Department of Surgical Gastroenterology, Karolinska University Hospital, Stockholm, Sweden.
Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA.
Br J Surg. 2016 Feb;103(3):267-75. doi: 10.1002/bjs.10046. Epub 2015 Nov 17.
Locoregional pancreatic ductal adenocarcinoma (PDAC) may progress rapidly and/or disseminate despite having an early stage at diagnostic imaging. A prolonged interval from imaging to resection might represent a risk factor for encountering tumour progression at laparotomy. The aim of this study was to determine the therapeutic window for timely surgical intervention.
This observational cohort study included patients with histologically confirmed PDAC scheduled for resection with curative intent from 2008 to 2014. The impact of imaging-to-resection/reassessment (IR) interval, vascular involvement and tumour size on local tumour progression or presence of metastases at reimaging or laparotomy was evaluated using univariable and multivariable regression. Risk estimates were approximated using hazard ratios (HRs).
Median IR interval was 42 days. Of 349 patients scheduled for resection, 82 had unresectable disease (resectability rate 76.5 per cent). The unresectability rate was zero when the IR interval was 22 days or shorter, and was lower for an IR interval of 32 days or less compared with longer waiting times (13 versus 26.2 per cent; HR 0.42, P = 0.021). It was also lower for tumours smaller than 30 mm than for larger tumours (13.9 versus 32.5 per cent; HR 0.34, P < 0.001). Tumours with no or minor vascular involvement showed decreased rates of unresectable disease (20.6 per cent versus 38 per cent when there was major or combined vascular involvement; HR 0.43, P = 0.007). However, this failed to reach statistical significance on multivariable analysis (P = 0.411), in contrast to IR interval (P = 0.028) and tumour size (P < 0.001).
Operation within 32 days of diagnostic imaging reduced the risk of tumour progression to unresectable disease by half compared with a longer waiting time. The results of this study highlight the importance of efficient clinical PDAC management.
局部区域胰腺导管腺癌（PDAC）尽管在诊断影像学上处于早期阶段，但可能会迅速进展和/或扩散。从影像学检查到手术切除之间的时间间隔延长可能是术中发现肿瘤进展的危险因素。本研究旨在确定及时手术干预的治疗窗口。
本观察性队列研究纳入了 2008 年至 2014 年间因有治愈性手术切除而接受组织学证实的 PDAC 患者。使用单变量和多变量回归分析了影像学检查至手术切除/重新评估（IR）时间间隔、血管侵犯和肿瘤大小对重新影像学检查或剖腹探查时局部肿瘤进展或转移存在的影响。风险估计采用风险比（HR）近似值。
中位 IR 间隔为 42 天。在 349 例计划手术切除的患者中，82 例为不可切除性疾病（可切除率为 76.5%）。当 IR 间隔为 22 天或更短时，不可切除率为 0，当 IR 间隔为 32 天或更短时，不可切除率低于较长的等待时间（13%比 26.2%；HR 0.42，P=0.021）。与较大肿瘤相比，肿瘤直径小于 30mm 的不可切除率也较低（13.9%比 32.5%；HR 0.34，P<0.001）。无或轻微血管侵犯的肿瘤不可切除率降低（主要或联合血管侵犯时为 38%，无或轻微血管侵犯时为 20.6%；HR 0.43，P=0.007）。然而，这在多变量分析中没有达到统计学意义（P=0.411），而与 IR 间隔（P=0.028）和肿瘤大小（P<0.001）不同。
与较长的等待时间相比，在诊断影像学检查后 32 天内进行手术可将肿瘤进展为不可切除疾病的风险降低一半。本研究结果强调了有效临床 PDAC 管理的重要性。
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