The Utility of Preoperative Vascular Grading in Patients Undergoing Surgery First for Pancreatic Cancer: Does Radiologic Arterial or Venous Involvement Predict Pathologic Margin Status?

Neha Goel,Harry Cooper,Sanjay Reddy,Jimson W D'Souza,Andreas Karachristos,John Hoffman,Barton Milestone,Karen J Ruth,Rajeswari Nagarathinam

doi:10.1155/2018/7675262

Abstract

Controversy exists on accurately grading vascular involvement on preoperative imaging for pancreatic ductal adenocarcinoma. We reviewed the association between preoperative imaging and margin status in 137 patients. Radiologists graded venous involvement based on the Ishikawa classification system and arterial involvement based on preoperative imaging. For patients with both classifications recorded, we categorized vascular involvement as “None,” “Arterial only,” “Venous only,” or “Both” and examined the association of vascular involvement and pathologic margin status. Of 134 patients with Ishikawa classifications, 63%, 17%, 11%, and 9% were graded as I, II, III, and IV, respectively. Of 96 patients with arterial staging, 74%, 16%, and 10% were categorized as stages i, ii, and iii, respectively. Of 93 patients with both stagings, 61% had no vascular involvement, 7% had arterial only, 14% had venous only, and 17% had both involved. Ishikawa classification was strongly associated with a positive SMA and SMV margin (p<0.001). However, for arterial staging, there was no association with SMA or SMV margin. Overall, Ishikawa grading was more predicative of arterial involvement and remained significant on multivariate analysis. The use of diagnostic imaging in predicting positive margins is more accurate when using a venous grading system.

Highlights

Pancreatic ductal adenocarcinoma (PDAC) is one of the leading causes of cancer related mortality worldwide with a 5-year survival rate less than 20% [1]
These findings suggest that Ishikawa staging was strongly associated with positive superior mesenteric artery (SMA) and superior mesenteric vein (SMV) margins
We further examined whether lymph node involvement and celiac axis (CA) 19-9 levels are associated with any positive vascular margins

Summary

Introduction

Pancreatic ductal adenocarcinoma (PDAC) is one of the leading causes of cancer related mortality worldwide with a 5-year survival rate less than 20% [1]. While surgical resection remains the only curative option, more than 80% of patients present with unresectable disease [2, 3]. Resectability of PDAC was defined by absence of distant metastases, absence of local tumor extension to the celiac axis (CA) and hepatic artery (HA), and lack of involvement of visceral vasculature. Data from the 1990s suggested that vein resection with negative margins was associated with equivalent survival to standard pancreatoduodenectomy (PD), leading to an increasing acceptance of vascular resection for curative resections [4].

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