Malignant biliary obstruction: efficacy of thin-section dynamic CT in determining resectability

Abstract

Objective: Several authorities advocate the use of preoperative angiography to determine the resectability of pancreatic and periampullary tumors, claiming that CT alone is not sufficiently accurate for this purpose. Our objective was to assess the value of CT in predicting surgical resectability in patients with malignant biliary obstruction.

Materials and methods: We performed a retrospective analysis of 380 consecutive cases of malignant biliary obstruction spanning a 4-year period. Most patients (230) were treated nonoperatively. Sixty-seven patients had surgery, pathologic confirmation of malignancy, and preoperative CT scans available for review. The CT scans were assessed for surgical resectability of tumor by an interpreter who did not know the patient's history.

Results: Forty-two patients had pancreatic adenocarcinoma, six had ampullary carcinoma, seven had cholangiocarcinoma, and 12 had other malignant neoplasms. Of 47 patients with tumors thought to be unresectable on the basis of CT findings, 42 had tumors that were found to be unresectable at surgery (positive predictive value, 89%). Of 20 patients with tumors thought to be resectable, 16 had tumors that were surgically resectable (positive predictive value, 80%). CT did not show metastases to duodenal lymph nodes (n = 2), portal vein infiltration (n = 1), and small hepatic metastases (n = 1). Visualization of most of these at angiography would not be expected. The CT finding of infiltration of the periarterial fat around the celiac or superior mesenteric arteries was reliable for predicting surgical unresectability. Lymphadenopathy and infiltration of nonperivascular fat planes were less reliable predictors of unresectability.

Conclusion: Although some findings on CT that suggest unresectability are less reliable than others, the accuracy of CT compares favorably with reports on the accuracy of angiography for assessing tumor resectability in cases of malignant biliary obstruction. The addition of angiography to the examination of patients with potentially resectable lesions is not justified when high-quality, thin-section dynamic CT has been performed.