Correlation between CT and operative findings in pancreatic cancers and role of pre-operative CA19-9 values in predicting metastatic disease

Rajat Prabhakar, Shyam S. Jaiswal, Ravi Prakash


Background: Pancreatic cancers carry a poor prognosis with 20-30% of cases found resectable on MDCT (Multi-detector CT). 60-91% of these lesions are actually found resectable during surgery. CA 19-9 is an extensively studied tumour marker in pancreatic cancers and its abnormally high value may point towards metastatic disease.

Methods: A study was conducted in a tertiary care centre in which all patients of pancreatic cancers found resectable on imaging were subjected to surgery after staging laparoscopy to find metastatic disease missed on MDCT, the findings were noted and correlated with the radiological findings. Also, pre-operative CA 19-9 levels were analysed to predict metastatic disease in patients with high CA 19-9 values.

Results: The study included 34 patients of pancreatic cancers deemed resectable on imaging. Out of these, four (11.7%) patients were found to be unresectable on staging laparoscopy in the form of subcentimetric liver/peritoneal metastasis. It was also found that preoperative CA 19-9 levels were higher in patients found to be metastatic. By using ROC curve, it was found that pre-operative values of CA 19-9 had 100% sensitivity and 80% specificity at the cut off level >106.75 U/ml.

Conclusions: MDCT fails to identify some unresectable diseases because of presence of distant metastasis in the form of liver and peritoneal metastatic nodules and malignant ascites. Staging laparoscopy prior to laparotomy is a useful procedure which prevents unwanted laparotomy in some cases of metastatic pancreatic cancer not identified on imaging. Abnormally high values of CA 19-9 may point towards metastatic disease.


Pancreatic cancer, Resectability pancreatic cancer, CA19-9, Staging laparoscopy

Full Text:



Yadav D, Lowenfels AB. The Epidemiology of Pancreatitis and Pancreatic Cancer. Gastroenterol. 2013;144(6):1252-61.

Dhir V, Mohandas KM. Epidemiology of digestive tract cancers in India IV. Gall bladder and pancreas. Ind J gastroenterol. 1999;18(1):24-8.

Evans DB, Christians KK, Foley WD. Pancreaticoduodenectomy (Whipple operation) & total pancreatectomy for cancer. In: Fischer JE, editor. Mastery of Surgery. 2. 6th edition. Philadelphia: Lippincott Williams & Wilkins. 2012;1445-65.

Prokesch RW, Chow LC, Beaulieu CF, Nino-Murcia M, Mindelzun RE, Bammer R, et al. Local staging of pancreatic carcinoma with multi-detector row CT: use of curved planar reformations initial experience. Radiology. 2002;225(3):759-65.

Jensen EH, Borja-Cacho D, Al-Refaie WB, Vickers SM. Exocrine pancreas. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, editors. Sabiston textbook of surgery: The biological basis of modern surgical practice. 19 ed. Philadelphia: Elsevier Saunders. 2012;1535-45.

John TG, Greig JD, Carter DC, Garden OJ. Carcinoma of the pancreatic head and periampullary region. Tumor staging with laparoscopy and laparoscopic ultrasonography. Ann surg. 1995;221(2):156-64.

Vargas R, Nino-Murcia M, Trueblood W, Jeffrey RB, Jr. MDCT in Pancreatic adenocarcinoma: prediction of vascular invasion and resectability using a multiphasic technique with curved planar reformations. Am J roentgenol. 2004;182(2):419-25.

Lu DS, Reber HA, Krasny RM, Kadell BM, Sayre J. Local staging of pancreatic cancer: criteria for unresectability of major vessels as revealed by pancreatic-phase, thin-section helical CT. Am J roentgenol. 1997;168(6):1439-43.

O'Malley ME, Boland GW, Wood BJ, Fernandez-del Castillo C, Warshaw AL, Mueller PR. Adenocarcinoma of the head of the pancreas: determination of surgical unresectability with thin-section pancreatic-phase helical CT. Am J roentgenol. 1999;173(6):1513-8.

Mehmet K. Value of preoperative serum CA 19.9 levels in predicting resectability for pancreatic cancer. Can J Surg. 2009;49(4);241-244.

SEER Stat Fact Sheets: Pancreas Cancer [Internet]. Last accessed on 5th December 2019.

Tucker ON, Rela M. Controversies in the management of borderline resectable proximal pancreatic adenocarcinoma with vascular involvement. HPB surgery: a world journal of hepatic, pancreatic and biliary surgery. 2008;2008:839503.

Yeo TP, Lowenfels AB. Demographics and epidemiology of pancreatic cancer. Cancer journal (Sudbury, Mass). 2012;18(6):477-84.

Malagelada JR. Pancreatic cancer: an overview of epidemiology, clinical presentation, and diagnosis. Mayo Clinic proceedings. 1979;54(7):459-67.

Kalser MH, Barkin J, Macintyre JM. Pancreatic cancer. Assessment of prognosis by clinical presentation. Cancer. 1985;56(2):397-402.

Modolell I, Guarner L, Malagelada JR. Vagaries of clinical presentation of pancreatic and biliary tract cancer. Annals of oncology : official journal of the European Society for Medical Oncology / ESMO. 1999;10(4):82-4.

Safi F, Schlosser W, Falkenreck S, Beger HG. Prognostic value of CA 19-9 serum course in pancreatic cancer. Hepato-gastroenterology. 1998;45(19):253-9.

Schlieman MG, Ho HS, Bold RJ. Utility of tumor markers in determining resectability of pancreatic cancer. Archives of surgery (Chicago, Ill : 1960). 2003;138(9):951-5.

Alexakis N, Gomatos IP, Sbarounis S, Toutouzas K, Katsaragakis S, Zografos G, et al. High serum CA 19-9 but not tumor size should select patients for staging laparoscopy in radiological resectable pancreas head and peri-ampullary cancer. European Journal of Surgical Oncology. 41(2):265-9.

Artinyan A, Soriano PA, Prendergast C, Low T, Ellenhorn JD, Kim J. The anatomic location of pancreatic cancer is a prognostic factor for survival. HPB. 2008;10(5):371-6.

Tummala P, Junaidi O, Agarwal B. Imaging of pancreatic cancer: An overview. J Gastrointest Oncol. 2011;2(3):168-74.

Wolfgang CL, Schulick RD, Cameron JL. Cancers of the Periampullary Region and the Pancreas. In: Zinner MJ, Ashley SW, editors. Maingot's abdominal operations. 12 ed: Mc Graw-Hill. 2013;1187-210.

Rickes S, Unkrodt K, Neye H, Ocran KW, Wermke W. Differentiation of pancreatic tumours by conventional ultrasound, unenhanced and echo-enhanced power Doppler sonography. Scandinavian journal of gastroenterology. 2002;37(11):1313-20.

Saisho H, Yamaguchi T. Diagnostic imaging for pancreatic cancer: computed tomography, magnetic resonance imaging, and positron emission tomography. Pancreas. 2004;28(3):273-8.

Karmazanovsky G, Fedorov V, Kubyshkin V, Kotchatkov A. Pancreatic head cancer: accuracy of CT in determination of resectability. Abdominal imaging. 2005;30(4):488-500.

Fisher WE, Andersen DK, Windsor JA, Saluja AK, Brunicardi FC. Pancreas. In: Brunicardi FC, editor. Schwartz’s Principles of Surgery. New York: McGraw-Hill education. 2015;1341-422.

Takakura K, Sumiyama K, Munakata K, Ashida H, Arihiro S, Kakutani H, et al. Clinical usefulness of diffusion-weighted MR imaging for detection of pancreatic cancer: comparison with enhanced multidetector-row CT. Abdominal imaging. 2011;36(4):457-62.

Singer E, Gschwantler M, Plattner D, Kriwanek S, Armbruster C, Schueller J, et al. Differential diagnosis of benign and malign pancreatic masses with 18F-fluordeoxyglucose-positron emission tomography recorded with a dual-head coincidence gamma camera. European journal of gastroenterology & hepatology. 2007;19(6):471-8.

Nishiyama Y, Yamamoto Y, Yokoe K, Monden T, Sasakawa Y, Tsutsui K, et al. Contribution of whole body FDG-PET to the detection of distant metastasis in pancreatic cancer. Annals of nuclear medicine. 2005;19(6):491-7.

Soriano A, Castells A, Ayuso C, Ayuso JR, de Caralt MT, Gines MA, et al. Preoperative staging and tumor resectability assessment of pancreatic cancer: prospective study comparing endoscopic ultrasonography, helical computed tomography, magnetic resonance imaging, and angiography. The American journal of gastroenterology. 2004;99(3):492-501.

Legmann P, Vignaux O, Dousset B, Baraza AJ, Palazzo L, Dumontier I, et al. Pancreatic tumors: comparison of dual-phase helical CT and endoscopic sonography. American Journal of Roentgenology. 1998;170(5):1315-22.

Hartwig W, Schneider L, Diener MK, Bergmann F, Büchler MW, Werner J. Preoperative tissue diagnosis for tumours of the pancreas. British Journal of Surgery. 2009;96(1):5-20.