The impact of MRI on real-world staging pathways and management timelines in pancreatic cancer: A systematic review.

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) has a poor prognosis, and accurate staging is crucial to avoid unnecessary surgery. MRI may improve the detection of occult liver metastases when compared with CT. The impact of adding MRI on treatment timelines and cost-effectiveness remains uncertain. This systematic review synthesises the available evidence of incorporating MRI alongside CT for pre-operative staging of pancreatic cancer.

METHODS

We systematically searched MEDLINE, Embase, Web of Science, and the Cochrane Library (2005-2025) for studies comparing staging pathways using CT + MRI versus CT alone in adults with PDAC. Primary outcomes were time to treatment/pathway delays. Secondary outcomes were changes in management, detection of liver metastases, and economic implications.

RESULTS

Fifteen studies (4 retrospective cohorts, 11 case series; n = 7243) were included. Cohort data showed inconsistent effects of MRI on time to surgery, ranging from a 5-day reduction to an 8-day increase (weighted mean + 5.7 days). In case series, the CT-MRI interval averaged 9.7 days and MRI-surgery interval 8.7 days. MRI identified additional liver metastases in 2-23% of CT-negative patients and in 12-45% of those with indeterminate CT findings.

CONCLUSIONS

MRI improves detection of occult liver metastases and influences surgical decision-making without consistently delaying treatment. However, pathway-level evidence is heterogeneous, and cost-effectiveness remains unexplored. High-quality prospective studies are needed to define MRI's role in contemporary staging pathways.