Consensus in determining the resectability of locally progressed pancreatic ductal adenocarcinoma - results of the Conko-007 multicenter trial

Abstract

Background: One critical step in the therapy of patients with localized pancreatic cancer is the determination of local resectability. The decision between primary surgery versus upfront local or systemic cancer therapy seems especially to differ between pancreatic cancer centers. In our cohort study, we analyzed the independent judgement of resectability of five experienced high volume pancreatic surgeons in 200 consecutive patients with borderline resectable or locally advanced pancreatic cancer.

Methods: Pretherapeutic CT or MRI scans of 200 consecutive patients with borderline resectable or locally advanced pancreatic cancer were evaluated by 5 independent pancreatic surgeons. Resectability and the degree of abutment of the tumor to the venous and arterial structures adjacent to the pancreas were reported. Interrater reliability and dispersion indices were compared.

Results: One hundred ninety-four CT scans and 6 MRI scans were evaluated and all parameters were evaluated by all surgeons in 133 (66.5%) cases. Low agreement was observed for tumor infiltration of venous structures (κ = 0.265 and κ = 0.285) while good agreement was achieved for the abutment of the tumor to arterial structures (interrater reliability celiac trunk κ = 0.708 P < 0.001). In patients with vascular tumor contact indicating locally advanced disease, surgeons highly agreed on unresectability, but in patients with vascular tumor abutment consistent with borderline resectable disease, the judgement of resectability was less uniform (dispersion index locally advanced vs. borderline resectable p < 0.05).

Conclusion: Excellent agreement between surgeons exists in determining the presence of arterial abutment and locally advanced pancreatic cancer. The determination of resectability in borderline resectable patients is influenced by additional subjective factors.

Trial registration: EudraCT:2009-014476-21 (2013-02-22) and NCT01827553 (2013-04-09).

Keywords: Borderline resectable; Determination of resectability; Locally advanced; Pancreatic cancer; Prospective randomized multicenter trial.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1

Treatment and Procedure of Evaluation of Pretherapeutic Radiographs. a Schematic view of the treatment algorithm of the Conko-007 trial. Patients will be restaged after induction chemotherapy and if no distant metastasis is present randomized to the two treatment arms. After 6 months of treatment, final evaluation is performed and surgical resection is attempted. Radiographs of the initial staging prior to neoadjuvant chemotherapy were analyzed (arrow with asterisk) b Flowchart for the evaluation of the pretherapeutic radiographs. After upload of the abdominal MRI or CT scans by the trial center, the evaluating surgeons were contacted by e-mail and requested to evaluate the radiographs within the next 3 workdays

Fig. 2

Dispersion indices of the parameters evaluated in the individual patients. This dispersion index is a measure of homogeneity of judgement of one parameter in individual patients by several observers. Zero describes a perfect match of all observers. a When the index of dispersion was calculated for the individual vessels evaluated by the surgeons, the dispersion of evaluated tumor contact was not different between the vessels. b To evaluate the influence of the degree of tumor contact to the peripancreatic vascular structures, cases were classified for their anatomical resectability in resectable, borderline resectable and locally advanced. The average of the dispersion index of tumor contact to the vasculature was similar in patients with resectable, borderline resectable, and locally advanced tumors indicating the degree of tumor contact does not influence the observation of tumor abutment to vessels. c Using the same classification, analyses of the dispersion index of the judgement of resectability indicated, however, that the homogeneity of the conclusion drawn from the observation of tumor contact to the blood vessels depended significantly on the degree of tumor abutment. Especially in patients with resectable and borderline resectable tumors, the heterogeneity in the judgement of resectability was significantly decreased (P < 0.05) indicating a gap between anatomical resectability and subjective judgement by the individual surgeon