Preoperative imaging characteristics predict poor survival and inadequate resection for left-sided pancreatic adenocarcinoma: a multi-institutional analysis

Abstract

Background: Optimal treatment of pancreatic ductal adenocarcinoma of the neck, body and tail (PDAC-NBT) is predicated upon complete surgical resection with negative (R0) margins. However, preoperative identification of patients who may achieve successful resection is difficult. Thus study seeks to identify preoperative imaging characteristics that may serve as prognostic markers associated with non-R0 resection and subsequent poor survival. Methods: Patients at five high-volume pancreatic centers with PDAC-NBT who underwent surgical resection with curative intent were retrospectively analyzed. The most immediate preoperative cross-sectional computed tomography scan was assessed and correlated with the primary outcome measures of overall survival and surgical margins. Results: 330 patients were surgically treated between 2001 and 2016. Of these, 247 underwent R0 (78.2%), 67 R1 (21.2%), and 2 R2 resection (0.6%). A non-R0 resection was significantly associated with worse survival (p = 0.0002). On preoperative imaging, patients with tumors greater than 20 mm, tumor attenuation greater than 70 Hounsfield units, or who demonstrated pancreatic atrophy or calcifications had significantly worse overall survival (p = 0.010, p = 0.036, p = 0.025 respectively). Tumors with any vascular interface with the splenic artery, splenic vein, or both were significantly more likely to undergo non-R0 resection (p = 0.0006, p = 0.0004, p = 0.020, respectively). Posterior extension of the tumor was also associated with non-R0 resection (p = 0.001). Conclusion: Preoperative cross-sectional imaging can identify tumor characteristics which are associated with poor survival and non-R0 resections. These data suggest PDAC-NBT patients with vascular involvement may benefit from aggressive, en-bloc surgical resection, preoperative medical therapy, and regionally directed margin-enhancement techniques.