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Retrospective Review of Clinical Outcomes in Undetectable Mass of the Pancreatic Head Prior to Pancreatoduodenectomy.
Hideo Takahashi*, Maitham a. Moslim, Naftali Presser, Sricharan Chalikonda, Gareth Morris-Stiff, R Matthew Walsh
general surgery, Cleveland Clinic, Cleveland, OH
BACKGROUND: The classic radiologic description of pancreatic carcinoma on cross-sectional imaging is a mass in the pancreatic head, however not uncommonly, no mass is identified on computed tomography (CT) or magnetic resonance imaging (MRI). The aim of this study was to assess whether the lack of a radiologic mass led to protracted diagnostic evaluation and delayed resection.
METHODS: The departmental pancreatic database was interrogated to identify all patients undergoing pancreatoduodenectomy (PD) for primary malignancies of the pancreatic head during the period 2000-2014. The pre-operative evaluation of the patients was reviewed and the presence or absence of a mass on CT and/or MRI was noted. The interval between imaging and surgery was evaluated, and related to the presence of a mass. The relationship between mass/no mass and the pathological profile (tumor size, histopathology [pancreatic, ampullary, cholangiocarcinoma], degree of differentiation, lymph node metastases, lymph node ratio, vascular invasion, neurological invasion, margin status) were also assessed. All analyses were done using R software (version 3.1.0) and significance taken at the 5% level.
RESULTS: 904 patients underwent PD during the study period, 514 of which had malignant lesions of the pancreatic head. There was no difference in the interval between the first cross-sectional imaging study and operation for patients with a mass compared with no mass (44 versus 46; p = 0.18). A mass was detected in 317 patients while no masses were seen on cross-sectional imaging in 196 patients. The absence of a mass was more common in cholangiocarcinomas than pancreatic or ampullary cancers (p<0.001). Although the size of the mass on final pathology was greater in the mass group (3.1cm versus 2.6cm; p<0.001), the tumor stage was significantly more advanced in the no mass cohort (p = 0.005). Other oncological factors were not significantly different between groups.
CONCLUSIONS: Although the absence of a mass in patients presenting with a periampullary neoplasm does not delay treatment, they are resected at a more advanced stage. Detection of a mass was less likely in patients with a final diagnosis of cholangiocarcinoma.
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