic 64-detector row CT: prospective evaluation in patients suspected of having pancreatic cancer. Radiology 2011; 259: 757-766
• 11 Fukukura Y, Takumi K, Kamiyama T et al. Pancreatic adenocarcinoma: a comparison of automatic bolus tracking and empirical scan delay. Abdom Imaging 2010; 35: 548-555
• 12 Partelli S, Crippa S, Barugola G et al. Splenic artery invasion in pancreatic adenocarcinoma of the body and tail: a novel prognostic parameter for patient selection. Ann Surg Oncol 2011; 18: 3608-3614
• 13 Seufferlein T, Adler G. Die S3-Leitlinie Exokrines Pankreaskarzinom. Med Klin (Munich) 2009; 104: 869-874
• 14 Boggi U, Del Chiaro M, Croce C et al. Prognostic implications of tumor invasion or adhesion to peripancreatic vessels in resected pancreatic cancer. Surgery 2009; 146: 869-881
• 15 Bilimoria KY, Bentrem DJ, Ko CY et al. Validation of the 6th edition AJCC Pancreatic Cancer Staging System: report from the National Cancer Database. Cancer 2007; 110: 738-744
• 16 Yekebas EF, Bogoevski D, Cataldegirmen G et al. En bloc vascular resection for locally advanced pancreatic malignancies infiltrating major blood vessels: perioperative outcome and long-term survival in 136 patients. Ann Surg 2008; 247: 300-309
• 17 Krumm P, Schraml C, Bretschneider C et al. Depiction of variants of the portal confluence venous system using multidetector row CT: analysis of 916 cases. Fortschr Röntgenstr 2011; 183: 1123-1129
• 18 Loyer EM, David CL, Dubrow RA et al. Vascular involvement in pancreatic adenocarcinoma: reassessment by thin-section CT. Abdom Imaging 1996; 21: 202-206
• 19 Nakao A, Kanzaki A, Fujii T et al. Correlation between radiographic classification and pathological grade of portal vein wall invasion in pancreatic head cancer. Ann Surg 2012; 255: 103-108
• 20 Grieser C, Steffen IG, Grajewski L et al. Preoperative multidetector row computed tomography for evaluation and assessment of resection criteria in patients with pancreatic masses. Acta Radiol 2010; 51: 1067-1077
• 21 Mollberg N, Rahbari NN, Koch M et al. Arterial resection during pancreatectomy for pancreatic cancer: a systematic review and meta-analysis. Ann Surg 2011; 254: 882-893
• 22 Lopez Hänninen E, Amthauer H, Hosten N et al. Prospective evaluation of pancreatic tumors: accuracy of MR imaging with MR cholangiopancreatography and MR angiography. Radiology 2002; 224: 34-41
• 23 Soriano A, Castells A, Ayuso C et al. Preoperative staging and tumor resectability assessment of pancreatic cancer: prospective study comparing endoscopic ultrasonography, helical computed tomography, magnetic resonance imaging, and angiography. Am J Gastroenterol 2004; 99: 492-501
• 24 Lu DS, Reber HA, Krasny RM et al. Local staging of pancreatic cancer: criteria for unresectability of major vessels as revealed by pancreatic-phase, thin-section helical CT. Am J Roentgenol Am J Roentgenol 1997; 168: 1439-1443
• 25 Grieser C, Denecke T, Steffen IG et al. Multidetector computed tomography for preoperative assessment of hepatic vasculature and prediction of splenic artery steal syndrome in patients with liver cirrhosis before transplantation. Eur Radiol 2010; 20: 108-117
• 26 Kaneko OF, Lee DM, Wong J et al. Performance of multidetector computed tomographic angiography in determining surgical resectability of pancreatic head adenocarcinoma. J Comput Assist Tomogr 2010; 34: 732-738
• 27 Mayo SC, Austin DF, Sheppard BC et al. Evolving preoperative evaluation of patients with pancreatic cancer: does laparoscopy have a role in the current era?. J Am Coll Surg 2009; 208: 87-95
• 28 Balachandran A, Darden DL, Tamm EP et al. Arterial variants in pancreatic adenocarcinoma. Abdom Imaging 2008; 33: 214-221
• 29 Pfannenberg C, Schwenzer NF, Bruecher BL. State-of-the-Art-Bildgebung bei Peritonealkarzinose. Fortschr Röntgenstr 2012; 184: 205-213
• 30 Glant JA, Waters JA, House MG et al. Does the interval from imaging to operation affect the rate of unanticipated metastasis encountered during operation for pancreatic adenocarcinoma?. Surgery 2011; 150: 607-616
• 31 Strobel K, Heinrich S, Bhure U et al. Contrast-enhanced 18F-FDG PET/CT: 1-stop-shop imaging for assessing the resectability of pancreatic cancer. J Nucl Med 2008; 49: 1408-1413
• 32 Appel BL, Tolat P, Evans DB et al. Current staging systems for pancreatic cancer. Cancer J 2012; 18: 539-549
• 33 Niekel MC, Bipat S, Stoker J. Diagnostic imaging of colorectal liver metastases with CT, MR imaging, FDG PET, and/or FDG PET/CT: a meta-analysis of prospective studies including patients who have not previously undergone treatment. Radiology 2010; 257: 674-684
• 34 Löwenthal D, Zeile M, Lim WY et al. Detection and characterisation of focal liver lesions in colorectal carcinoma patients: comparison of diffusion-weighted and Gd-EOB-DTPA enhanced MR imaging. Eur Radiol 2011; 21: 832-840
• 35 Coenegrachts K, De Geeter F, ter Beek L et al. Comparison of MRI (including SS SE-EPI and SPIO-enhanced MRI) and FDG-PET/CT for the detection of colorectal liver metastases. Eur Radiol 2009; 19: 370-379
• 36 Izuishi K, Yamamoto Y, Sano T et al. Impact of 18-fluorodeoxyglucose positron emission tomography on the management of pancreatic cancer. J Gastrointest Surg 2010; 14: 1151-1158
• 37 Kamphues C, Bova R, Schricke D et al. Postoperative complications deteriorate long-term outcome in pancreatic cancer patients. Ann Surg Oncol 2012; 19: 856-856
• 38 Pai RK, Beck AH, Mitchem J et al. Pattern of lymph node involvement and prognosis in pancreatic adenocarcinoma: direct lymph node invasion has similar survival to node-negative disease. Am J Surg Pathol 2011; 35: 228-234
• 39 Slidell MB, Chang DC, Cameron JL et al. Impact of total lymph node count and lymph node ratio on staging and survival after pancreatectomy for pancreatic adenocarcinoma: a large, population-based analysis. Ann Surg Oncol 2008; 15: 165-174
• 40 Imai H, Doi R, Kanazawa H et al. Preoperative assessment of para-aortic lymph node metastasis in patients with pancreatic cancer. Int J Clin Oncol 2010; 15: 294-300
• 41 Yamada S, Fujii T, Sugimoto H et al. Pancreatic cancer with distant metastases: a contraindication for radical surgery?. Hepatogastroenterology 2009; 56: 881-5
• 42 Hosein PJ, Macintyre J, Kawamura C et al. A retrospective study of neoadjuvant FOLFIRINOX in unresectable or borderline-resectable locally advanced pancreatic adenocarcinoma. BMC Cancer 2012; 12: 199
• 43 Denecke T, Rau B, Hoffmann KT et al. Comparison of CT, MRI and FDG-PET in response prediction of patients with locally advanced rectal cancer after multimodal preoperative therapy: is there a benefit in using functional imaging?. Eur Radiol 2005; 15: 1658-1666
• 44 Denecke T, Hundsdörfer P, Misch D et al. Assessment of histological response of paediatric bone sarcomas using FDG PET in comparison to morphological volume measurement and standardized MRI parameters. Eur J Nucl Med Mol Imaging 2010; 37: 1842-1853
• 45 Tateishi U, Miyake M, Nagaoka T et al. Neoadjuvant chemotherapy in breast cancer: prediction of pathologic response with PET/CT and dynamic contrast-enhanced MR imaging--prospective assessment. Radiology 2012; 263: 53-63
• 46 Tamm EP, Loyer EM, Faria S et al. Staging of pancreatic cancer with multidetector CT in the setting of preoperative chemoradiation therapy. Abdom Imaging 2006; 31: 568-574
• 47 Katz MH, Fleming JB, Bhosale P et al. Response of borderline resectable pancreatic cancer to neoadjuvant therapy is not reflected by radiographic indicators. Cancer 2012; [Epub ahead of print]
• 48 Donahue TR, Isacoff WH, Hines OJ et al. Downstaging chemotherapy and alteration in the classic computed tomography/magnetic resonance imaging signs of vascular involvement in patients with pancreaticobiliary malignant tumors: influence on patient selection for surgery. Arch Surg 2011; 146: 836-843
• 49 Kim YE, Park MS, Hong HS et al. Effects of neoadjuvant combined chemotherapy and radiation therapy on the CT evaluation of resectability and staging in patients with pancreatic head cancer. Radiology 2009; 250: 758-765
• 50 Sperti C, Berselli M, Pedrazzoli S. Distal pancreatectomy for body-tail pancreatic cancer: is there a role for celiac axis resection?. Pancreatology 2010; 10: 491-498
• 51 Kondo S, Katoh H, Hirano S et al. Ischemic gastropathy after distal pancreatectomy with celiac axis resection. Surg Today 2004; 34: 337-340
• 52 Andreou A, Glanemann M, Guckelberger O et al. Pankreaslinksresektion mit Splenektomie und Resektion des Truncus coeliacus bei einem Pankreaskorpuskarzinom mit Infiltration des Truncus coeliacus. Med Klin (Munich) 2010; 105: 227-231
• 53 Denecke T, Andreou A, Podrabsky P et al. Distal pancreatectomy with en bloc resection of the celiac trunk for extended pancreatic tumor disease: an interdisciplinary approach. Cardiovasc Intervent Radiol 2011; 34: 1058-1064
• 54 Kondo S, Katoh H, Shimizu T et al. Preoperative embolization of the common hepatic artery in preparation for radical pancreatectomy for pancreas body cancer. Hepatogastroenterology 2000; 47: 1447-1449