**4. Staging**

Surgery is currently the only possibility for cure in PC. 15–20% of PC cases at time of diagnosis are eligible for resection. For those who undergo a successful surgical resection, the morbidity of the procedure is significant, and the 5-year survival rate (5YSR) remains low at 10–25% [30]. Surgery is indicated in the treatment of localised, or minimally-locally-advanced (Stages I-II) PC. Better cure rates are found with node-negative disease (5YSR ~30%); approximately 10% of patients who undergo complete (R0) resection with limited nodal disease progress to long-term survival [31].

The role of preoperative staging is to accurately assess the above features to guide the surgeon as to the likelihood of obtaining an R0 resection. This can be thought of in terms of assessing the extent of local invasion, as well as the presence of distal disease. Standard abdominal CT scanning is the investigation of-choice for assessing distant disease, but has a low sensitivity for assessing local invasion and peritoneal spread. In one study, 61% of cases deemed resectable by CT assessment were found to be unresectable at laparotomy [32]. This modality should not be used alone in assessing appropriateness for surgical intervention.

Standard abdominal CT scans are performed around 60–120 s after injection of intravenous contrast. The optimal timing for imaging of contrast within the pancreas is around 35 s. By using a pancreatic protocol CT, where images are captured at this time point, and then during the washout phase, both local configuration of pancreatic lesions and evidence of local hepatic metastases are elucidated. Pancreatic-protocol CTs are considered the standard imaging investigation for local staging of pancreatic cancer.

The accurate appraisal of the extent of local spread is crucial not only for identifying unresectable disease, but for avoiding false hope and subjecting a patient to an 'open-and-close' laparotomy for no therapeutic benefit.

Local surgical expertise often determines the definition of resectable disease on a pragmatic level, however the National Comprehensive Cancer Network (NCCN) guidelines [33] refer to the following factors when determining resectability:


• Aortic involvement

**Figures 1** and **2** below show the abdominal CT scan and EUS images of two patients referred to our institution for investigation of painless jaundice and a pancreatic mass. The red arrows in the CT images indicate the pancreatic lesion; the red arrows in the ultrasound image indicted the EUS-FNA needle within the pancreatic mass. In the first case (**Figure 1**), the CT scan and US findings were suspicious for autoimmune pancreatitis. The patient was commenced on high-dose steroids and the lesion resolved and liver function tests returned to normal. In the second case (**Figure 2**) the EUS FNA confirmed the clinical and radiological

Surgery is currently the only possibility for cure in PC. 15–20% of PC cases at time of diagnosis are eligible for resection. For those who undergo a successful surgical resection, the morbidity of the procedure is significant, and the 5-year survival rate (5YSR) remains low at 10–25% [30]. Surgery is indicated in the treatment of localised, or minimally-locally-advanced (Stages I-II) PC. Better cure rates are found with node-negative disease (5YSR ~30%); approximately 10% of patients who undergo complete (R0) resection with limited nodal disease progress to long-term

The role of preoperative staging is to accurately assess the above features to guide the surgeon as to the likelihood of obtaining an R0 resection. This can be thought of in terms of assessing the extent of local invasion, as well as the presence of distal disease. Standard abdominal CT scanning is the investigation of-choice for assessing distant disease, but has a low sensitivity for assessing local invasion and peritoneal spread. In one study, 61% of cases deemed resectable by CT assessment were found to be unresectable at laparotomy [32]. This modality

Standard abdominal CT scans are performed around 60–120 s after injection of intravenous contrast. The optimal timing for imaging of contrast within the pancreas is around 35 s. By using a pancreatic protocol CT, where images are captured at this time point, and then during the washout phase, both local configuration of pancreatic lesions and evidence of local hepatic metastases are elucidated. Pancreatic-protocol CTs are considered the standard imag-

The accurate appraisal of the extent of local spread is crucial not only for identifying unresectable disease, but for avoiding false hope and subjecting a patient to an 'open-and-close'

Local surgical expertise often determines the definition of resectable disease on a pragmatic level, however the National Comprehensive Cancer Network (NCCN) guidelines [33] refer to

• Relation to the superior mesenteric artery (SMA), celiac axis, superior mesenteric vein

should not be used alone in assessing appropriateness for surgical intervention.

ing investigation for local staging of pancreatic cancer.

the following factors when determining resectability:

laparotomy for no therapeutic benefit.

(SMV), and inferior vena cava (IVC) • Unreconstructable SMV or portal vein

suspicion of pancreatic cancer.

78 Advances in Pancreatic Cancer

**4. Staging**

survival [31].


EUS provides high-resolution images of the primary mass, its relationship to local structures, and the appearance of regional lymph nodes. Conversely to CT, although EUS can detect some liver metastases, it provides insufficient information on distant disease. There have been few studies directly comparing the two modalities, however the combination of both modalities for their relative strengths seems to be the way forward. One study has shown an equivalent PPV of surgical resectability with regards to T-staging of either modality (63%), with a significant increase to 86% when used in combination [34]. While most studies have shown equivalence of EUS and CT with regards to N-staging, EUS has shown greater accuracy in assessing mesenteric vessel involvement, which often has a significant impact on determining surgical resectability [35].

EUS has previously been thought to be superior to CT scanning for the detection and assessment of smaller pancreatic lesions, however comment has been made that the technological advances in radiology continually improving the resolution of CT images that contemporary CT scans may show more accurate results. EUS has however, been shown to lead to less overstaging than multidetector CT (MDCT) and MRI [35]. This is crucial so that resectable cases are not appreciated as unresectable.
