Treatment Decision Making in Pancreatic Adenocarcinoma—Invited Critique

In 1972, when asked about the lasting effects of the French Revolution, Zhou Enlai replied, “Too soon to tell.”¹ The same answer is given when questions arise about the value of updated radiologic imaging in staging and managing pancreatic cancer. Consider, for example, the year 1977. In July, Creditor and Garrett² reported in The New England Journal of Medicine about how the innovations of CT were being introduced into clinical practice. They decried that expensive technologies were widely adopted without evidence of clinical utility. In an era when more than 40% of Blue Cross plans did not reimburse for whole-body scanning, evidence for the efficacy of CT scanning was missing.³ What was clear in 1977, however, was that current diagnostic tests for pancreatic cancer were of limited utility. Abdominal ultrasonography, pancreatic function tests, ERCP, and arteriography were the sequence of tests recommended in a prospective study from the Mayo Clinic.⁴ When Fitzgerald et al⁵ examined pancreatic cancer diagnosis, CT scanning was identified as the best test despite a false-positive rate of 40%. This is when the exploratory laparotomy really was an exploration. Let's fast forward to 2007 and ask again, What is the clinical use of CT scanning in treating pancreatic cancer? Furukawa and colleagues provide a number of useful and practical answers for physicians and patients. What they have demonstrated is that, when MDCT images show that a pancreatic cancer is probably resectable, it probably is. When a tumor is probably unresectable, it is unresectable. The advantage to patients is that they can be spared multiple evaluations with EUS, MRI, ERCP, and angiography and undergo the indicated treatment. In some patients with probably resectable disease, laparotomy can be averted with use of laparoscopy, which is a superb method for detecting miniscule liver and peritoneal metastatic disease. What is notable is that MDCT technology is superb in providing precise tumor and vascular information. Tumor extension along the superior mesenteric artery and celiac axis is better displayed using MDCT than with intraoperative assessment. Remember that resectability of pancreatic cancer is best determined preoperatively, not intraoperatively. One last question: Does MDCT have an effect on pancreatic cancer outcome? Too soon to tell.