Perioperative CT angiography assessment of locally advanced distal pancreatic carcinoma to evaluate feasibility of the modified Appleby procedure

Ayushi P Gupta; Satomi Kawamoto; Ammar A Javed; Matthew J Weiss; Christopher L Wolfgang; Jin He; Elliot K Fishman; Harshna V Vadvala

doi:10.1016/j.ejrad.2020.109248

Perioperative CT angiography assessment of locally advanced distal pancreatic carcinoma to evaluate feasibility of the modified Appleby procedure

Eur J Radiol. 2020 Oct:131:109248. doi: 10.1016/j.ejrad.2020.109248. Epub 2020 Aug 31.

Authors

Ayushi P Gupta¹, Satomi Kawamoto², Ammar A Javed³, Matthew J Weiss⁴, Christopher L Wolfgang⁵, Jin He⁶, Elliot K Fishman⁷, Harshna V Vadvala⁸

Affiliations

¹ Department of Radiology and Radiological Science, Johns Hopkins Hospital, Johns Hopkins University, 601 N. Caroline Street, Baltimore, MD 21287, United States. Electronic address: agupt31@emory.edu.
² Department of Radiology and Radiological Science, Johns Hopkins Hospital, Johns Hopkins University, 601 N. Caroline Street, Baltimore, MD 21287, United States. Electronic address: skawamo1@jhmi.edu.
³ Department of Surgery, Johns Hopkins Hospital, Johns Hopkins University, 1800 Orleans Street, Baltimore, MD 21287, United States. Electronic address: ajaved1@jhmi.edu.
⁴ Department of Surgery, Johns Hopkins Hospital, Johns Hopkins University, 1800 Orleans Street, Baltimore, MD 21287, United States. Electronic address: mweiss5@jhmi.edu.
⁵ Department of Surgery, Johns Hopkins Hospital, Johns Hopkins University, 1800 Orleans Street, Baltimore, MD 21287, United States. Electronic address: cwolfga2@jhmi.edu.
⁶ Department of Surgery, Johns Hopkins Hospital, Johns Hopkins University, 1800 Orleans Street, Baltimore, MD 21287, United States. Electronic address: jhe11@jhmi.edu.
⁷ Department of Radiology and Radiological Science, Johns Hopkins Hospital, Johns Hopkins University, 601 N. Caroline Street, Baltimore, MD 21287, United States. Electronic address: efishman@jhmi.edu.
⁸ Department of Radiology and Radiological Science, Johns Hopkins Hospital, Johns Hopkins University, 601 N. Caroline Street, Baltimore, MD 21287, United States. Electronic address: drharshna@gmail.com.

PMID: 32919264
DOI: 10.1016/j.ejrad.2020.109248

Abstract

Purpose: To study the perioperative CT angiography (CTA) findings of modified Appleby procedure candidates for the surgical feasibility in patients with locally advanced distal pancreatic cancer (LAPC) and to assess CTA performance.

Materials and methods: This retrospective study evaluated CTA of patients with distal LAPC who underwent modified Appleby procedure between March 2004 and October 2017. Preoperative CT scans performed within up to three months prior to the surgery and postoperative scans, at least one of which was within one month of surgery, were reviewed. Data was collected reporting tumor size, relation to vessels, changes from neoadjuvant chemoradiation, modifications to the surgery and complications. The CTA findings were correlated with operative notes and surgical pathology. Statistical analysis was performed using binary classification method to evaluate CTA performance.

Results: Consecutive 20 patients underwent modified Appleby procedure in the study period. In 18/20 patients who received neoadjuvant chemoradiation, mean pancreatic mass size significantly reduced from 4.58 + 1.17 cm to 3.55 + 0.84 cm (p = 0.002). The celiac axis (CA) was encased in all, whereas none of the patients had encasement of the superior mesenteric artery (SMA) or involvement of gastroduodenal artery (GDA). The CTA had 88.89% sensitivity, 100% specificity, and 90% accuracy for evaluating the arterial involvement.

Conclusion: Distal LAPC patients, in particular those who have significant size reduction after neoadjuvant chemoradiation, with encasement of CA and without encasement of SMA and GDA can undergo a technically successful modified Appleby procedure. CTA offers accurate and valuable perioperative assessment of the surgical candidates.

Keywords: CT angiography; Distal pancreatectomy; Locally advanced pancreatic carcinoma and neoadjuvant chemoradiation; Modified Appleby procedure; Pancreatic adenocarcinoma.

MeSH terms

Adult
Aged
Computed Tomography Angiography / methods*
Feasibility Studies
Female
Humans
Male
Middle Aged
Neoadjuvant Therapy / methods
Pancreas / diagnostic imaging
Pancreas / surgery
Pancreatectomy / methods*
Pancreatic Neoplasms / diagnostic imaging*
Pancreatic Neoplasms / surgery*
Pancreatic Neoplasms / therapy
Perioperative Care / methods*
Retrospective Studies
Sensitivity and Specificity
Treatment Outcome