Abstract
BackgroundOne critical step in the therapy of patients with localized pancreatic cancer is the determination of local resectability. The decision between primary surgery versus upfront local or systemic cancer therapy seems especially to differ between pancreatic cancer centers. In our cohort study, we analyzed the independent judgement of resectability of five experienced high volume pancreatic surgeons in 200 consecutive patients with borderline resectable or locally advanced pancreatic cancer.MethodsPretherapeutic CT or MRI scans of 200 consecutive patients with borderline resectable or locally advanced pancreatic cancer were evaluated by 5 independent pancreatic surgeons. Resectability and the degree of abutment of the tumor to the venous and arterial structures adjacent to the pancreas were reported. Interrater reliability and dispersion indices were compared.ResultsOne hundred ninety-four CT scans and 6 MRI scans were evaluated and all parameters were evaluated by all surgeons in 133 (66.5%) cases. Low agreement was observed for tumor infiltration of venous structures (κ = 0.265 and κ = 0.285) while good agreement was achieved for the abutment of the tumor to arterial structures (interrater reliability celiac trunk κ = 0.708 P < 0.001). In patients with vascular tumor contact indicating locally advanced disease, surgeons highly agreed on unresectability, but in patients with vascular tumor abutment consistent with borderline resectable disease, the judgement of resectability was less uniform (dispersion index locally advanced vs. borderline resectable p < 0.05).ConclusionExcellent agreement between surgeons exists in determining the presence of arterial abutment and locally advanced pancreatic cancer. The determination of resectability in borderline resectable patients is influenced by additional subjective factors.Trial registrationEudraCT:2009-014476-21 (2013-02-22) and NCT01827553 (2013-04-09).
Highlights
One critical step in the therapy of patients with localized pancreatic cancer is the determination of local resectability
According to ISGPS definitions, the tumor contact to the celiac trunk, more than 180° abutment to the superior mesenteric artery, infiltration of the inferior vena cava, unreconstructable superior mesenteric vein or occlusion of the portal vein, or aortic invasion or encasement are considered signs of locally advanced pancreatic cancer [12]
We examined and compared the judgement obtained in the first 200 consecutive patients enrolled in the CONKO-007 trial and identified critical factors in evaluating tumor abutment and resectability in patients with borderline and locally advanced pancreatic cancer
Summary
One critical step in the therapy of patients with localized pancreatic cancer is the determination of local resectability. In 50–55%, pancreatic cancer has already metastasized, but in the remaining patients the tumor cannot be removed surgically due to local disease progression [5, 6]. This is due to invasion or contact of the tumor to peripancreatic vessels [7]. According to ISGPS definitions, the tumor contact to the celiac trunk, more than 180° abutment to the superior mesenteric artery, infiltration of the inferior vena cava, unreconstructable superior mesenteric vein or occlusion of the portal vein, or aortic invasion or encasement are considered signs of locally advanced pancreatic cancer [12]. These patients may display gastroduodenal artery encasement including possible short segment encasement or direct abutment of the hepatic artery and less than 180° abutment of the superior mesenteric artery [8]
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