Determination Of Resectability Research Articles

The oncologic efficacy of extended resections for lung cancer.

Extended lung resections for T3-T4 non-small-cell lung cancer remainchallenging. Multimodal management is mandatory in multidisciplinary tumor boards, and here the determination of resectability is key. Long-term oncologic efficacy depends mostly on complete resection (R0) and the extent of N2 disease. The development of novel innovative treatments (targeted therapy and immune checkpoint inhibitors) sets interesting perspectives to reinforce current therapeutic options in the induction and adjuvant setting.

Current status and perspectives of the future of pancreatic surgery: Establishment of evidence by integration of "art" and "science".

Pancreatic cancer surgery continues to be associated with a high operative morbidity rate, poor long‐term survival outcomes, and various challenges in obtaining high‐level evidence. Not only is the early postoperative morbidity rate high, but also late morbidity involves lifelong nutritional support for long‐term survivors. Due to poor survival outcomes even after curative surgery, pancreatic surgeons have doubts about the role of surgery as the definitive treatment for pancreatic cancer. Additionally, conducting clinical trials to obtain high‐level evidence in the field of pancreatic surgery is difficult, and the results have only had a moderate impact on clinical practice due to skepticism regarding their quality. Therefore, quality evidence regarding the extent of resection, mode of approach to dissection, reconstruction methods for pancreatico‐enteric anastomosis, determination of resectability, timing of surgery, and the definition of the resection margin is lacking. However, numerous innovative pancreatic surgical procedures have been developed, which may aptly have been called “art” when they were first introduced, regardless of whether they subsequently were supported by scientific evidence. In this review, we provide recent examples of the integration of art and science in the field of pancreatic surgery, which illustrate how the creative ideas of pancreatic surgeons evolved into generally accepted clinical practice. Pancreatic surgeons should be considered “surgical artists,” “surgical scientists,” and “surgical practitioners.” We look forward to more “surgical artists” educating future “surgical artists and scientists” to create a richer “spirit of innovation,” leading to a more beautiful integration of art and science in the field of pancreatic surgery.

Borderline resectable pancreatic cancer: Certainties and controversies.

Borderline resectable (BR) pancreatic ductal adenocarcinoma (PDAC) is currently a well-recognized entity, characterized by some specific anatomic, biological and conditional features: It includes patients with a stage of disease intermediate between the resectable and the locally advanced ones. The term BR identifies a tumour with an aggressive biological behaviour, on which a neoadjuvant approach instead of an upfront surgery one should be preferred, in order to obtain a radical resection (R0) and to avoid an early recurrence after surgery. Even if during the last decades several studies on this topic have been published, some aspects of BR-PDAC still represent a matter of debate. The aim of this review is to critically analyse the available literature on this topic, particularly focusing on: The problem of the heterogeneity of definition of BR-PDAC adopted, leading to a misinterpretation of published data; its current management (neoadjuvant vs upfront surgery); which neoadjuvant regimen should be preferably adopted; the problem of radiological restaging and the determination of resectability after neoadjuvant therapy; the post-operative outcomes after surgery; and the role and efficacy of adjuvant treatment for resected patients that already underwent neoadjuvant therapy.

Improved indocyanine green retention after short-term lenvatinib withdrawal in three patients with hepatocellular carcinoma

Use of lenvatinib, which has a high response rate in advanced hepatocellular carcinoma, sometimes results in tumor shrinkage and resectability of previously unresectable liver cancers. In Asia, including Japan, liver reserve, one of the determinants of resectability, is mainly determined by the indocyanine green (ICG) retention rate. Three patients with advanced liver cancer treated at our institution had very poor ICG retention rates during treatment with lenvatinib. Lenvatinib may reduce blood flow in both cancerous and non-cancerous regions by inhibiting vascular endothelial growth factor. Therefore, accurate determination of liver function likely requires withdrawal of this treatment several days before ICG retention testing.

Consensus in determining the resectability of locally progressed pancreatic ductal adenocarcinoma \u2013 results of the Conko-007 multicenter trial

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).

Apparent diffusion coefficient of pancreatic adenocarcinoma: is there any congruity with tumor resectability?

BackgroundThe accurate determination of resectability in patients with pancreatic cancer is a main goal of preoperative imaging after diagnosis. With advances in surgical techniques, the definition of resectability is in evolution, and it is crucial for radiologists to have an understanding of findings that are relevant to the determination of resectability. The parallel advancements in imaging technology are aiming to improve the ability of imaging modalities to predict resectability. Fifty patients with pancreatic ductal adenocarcinoma (PDAC) were analyzed for capability of apparent diffusion coefficient (ADC) values to predict possible tumor resectability. The patients were classified into resectable and unresectable groups based on magnetic resonance (MR) imaging criteria. Logistic regression analysis was used. Receiver operator characteristic (ROC) curve was reconstructed.ResultsOut of different prognostic variables, tumor size was the only significant predictor of tumor resectability. ROC curve analysis showed that ADC value is not a discriminator of tumor resectability (area under the curve (AUC) = 0.5, P value = 0.452).ConclusionsIn patients with pancreatic adenocarcinoma, ADC values might be unreliable for prediction of tumor resectability in clinical practice. Low ADC value in such tumors is more attributed to fibrotic nature rather than grade of the tumor.

Safety, Diagnostic Accuracy, and Effects of Endoscopic Ultrasound Fine-Needle Aspiration on Detection of Extravascular Migratory Metastases

Tumor cells can migrate via diminutive perivascular cuffing to distant sites along blood vessels to form extravascular migratory metastases (EVMM). These metastases usually areidentified during surgery or autopsies. We aimed to evaluate the feasibility and safety ofendoscopic ultrasound fine-needle aspiration (EUS-FNA) of perivascular soft-tissue cuffs todetect EVMM. We compared findings from EUS with those from noninvasive cross-sectionalimaging (reference standard) of patients who underwent EUS-FNA to assess suspected EVMM and studied the effects on pancreatic tumor staging and determination of resectability. We performed a retrospective analysis of 253 patients (mean age, 62 ± 12 y) who underwent EUS-FNA of 267 vessels for evaluation of suspected EVMM, from April 2001 through May 2018. EUS findings were compared with those from computed tomography (CT) and magnetic resonance imaging (MRI) as the reference standard. Lesions were considered to be malignant based on cytology analysis of FNA samples, histology analyses of surgical or biopsy specimens, or vascular abnormalities detected by CT or MRI that clearly indicate EVMM. Thirty patients were found to have benign lesions. The remaining 223 patients who had malignancies (166 with pancreatic ductal adenocarcinomas [PDACs]), underwent further analyses. A median of 4 FNAs (range, 1-20 FNAs) were obtained from 4-mm perivascular soft-tissue cuffs (range, 2-20 mm). FNA and cytology analysis showed malignant cells in 163 vessels (69.4%) from 157 patients (70.4%). CT or MRI did not detect EVMM in 44 patients (28%) with malignancies, including 24 patients (24%) with newly diagnosed PDAC. Detection of EVMM by EUS-FNA resulted in upstaging of 15 patients and conversion of 14 patients with PDAC from resectable (based on CT or MRI) to unresectable. No adverse events were reported during a follow-up period of 3.9 months (range, 0-117 mo). EUS-FNA and cytologic analysis of perivascular soft-tissue cuffs can detect EVMM that were not found in 28% of patients by CT or MRI. Detection of EVMM affects tumor staging and determination of tumor resectability.

Surgery for pancreatic cancer: critical radiologic findings for clinical decision making.

Pancreatic cancer is the fourth leading cause of cancer-related deaths in the United States, with an estimated 53,670 new cases diagnosed and an estimated 43,090 deaths in 2017. This high mortality rate is in part due to the small percentage of patients diagnosed with local disease, as well as the biologically aggressive nature of the disease. While only 10-20% of patients will present with surgically resectable disease, this is the only possible curative therapy. Five-year survival of resected pancreatic cancer ranges from 12 to 27%. The National Comprehensive Cancer Network (NCCN) guidelines recommend specific guidelines for imaging modalities used in the diagnosis and staging of pancreatic adenocarcinoma. Indeed, high-quality imaging is not only necessary to accurately stage the disease, but is critical for the determination of key clinical decision branch points such as the determination of surgical resectability. Identification of the lesion within the pancreas, the degree of extra-pancreatic extension, and potential involvement of surrounding vascular structures with the tumor are all findings necessary to classify patients as having resectable, borderline resectable, or with unresectable primary tumors. This article reviews imaging modalities used to evaluate the pancreatic cancer patient from the surgeon's perspective, with particular emphasis on determination of resectability and preoperative planning, as well as imaging in the postoperative period.

Preoperative tumor restaging and resectability assessment of gastric cancers after chemotherapy: diagnostic accuracy of MDCT using new staging criteria.

To evaluate the diagnostic performance of preoperative MDCT for tumor restaging and determination of resectability in gastric cancers after chemotherapy using new staging criteria. This retrospective study was approved by our institutional review board and the requirement for informed consent was waived. Thirty-seven patients with initially unresectable gastric cancers who had received chemotherapy followed by surgery were included. Two independent radiologists reviewed preoperative MDCT images to determine the TNM staging and rate the overall likelihood of resectability using a 5-point scale (5: definitely unresectable, 1: definitely resectable). New post-chemotherapy MDCT criteria do not use non-enhancing perigastric infiltrations, non-enhancing lymph nodes (LNs), and subtle remaining infiltrations after marked decrease in the size of distant metastases for T, N, and M upstaging, respectively. Discrepancies in TNM staging were resolved by a third reviewer. The diagnostic performances of MDCT were assessed using pathologic results or operation records as reference standards. For predicting resectability, the areas under the ROC curve were 0.885 and 0.882 (95% CIs 0.737-0.966 and 0.733-0.964) in reviewers 1 and 2, respectively, with substantial inter-reader agreement (weighted κ=0.689). Sensitivities and specificities of MDCT for tumor restaging on a consensus review were 80.0% (4/5) and 100% (29/29) for T4b, 35.3% (6/17) and 81.3% (13/16) for N-positive, and 63.6% (7/11) and 100% (26/26) for M1, respectively. For gastric cancers after chemotherapy, new MDCT criteria demonstrated high specificities for T4b and M-staging and good performances to predict resectability before conversion surgery.

Agreement validation between axial imaging modalities and endoscopic ultrasonography in staging resectability of pancreatic cancer.

273 Background: Vascular involvement is a key determinant of resectability and treatment sequencing in pancreatic cancer (PC). Current staging requires multidetector CT (MDCT) and endoscopic ultrasonography (EUS), but there are still occasions when vascular involvement cannot be fully assessed. Current NCCN guidelines recommend using magnetic resonance imaging (MRI) for clarifying these ambiguities. The primary aim of our study is to access the accuracy of CT, MRI, and EUS in staging resectabilty of PC. The secondary aim is to assess internal consistency in the evaluation of vascular involvement among different staging modalities. Methods: We retrospectively reviewed 40 medical records of patients who were treated at LUMC for PC from 2006 to present. We evaluated 8 MDCT scans and 8 MRI scans in addition to their EUS reports. Seven board certified radiologists analyzed the 16 imaging studies using a standardized template. Unweighted Kappa statistic and observed agreement analysis was calculated to assess inter-observer agreement on vessel involvement between the imaging studies compared to the EUS reports. We sought to examine degree of concordance for involvement of the superior mesenteric artery (SMA), superior mesenteric vein (SMV), and main portal vein (MPV) with the pancreatic tumor. Results: Low Kappa and observed agreement in respect to vascular involvement between MDCT and EUS was found for SMV (K = 0.33, 62.5%), SMA (K = -0.2, 62.5%), and MPV (K = 0.38, 75%), indicating low concordance. Low Kappa and observed agreement in respect to vascular involvement between MRI and EUS was found for SMV (K = 0.09, 37.5%), SMA (K = 0.14, 62.5%), and MPV (K = 0.47, 75%). Low Kappa and observed agreement in respect to vascular involvement between MRI and MDCT in comparison to EUS was found for SMV (K = 0.11, 50%), SMA (K = 0.20, 75%), and MPV (K = 0.14, 62.5%). Conclusions: Concordance was shown within each imaging modality when analyzed by radiologists. Due to high discordance across different staging modalities, however, MRI and CT scans complement each other in determining degree of vascular involvement. We believe both imaging modalities should be used in staging borderline resectable PC.

Navigating the Root of the Mesentery: A Guided Approach to an Artery-First Pancreatoduodenectomy.

In the standard technique of pancreatoduodenectomy (PD), the superior mesenteric artery (SMA) is approached following Kocher maneuver of the duodenum. Alternative approaches include SMA first with no touch approaches. The aim of this article is to report the preoperative planning for and operative techniques of a combined artery first with no touch technique (CTPD) for the performance of PD. The CTPD technique is described with a detailed discussion of the operative anatomy, and of the importance of preoperative mapping using computed tomography to aid dissection of the mesenteric root and identification of the SMA. The use of careful preoperative mapping of arterial anatomy on cross-sectional imaging helps to facilitate identification of the SMA and simplifies the operative approach to PD. By incorporating detailed preoperative planning and a careful anatomical dissection, the CTPD technique provides an earlier assessment of the superior mesenteric vessels and determination of resectability.

Preoperative Radiologic Evaluation of Cholangiocarcinoma.

In patients with cholangiocarcinoma, surgical resection with curative intent is the only way to achieve cure. Since surgical resection of cholangiocarcinomas is technically demanding, determination of resectability and accurate preoperative staging are crucial. For these purposes, high quality imaging including multidetector computed tomography and magnetic resonance imaging with magnetic resonance cholangiopancreaticography, is mandatory. This article will present recent advances in imaging techniques for cholangiocarginomas, potential pitfalls in imaging evaluation, and a checklist for preoperative radiologic assessment of resectability in these patients with an emphasis on perihilar cholangiocarinoma.

Predictors of surgical non-referral for colorectal liver metastases

BackgroundSurgical resection is the only curative option for patients with colorectal liver metastases (CRLM). The objective of our study was to identify factors associated with failure to refer patients with CRLM to a surgeon with oncologic and hepatobiliary expertise. Materials and methodsData were retrospectively reviewed on 75 patients with CRLM treated at our institution. Patients were divided into referred and nonreferred groups for comparison. Quantitative assessment of association was tabulated using the odds ratio (OR). Statistical comparison was performed using the chi-square test and multiple regression models. Overall survival (OS) was calculated using the Kaplan–Meier method. Multivariate analysis was done using Cox regression. ResultsFactors independently associated with lower surgical referral rates included age ≥ 65 y (OR 0.29, 95% confidence interval [CI] 0.09-0.89, P = 0.032), bilobar CRLM (OR 0.35, 95% CI 0.09-0.97, P = 0.048), and presence of >3 CRLM (OR 0.33, 95% CI 0.11-0.94, P = 0.044). The 5-y OS for referred patients was 33% compared with only 8% in patients who were not referred (P < 0.001). Factors independently associated with worse OS included age ≥ 65 y (hazard ratio [HR] 2.01, 95% CI 1.12-3.59, P = 0.019), bilobar hepatic metastases (HR 3.04, 95% CI 1.62-5.70, P < 0.001), and the presence of extrahepatic metastases (HR 2.11, 95% CI 1.02-4.16, P = 0.011). Referral to a surgeon was associated with improved OS (HR 0.42, 95% CI 0.24-0.74, P = 0.003). ConclusionsFailure to refer CRLM patients for surgical evaluation is associated with aggressive biologic features that do not necessarily preclude resection. Determination of resectability should be made with input from appropriately trained surgical experts.

Autologous tracheal replacement for cancer.

Surgical research has failed during fifty years to find an ideal substitute for the trachea after extended resection. All the prostheses could erode the adjacent structures or lead to infection or obstructive issues. Innovation in surgery development has been improved using novel techniques of plastic surgery. During the last ten years, we have developed a technique using free fasciocutaneous flaps. This allows us to construct tubes for tracheal replacement. The most accurate flap used for this technique is the forearm free flap (FFF). Reinforcement of the flap with autologous strips of cartilage harvested from the last ribs offers sufficient resistance to respiratory pressure. This technique is also completely autologous without any stent in the tracheal lumen. From 2004 to 2015 we have already reconstructed the trachea of 16 patients for 12 primary tracheal neoplasms [including 9 adenoid cystic carcinoma (ACC) and 3 squamous cell carcinoma (SCC)], 3 secondary tracheal Neoplasms and one for benign lesion. This article describes the indications, determination of resectability, patient selection, subheading for surgery, postoperative management and results of this technique.

La TEP des tumeurs neuroendocrines de l’intestin grêle

This article focuses on the indication and the choice of tracer for PET/CT in case of neuroendocrine tumours (NET) of the small intestine, which are the most common digestive NETs. PET/CT can be used to search for the primary NET in case of detection of a metastasis, for staging and determination of resectability, for restaging, for optimising and determining the efficacy of therapeutic modalities in extended or recurrent forms. Currently, three types of PET tracers are routinely used: FDG can be useful in the case of aggressive NET especially the duodenum and proximal jejunum, FDOPA is the best tracer in the case of NET of distal jejunum or of ileum, the labeled somatostatin analogues 68Ga in the case of well-differentiated NET from the duodenum or proximal jejunum, or irrespective of the location of primary NET if treatment with somatostatin analogue is intended, to confirm the overexpression of somatostatin receptors by lesions.

Neurosurgical Applications of Magnetic Resonance Diffusion Tensor Imaging

Magnetic Resonance (MR) Diffusion Tensor Imaging (DTI) is a rapidly evolving technology that enables the visualization of neural fiber bundles, or white matter (WM) tracts. There are numerous neurosurgical applications for MR DTI including: (1) Tumor grading and staging; (2) Pre-surgical planning (determination of resectability, determination of surgical approach, identification of WM tracts at risk); (3) Intraoperative navigation (tumor resection that spares WM damage, epilepsy resection that spares WM damage, accurate location of deep brain stimulation structures); (4) Post-operative assessment and monitoring (identification of WM damage, identification of tumor recurrence). Limitations of MR DTI include difficulty tracking small and crossing WM tracts, lack of standardized data acquisition and post-processing techniques, and practical equipment, software, and timing considerations. Overall, MR DTI is a useful tool for planning, performing, and following neurosurgical procedures, and has the potential to significantly improve patient care. Technological improvements and increased familiarity with DTI among clinicians are next steps.

Determinants of Resectability in Recurrent Rectal Cancer: A radiological perspective

Purpose: As the range of surgical options expands for patients with recurrent rectal cancer, accurate preoperative imaging plays an integral role in the identification of patients suitable for resection. We present the radiological features of patients with recurrent rectal cancer declined for surgery based on adverse imaging features.

Reviewing the standard of care in pancreatic adenocarcinoma: A critical appraisal

Treatment of pancreatic adenocarcinoma is still a great challenge to the surgeon. Although recent investigation and treatment protocols have redefined the limits of resectability and adjuvant care, survival outcome still remains dismally low. Because surgical resection of localized disease remains the only hope for curing pancreatic adenocarcinoma, all advances in diagnostic imaging and perioperative care have been aimed at improving the surgical outcome. In the present article, we discuss new developments and the existing controversies in the diagnosis, staging, determination of resectability, and the progress in surgical technique, palliation and, importantly, adjuvant and neoadjuvant therapy, and highlight the latest standard of care wherever possible. Where consensus is lacking, available literature is discussed to narrow the debate and provide a working formula for the readers at large. It is finally understood that for the best outcome, treatment should be tailored to the patient. Although surgical outcome improves in expert hands, the overall survival remains poor irrespective of centres.

Computer-Assisted Surgery Planning for Complex Liver Resections

The purpose of this study was (1) to compare 2-dimensional computed tomographic (2D-CT) and 3D-CT computer-assisted preoperative surgical planning, and (2) to define the indications for the latter method. The determination of functional residual liver volumes and the imaging of intrahepatic anatomy are critical when planning complex liver resections. Prospective study of 202 consecutive patients who underwent high-risk procedures (extended right/left hepatectomies, central resections, polysegmentectomies, large atypical resections, repeated resections, and hepatectomies in the setting of abnormal liver parenchyma). Preoperative evaluation included 3D-CT computer-assisted surgical planning (3D-CASP) and conventional 2D-CT imaging. Endpoints of the study were (1) determination of resectability and (2) changes in operative strategy (resection modifications/extensions/intrahepatic vascular reconstructions). Thirty-four of 202 cases were considered nonresectable on the basis of both 2D and 3D imaging results. In 56 (33%) instances, 3D-CASP either changed the 2D strategy (expansion of resection, n = 40; intrahepatic vascular reconstructions, n = 13) or provided an entirely different approach (n = 3). Eleven (5.4%) cases were considered unresectable at laparotomy on the basis of poor liver quality (n = 8) or unfeasible vascular reconstructions resulting in remnants too small to sustain physiologic function (n = 3). Significant differences between resectional 2D and functional 3D remnant liver volumes were observed in extended left hepatectomies and left trisectionectomies. 3D-CASP was particularly helpful in patients with unconventional resection planes and in those with central left tumors. Its main advantages were the individualized inflow/outflow virtual analyses and the accurate determination of safely perfused/drained retained liver volumes.

Pancreatic head cancer: accuracy of CT in determination of resectability

Pancreatic cancer is a devastating disease whose early detection remains difficult. There is no 100% reliable imaging test to diagnose and stage pancreatic cancer. We assessed the surgical value of contrast-enhanced spiral computed tomography (CT) in predicting the resectability and survival rates of patients who had pancreatic head cancer. Eighty-nine patients who had pancreatic head cancer were investigated with spiral CT. Based on the preoperative CT results, we assigned patients to one of three CT groups based on resectability. A correlation between classification of CT resectability and intraoperative finding was found in 83% of patients. The sensitivity, specificity, negative predictive value, positive predictive value, and accuracy of spiral CT in identifying predictive unresectability were 79%, 82%, 91%, 62%, and 81%, respectively. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of CT in diagnosis of vascular invasion were 94%, 84.2%, 94%, 84%, and 91.3%, respectively. The use of CT in the evaluation of pancreatic tumors provides valuable preoperative assessment of surgical resectability and should be performed for clinical examination. Classifying patients by tumor resectability on CT helps to estimate more precisely the tumor stage and to prognosticate survival rates of these patients.