br A PROSPECTIVE CLINICAL TRIAL TO DETERMINE THE EFFECT OF
A PROSPECTIVE CLINICAL TRIAL TO DETERMINE THE EFFECT OF INTRAOPERATIVE ULTRASOUND ON SURGICAL STRATEGY AND RESECTION OUTCOME IN PATIENTS WITH PANCREATIC CANCER B G. S M ,* S F ,y A F ~ S ,z PTDEGAABS IBINGA ULDER HIRIN ESHTALI RANTZA ARINA ARASQUETA
ALEXANDER L. VAHRMEIJER,* RUTGER-JAN SWIJNENBURG,* BERT A. BONSING,* and J. SVEN D. MIEOG*TEAGND
* Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands; y Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands; and z Department of Pathology, Leiden University Medical Center, Leiden, the Netherlands
Abstract—Surgical exploration in patients with pancreatic or periampullary cancer is often performed without intraoperative image guidance. Although intraoperative ultrasound (IOUS) may enhance visualization during resection, this AS1517499 tool has not been investigated in detail until now. Here, we performed a prospective cohort study to evaluate the effect of IOUS on surgical strategy and to evaluate whether vascular involvement and radicality of the resection could be correctly assessed with IOUS. IOUS was performed by an experienced abdominal radiologist during surgical exploration in 31 consecutive procedures. IOUS affected surgical strategy by either (i) having no effect, (ii) determining tumor localization, (iii) evaluating vascular involvement or (iv) waiving surgery. Radicality of the resections and vascular contact were determined during pathologic analysis and compared with preoperative imaging and IOUS findings. Overall, IOUS influenced surgical strategy in 61% of procedures. In 21 out of 27 malig-nant tumors, a radical resection was achieved (78%). Vascular contact was assessed correctly using IOUS in 89% compared with 74% of patients using preoperative imaging. IOUS can help the surgical team to assess the resect-ability and to visualize the tumor and possible vascular contact in real time during resection. IOUS may therefore increase the likelihood of achieving a radical resection. (E-mail: [email protected]) © 2019 World Federation for Ultrasound in Medicine & Biology. All rights reserved.
Key Words: Pancreatic cancer, Intraoperative ultrasound, resection.
The prognosis for patients with pancreatic cancer who undergo surgery with curative intent depends largely on the ability to achieve a radical resection (Kim et al. 2016). Typ-ically, preoperative computed tomography (CT) imaging is used to determine the local extent of the tumor (Ichikawa et al. 2006). Factors that determine local resectability include contact with surrounding structures, vascular involvement and the absence of distant metastases (Feld-man and Gandhi 2016). To improve outcomes, neoadjuvant chemotherapy is often administered to patients who present with borderline-resectable or locally advanced tumors (Liao et al. 2017). However, neoadjuvant chemotherapy can com-plicate the ability to assess the resectability of the tumor using CT imaging, largely because of the difficulties associ-ated with distinguishing between chemotherapy-induced
Address correspondence to: J.S.D. Mieog, Department of Sur-gery, Leiden University Medical Center, P.O. Box 9600, 2300 RC Lei-den, The Netherlands. E-mail: [email protected]
Surgical treatment for pancreatic cancer generally begins with surgical exploration to identify occult metas-tases and to assess the tumor’s resectability. During Testcross procedure, the surgeon must rely solely on visual inspec-tion and palpation in order to distinguish between tumor and normal tissue. This can be challenging, particularly in the presence of peri-tumoral inflammation. Moreover, in up to 60% of patients who undergo a resection of their pancreatic tumor, histologic microscopic assessment reveals tumor infiltration into the borders of the resected specimen, resulting in a high rate of local recurrence (Campbell et al. 2009; Ghaneh et al. 2017; Neoptolemos et al. 2017). On the other hand, approximately half the patients who underwent venous resection because of sus-pected tumor invasion were found to have no tumor infil-tration based on a pathologic examination in the resected vascular patch (Giovinazzo et al. 2016). Given these fac-tors, the current treatment is to perform high-risk