Preoperative Multidetector CT Diagnosis of Extrapancreatic Perineural or Duodenal Invasion Is Associated with Reduced Postoperative Survival after Pancreaticoduodenectomy for Pancreatic Adenocarcinoma: Preliminary Experience and Implications for Patient Care

Abstract

Purpose To test the hypothesis that patients with pancreatic adenocarcinoma who otherwise are viewed to have resectable disease but have preoperative findings of extrapancreatic perineural invasion (EPNI) and/or duodenal invasion at multidetector computed tomography (CT) have reduced postoperative survival after pancreaticoduodenectomy for pancreatic ductal adenocarcinoma (PDAC). Materials and Methods This study was approved by the institutional review board and complied with HIPAA. The authors retrospectively evaluated 76 consecutive patients with PDAC who underwent preoperative multidetector CT and subsequent pancreaticoduodenectomy. Two radiologists blinded to surgical pathology results and clinical outcome evaluated multidetector CT images for evidence of EPNI and duodenal invasion; discrepancies were resolved by consensus. Also determined for each patient were resected lymph node status, tumor size, surgical margin status, time to progression, and time to death. Data were assessed with the Goodman-Kruskal gamma for correlations among indicators and the log-rank test, Kaplan-Meier estimates, and multivariate Cox proportional hazards regression for survival analysis. Results In univariate analysis, duodenal invasion and/or EPNI on preoperativemultidetector CT images was associated with significantly decreased progression-free survival (P < .0001) and overall survival (P = .0013), and the clinical indicators (lymph node status, tumor size, and surgical margin status) as well as duodenal invasion and/or EPNI showed correlation with each other. In multivariate regression that included multidetector CT findings as well as the three traditional clinical indicators, only duodenal invasion and/or EPNI showed significant independent association with reduction in both modes of survival (P < .0001 and P = .014, respectively). Interobserver agreement was substantial with respect to EPNI and duodenal invasion (κ = 0.691 and 0.682, respectively). Conclusion Patients with evidence of EPNI and/or duodenal invasion on preoperative multidetector CT images have significantly reduced survival after pancreaticoduodenectomy for PDAC. RSNA, 2016.

Preoperative prediction of futile surgery in patients with radiologically resectable or borderline resectable pancreatic adenocarcinoma

“…The results of our multivariate analysis, however, suggest that the addition of tumor size did not have a significant additional impact on improving the predictive ability in the presence of stronger predictors, that is, peripancreatic tumor extension, regional LN metastasis, and CA 19‐9 level. A recent study also showed that extrapancreatic perineural invasion and duodenal invasion, which cannot exist without considerable peripancreatic tumor invasion, were independently associated with a worse prognosis …”

Malignant Duodenal Lesion - Duodenal Tumor Vs Pancreatic Tumor - Semiological Radioimaging Characteristics

“…T3 stage pancreatic tumors may or may not be suitable for surgery, so in terms surgery they are borderline [16]. There are authors who said that duodenal invasion significantly reduces the survival rate in pancreatic neoplasms [17]. Unlike pancreatic cancer invading the duodenum, primary duodenal neoplasm benefits of radical surgical therapy and has more favorable outcomes compared to other periampullary malignancies and excision is considered the backbone of treatment for patients with localized tumors or limited metastatic disease when feasible [18,19].…”

Novel Diagnostic and Predictive Biomarkers in Pancreatic Adenocarcinoma

“…Due to the significant morbidity and the poor overall long-term survival of pancreaticoduodenectomy, it is critical to appropriately triage even early stage patients [52]. In patients who are resectable by known CT criteria, the overall progression free survival decreases dramatically with the presence of perineural or duodenal invasion (median overall survival without either finding: 237 days; with either finding: 58 days) [53]. Examples of these from Chang et al [53] are shown in Figure 1.…”

“…In patients who are resectable by known CT criteria, the overall progression free survival decreases dramatically with the presence of perineural or duodenal invasion (median overall survival without either finding: 237 days; with either finding: 58 days) [53]. Examples of these from Chang et al [53] are shown in Figure 1. In addition to early invasion of nerves and vessels, delivery of the chemotherapy to the cells are also important.…”

“…( B ) Pancreatic head mass (T) invading the duodenal wall (arrowhead), but sparing the posterior-inferior pancreaticoduodenal artery (arrow). Reproduced with permission from [53]. …”