Preoperative Imaging for Resectable Periampullary Cancer: Clinicopathologic Implications of Reported Radiographic Findings

Zhi Ven Fong, Wei Phin Tan, Harish Lavu, Eugene P. Kennedy, Donald G. Mitchell, Leonidas Koniaris, Patricia K. Sauter, Ernest L. Rosato, Charles J. Yeo, Jordan M. Winter

Research output: Contribution to journalArticle

15 Citations (Scopus)

Abstract

Background: High-resolution, multiphase, computed tomography (CT) is a standard preoperative test prior to pancreatectomy, yet the clinical significance of routinely reported findings remains unknown. Methods: We identified patients who underwent a pancreaticoduodenectomy for a periampullary adenocarcinoma (PA) over the previous 5 years and had a pancreas protocol CT at our institution. Clinicopathologic implications of reported CT findings were evaluated. Results: There were 155 pancreatic ductal adenocarcinomas (PDA) and 47 non-pancreatic PAs. No mass was visualized on CT in 6 % of PDAs and 23 % of non-pancreatic PA. A size discrepancy of ≥1 cm between radiographic and pathologic tumor diameters was observed in 40 % of PAs, with CT underestimating the size in most instances (75 %). Radiographically enlarged lymph nodes were not associated with true lymph node metastases in PDAs (70 % lymph node positive cases were enlarged on CT vs 74 % lymph node negative, p = 0.5), but were associated with a preoperatively placed biliary endoprosthesis (63 % with endoprosthesis were enlarged vs 37 % no endoprosthesis, p = 0.013). Major visceral vessel involvement on CT was not associated with a vascular resection (3 % with CT vessel involvement vs 2 % without, p = 0.8) or a positive uncinate resection margin (24 vs 20 %, respectively, p = 0.6). Discussion: While dedicated pancreas protocol CT provides unprecedented detail, the test may lead to overinterpretation of the extent of disease in some instances. A radiographic suggestion of enlarged lymph nodes and vascular involvement does not necessarily preclude exploration with curative intent. CTs with local disease should be reported in an objective template and carefully reviewed by a multidisciplinary group of surgeons, radiologists, and oncologists to avoid missing an opportunity for neoadjuvant therapy or cure by resection.

Original languageEnglish (US)
Pages (from-to)1098-1106
Number of pages9
JournalJournal of Gastrointestinal Surgery
Volume17
Issue number6
DOIs
StatePublished - Mar 2013
Externally publishedYes

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Tomography
Lymph Nodes
Neoplasms
Adenocarcinoma
Blood Vessels
Pancreas
Pancreatectomy
Neoadjuvant Therapy
Pancreaticoduodenectomy
Neoplasm Metastasis

Keywords

  • Computed tomography
  • Pancreatic ductal adenocarcinoma
  • Periampullary cancers

ASJC Scopus subject areas

  • Surgery
  • Gastroenterology

Cite this

Preoperative Imaging for Resectable Periampullary Cancer : Clinicopathologic Implications of Reported Radiographic Findings. / Fong, Zhi Ven; Tan, Wei Phin; Lavu, Harish; Kennedy, Eugene P.; Mitchell, Donald G.; Koniaris, Leonidas; Sauter, Patricia K.; Rosato, Ernest L.; Yeo, Charles J.; Winter, Jordan M.

In: Journal of Gastrointestinal Surgery, Vol. 17, No. 6, 03.2013, p. 1098-1106.

Research output: Contribution to journalArticle

Fong, ZV, Tan, WP, Lavu, H, Kennedy, EP, Mitchell, DG, Koniaris, L, Sauter, PK, Rosato, EL, Yeo, CJ & Winter, JM 2013, 'Preoperative Imaging for Resectable Periampullary Cancer: Clinicopathologic Implications of Reported Radiographic Findings', Journal of Gastrointestinal Surgery, vol. 17, no. 6, pp. 1098-1106. https://doi.org/10.1007/s11605-013-2181-x
Fong, Zhi Ven ; Tan, Wei Phin ; Lavu, Harish ; Kennedy, Eugene P. ; Mitchell, Donald G. ; Koniaris, Leonidas ; Sauter, Patricia K. ; Rosato, Ernest L. ; Yeo, Charles J. ; Winter, Jordan M. / Preoperative Imaging for Resectable Periampullary Cancer : Clinicopathologic Implications of Reported Radiographic Findings. In: Journal of Gastrointestinal Surgery. 2013 ; Vol. 17, No. 6. pp. 1098-1106.
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abstract = "Background: High-resolution, multiphase, computed tomography (CT) is a standard preoperative test prior to pancreatectomy, yet the clinical significance of routinely reported findings remains unknown. Methods: We identified patients who underwent a pancreaticoduodenectomy for a periampullary adenocarcinoma (PA) over the previous 5 years and had a pancreas protocol CT at our institution. Clinicopathologic implications of reported CT findings were evaluated. Results: There were 155 pancreatic ductal adenocarcinomas (PDA) and 47 non-pancreatic PAs. No mass was visualized on CT in 6 {\%} of PDAs and 23 {\%} of non-pancreatic PA. A size discrepancy of ≥1 cm between radiographic and pathologic tumor diameters was observed in 40 {\%} of PAs, with CT underestimating the size in most instances (75 {\%}). Radiographically enlarged lymph nodes were not associated with true lymph node metastases in PDAs (70 {\%} lymph node positive cases were enlarged on CT vs 74 {\%} lymph node negative, p = 0.5), but were associated with a preoperatively placed biliary endoprosthesis (63 {\%} with endoprosthesis were enlarged vs 37 {\%} no endoprosthesis, p = 0.013). Major visceral vessel involvement on CT was not associated with a vascular resection (3 {\%} with CT vessel involvement vs 2 {\%} without, p = 0.8) or a positive uncinate resection margin (24 vs 20 {\%}, respectively, p = 0.6). Discussion: While dedicated pancreas protocol CT provides unprecedented detail, the test may lead to overinterpretation of the extent of disease in some instances. A radiographic suggestion of enlarged lymph nodes and vascular involvement does not necessarily preclude exploration with curative intent. CTs with local disease should be reported in an objective template and carefully reviewed by a multidisciplinary group of surgeons, radiologists, and oncologists to avoid missing an opportunity for neoadjuvant therapy or cure by resection.",
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AU - Fong, Zhi Ven

AU - Tan, Wei Phin

AU - Lavu, Harish

AU - Kennedy, Eugene P.

AU - Mitchell, Donald G.

AU - Koniaris, Leonidas

AU - Sauter, Patricia K.

AU - Rosato, Ernest L.

AU - Yeo, Charles J.

AU - Winter, Jordan M.

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N2 - Background: High-resolution, multiphase, computed tomography (CT) is a standard preoperative test prior to pancreatectomy, yet the clinical significance of routinely reported findings remains unknown. Methods: We identified patients who underwent a pancreaticoduodenectomy for a periampullary adenocarcinoma (PA) over the previous 5 years and had a pancreas protocol CT at our institution. Clinicopathologic implications of reported CT findings were evaluated. Results: There were 155 pancreatic ductal adenocarcinomas (PDA) and 47 non-pancreatic PAs. No mass was visualized on CT in 6 % of PDAs and 23 % of non-pancreatic PA. A size discrepancy of ≥1 cm between radiographic and pathologic tumor diameters was observed in 40 % of PAs, with CT underestimating the size in most instances (75 %). Radiographically enlarged lymph nodes were not associated with true lymph node metastases in PDAs (70 % lymph node positive cases were enlarged on CT vs 74 % lymph node negative, p = 0.5), but were associated with a preoperatively placed biliary endoprosthesis (63 % with endoprosthesis were enlarged vs 37 % no endoprosthesis, p = 0.013). Major visceral vessel involvement on CT was not associated with a vascular resection (3 % with CT vessel involvement vs 2 % without, p = 0.8) or a positive uncinate resection margin (24 vs 20 %, respectively, p = 0.6). Discussion: While dedicated pancreas protocol CT provides unprecedented detail, the test may lead to overinterpretation of the extent of disease in some instances. A radiographic suggestion of enlarged lymph nodes and vascular involvement does not necessarily preclude exploration with curative intent. CTs with local disease should be reported in an objective template and carefully reviewed by a multidisciplinary group of surgeons, radiologists, and oncologists to avoid missing an opportunity for neoadjuvant therapy or cure by resection.

AB - Background: High-resolution, multiphase, computed tomography (CT) is a standard preoperative test prior to pancreatectomy, yet the clinical significance of routinely reported findings remains unknown. Methods: We identified patients who underwent a pancreaticoduodenectomy for a periampullary adenocarcinoma (PA) over the previous 5 years and had a pancreas protocol CT at our institution. Clinicopathologic implications of reported CT findings were evaluated. Results: There were 155 pancreatic ductal adenocarcinomas (PDA) and 47 non-pancreatic PAs. No mass was visualized on CT in 6 % of PDAs and 23 % of non-pancreatic PA. A size discrepancy of ≥1 cm between radiographic and pathologic tumor diameters was observed in 40 % of PAs, with CT underestimating the size in most instances (75 %). Radiographically enlarged lymph nodes were not associated with true lymph node metastases in PDAs (70 % lymph node positive cases were enlarged on CT vs 74 % lymph node negative, p = 0.5), but were associated with a preoperatively placed biliary endoprosthesis (63 % with endoprosthesis were enlarged vs 37 % no endoprosthesis, p = 0.013). Major visceral vessel involvement on CT was not associated with a vascular resection (3 % with CT vessel involvement vs 2 % without, p = 0.8) or a positive uncinate resection margin (24 vs 20 %, respectively, p = 0.6). Discussion: While dedicated pancreas protocol CT provides unprecedented detail, the test may lead to overinterpretation of the extent of disease in some instances. A radiographic suggestion of enlarged lymph nodes and vascular involvement does not necessarily preclude exploration with curative intent. CTs with local disease should be reported in an objective template and carefully reviewed by a multidisciplinary group of surgeons, radiologists, and oncologists to avoid missing an opportunity for neoadjuvant therapy or cure by resection.

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