Meet The Professors: Pancreatic Cancer Edition, 2016 - Video 28Imaging tests to determine surgical resectability of pancreatic cancer
3:24 minutes.
TRANSCRIPTION:
DR LOVE: Are there specific terms we can look at or things we could objectify to say that someone is not borderline resectable but they’re unresectable? DR BEKAII-SAAB: So borderline resectable is that gray area. It’s really the area between clearly resectable and unresectable. And everything in between that is defined as borderline resectable. I mean, the definition that vague. You could probably spend the whole hour talking about these nuances. But when there is clear encasement, the SMA or clear involvement of the celiac plexus without metastatic disease, that’s a disease that’s technically unresectable, although there are a small percent of patients who may achieve surgical resection, although their outcomes are not as good as the borderline. The clearly resectable are just patients with tumors that are really free of any vascular involvement. There’s clear planes on the scans; no involvement of the celiac plexus. Everything else is that gray zone that’s called “borderline resectable.” That’s, by the way, a growing — right? And we see that once you established those guidelines, that became a growing proportion of the patients we see with local disease, because any little concern about too close to the vessel, pushing a little bit on the vessel, makes the surgeon nervous, that’s clearly borderline. And that’s requiring neoadjuvant therapy. DR BROOKS: Before you make that decision, what imaging studies in addition to CT are you getting? DR BEKAII-SAAB: Oh, dedicated CTs are, of course, important, so pancreas CTs, 3-D. I mean, whatever you have capacity for. A CT angiogram. You really have to have a good definition of the blood vessels around and close to the tumor. So these have to be very dedicated CT scans. And most centers have that capacity. But I think the most important thing is, you need the eyes of a trained surgeon who’d been there multiple times to help you really interpret that CT. A radiologist on their own would not be able to do that for you. You really need to have that trained eye of a surgeon who’s been there. DR TEMPERO: I was going to say that it’s really important that the patient have a pancreas protocol CT scan, which is a dynamic-contrast CT with arterial and venous phases. There is no additional staging information that is gained really with an endoscopic ultrasound, unless something is found outside of the vascular field. So, for instance, maybe the sonographer finds an enlarged lymph node that’s outside of the operative field. But in terms of the vasculature, the gold standard is a pancreas protocol CT scan. And the reason I believe that many things get sort of misdirected is that we see patients who come in who have been evaluated on the outside by a surgeon who has looked at a routine CT scan and deemed that the patient was or was not resectable. And this is frightening to us, because it just is so important to have an understanding of the potential vascular involvement. |