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Background
Restaging of locally advanced pancreatic cancer (LAPC) after induction chemotherapy using contrast-enhanced computed tomography (CE-CT) imaging is imprecise in evaluating local tumor response. This study explored the value of 3 Tesla (3 T) contrast-enhanced (CE) and diffusion-weighted (DWI) magnetic resonance imaging (MRI) for local tumo...
Citations
... For arterial anatomy, vessel encasement either represents dissectible involvement via periadventitial dissection or true vessel invasion that is unresectable [9]. Magnetic resonance imaging-halo sign, defined as replacement of solid perivascular (arterial and venous) tumor tissue by a zone of fattylike signal intensity-might be helpful to assess the effect of induction chemotherapy in patients with LAPC [10]. Further investigations incorporating quantitative parameters such as radiomics and deep learning may improve diagnostic performance of MDCT for predicting R0 resection [11]. ...
Simple Summary
Neoadjuvant treatment followed by highly complex surgical procedures has been studied over the last decade with promising short- and long-term results in patients with locally advanced pancreatic ductal adenocarcinoma (LAPC). In recent years, a wide variety of complex surgical techniques that involve extended pancreatectomies, including portomesenteric venous resection, arterial resection, or multi-organ resection, have emerged to optimize local control of the disease and improve postoperative outcomes. We aim to describe the preoperative surgical planning as well different surgical resections strategies in LAPC after neoadjuvant treatment in an integrated way for selected patients with no other potentially curative option other than surgery.
Abstract
Pancreatic ductal adenocarcinoma remains a global health challenge and is predicted to soon become the second leading cause of cancer death in developed countries. Currently, surgical resection in combination with systemic chemotherapy offers the only chance of cure or long-term survival. However, only 20% of cases are diagnosed with anatomically resectable disease. Neoadjuvant treatment followed by highly complex surgical procedures has been studied over the last decade with promising short- and long-term results in patients with locally advanced pancreatic ductal adenocarcinoma (LAPC). In recent years, a wide variety of complex surgical techniques that involve extended pancreatectomies, including portomesenteric venous resection, arterial resection, or multi-organ resection, have emerged to optimize local control of the disease and improve postoperative outcomes. Although there are multiple surgical techniques described in the literature to improve outcomes in LAPC, the comprehensive view of these strategies remains underdeveloped. We aim to describe the preoperative surgical planning as well different surgical resections strategies in LAPC after neoadjuvant treatment in an integrated way for selected patients with no other potentially curative option other than surgery.
... The use of MRI in pancreatic imaging is increasing and MRI PET like CT PET can accurately identify reduced metabolic activity highlighting disease response in locally advanced pancreatic cancer (11). A pilot study from The Netherlands has shown, that 3 Tesla (3 T) contrast enhanced and diffusion weighted (DWI) magnetic resonance imaging (MRI) was more sensitive than CT at identifying tumour response following NAT (12). They described a Halo sign where viable tumour was replaced by fibrotic tissue. ...
... Napoli et al. developed a nomogram to predict survival for patients with LAPC requiring arterial resection with a median overall survival of 14, 24, and 31 months in high-, intermediate-, and low-risk patients, respecitvely 17 . Additionally, the presence of a halo or string sign around an artery could help in the selection of patients for arterial divestment or resection 18,19 . Intraoperative ultrasonography and frozen section biopsies could further distinguish between vital tumour and fibrotic tissue after preoperative chemo(radio)therapy 20 . ...
Introduction
Arterial resections in pancreatic surgery may be planned to obtain a radical oncological resection, or unplanned after iatrogenic injury during dissection. Most data on planned arterial resection come from single, very-high-volume centres and suggest that these resections might be feasible and even beneficial after preoperative chemotherapy in highly selected patients with pancreatic cancer1–3. However, real-world data on such planned and unplanned arterial resection at a nationwide level are scarce⁴. Furthermore, distinctions between planned and unplanned arterial resection are seldomly reported, even though this might have clinical implications5,6. The present study evaluated the incidence and surgical outcome of all planned and unplanned arterial resections for pancreatic and periampullary cancer in The Netherlands.
Methods
The study protocol was approved by the scientific committee of the Dutch Pancreatic Cancer Group. Fifteen of 16 hospitals affiliated to the Dutch Pancreatic Cancer Group participated in this study; data were obtained from the mandatory Dutch Pancreatic Cancer Audit. Additional data were collected from local medical records.
Surgical resection combined with systemic chemotherapy is the cornerstone of treatment for patients with localized pancreatic cancer. Upfront surgery is considered suboptimal in cases with extensive vascular involvement, which can be classified as either borderline resectable pancreatic cancer or locally advanced pancreatic cancer. In these patients, FOLFIRINOX or gemcitabine plus nab-paclitaxel chemotherapy is currently used as preoperative chemotherapy and is eventually combined with radiotherapy. Thus, more patients might reach 5-year overall survival. Patient selection for chemotherapy, radiotherapy and subsequent surgery is based on anatomical, biological and conditional parameters. Current guidelines and clinical practices vary considerably regarding preoperative chemotherapy and radiotherapy, response evaluation, and indications for surgery. In this Review, we provide an overview of the clinical evidence regarding disease staging, preoperative therapy, response evaluation and surgery in patients with borderline resectable pancreatic cancer or locally advanced pancreatic cancer. In addition, a clinical work-up is proposed based on the available evidence and guidelines. We identify knowledge gaps and outline a proposed research agenda.
Background: Pancreatic ductal adenocarcinoma (PDAC) is the seventh leading cause of cancer-related deaths worldwide. Surgical resection is the main driver to improving survival in resectable tumors, while neoadjuvant treatment based on chemotherapy (and radiotherapy) is the best option-treatment for a non-primally resectable disease. CT-based imaging has a central role in detecting, staging, and managing PDAC. As several authors have proposed radiomics for risk stratification in patients undergoing surgery for PADC, in this narrative review, we have explored the actual fields of interest of radiomics tools in PDAC built on pre-surgical imaging and clinical variables, to obtain more objective and reliable predictors. Methods: The PubMed database was searched for papers published in the English language no earlier than January 2018. Results: We found 301 studies, and 11 satisfied our research criteria. Of those included, four were on resectability status prediction, three on preoperative pancreatic fistula (POPF) prediction, and four on survival prediction. Most of the studies were retrospective. Conclusions: It is possible to conclude that many performing models have been developed to get predictive information in pre-surgical evaluation. However, all the studies were retrospective, lacking further external validation in prospective and multicentric cohorts. Furthermore, the radiomics models and the expression of results should be standardized and automatized to be applicable in clinical practice.
