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Tesi etd-04172015-115208

Thesis type
Tesi di specializzazione (5 anni)
Radiopathological correlation in borderline resectable pancreatic cancer
Corso di studi
relatore Prof. Bartolozzi, Carlo
Parole chiave
  • Multidetector Computed Tomography
  • pancreatic cancer
Data inizio appello
Riassunto analitico
Background: The arterial involvement in locally advanced pancreatic carcinoma has long been a contraindication for surgical resection, due to a high morbility and mortality rate and limited oncological benefit. The term "borderline resectable pancreatic cancer" (BRPC) was introduced to describe pancreatic cancer involving the mesentericoportal or arterial axis, in which the multidisciplinary team thinks an R0 resection can likely be achieved.
However, literature data still report an inadequate diagnostic accuracy of the preoperative computed tomography (CT) in the arterial infiltration staging.
The purpose of our study is evaluate the correlation between CT and pathology in BRPC and discuss its prognostic implications.

Materials and Methods: We retrospectively examined 70 arteries (7 celiac artery; 19 hepatic arteries; 28 splenic arteries; 16 superior mesenteric arteries) resected in 30 patients submitted to pancreatectomy for locally advanced tumor. Venous resection was associated in 24 patients. Twenty patients had been previously submitted to neoadjuvant chemotherapy. The relationship between tumor and each artery was defined according to the following grading system: grade 0: no contact; grade I: focal tumor abutment; grade II: ≤180° tumor encasement (IIa) or >180° encasement (IIb) of the artery, without reduction of its calibre; grade III: ≤ 180° encasement (IIIa) o >180° encasement (IIIb) with irregularity and distortion of the artery. The neural plexus (celiac and SMA branches) and celiac ganglia involvement was graded, by attributing a score between 1 and 3.

Results: At CT, 20 resected artery was graded as 0, 11 as I, 27 as IIa, 8 as IIb, 7 as IIIa and 5 as IIIb. According to the NCCN criteria, at CT 17/30 patients were considered borderline resectable and 13/30 unresectable. At pathology, none of 0, I and IIa arteries resulted to be infiltrated; focal infiltration of the adventitia was identified in 12 arteries of 10 patients: 4/8 IIa, 4/7 IIIa and 4/5 IIIb arteries. Circumferential encasement of the artery showed a PPV=61% of infiltration while the reduction of the arterial caliber a PPV=67%. Arterial infiltration was significantly related with average involvement of celiac ganglia (p = 0.007) and with overall involvement of ganglia and plexus (p = 0.004).
No correlation was demostrated between survival and the presence of arterial invasion at histology. On the contrary the survival was significantly correlate with overall NCCN judgment resectability (p = 0.029) and with the perineural involvement, and in particular ganglia involvement (p = 0.0016).

Conclusions: The strong tropism of ductal carcinoma for perineural spreading along arterial structures, justifies the need to use different criteria for grading venous and arterial infiltration in preoperative CT local staging. In addiction, the involvement of neural plexus and celiac ganglia, being crucial in predicting arterial involvement and prognosis, should be reported in the preoperative CT staging, to improve the accuracy in the local spreading description and thus to guide the therapeutic management.