New Concepts in Staging and Treatment of Locally Advanced Pancreatic Head Cancer

Lall, Chandana; Howard, Thomas J.; Skandarajah, Arunan; DeWitt, John M.; Aisen, Alex M.; Sandrasegaran, Kumaresan

doi:10.2214/ajr.07.2131

Cited by 47 publications

(24 citation statements)

References 40 publications

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“…One of the key requirements for a successful surgery is a negative retroperitoneal soft-tissue margin [4] . While the pancreatic and bile duct margins may be re-resected if the intraoperative frozen section analysis suggests a positive margin, the SMA margin cannot be re-resected because, in general, surgeons do not resect the SMA for adenocarcinoma.…”

Section: Margin Assessmentmentioning

confidence: 99%

“…Venous resections and reconstructions are increasingly performed as the technique is feasible and reliable, with а morbidity and mortality similar to pancreaticoduodenectomy without vascular reconstruction [4] . The invasion of the superior mesenteric or PV is not itself a criteria of unresectability [30] .…”

Section: Vascular Involvementmentioning

confidence: 99%

“…Vascular resection and reconstitution during pancreatic surgery offers a challenge for surgeons; excellent experience in surgical anatomy and vascular anastomosis is required [3] . With improved surgical techniques and advanced perioperative management, vascular resection and reconstruction are performed more frequently; patients thought once to be unresectable are undergoing radical surgery [4] . MDCT with volume-rendering helps surgeons to determine the operability, predict surgical difficulty and prognosis before the operation, but sometimes incorrect predictions lead to inappropriate therapy ( Figure 1).…”

Section: Introductionmentioning

confidence: 99%

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Pancreatic adenocarcinoma: Outstanding problems

Zakharova

Kаrmаzаnovsky²,

Егоров³

2012

WJGS

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Pancreatic adenocarcinoma remains the fourth leading cause of cancer-related death and is one of the most aggressive malignant tumors with an overall 5-year survival rate of less than 4%. Surgical resection remains the only potentially curative treatment but is only possible for 15%-20% of patients with pancreatic adenocarcinoma. About 40% of patients have locally advanced nonresectable disease. In the past, determination of pancreatic cancer resectability was made at surgical exploration. The development of modern imaging techniques has allowed preoperative staging of patients. Institutions disagree about the criteria used to classify patients. Vascular invasion in pancreatic cancers plays a very important role in determining treatment and prognosis. There is no evidence-based consensus on the optimal preoperative imaging assessment of patients with suspected pancreatic cancer and a unified definition of borderline resectable pancreatic cancer is also lacking. Thus, there is much room for improvement in all aspects of treatment for pancreatic cancer. Multi-detector computed tomography has been widely accepted as the imaging technique of choice for diagnosing and staging pancreatic cancer. With improved surgical techniques and advanced perioperative management, vascular resection and reconstruction are performed more frequently; patients thought once to be unresectable are undergoing radical surgery. However, when attempting heroic surgery, a realistic approach concerning the patient's age and health status, probability of recovery after surgery, perioperative morbidity and mortality and life quality after tumor resection is necessary.

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Section: Margin Assessmentmentioning

confidence: 99%

Section: Vascular Involvementmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Pancreatic adenocarcinoma: Outstanding problems

Zakharova

Kаrmаzаnovsky²,

Егоров³

2012

WJGS

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“…In patients with pancreatic carcinoma that encases the portal vein, pancreaticoduodenectomy with vascular reconstruction is performed at some centers. However, circumferential encasement of a portal vein segment longer than 2 cm or involvement of a segment of less than 2 cm that is close to the portal confluence is indicative of unresectability owing to the likelihood of positive margins (29).…”

Section: Portal Venous Stenosismentioning

confidence: 99%

Imaging Assessment of Congenital and Acquired Abnormalities of the Portal Venous System

Lee¹,

Chang²,

Duddalwar³

et al. 2011

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Abnormalities of the portal venous system are a heterogeneous group of conditions that can cause substantial morbidity and mortality and may lead to complications during surgery or percutaneous interventions involving the portal venous system. High-resolution computed tomography, ultrasonography, and magnetic resonance imaging permit a comprehensive, noninvasive evaluation of the portal venous system, enabling the detection of both structural and functional abnormalities. However, an understanding of the embryologic development of the normal portal venous anatomy and anatomic variants is essential to accurately interpret the imaging findings. Knowledge of the characteristic appearances of abnormalities of the portal venous system allows a more confident diagnosis, permitting timely treatment and more informed guidance of surgical procedures and percutaneous interventions, which may lead to an improved outcome.

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“…17). However, in current surgical management, a focal invasion of less than 2 cm in length of the main PV may not be a contraindication for the curative resection and could be the indication for curative resection of involved portal vein with venous graft placement [19,[29][30][31]. Meanwhile, tumors of the middle CBD origin extending to the liver or pancreas at the T3 stage may actually be more widely extended than those Fig.…”

Section: Problems In the Current T Stagingmentioning

confidence: 99%

Staging of extrahepatic cholangiocarcinoma

et al. 2008

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Preoperative staging of extrahepatic cholangiocarcinoma is important in determining the best treatment plan. Several classification systems have been suggested to determine the operability and extent of surgery. Longitudinal tumor extent is especially important in extrahepatic cholangiocarcinoma because operative methods differ depending on the tumor extent. The Bismuth-Corlette classification system provides useful information when planning for surgery. However, this classification system is not adequate for selecting surgical candidates. Anatomic variation of the bile duct and gross morphology of the tumor must be considered simultaneously. Lateral spread of the tumor can be evaluated based on the TNM staging provided by American Joint Committee on Cancer (AJCC). However, there is a potential for ambiguity in the distinction of T1 and T2 cancer from one another. In addition, T stage does not necessarily mean invasiveness. Blumgart T staging is helpful for the assessment of resectability with the consideration of nodal status and distant metastasis as suggested by the AJCC cancer staging system. Computed tomography (CT) and magnetic resonance imaging (MRI) are the primary tools used in the assessment of longitudinal and lateral spread of a tumor when determining respectability. Diagnostic laparoscopy and positron emission tomography (PET) may play additional roles in this regard.

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New Concepts in Staging and Treatment of Locally Advanced Pancreatic Head Cancer

Abstract: Vascular resection as an adjunct to pancreaticoduodenectomy is increasingly used in pancreatic head cancer. As a result, the imaging criteria to determine which patients are candidates for potentially curative resection are evolving.

Cited by 47 publications

References 40 publications

Pancreatic adenocarcinoma: Outstanding problems

Pancreatic adenocarcinoma: Outstanding problems

Imaging Assessment of Congenital and Acquired Abnormalities of the Portal Venous System

Staging of extrahepatic cholangiocarcinoma

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