Ann Hepatobiliary Pancreat Surg.  2023 Nov;27(4):403-414. 10.14701/ahbps.23-042.

Does an extensive diagnostic workup for upfront resectable pancreatic cancer result in a delay which affects survival? Results from an international multicentre study

• Russell TB
• Labib PL
• Denson J
• Ausania F
• Pando E
• Roberts KJ
• Kausar A
• Mavroeidis VK
• Marangoni G
• Thomasset SC
• Frampton AE
• Lykoudis P
• Maglione M
• Alhaboob N
• Bari H
• Smith AM
• Spalding D
• Srinivasan P
• Davidson BR
• Bhogal RH
• Croagh D
• Rajagopalan A
• Dominguez I
• Thakkar R
• Gomez D
• Silva MA
• Lapolla P
• Mingoli A
• Porcu A
• Perra T
• Shah NS
• Hamady ZZR
• Al-Sarrieh B
• Serrablo A
• RAW Study Collaborators
• Aroori S

• KMID: 2548507
• DOI: http://doi.org/10.14701/ahbps.23-042

Abstract

Backgrounds/Aims
Pancreatoduodenectomy (PD) is recommended in fit patients with a carcinoma (PDAC) of the pancreatic head, and a delayed resection may affect survival. This study aimed to correlate the time from staging to PD with long-term survival, and study the impact of preoperative investigations (if any) on the timing of surgery.
Methods
Data were extracted from the Recurrence After Whipple’s (RAW) study, a multicentre retrospective study of PD outcomes. Only PDAC patients who underwent an upfront resection were included. Patients who received neoadjuvant chemo-/radiotherapy were excluded. Group A (PD within 28 days of most recent preoperative computed tomography [CT]) was compared to group B (> 28 days).
Results
A total of 595 patents were included. Compared to group A (median CT-PD time: 12.5 days, interquartile range: 6–21), group B (49 days, 39–64.5) had similar one-year survival (73% vs. 75%, p = 0.6), five-year survival (23% vs. 21%, p = 0.6) and median time-todeath (17 vs. 18 months, p = 0.8). Staging laparoscopy (43 vs. 29.5 days, p = 0.009) and preoperative biliary stenting (39 vs. 20 days, p < 0.001) were associated with a delay to PD, but magnetic resonance imaging (32 vs. 32 days, p = 0.5), positron emission tomography (40 vs. 31 days, p > 0.99) and endoscopic ultrasonography (28 vs. 32 days, p > 0.99) were not.
Conclusions
Although a treatment delay may give rise to patient anxiety, our findings would suggest this does not correlate with worse survival. A delay may be necessary to obtain further information and minimize the number of PD patients diagnosed with early disease recurrence.

Keyword

Endoscopic retrograde cholangiopancreatography; Magnetic resonance imaging; Pancreatic ductal carcinoma; Pancreaticoduodenectomy; X-ray computed tomography

Figure

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  Fig. 1 Cohort flow diagram. AA, ampullary adenocarcinoma; CC, cholangiocarcinoma; CT, computed tomography; PD, pancreatoduodenectomy; PDAC, pancreatic ductal adenocarcinoma.

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  Fig. 2 Kaplan-Meier survival curves which compare those who underwent PD within 28 days of radiological staging to those who did not. Patients who achieved five-year survival were excluded from this sub-analysis. PD, pancreatoduodenectomy; CI, confidence interval; CT, computed tomography.

Reference

1. Russell TB, Labib PLZ, Aroori S. 2023; Five-year follow-up after pancreatoduodenectomy performed for malignancy: a single-centre study. Ann Hepatobiliary Pancreat Surg. 27:76–86. DOI: 10.14701/ahbps.22-039. PMID: 36168824. PMCID: PMC9947371.

2. Tamm EP, Balachandran A, Bhosale PR, Katz MH, Fleming JB, Lee JH, et al. 2012; Imaging of pancreatic adenocarcinoma: update on staging/resectability. Radiol Clin North Am. 50:407–428. DOI: 10.1016/j.rcl.2012.03.008. PMID: 22560689.

3. Ghaneh P, Hanson R, Titman A, Lancaster G, Plumpton C, Lloyd- Williams H, et al. 2018; PET-PANC: multicentre prospective diagnostic accuracy and health economic analysis study of the impact of combined modality 18fluorine-2-fluoro-2-deoxy-d-glucose positron emission tomography with computed tomography scanning in the diagnosis and management of pancreatic cancer. Health Technol Assess. 22:1–114. DOI: 10.3310/hta22070. PMID: 29402376. PMCID: PMC5817411.

4. Pietryga JA, Morgan DE. 2015; Imaging preoperatively for pancreatic adenocarcinoma. J Gastrointest Oncol. 6:343–357. DOI: 10.3978/j.issn.2078-6891.2015.024. PMID: 26261722. PMCID: PMC4502157.

5. Ashraf MI. 2019; Role of staging laparoscopy in patients undergoing pancreaticoduodenectomy. Cureus. 11:e5906. DOI: 10.7759/cureus.5906. PMID: 31777693. PMCID: PMC6853269.

6. Yousaf MN, Chaudhary FS, Ehsan A, Suarez AL, Muniraj T, Jamidar P, et al. 2020; Endoscopic ultrasound (EUS) and the management of pancreatic cancer. BMJ Open Gastroenterol. 7:e000408. DOI: 10.1136/bmjgast-2020-000408. PMID: 32414753. PMCID: PMC7232396.

7. Lee PJ, Podugu A, Wu D, Lee AC, Stevens T, Windsor JA. 2018; Preoperative biliary drainage in resectable pancreatic cancer: a systematic review and network meta-analysis. HPB (Oxford). 20:477–486. DOI: 10.1016/j.hpb.2017.12.007. PMID: 29526466.

8. Arnold M, Abnet CC, Neale RE, Vignat J, Giovannucci EL, McGlynn KA, et al. 2020; Global burden of 5 major types of gastrointestinal cancer. Gastroenterology. 159:335–349.e15. DOI: 10.1053/j.gastro.2020.02.068. PMID: 32247694. PMCID: PMC8630546.

9. Raman SP, Reddy S, Weiss MJ, Manos LL, Cameron JL, Zheng L, et al. 2015; Impact of the time interval between MDCT imaging and surgery on the accuracy of identifying metastatic disease in patients with pancreatic cancer. AJR Am J Roentgenol. 204:W37–42. DOI: 10.2214/AJR.13.12439. PMID: 25539271. PMCID: PMC4872713.

10. O'Reilly D, Fou L, Hasler E, Hawkins J, O'Connell S, Pelone F, et al. 2018; Diagnosis and management of pancreatic cancer in adults: a summary of guidelines from the UK National Institute for Health and Care Excellence. Pancreatology. 18:962–970. DOI: 10.1016/j.pan.2018.09.012. PMID: 30292643.

11. Niesen W, Hank T, Büchler M, Strobel O. 2019; Local radicality and survival outcome of pancreatic cancer surgery. Ann Gastroenterol Surg. 3:464–475. DOI: 10.1002/ags3.12273. PMID: 31549006. PMCID: PMC6749949.

12. Cong L, Liu Q, Zhang R, Cui M, Zhang X, Gao X, et al. 2018; Tumor size classification of the 8th edition of TNM staging system is superior to that of the 7th edition in predicting the survival outcome of pancreatic cancer patients after radical resection and adjuvant chemotherapy. Sci Rep. 8:10383. DOI: 10.1038/s41598-018-28193-4. PMID: 29991730. PMCID: PMC6039534.

13. National Institute for Health and Care Excellence. Pancreatic cancer in adults: diagnosis and management. National Institute for Health and Care Excellence (NICE);2018. DOI: 10.1016/j.pan.2018.09.012.

14. Steen MW, van Rijssen LB, Festen S, Busch OR, Groot Koerkamp B, van der Geest LG, et al. 2020; Impact of time interval between multidisciplinary team meeting and intended pancreatoduodenectomy on oncological outcomes. BJS Open. 4:884–892. DOI: 10.1002/bjs5.50319. PMID: 32841533. PMCID: PMC7528524.

15. Huang S, Chong H, Sun X, Wu Z, Jia Q, Zhang Y, et al. 2021; The Value of 18F-FDG PET/CT in diagnosing pancreatic lesions: comparison With CA19-9, enhanced CT or enhanced MR. Front Med (Lausanne). 8:668697. DOI: 10.3389/fmed.2021.668697. PMID: 34692714. PMCID: PMC8531126.

16. Deng Y, Ming B, Wu JL, Zhou T, Zhang SY, Chen Y, et al. 2020; Magnetic resonance imaging for preoperative staging of pancreatic cancer based on the 8(th) edition of AJCC guidelines. J Gastrointest Oncol. 11:329–336. DOI: 10.21037/jgo.2020.03.06. PMID: 32399274. PMCID: PMC7212112.

17. Kamata K, Kitano M, Kudo M, Sakamoto H, Kadosaka K, Miyata T, et al. 2014; Value of EUS in early detection of pancreatic ductal adenocarcinomas in patients with intraductal papillary mucinous neoplasms. Endoscopy. 46:22–29. DOI: 10.1055/s-0034-1367539. PMID: 24218310.

18. Sakamoto H, Kitano M, Suetomi Y, Maekawa K, Takeyama Y, Kudo M. 2008; Utility of contrast-enhanced endoscopic ultrasonography for diagnosis of small pancreatic carcinomas. Ultrasound Med Biol. 34:525–532. DOI: 10.1016/j.ultrasmedbio.2007.09.018. PMID: 18045768.

19. Morris S, Gurusamy KS, Sheringham J, Davidson BR. 2015; Cost-effectiveness of preoperative biliary drainage for obstructive jaundice in pancreatic and periampullary cancer. J Surg Res. 193:202–209. DOI: 10.1016/j.jss.2014.07.060. PMID: 25172090. PMCID: PMC4274324.

20. Sahani DV, Shah ZK, Catalano OA, Boland GW, Brugge WR. 2008; Radiology of pancreatic adenocarcinoma: current status of imaging. J Gastroenterol Hepatol. 23:23–33. DOI: 10.1111/j.1440-1746.2007.05117.x. PMID: 18171340.