Systematic analysis of accuracy in predicting complete oncological resection in pancreatic cancer patients - proposal of a new simplified borderline resectability definition

L Bolm,K Mueller,K May,S Sondermann,E Petrova,H Lapshyn,K Honselmann,D Bausch,S Zemskov,P Bronsert,T Keck,S Deichmann,U Wellner

doi:10.1016/j.pan.2020.07.376

Abstract

Background: Borderline resectability in pancreatic cancer (PDAC) is currently debated. Methods: Patients undergoing pancreatic resections for PDAC were identified from a prospectively maintained database. As new borderline criteria, the presence of any superior mesenterico-portal vein alteration (SMPV) and perivascular stranding of the superior mesenteric artery (SMA) was evaluated in preoperative imaging. The accuracy of established radiological borderline criteria as compared to the new borderline criteria in predicting R status (sensitivity/negative predictive value) and overall survival was assessed. Results: 118 patients undergoing pancreatic resections for PDAC from 2013 to 2018 were identified. Forty-three (36.4%) had radiological perivascular SMA stranding and 55 (46.6%) had SMPV alterations. Interrater reliability was 90% for SMA stranding and 87% for SMPV alterations. The new borderline definition including SMPV alterations and perivascular SMA stranding was the best predictor of conventional R status (p = 0.040, sensitivity 53%, negative predictive value 81%) and Leeds/Wittekind circumferential margin status (p = 0.050, sensitivity 73%, negative predictive value 79%) as compared to established borderline resectability definition criteria. Perivascular SMA stranding qualified as an independent negative prognostic parameter (HR 3.066, 95% CI 1.078–5.716, p = 0.036). Conclusion: The radiological evaluation of any SMPV alteration and perivascular SMA stranding predicts R status and overall survival in PDAC patients, and may serve to identify potential candidates for neoadjuvant therapy.

Highlights

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive solid malignancy associated with poor prognosis [1,2]
The criteria of borderline resectability were adopted from the National Comprehensive Cancer Network (NCCN) definition, comprising the absence of distant metastases, the involvement of the superior mesenterico-portal vein (SMPV)
SMPV occlusion and any arterial encasement had been considered a criterion of irresectability before, the International Study Group of Pancreatic Surgery (ISGPS) followed the National Comprehensive Cancer Network (NCCN) definition of borderline resectability and classified SMPV distortion and even short-segment venous occlusion—as well as the encasement of the gastroduodenal or hepatic artery and up to 180◦ abutment of the superior mesenteric artery (SMA)—as borderline resectable cases

Summary

Introduction

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive solid malignancy associated with poor prognosis [1,2]. The majority of patients present with distant metastases at the time of diagnosis, and less than 50% of all PDAC patients are eligible for upfront curative resection [3]. Attempts were made to specify resectability criteria in pancreatic cancer patients. While irresectability is well-defined, the definition of borderline resectability is currently debated. Borderline resectable PDAC tumors are technically resectable at a high risk of margin positive resection [4]. In 2014, the International Study Group of Pancreatic Surgery (ISGPS) aimed to standardize the definition and approach to borderline resectable PDAC [5]. The criteria of borderline resectability were adopted from the National Comprehensive Cancer Network (NCCN) definition, comprising the absence of distant metastases, the involvement of the superior mesenterico-portal vein (SMPV). Borderline resectability in pancreatic cancer (PDAC) is currently debated

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