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Postoperative surveillance of pancreatic ductal adenocarcinoma (PDAC) recurrence: practice pattern on standardized imaging and reporting from the society of abdominal radiology disease focus panel on PDAC

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Abstract

Purpose

Surgical resection is the only potential curative treatment for patients with pancreatic ductal adenocarcinoma (PDAC), but unfortunately most patients recur within 5 years of surgery. This article aims to assess the practice patterns across major academic institutions and develop consensus recommendations for postoperative imaging and interpretation in patients with PDAC.

Methods

The consensus recommendations for postoperative imaging surveillance following PDAC resection were developed using the Delphi method. Members of the Society of Abdominal Radiology (SAR) PDAC Disease Focused Panel (DFP) underwent three rounds of surveys followed by live webinar group discussions to develop consensus recommendations.

Results

Significant variations currently exist in the postoperative surveillance of PDAC, even among academic institutions. Differentiating common postoperative inflammatory and fibrotic changes from tumor recurrence remains a diagnostic challenge, and there is no reliable size threshold or growth rate of imaging findings that can provide differentiation. A new liver lesion or peritoneal nodule should be considered suspicious for tumor recurrence, and the imaging features should be interpreted in the appropriate clinical context (e.g., CA 19–9, clinical presentation, pathologic staging).

Conclusion

Postoperative imaging following PDAC resection is challenging to interpret due to the presence of confounding postoperative inflammatory changes. A standardized reporting template for locoregional findings and report impression may improve communication of relaying risk of recurrence with referring providers, which merits validation in future studies.

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Author information

Authors and Affiliations

  1. The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Linda C. Chu, Elliot K. Fishman & Atif Zaheer

  2. Department of Radiology, University of California San Francisco School of Medicine, San Francisco, CA, USA

    Zhen J. Wang

  3. Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA

    Avinash Kambadakone

  4. Department of Radiology, Weill Cornell Medicine, New York, NY, USA

    Elizabeth M. Hecht

  5. Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Jin He

  6. Department of Radiation Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Amol K. Narang

  7. Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Daniel A. Laheru

  8. Department of Medical Imaging, University of Arizona, Tuscon, AZ, USA

    Hina Arif-Tiwari

  9. Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, TX, USA

    Priya Bhosale, Ott Le & Eric P. Tamm

  10. Department of Radiology, Mayo Clinic, Jacksonville, FL, USA

    Candice W. Bolan

  11. Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA

    Olga R. Brook & Abraham F. Bezuidenhout

  12. Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA

    Richard K. G. Do

  13. Department of Radiology, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA

    Samuel J. Galgano

  14. Department of Radiology, Mayo Clinic, Rochester, MN, USA

    Ajit H. Goenka & David M. Hough

  15. Department of Diagnostic Radiology, Oregon Health & Science University, Portland, OR, USA

    Alexander R. Guimaraes

  16. Department of Radiology, Medical College of Wisconsin & Froedtert Health, Milwaukee, WI, USA

    Naveen Kulkarni & Parag P. Tolat

  17. Department of Radiology, Columbia University Irving Medical Center, New York, NY, USA

    Lyndon Luk

  18. Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) SDN, Naples, Italy

    Lorenzo Mannelli

  19. Department of Imaging, Dana-Farber Cancer Institute, Brigham and Women’s Hospital, and Harvard Medical School, Boston, MA, USA

    Michael Rosenthal

  20. Department of Radiology, Ochsner Louisiana State University Health Shreveport, Shreveport, LA, USA

    Guillermo Sangster

  21. Department of Radiology, Ohio State University Wexner Medical Center, Columbus, OH, USA

    Zarine K. Shah

  22. Department of Radiology, University of Washington, Seattle, WA, USA

    Erik V. Soloff

  23. Department of Radiology, Hôpital Paris Saint Joseph, Paris, France

    Marc Zins

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  1. Linda C. Chu
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  2. Zhen J. Wang
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  3. Avinash Kambadakone
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  4. Elizabeth M. Hecht
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  5. Jin He
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  13. Richard K. G. Do
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  19. Ott Le
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  20. Lyndon Luk
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  21. Lorenzo Mannelli
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  22. Michael Rosenthal
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  23. Guillermo Sangster
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  25. Erik V. Soloff
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  26. Parag P. Tolat
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  27. Marc Zins
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  28. Elliot K. Fishman
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  29. Eric P. Tamm
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  30. Atif Zaheer
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Contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by LCC, ZJW, AK, EMH, EPT, and AZ. The first draft of the manuscript was written by LCC and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Linda C. Chu.

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Appendices

Appendix 1 Round 1 survey questions and responses

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Appendix 2 Round 2 survey questions and responses

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Appendix 3 Round 3 survey questions and responses

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Appendix 4 Pancreatic ductal adenocarcinoma postoperative surveillance macro

Pancreatic parenchyma: [Pancreaticoduodenectomy/Appleby/Distal pancreatectomy]. Pancreatic remnant [normal in morphology and enhance/atrophic]. Comment on any solid or cystic lesion in the remnant pancreas and any change.

Main pancreatic duct (MPD): [Non-dilated/Dilated]. [Pancreaticojejunostomy is normal.] Comment on any change.

Perivascular soft tissue: [None/Ill-defined soft tissue]. Comment on any change compared to most recent cross-sectional study and baseline postoperative study, if available.

Vascular enhancement: [Unchanged/Increased luminal compression/decreased luminal compression/portal vein thrombosis].

Liver: [Normal background parenchyma/Steatosis/Cirrhosis]. Comment on any new liver lesions and changes in sizes of existing lesions. [Hepaticojejunostomy is normal.]

Lymphadenopathy: [None/Present]. Comment on size, location, and interval change.

Peritoneum: Ascites [none/mild/moderate/severe], peritoneal nodules [none/describe representative nodule size and location].

Other sites of metastatic disease: Comment on any other lesions in lungs, bones, etc. that are suspicious for metastatic disease.

Impression:

Pancreatic resection with findings [PICK LIST]

[PICK LIST OPTIONS]

  • consistent with expected postoperative changes (> 90% certainty).

  • consistent with local tumor recurrence/metastatic disease (> 90% certainty).

  • suspicious for local tumor recurrence/metastatic disease (~ 75% certainty).

  • with possible local tumor recurrence/metastatic disease (~ 50% certainty).

  • less likely to represent local tumor recurrence/metastatic disease (~ 25% certainty).

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Chu, L.C., Wang, Z.J., Kambadakone, A. et al. Postoperative surveillance of pancreatic ductal adenocarcinoma (PDAC) recurrence: practice pattern on standardized imaging and reporting from the society of abdominal radiology disease focus panel on PDAC. Abdom Radiol 48, 318–339 (2023). https://doi.org/10.1007/s00261-022-03693-0

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