What are the guidelines for determining resectability of periampullary tumors?

Determining Resectability of Periampullary Tumors

Periampullary tumors should be classified as resectable, borderline resectable, locally advanced, or metastatic using NCCN anatomical criteria based on vessel involvement, supplemented by biological factors (CA 19-9 >500 IU/ml, regional lymph node metastases) and conditional factors (ECOG performance status), with final determination made through multidisciplinary team discussion at an expert center. 1, 2

Anatomical Resectability Criteria (NCCN Classification)

The degree of contact between tumor and peripancreatic vessels determines resectability status 1:

Resectable Disease

• No arterial involvement: No contact with superior mesenteric artery (SMA), celiac trunk, or common hepatic artery 1
• Limited venous involvement: No contact or ≤180° contact with superior mesenteric vein (SMV) or portal vein (PV) without vein contour irregularity 1
• These patients proceed directly to surgical consultation without tissue diagnosis 2

Borderline Resectable Disease

• Arterial involvement: Contact with SMA or celiac trunk ≤180°, or short-segment contact with common hepatic artery 1
• Venous involvement: Contact >180° with SMV/PV, contact ≤180° with contour irregularity, or reconstructable occlusion 1

Locally Advanced (Unresectable)

• Arterial encasement: Contact >180° with SMA or celiac trunk 1
• Unreconstructable venous occlusion: Aortic or inferior vena cava involvement 1

Biological and Conditional Factors

Beyond anatomical criteria, the International Association of Pancreatology consensus identifies additional determinants 1:

Biological Factors (Tumor Aggressiveness)

• CA 19-9 >500 IU/ml: Indicates more aggressive disease 1
• Regional lymph node metastases: Diagnosed by biopsy or PET-CT 1

Conditional Factors (Patient Fitness)

• ECOG performance status 2: Impacts treatment eligibility and surgical candidacy 1
• Age >65 years, albumin <35 g/l: Associated with worse prognosis in advanced disease 1

Imaging Protocol for Resectability Assessment

Primary Imaging Modality

• Pancreas protocol CT with dual-phase contrast enhancement: First-line imaging to assess resectability and vascular involvement 2
• Helical CT with maximum intensity projection (MIP): Best predicts arterial vessel infiltration with 85% accuracy 3
• Chest imaging: Required to evaluate for pulmonary metastases 2

Supplementary Imaging

• MRI with MRCP: When IV contrast contraindicated; offers superior soft-tissue contrast and 85% accuracy for venous vessel infiltration 2, 3
• Endoscopic ultrasound (EUS): 100% sensitivity for small tumors, 93% accuracy for local nonresectability 3
• PET-CT: Useful for equivocal tumors or possible metastases 3

Critical pitfall: Biliary stenting reduces CT diagnostic accuracy for malignancy from 88% to 73%, so CT should be obtained before stenting when possible 3

Resectability Rates by Tumor Origin

Periampullary tumors show significantly different resectability based on anatomical origin 4:

• Periampullary duodenum: 88% resectable 4
• Ampulla of Vater: 76% resectable 4
• Distal bile duct: 71% resectable 4
• Pancreatic head: 20% resectable 4

Pancreatic tumors demonstrate significantly different resectability and survival compared to other periampullary carcinomas (p=0.04 for resectability, p=0.002 for survival) 4

Mandatory Multidisciplinary Team Review

• MDTB discussion in expert centers required: To define treatment strategy accounting for nutritional status, performance status, and comorbidities 1
• Specialized centers achieve better outcomes: Operative mortality should be <10% in experienced hands 2
• Reexploration at high-volume centers: Patients deemed unresectable at outside institutions achieve 67% resectability rate when reexplored at specialized centers 5

Special Considerations

Familial Adenomatous Polyposis (FAP)

• Stage 4 duodenal polyposis: Warrants surgical resection via pylorus-preserving pancreaticoduodenectomy 1, 2
• Surveillance intervals: Stage 0/1 every 5 years, stage 2 every 3 years, stage 3 every 1-2 years 1

Tissue Diagnosis Requirements

• Resectable disease: Proceed directly to surgery without tissue diagnosis 2
• Advanced/metastatic disease: Tissue diagnosis mandatory before initiating systemic therapy 2

Preoperative Biliary Drainage

• Endoscopic drainage preferred: Over percutaneous drainage for distal cholangiocarcinoma and periampullary masses 2
• Self-expanding metal stents (SEMS): Preferred for palliative drainage; offer higher success, lower occlusion rates, fewer re-interventions 2