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Soydan L, Atalay HÖ, Torun M, Arar M, Canpolat K. Prediction of R0 Resectability in Pancreatic Adenocarcinoma by MRI Using NCCN Criteria. Indian J Surg 2024. [DOI: 10.1007/s12262-024-04170-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 10/05/2024] [Indexed: 11/29/2024] Open
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Jia WY, Gui Y, Chen XQ, Tan L, Zhang J, Xiao MS, Chang XY, Dai MH, Guo JC, Cheng YJ, Wang X, Zhang JH, Zhang XQ, Lv K. Efficacy of color Doppler ultrasound and contrast-enhanced ultrasound in identifying vascular invasion in pancreatic ductal adenocarcinoma. Insights Imaging 2024; 15:181. [PMID: 39060856 PMCID: PMC11282047 DOI: 10.1186/s13244-024-01779-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 07/10/2024] [Indexed: 07/28/2024] Open
Abstract
OBJECTIVES To compare color Doppler ultrasound and contrast-enhanced ultrasound (CEUS) in evaluating vascular invasion in pancreatic ductal adenocarcinoma (PDAC). MATERIALS AND METHODS This retrospective study included 210 patients with PDAC who were evaluated by color Doppler ultrasound, CEUS, and contrast-enhanced computed tomography (CECT) at our institution between January 2017 and December 2020. Pathologic results were used as the gold standard in patients who underwent surgical and intraoperative exploration. For nonsurgical patients, CECT results were used as the reference standard. The vessels evaluated included those in the peripancreatic arterial system and venous system. The diagnostic performances of color Doppler ultrasound and CEUS for vascular invasion were compared. RESULTS In 51 patients who underwent surgery and intraoperative exploration, color Doppler ultrasound and CEUS differed only in assessing venous system invasion in patients with PDAC of the pancreatic body and tail, with the former being superior to the latter. In 159 nonsurgical patients, there was no difference between CEUS and color Doppler ultrasound in assessing superior mesenteric arteriovenous invasion. CEUS was superior to color Doppler ultrasound in evaluating the celiac artery and its branches, with an accuracy of up to 97.8% for some vessels. Color Doppler ultrasound was ideal for evaluating the splenic and portal veins. CONCLUSION CEUS is more suitable for the evaluation of peripancreatic arteries than color Doppler. CEUS combined with color Doppler ultrasound can be used as a potential supplement to CECT and is also expected to be used to evaluate vascular invasion of PDAC after chemotherapy. CRITICAL RELEVANCE STATEMENT Contrast-enhanced US and color Doppler in the assessment of vascular invasion in pancreatic ductal adenocarcinoma have their respective advantages, through standardized ultrasound processes are expected to improve the efficiency of inspection. KEY POINTS Contrast-enhanced US has unique advantages in assessing pancreatic ductal adenocarcinoma invasion of the celiac artery. Doppler imaging is of high value in assessing venous system invasion. Standardization of ultrasound imaging procedures for pancreatic ductal adenocarcinoma is expected to improve efficiency.
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Affiliation(s)
- Wan-Ying Jia
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yang Gui
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xue-Qi Chen
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Li Tan
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Zhang
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Meng-Su Xiao
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao-Yan Chang
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Meng-Hua Dai
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun-Chao Guo
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yue-Juan Cheng
- Department of Medical Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiang Wang
- Department of Medical Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jia-Hui Zhang
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao-Qian Zhang
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ke Lv
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Jajodia A, Wang A, Alabousi M, Wilks C, Kulkarni A, van der Pol CB. MRI vs. CT for pancreatic adenocarcinoma vascular invasion: comparative diagnostic test accuracy systematic review and meta-analysis. Eur Radiol 2023; 33:6883-6891. [PMID: 37083741 DOI: 10.1007/s00330-023-09659-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/26/2023] [Accepted: 02/22/2023] [Indexed: 04/22/2023]
Abstract
OBJECTIVES To perform a systematic review comparing the diagnostic accuracy of MRI vs. CT for assessing pancreatic ductal adenocarcinoma (PDAC) vascular invasion. METHODS MEDLINE, EMBASE, Cochrane Central, and Scopus were searched until December 2021 for diagnostic accuracy studies comparing MRI vs. CT to evaluate vascular invasion of pathologically confirmed PDAC in the same patients. Findings on resection or exploratory laparotomy were the preferred reference standard. Data extraction, risk of bias, and applicability assessment were performed by two authors using the Quality Assessment of Diagnostic Accuracy Studies-Comparative Tool. Bivariate random-effects meta-analysis and meta-regression were performed with 95% confidence intervals (95% CI). RESULTS Three studies were included assessing 474 vessels without vascular invasion and 65 with vascular invasion in 107 patients. All patients were imaged using MRI at ≥ 1.5 T and a pancreatic protocol CT. No difference was shown between MRI and CT for diagnosing PDAC vascular invasion: MRI/CT sensitivity (95% CI) were 71% (47-87%)/74% (56-86%), and specificity were 97% (94-99%)/97% (94-98%). Sources of bias included selection bias from only a subset of CT patients undergoing MRI and verification bias from patients with unresectable disease not confirmed on surgery. No patients received neoadjuvant therapy prior to staging. CONCLUSIONS Based on limited data, no difference was observed between MRI and pancreatic protocol CT for PDAC vascular invasion assessment. MRI may be an adequate substitute for pancreatic protocol CT in some patients, particularly those who have already had a single-phase CT. Larger and more recent cohort studies at low risk of bias, including patients who have received neoadjuvant therapy, are needed. CLINICAL RELEVANCE STATEMENT Abdominal MRI performed similarly to pancreatic protocol CT at assessing pancreatic ductal adenocarcinoma vascular invasion, suggesting local staging is adequate in some patients using MRI. More data are needed using larger, more recent cohorts including patients with neoadjuvant treatment. KEY POINTS • Based on limited data, no difference was found between MRI and pancreatic protocol CT sensitivity and specificity for diagnosing PDAC vascular invasion (p = 0.81, 0.73 respectively). • Risk of bias could be reduced in future PDAC MRI vs CT comparative diagnostic test accuracy research by ensuring all enrolled patients undergo both imaging modalities being compared in random order and regardless of the findings on either modality. • More studies are needed that directly compare the diagnostic performance of MRI and CT for PDAC staging after neoadjuvant therapy.
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Affiliation(s)
- Ankush Jajodia
- Department of Radiology, McMaster University, Hamilton Health Sciences, Hamilton, Canada
| | - Ashley Wang
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | - Mostafa Alabousi
- Joint Department of Medical Imaging, University of Toronto, University Health Network, Toronto, Canada
| | - Christopher Wilks
- Department of Radiology, McMaster University, Hamilton Health Sciences, Hamilton, Canada
| | - Ameya Kulkarni
- Department of Radiology, McMaster University, Hamilton Health Sciences, Hamilton, Canada
- Department of Diagnostic Imaging, Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, 711 Concession Street, Hamilton, ON, L8V 1C3, Canada
| | - Christian B van der Pol
- Department of Radiology, McMaster University, Hamilton Health Sciences, Hamilton, Canada.
- Department of Diagnostic Imaging, Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, 711 Concession Street, Hamilton, ON, L8V 1C3, Canada.
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Kim H, Kim DH, Song IH, Kim B, Oh SN, Choi JI, Rha SE. Survival Prediction after Curative Resection of Pancreatic Ductal Adenocarcinoma by Imaging-Based Intratumoral Necrosis. Cancers (Basel) 2022; 14:cancers14225671. [PMID: 36428764 PMCID: PMC9688323 DOI: 10.3390/cancers14225671] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 11/15/2022] [Accepted: 11/15/2022] [Indexed: 11/22/2022] Open
Abstract
We aimed to determine the histopathological characteristics and prognosis of curatively resected pancreatic ductal adenocarcinoma (PDAC) showing intratumoral necrosis on preoperative CT or MRI. This study consecutively included 102 patients who underwent upfront surgery with margin-negative resection from 2012 to 2020. All patients underwent both pancreatic CT and MRI within 1 month before surgery. Two radiologists independently assessed CT/MRI findings, including the presence of CT- and MRI-detected necrosis. Histopathological characteristics of PDACs according to CT or MRI detection of necrosis were evaluated. Disease-free survival (DFS) and overall survival (OS) were assessed by the Kaplan−Meier method and the Cox proportional hazards model. Among the 102 PDAC patients, 14 patients (13.7%) had CT-detected necrosis, and 16 patients (15.7%) had MRI-detected necrosis, of which 9 showed both CT- and MRI-detected necrosis. PDACs with CT- or MRI-detected necrosis demonstrated a significantly higher degree of histopathological necrosis than those without (p < 0.001). Multivariable analysis revealed that tumor size (hazard ratio [HR], 1.19; p = 0.040), tumor location (HR, 0.46; p = 0.009), and MRI-detected necrosis (HR, 2.64; p = 0.002) had independent associations with DFS. Only MRI-detected necrosis was significantly associated with OS (HR, 2.59; p = 0.004). Therefore, MRI-detected necrosis might be a potential imaging predictor of poor survival after curative resection of PDAC.
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Affiliation(s)
- Hokun Kim
- Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
| | - Dong Hwan Kim
- Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
- Correspondence: ; Tel.: +82-2-2258-1427; Fax: +82-2-599-6771
| | - In Hye Song
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul 05505, Republic of Korea
| | - Bohyun Kim
- Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
| | - Soon Nam Oh
- Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
| | - Joon-Il Choi
- Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
| | - Sung Eun Rha
- Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
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Noda Y, Kawai N, Kaga T, Ishihara T, Hyodo F, Kato H, Kambadakone AR, Matsuo M. Vascular involvement and resectability of pancreatic ductal adenocarcinoma on contrast-enhanced MRI: comparison with pancreatic protocol CT. Abdom Radiol (NY) 2022; 47:2835-2844. [PMID: 35760922 DOI: 10.1007/s00261-022-03581-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/05/2022] [Accepted: 06/06/2022] [Indexed: 01/18/2023]
Abstract
PURPOSE To compare the diagnostic performance for detecting vascular involvement and determining resectability differences regarding pancreatic ductal adenocarcinoma (PDAC) between contrast-enhanced CT and MRI. METHODS This retrospective study evaluated 82 patients (73 years, 46 men) with PDAC who underwent both preoperative contrast-enhanced CT and MRI from January 2008 to March 2021. Two radiologists independently categorized vascular involvements for celiac, superior mesenteric, splenic, and common hepatic arteries, and portal, superior mesenteric, and splenic veins into no tumor contact, solid soft-tissue contact ≤ 180°, or solid soft-tissue contact > 180°. The radiologists also classified resectability into resectable, borderline resectable, or locally advanced. Receiver-operating-characteristic (ROC) analysis was conducted to evaluate the diagnostic performances for detecting vascular involvements which were confirmed by pathological or intraoperative findings. The proportion of resectability classifications was compared between CT and MRI by the Fisher's exact test. RESULTS No statistical difference was found in the diagnostic performances for detecting vascular involvement in CT (area under the ROC curve [AUC], 0.50-0.89) and MRI (AUC, 0.51-0.75) (P = 0.06-> 0.99). Resectability on CT were 79% and 68%, 20% and 26%, and 1% and 6% for resectable, borderline resectable, and locally advanced tumors for reviewers 1 and 2; those on MRI were 87% and 81%, 12% and 13%, and 1% and 6%, respectively. The proportion of resectability classifications was not different between CT and MRI (P = 0.48 and = 0.15 for reviewers 1 and 2, respectively). CONCLUSION The diagnostic performance for detecting vascular involvement and determining resectability of PDAC on contrast-enhanced MRI were comparable with pancreatic protocol CT.
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Affiliation(s)
- Yoshifumi Noda
- Department of Radiology, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan.
| | - Nobuyuki Kawai
- Department of Radiology, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Tetsuro Kaga
- Department of Radiology, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Takuma Ishihara
- Innovative and Clinical Research Promotion Center, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Fuminori Hyodo
- Institute for Advanced Study, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Hiroki Kato
- Department of Radiology, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Avinash R Kambadakone
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, White 270, Boston, MA, 02114, USA
| | - Masayuki Matsuo
- Department of Radiology, Gifu University, 1-1 Yanagido, Gifu, 501-1194, Japan
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Bae JS, Kim JH, Kang HJ, Han JK. Prediction of residual tumor and overall survival after first-line surgery in patients with pancreatic ductal adenocarcinoma using preoperative magnetic resonance imaging findings. Acta Radiol 2022; 63:435-446. [PMID: 33682455 DOI: 10.1177/0284185121999998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Complete resection is the only potentially curative treatment in patients with pancreatic ductal adenocarcinoma (PDA) and is associated with a longer overall survival (OS) than incomplete resection of tumor. Hence, prediction of the resection status after surgery would help predict the prognosis of patients with PDA. PURPOSE To predict residual tumor (R) classification and OS in patients who underwent first-line surgery for PDA using preoperative magnetic resonance imaging (MRI). MATERIAL AND METHODS In this study, 210 patients with PDA who underwent MRI and first-line surgery were randomly categorized into a test group (n=150) and a validation group (n=60). The R classification was divided into R0 (no residual tumor) and R1/R2 (microscopic/macroscopic residual tumor). Preoperative MRI findings associated with R classification and OS were assessed by using logistic regression and Cox proportional hazard models. In addition, the prediction models for the R classification and OS were validated using calibration plots and C statistics. RESULTS On preoperative MRI, portal vein encasement (odds ratio 4.755) was an independent predictor for R1/R2 resection (P=0.040). Tumor size measured on MRI (hazard ratio [HR] per centimeter 1.539) was a predictor of OS, along with pathologic N1 and N2 stage (HR 1.944 and 3.243, respectively), R1/R2 resection (HR 3.273), and adjuvant chemoradiation therapy (HR 0.250) (P<0.050). Calibration plots demonstrated satisfactory predictive performance. CONCLUSION Preoperative MRI was valuable for predicting R1/R2 resection using portal vein encasement. Tumor size measured on MRI was useful for the prediction of OS after first-line surgery for PDA.
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Affiliation(s)
- Jae Seok Bae
- Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jung Hoon Kim
- Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyo-Jin Kang
- Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Joon Koo Han
- Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul, Republic of Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
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Deng Y, Ming B, Wu JL, Zhou T, Zhang SY, Chen Y, Lan C, Zhang XM. Magnetic resonance imaging for preoperative staging of pancreatic cancer based on the 8 th edition of AJCC guidelines. J Gastrointest Oncol 2020; 11:329-336. [PMID: 32399274 DOI: 10.21037/jgo.2020.03.06] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Preoperative staging of pancreatic cancer determines the choice of treatment. Magnetic resonance imaging (MRI) plays an important role in preoperative staging of pancreatic cancer. The American Joint Committee on Cancer (AJCC) TNM staging system was revised to its 8th version in 2016, there has been no report correlating the 8th edition of the AJCC TNM staging with preoperative MRI examinations and pathological findings. The purpose of our study is to determine the staging accuracy and evaluate the resectability by using MRI about pancreatic cancer compared with intraoperative or pathological findings according to the 8th edition of the AJCC TNM staging system. Methods One hundred thirty-two patients with a pathological diagnosis of pancreatic cancer who underwent preoperative MRI were identified. The clinical data, MRI findings and pathological findings were analyzed. Preoperative MRI staging and resectability evaluation were compared with pathological findings. The accuracy of MRI for preoperative T and N staging was evaluated, and the sensitivity, specificity and accuracy of MRI in evaluating the resectability were assessed. All the staging and resectability assessments were according to the 8th edition of the AJCC TNM staging system. Results Analysis showed that the accuracy of MRI for evaluation of the T and N stages was 82.6% (109/132) and 74.2% (98/132), respectively. The sensitivity and specificity of MRI in assessing the resectability were 94.2% and 71.4%, respectively. Integrating the 8th edition of the AJCC TNM stage, no significant differences were identified between the preoperative MRI and pathological results for the staging of pancreatic cancer (P=0.805). Conclusions MRI is highly accurate for T staging and moderately accurate for N staging. MRI provides important preoperative evaluation of the stage and resectability of pancreatic cancer based on the 8th edition of the AJCC TNM staging system.
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Affiliation(s)
- Yan Deng
- Sichuan Key Laboratory of Medical Imaging, Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China
| | - Bing Ming
- Department of Radiology, Deyang People's Hospital, Deyang 618000, China
| | - Jia-Long Wu
- Sichuan Key Laboratory of Medical Imaging, Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China
| | - Ting Zhou
- Sichuan Key Laboratory of Medical Imaging, Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China
| | - Shi-Yong Zhang
- Department of Radiology, Deyang People's Hospital, Deyang 618000, China
| | - Yong Chen
- Sichuan Key Laboratory of Medical Imaging, Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China
| | - Chuan Lan
- Department of Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China
| | - Xiao-Ming Zhang
- Sichuan Key Laboratory of Medical Imaging, Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China
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Elbanna KY, Jang HJ, Kim TK. Imaging diagnosis and staging of pancreatic ductal adenocarcinoma: a comprehensive review. Insights Imaging 2020; 11:58. [PMID: 32335790 PMCID: PMC7183518 DOI: 10.1186/s13244-020-00861-y] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 03/06/2020] [Indexed: 02/06/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) has continued to have a poor prognosis for the last few decades in spite of recent advances in different imaging modalities mainly due to difficulty in early diagnosis and aggressive biological behavior. Early PDAC can be missed on CT due to similar attenuation relative to the normal pancreas, small size, or hidden location in the uncinate process. Tumor resectability and its contingency on the vascular invasion most commonly assessed with multi-phasic thin-slice CT is a continuously changing concept, particularly in the era of frequent neoadjuvant therapy. Coexistent celiac artery stenosis may affect the surgical plan in patients undergoing pancreaticoduodenectomy. In this review, we discuss the challenges related to the imaging of PDAC. These include radiological and clinical subtleties of the tumor, evolving imaging criteria for tumor resectability, preoperative diagnosis of accompanying celiac artery stenosis, and post-neoadjuvant therapy imaging. For each category, the key imaging features and potential pitfalls on cross-sectional imaging will be discussed. Also, we will describe the imaging discriminators of potential mimickers of PDAC.
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Affiliation(s)
- Khaled Y Elbanna
- Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital and Women's College Hospital, University of Toronto, Toronto, ON, Canada.
| | - Hyun-Jung Jang
- Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital and Women's College Hospital, University of Toronto, Toronto, ON, Canada
| | - Tae Kyoung Kim
- Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital and Women's College Hospital, University of Toronto, Toronto, ON, Canada
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Martin-Perez E, Domínguez-Muñoz JE, Botella-Romero F, Cerezo L, Matute Teresa F, Serrano T, Vera R. Multidisciplinary consensus statement on the clinical management of patients with pancreatic cancer. Clin Transl Oncol 2020; 22:1963-1975. [PMID: 32318964 PMCID: PMC7505812 DOI: 10.1007/s12094-020-02350-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 04/01/2020] [Indexed: 12/14/2022]
Abstract
Pancreatic cancer (PC) remains one of the most aggressive tumors with an increasing incidence rate and reduced survival. Although surgical resection is the only potentially curative treatment for PC, only 15–20% of patients are resectable at diagnosis. To select the most appropriate treatment and thus improve outcomes, the diagnostic and therapeutic strategy for each patient with PC should be discussed within a multidisciplinary expert team. Clinical decision-making should be evidence-based, considering the staging of the tumor, the performance status and preferences of the patient. The aim of this guideline is to provide practical and evidence-based recommendations for the management of PC.
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Affiliation(s)
- E Martin-Perez
- Department of Surgery, Hospital Universitario de La Princesa, Diego de Leon 62, 28006, Madrid, Spain.
| | - J E Domínguez-Muñoz
- Department of Gastroenterology and Hepatology, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - F Botella-Romero
- Department of Endocrinology, Hospital General Universitario, Albacete, Spain
| | - L Cerezo
- Department of Radiation Oncology, Hospital Universitario de La Princesa, Madrid, Spain
| | - F Matute Teresa
- Department of Radiology, Hospital Clínico San Carlos, Madrid, Spain
| | - T Serrano
- Department of Pathology, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.,Oncology Program, CIBEREHD National Biomedical Research Institute on Liver and Gastrointestinal Diseases, Instituto de Salud Carlos III, Madrid, Spain
| | - R Vera
- Department of Medical Oncology, Complejo Hospitalario de Navarra, Pamplona, Spain
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Yamada K, Kawashima H, Ohno E, Ishikawa T, Tanaka H, Nakamura M, Miyahara R, Ishigami M, Hirooka Y, Fujishiro M. Diagnosis of vascular invasion in pancreatic ductal adenocarcinoma using endoscopic ultrasound elastography. BMC Gastroenterol 2020; 20:81. [PMID: 32228472 PMCID: PMC7106834 DOI: 10.1186/s12876-020-01228-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/19/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Vascular invasion is an important criterion for resectability and deciding the therapeutic strategy for pancreatic ductal adenocarcinoma (PDAC), but imaging diagnosis is currently difficult. Endoscopic ultrasound (EUS) elastography (EG) images have band-like artifacts on the border between tumor and vessel due to different movement if the tumor is not connected to the vessel, i.e., no invasion. Based on this phenomenon, we assessed the usefulness of EUS-EG in the diagnosis of vascular invasion in PDAC. METHODS The subjects were 44 out of 313 patients with PDAC who underwent EUS between January 2015 and November 2018, followed by surgery, no chemotherapy or radiotherapy, and pathological evaluation. Diagnostic accuracies of vascular invasion using dynamic computed tomography (CT), EUS B-mode and EUS-EG were compared with histopathological diagnosis. RESULTS In 44 subjects (48 sites) who underwent both dynamic CT and EUS-B mode, the sensitivity, specificity and accuracy were 0.733, 0.697 and 0.708 on dynamic CT (48 sites); 0.733, 0.606 and 0.646 in EUS B-mode (48 sites); and 0.917, 0.900 and 0.906 in EUS-EG (32 sites). In 27 subjects (29 sites) with a tumor contacting a vessel with no vascular obstruction or stenosis on dynamic CT, the sensitivity, specificity and accuracy were 0.556, 0.750 and 0.690 on dynamic CT; 0.667, 0.700 and 0.690 in EUS B-mode; and 0.889, 0.850 and 0.862 in EUS-EG. CONCLUSIONS These results suggest that EUS combined with EG improves diagnostic performance of vascular invasion in PDAC, especially in cases of which vascular invasion cannot be clearly assessed by dynamic CT.
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Affiliation(s)
- Kenta Yamada
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Hiroki Kawashima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, 466-8550, Japan.
| | - Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Takuya Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Hiroyuki Tanaka
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Masanao Nakamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Ryoji Miyahara
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Masatoshi Ishigami
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Yoshiki Hirooka
- Department of Liver, Biliary Tract and Pancreas Diseases, Fujita Health University, 1-98 kutsukake-cho dengakekakubo, Toyoake, 470-1192, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, 466-8550, Japan
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Hong SB, Lee SS, Kim JH, Kim HJ, Byun JH, Hong SM, Song KB, Kim SC. Pancreatic Cancer CT: Prediction of Resectability according to NCCN Criteria. Radiology 2018; 289:710-718. [PMID: 30251929 DOI: 10.1148/radiol.2018180628] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Purpose To evaluate the diagnostic performance of CT in the determination of pancreatic cancer resectability according to the National Comprehensive Cancer Network (NCCN) criteria to predict R0 resection. Materials and Methods Structured reports of pancreatic CT clinically prepared by board-certified abdominal radiologists from January 2014 to March 2017 were retrospectively reviewed to assess resectability (resectable, borderline resectable, or unresectable) according to NCCN criteria (version 1.2017) in 616 patients (369 men, 247 women; mean age, 63 years ± 10 [standard deviation]) with pancreatic cancer. Negative resection margin (R0) rates were assessed based on CT resectability status in patients who underwent upfront surgery. R0 resection-associated factors were identified by using logistic regression analysis. Results In 371 patients who underwent surgery, R0 resection rates were 73% (171 of 235), 55% (57 of 104), and 16% (five of 32) for resectable, borderline resectable, and unresectable disease, respectively (P < .001). At multivariable analysis, tumor diameter larger than 4 cm (P < .001) and abutment to the portomesenteric vein (P < .001) were significantly associated with margin-positive resection in patients with resectable disease at CT. R0 resection rates were 80% (123 of 154) for resectable disease without portomesenteric vein abutment, 59% (48 of 81) for resectable disease with portomesenteric vein abutment, 83% (57 of 69) for resectable disease 2 cm or smaller, and 29% (five of 17) for tumors larger than 4 cm. Conclusion CT resectability is used to stratify patients with pancreatic cancer according to the possibility of R0 resection. Larger tumor size and tumor abutment to the portomesenteric vein are associated with margin-positive resection in patients with resectable pancreatic cancer. © RSNA, 2018 Online supplemental material is available for this article. See also the editorial by Fowler in this issue.
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Affiliation(s)
- Seung Baek Hong
- From the Departments of Radiology and Research Institute of Radiology (S.B.H., S.S.L., J.H.K., H.J.K., J.H.B.), Pathology (S.M.H.), and Surgery (K.B.S., S.C.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul 138-736, Korea
| | - Seung Soo Lee
- From the Departments of Radiology and Research Institute of Radiology (S.B.H., S.S.L., J.H.K., H.J.K., J.H.B.), Pathology (S.M.H.), and Surgery (K.B.S., S.C.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul 138-736, Korea
| | - Jin Hee Kim
- From the Departments of Radiology and Research Institute of Radiology (S.B.H., S.S.L., J.H.K., H.J.K., J.H.B.), Pathology (S.M.H.), and Surgery (K.B.S., S.C.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul 138-736, Korea
| | - Hyoung Jung Kim
- From the Departments of Radiology and Research Institute of Radiology (S.B.H., S.S.L., J.H.K., H.J.K., J.H.B.), Pathology (S.M.H.), and Surgery (K.B.S., S.C.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul 138-736, Korea
| | - Jae Ho Byun
- From the Departments of Radiology and Research Institute of Radiology (S.B.H., S.S.L., J.H.K., H.J.K., J.H.B.), Pathology (S.M.H.), and Surgery (K.B.S., S.C.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul 138-736, Korea
| | - Seung Mo Hong
- From the Departments of Radiology and Research Institute of Radiology (S.B.H., S.S.L., J.H.K., H.J.K., J.H.B.), Pathology (S.M.H.), and Surgery (K.B.S., S.C.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul 138-736, Korea
| | - Ki-Byung Song
- From the Departments of Radiology and Research Institute of Radiology (S.B.H., S.S.L., J.H.K., H.J.K., J.H.B.), Pathology (S.M.H.), and Surgery (K.B.S., S.C.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul 138-736, Korea
| | - Song Cheol Kim
- From the Departments of Radiology and Research Institute of Radiology (S.B.H., S.S.L., J.H.K., H.J.K., J.H.B.), Pathology (S.M.H.), and Surgery (K.B.S., S.C.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul 138-736, Korea
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Somers I, Bipat S. Contrast-enhanced CT in determining resectability in patients with pancreatic carcinoma: a meta-analysis of the positive predictive values of CT. Eur Radiol 2017; 27:3408-3435. [PMID: 28093626 PMCID: PMC5491588 DOI: 10.1007/s00330-016-4708-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 11/29/2016] [Accepted: 12/15/2016] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To obtain a summary positive predictive value (sPPV) of contrast-enhanced CT in determining resectability. METHODS The MEDLINE and EMBASE databases from JAN2005 to DEC2015 were searched and checked for inclusion criteria. Data on study design, patient characteristics, imaging techniques, image evaluation, reference standard, time interval between CT and reference standard, and data on resectability/unresectablity were extracted by two reviewers. We used a fixed-effects or random-effects approach to obtain sPPV for resectability. Several subgroups were defined: 1) bolus-triggering versus fixed-timing; 2) pancreatic and portal phases versus portal phase alone; 3) all criteria (liver metastases/lymphnode involvement/local advanced/vascular invasion) versus only vascular invasion as criteria for unresectability. RESULTS Twenty-nine articles were included (2171 patients). Most studies were performed in multicentre settings, initiated by the department of radiology and retrospectively performed. The I2-value was 68%, indicating heterogeneity of data. The sPPV was 81% (95%CI: 75-86%). False positives were mostly liver, peritoneal, or lymphnode metastases. Bolus-triggering had a slightly higher sPPV compared to fixed-timing, 87% (95%CI: 81-91%) versus 78% (95%CI: 66-86%) (p = 0.077). No differences were observed in other subgroups. CONCLUSIONS This meta-analysis showed a sPPV of 81% for predicting resectability by CT, meaning that 19% of patients falsely undergo surgical exploration. KEY POINTS • Predicting resectability of pancreatic cancer by CT is 81% (95%CI: 75-86%). • The percentage of patients falsely undergoing surgical exploration is 19%. • The false positives are liver metastases, peritoneal metastases, or lymph node metastases.
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Affiliation(s)
- Inne Somers
- Department of Radiology, Academic Medical Centre, University of Amsterdam, G1-212, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Shandra Bipat
- Department of Radiology, Academic Medical Centre, University of Amsterdam, G1-212, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Gilabert M, Boher JM, Raoul JL, Paye F, Bachellier P, Turrini O, Delpero JR. Comparison of preoperative imaging and pathological findings for pancreatic head adenocarcinoma: A retrospective analysis by the Association Française de Chirurgie. Medicine (Baltimore) 2017; 96:e7214. [PMID: 28614269 PMCID: PMC5478354 DOI: 10.1097/md.0000000000007214] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 04/27/2017] [Accepted: 05/19/2017] [Indexed: 12/22/2022] Open
Abstract
Initial imaging of pancreatic ductal adenocarcinoma is of crucial importance in the decision-making process. The aim of this study was to compare preoperative imaging, pathological data, and outcomes in a series of patients who underwent resection for pancreatic head cancer.From January 2004 to December 2009, data were collected by the Association Française de Chirurgie on 1044 patients who received first-line R0 resection of pancreatic head cancer.On imaging (computed tomography scan 97%, echoendoscopic ultrasound 61.3%, magnetic resonance imaging 46.5%), arterial, venous, or lymph node invasion was suspected in 20, 161, and 197 patients, respectively; arterial, venous, or lymph node invasion was observed histologically in 11, 116, and 736 cases, respectively. In the patients for whom both imaging and pathological data were available, the concordance, sensitivity, specificity, positive predictive value, and negative predictive value were as follows: 97.5%, 27.3%, 98%, 20%, and 99%, for arterial invasion; 86.5%, 54%, 91%, 47.8%, and 93.2%, for venous invasion; and 38%, 21%, 86%, 78%, and 41%, respectively, for lymph node invasion. Imaging of arterial invasion had no prognostic value, while histological evidence of invasion was associated with a poor prognosis. Venous and lymph node invasion, as demonstrated by imaging and by pathological analysis, had an adverse prognostic value.Imaging gives a fair positive predictive value for venous or arterial invasion; venous invasion on imaging and histology was associated with a poor prognosis; arterial invasion on imaging does not have any significant prognostic value.
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Affiliation(s)
| | - Jean-Marie Boher
- Clinical Trial Office and Biostatistics Unit, Paoli-Calmettes Institute, Marseille
| | - Jean-Luc Raoul
- Department of Medical Oncology, Paoli-Calmettes Institute
| | - François Paye
- Department of Digestive Surgery, Hôpital Saint-Antoine, Paris
| | - Philippe Bachellier
- Hepatobiliary Surgery and Liver Transplantation, Hôpital Universitaire de Strasbourg, Strasbourg
| | - Olivier Turrini
- Department of Digestive Surgery, Paoli-Calmettes Institute, Marseille, France
| | - Jean Robert Delpero
- Department of Digestive Surgery, Paoli-Calmettes Institute, Marseille, France
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Yeh R, Steinman J, Luk L, Kluger MD, Hecht EM. Imaging of pancreatic cancer: what the surgeon wants to know. Clin Imaging 2017; 42:203-217. [DOI: 10.1016/j.clinimag.2016.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 09/14/2016] [Accepted: 10/03/2016] [Indexed: 02/07/2023]
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Prediction of Vascular Invasion Using a 3-Point Scale Computed Tomography Grading System in Pancreatic Ductal Adenocarcinoma: Correlation With Surgery. J Comput Assist Tomogr 2016; 41:394-400. [PMID: 27798447 DOI: 10.1097/rct.0000000000000530] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the correlation between a 3-point scale multidetector computed tomography (MDCT) grading system and surgical exploration in predicting vascular invasion and resectability in patients with pancreatic ductal adenocarcinoma (PDA). METHODS Fifty-five patients with surgical and pathologic confirmation of PDA were retrospectively analyzed by 3 radiologists independently. All patients had MDCT examination with multiplanar reformatted images, computed tomography (CT) angiography, and negative-contrast CT cholangiopancreatography (nCTCP). A 3-point scale CT grading system and criteria for unresectability adopting the latest guidelines were used in predicting the correlation between the invasion and resectability of 5 peripancreatic vessels and surgical grade and pathology. RESULTS Tumor location was correctly identified in all patients including 2 isodense lesions by means of nCTCP. The mean sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MDCT were 92%, 83%, 95%, 78%, and 90%, respectively, in predicting tumor resectability compared with surgery and pathology and with good agreement (κ = 0.72-0.77). A correlation was observed between CT and surgical grade in predicting vascular invasion on a per-vessel basis, and the agreement presented as good to excellent (κ = 0.66-1.00). CONCLUSIONS A 3-point scale CT grading system is a simple and practical method in predicting peripancreatic vessel invasion and, importantly, correlates with surgical grade and pathology. Axial images combined with multiplanar reformation, nCTCP, and CT angiography can strengthen the comprehensive evaluation of PDA for resectability.
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Tamburrino D, Riviere D, Yaghoobi M, Davidson BR, Gurusamy KS, Cochrane Upper GI and Pancreatic Diseases Group. Diagnostic accuracy of different imaging modalities following computed tomography (CT) scanning for assessing the resectability with curative intent in pancreatic and periampullary cancer. Cochrane Database Syst Rev 2016; 9:CD011515. [PMID: 27631326 PMCID: PMC6457597 DOI: 10.1002/14651858.cd011515.pub2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Periampullary cancer includes cancer of the head and neck of the pancreas, cancer of the distal end of the bile duct, cancer of the ampulla of Vater, and cancer of the second part of the duodenum. Surgical resection is the only established potentially curative treatment for pancreatic and periampullary cancer. A considerable proportion of patients undergo unnecessary laparotomy because of underestimation of the extent of the cancer on computed tomography (CT) scanning. Other imaging methods such as magnetic resonance imaging (MRI), positron emission tomography (PET), PET-CT, and endoscopic ultrasound (EUS) have been used to detect local invasion or distant metastases not visualised on CT scanning which could prevent unnecessary laparotomy. No systematic review or meta-analysis has examined the role of different imaging modalities in assessing the resectability with curative intent in patients with pancreatic and periampullary cancer. OBJECTIVES To determine the diagnostic accuracy of MRI, PET scan, and EUS performed as an add-on test or PET-CT as a replacement test to CT scanning in detecting curative resectability in pancreatic and periampullary cancer. SEARCH METHODS We searched MEDLINE, Embase, Science Citation Index Expanded, and Health Technology Assessment (HTA) databases up to 5 November 2015. Two review authors independently screened the references and selected the studies for inclusion. We also searched for articles related to the included studies by performing the "related search" function in MEDLINE (OvidSP) and Embase (OvidSP) and a "citing reference" search (by searching the articles that cite the included articles). SELECTION CRITERIA We included diagnostic accuracy studies of MRI, PET scan, PET-CT, and EUS in patients with potentially resectable pancreatic and periampullary cancer on CT scan. We accepted any criteria of resectability used in the studies. We included studies irrespective of language, publication status, or study design (prospective or retrospective). We excluded case-control studies. DATA COLLECTION AND ANALYSIS Two review authors independently performed data extraction and quality assessment using the QUADAS-2 (quality assessment of diagnostic accuracy studies - 2) tool. Although we planned to use bivariate methods for analysis of sensitivities and specificities, we were able to fit only the univariate fixed-effect models for both sensitivity and specificity because of the paucity of data. We calculated the probability of unresectability in patients who had a positive index test (post-test probability of unresectability in people with a positive test result) and in those with negative index test (post-test probability of unresectability in people with a positive test result) using the mean probability of unresectability (pre-test probability) from the included studies and the positive and negative likelihood ratios derived from the model. The difference between the pre-test and post-test probabilities gave the overall added value of the index test compared to the standard practice of CT scan staging alone. MAIN RESULTS Only two studies (34 participants) met the inclusion criteria of this systematic review. Both studies evaluated the diagnostic test accuracy of EUS in assessing the resectability with curative intent in pancreatic cancers. There was low concerns about applicability for most domains in both studies. The overall risk of bias was low in one study and unclear or high in the second study. The mean probability of unresectable disease after CT scan across studies was 60.5% (that is 61 out of 100 patients who had resectable cancer after CT scan had unresectable disease on laparotomy). The summary estimate of sensitivity of EUS for unresectability was 0.87 (95% confidence interval (CI) 0.54 to 0.97) and the summary estimate of specificity for unresectability was 0.80 (95% CI 0.40 to 0.96). The positive likelihood ratio and negative likelihood ratio were 4.3 (95% CI 1.0 to 18.6) and 0.2 (95% CI 0.0 to 0.8) respectively. At the mean pre-test probability of 60.5%, the post-test probability of unresectable disease for people with a positive EUS (EUS indicating unresectability) was 86.9% (95% CI 60.9% to 96.6%) and the post-test probability of unresectable disease for people with a negative EUS (EUS indicating resectability) was 20.0% (5.1% to 53.7%). This means that 13% of people (95% CI 3% to 39%) with positive EUS have potentially resectable cancer and 20% (5% to 53%) of people with negative EUS have unresectable cancer. AUTHORS' CONCLUSIONS Based on two small studies, there is significant uncertainty in the utility of EUS in people with pancreatic cancer found to have resectable disease on CT scan. No studies have assessed the utility of EUS in people with periampullary cancer.There is no evidence to suggest that it should be performed routinely in people with pancreatic cancer or periampullary cancer found to have resectable disease on CT scan.
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Affiliation(s)
| | - Deniece Riviere
- Radboud University Medical Center NijmegenDepartment of SurgeryGeert Grooteplein Zuid 10route 618Nijmegen6500 HBNetherlandsP.O. Box 9101
| | - Mohammad Yaghoobi
- McMaster University and McMaster University Health Sciences CentreDivision of Gastroenterology1200 Main Street WestHamiltonONCanada
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryPond StreetLondonUKNW3 2QG
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Lee JH, Cassani LS, Bhosale P, Ross WA. The endoscopist's role in the diagnosis and management of pancreatic cancer. Expert Rev Gastroenterol Hepatol 2016; 10:1027-39. [PMID: 27087265 DOI: 10.1080/17474124.2016.1176910] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pancreatic cancer remains one of the most lethal malignancies with little improvement in survival over the past several decades in spite of advances in imaging, risk factor identification, surgical technique and chemotherapy. This disappointing outcome is mainly due to failures to make an early diagnosis. In fact, the majority of the patients present with inoperable advanced stages of the disease. Though some of the new tumor markers are promising, we are still in search of the one that has a high sensitivity and accuracy, yet is inexpensive and easy to obtain. The paradigm of management has shifted from up-front surgery followed by adjuvant chemotherapy to neoadjuvant chemoradiation followed by surgery, especially for borderline resectable cancers and even for some resectable cancers. In this article, we will critically assess the limitations of tumor markers and review the advancements in endoscopic techniques in the management of pancreatic cancer.
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Affiliation(s)
- Jeffrey H Lee
- a Department of Gastroenterology, Hepatology, and Nutrition , MD Anderson Cancer Center , Houston , TX , USA
| | - Lisa S Cassani
- b Division of Digestive Diseases, Department of Medicine , Emory University School of Medicine , Atlanta , GA , USA
| | - Priya Bhosale
- c Department of Radiology , MD Anderson Cancer Center , Houston , TX , USA
| | - William A Ross
- a Department of Gastroenterology, Hepatology, and Nutrition , MD Anderson Cancer Center , Houston , TX , USA
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Abstract
Imaging tests are central to the diagnosis and staging of pancreatic adenocarcinoma. We performed a systematic review and meta-analysis of the pertinent evidence on 5 imaging tests (computed tomography (CT), magnetic resonance imaging, CT angiography, endoscopic ultrasound with fine-needle aspiration, and combined positron emission tomography with CT). Searches of several databases up to March 1, 2014, yielded 9776 articles, and 24 provided comparative effectiveness of 2 or more imaging tests. Multiple reviewers applied study inclusion criteria, extracted data from each study, rated the risk of bias, and graded the strength of evidence. Data included accuracy of diagnosis and resectability in primary untreated pancreatic adenocarcinoma, including tumor stage, nodal stage, metastases, and vascular involvement. Where possible, study results were combined using bivariate meta-analysis. Studies were at low or moderate risk of bias. Most comparisons between imaging tests were insufficient to permit conclusions, due to imprecision or inconsistency among study results. However, moderate-grade evidence revealed that CT and magnetic resonance imaging had similar sensitivities and specificities for both diagnosis and vascular involvement. Other conclusions were based on low-grade evidence. In general, more direct evidence is needed to inform decisions about imaging tests for pancreatic adenocarcinoma.
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Presurgical Evaluation of Pancreatic Cancer: A Comprehensive Imaging Comparison of CT Versus MRI. AJR Am J Roentgenol 2016; 206:526-35. [PMID: 26901008 DOI: 10.2214/ajr.15.15236] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The purpose of this study was to compare comprehensive CT and MRI in the presurgical evaluation of pancreatic cancer. MATERIALS AND METHODS Thirty-eight patients with pathologically proven pancreatic cancer were included in a retrospective study. CT with negative-contrast CT cholangiopancreatography and CT angiography (CTA) (CT image set) versus MRI with MRCP and MR angiography (MRI image set) were analyzed independently by two reviewers for tumor detection, extension, metastasis, vascular invasion, and resectability. These results were compared with the surgical and pathologic findings. RESULTS The rate of detection of tumors was higher with MRI than with CT but not significantly so (reviewer 1, p = 1.000; reviewer 2, p = 0.500). In the evaluation of vessel involvement, nodal status, and resectability, although CT had higher ROC AUC values than did MRI (reviewer 1, 0.913 vs 0.858, 0.613 vs 0.503, and 0.866 vs 0.774; reviewer 2, 0.879 vs 0.849, 0.640 vs 0.583, and 0.830 vs 0.815), the differences were not statistically significant (p = 0.189 vs 0.494, 0.328 vs 0.244, and 0.193 vs 0.813 for reviewers 1 and 2). In the evaluation of tumor extension and organ metastases in the 38 patients, correct diagnosis of one of two liver metastases was achieved with both image sets, one case of omental and one case of peritoneal seeding were underestimated, and one case of stomach invasion was overestimated. CONCLUSION MRI and CT had similar performance in the presurgical evaluation of pancreatic cancer.
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Krishnamurthy R, Malone L, Lyons K, Ketwaroo P, Dodd N, Ashton D. Body MR angiography in children: how we do it. Pediatr Radiol 2016; 46:748-63. [PMID: 27229494 DOI: 10.1007/s00247-016-3614-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 03/03/2016] [Accepted: 03/18/2016] [Indexed: 10/21/2022]
Abstract
Vascular pathology is ubiquitous in children. Common indications for angiographic imaging in the body include congenital anomalies, portal hypertension, assessing resectability of neoplasms, renovascular hypertension, vascular malformations, vasculitis, systemic vein thrombosis, and trauma. MR angiography, with or without the use of intravenous contrast agents, is therefore a mainstay in the repertoire of MR imaging in children. Pediatric contrast-enhanced MR angiography has benefited from several innovations in recent years, including improved hardware options like high-field-strength scanners and integrated high-density coil arrays, new sequences that combine parallel imaging, innovative k-space sampling and Dixon fat suppression with time-resolved imaging, new contrast agents with longer blood-pool residence time, and advanced post-processing solutions like image fusion. This article focuses on the principles of contrast-enhanced MR angiography of the body as it pertains to the physiologies and pathologies encountered in children. It also discusses tools to adapt the MR angiographic technique to the clinical indication, as well as pitfalls of post-processing and interpretation in commonly encountered vascular imaging scenarios in the pediatric body.
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Affiliation(s)
- Rajesh Krishnamurthy
- EB Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin St., Suite 1280, Houston, TX, 77030, USA. .,Department of Radiology and Pediatrics, Baylor College of Medicine, Houston, TX, USA.
| | - LaDonna Malone
- Department of Radiology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Karen Lyons
- Department of Radiology, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Pamela Ketwaroo
- EB Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin St., Suite 1280, Houston, TX, 77030, USA
| | - Nicholas Dodd
- EB Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin St., Suite 1280, Houston, TX, 77030, USA
| | - Daniel Ashton
- EB Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin St., Suite 1280, Houston, TX, 77030, USA
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McDonald N, Ahmad S, Ann Choe K. Knowing Your Boundaries: A Review of the Definitions and Imaging Features of Borderline Resectable Pancreatic Carcinoma. Semin Roentgenol 2016; 51:82-7. [PMID: 27105962 DOI: 10.1053/j.ro.2016.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Nicholas McDonald
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Syed Ahmad
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kyuran Ann Choe
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH.
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Abstract
Surgical resection remains the only potentially curative therapy for pancreatic cancer, despite a high rate of systemic recurrence. Because of local invasion or distant spread, a minority of patients presenting with pancreatic cancer are candidates for surgery. Although perioperative mortality is low in high-volume settings, pancreatic surgery remains associated with considerable morbidity. Minimally invasive and robotic surgical techniques are increasingly used for pancreatic resection, although not always applicable to all patients. Strategies to extend the benefits of margin-negative surgical resection to more patients include surgery with vascular resection and reconstruction for locally invasive tumors, and resection after neoadjuvant therapy.
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Affiliation(s)
- Thomas E Clancy
- Division of Surgical Oncology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA; Pancreas and Biliary Tumor Center, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA 02115-5450, USA; Harvard Medical School, Boston, MA 02115, USA.
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An Update of Clinical CT Imaging of Pancreatic Neoplasm: Tips, Tricks, and Pitfalls. CURRENT RADIOLOGY REPORTS 2015. [DOI: 10.1007/s40134-015-0104-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Yang R, Lu M, Qian X, Chen J, Li L, Wang J, Zhang Y. Diagnostic accuracy of EUS and CT of vascular invasion in pancreatic cancer: a systematic review. J Cancer Res Clin Oncol 2014; 140:2077-86. [PMID: 24916170 DOI: 10.1007/s00432-014-1728-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 05/30/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of this study was to summarize the accuracy of preoperative vascular invasion with endoscopic ultrasound (EUS) and computed tomography (CT) test performance in pancreatic cancer with meta-analysis METHOD Two reviewers searched MEDLINE database to identify relevant studies. The reference lists of the trials were manually searched. Included studies used surgical and/or histological findings as the "gold standard," and provided sufficient data to construct a diagnostic 2 × 2 table. A statistical program of Meta-Disc was used to calculate the pooled sensitivity, specificity, positive LR, negative LR, DOR, and the SROC curve. Publication bias was assessed by Deeks' asymmetry test. Sensitivity analysis and subgroup analysis were calculated to down the heterogeneity. Meta-regression was calculated to evaluate potential sources of heterogeneity RESULT A total of 30 studies with 1,554 patients were included for the analysis, nine of these studies compared EUS with CT to assess the diagnostic efficiency The pooled sensitivity of EUS and CT was 72 % (95 % CI 67-77 %) and 63 % (95 % CI 58-67 %), and the pooled specificity of EUS and CT was 89 % (95 % CI 86-92 %) and 92 % (95 % CI 90-94 %), respectively. The positive LR of EUS and CT was 5.14 (95 % CI 3.14-8.40) and 6.21 (95 % CI 3.96-9.71), and the negative LR was 0.36 (95 % CI 0.25-0.52) and 0.41 (95 % CI 0.31-0.55), respectively. The AUCs of EUS and CT were 0.9037 and 0.8948. The subgroup analysis of nine studies performed both EUS and CT showed CT scan with a lower sensitivity of 48 % (95 % CI 0.40-0.56), when compared to EUS of 69 % (95 % CI 0.61-0.77). The overall AUCs of CT scan appear to be lower (AUCs = 0.8589), compared with EUS (AUCs = 0.9379) CONCLUSION: EUS performed better than CT in differentiating vascular invasion preoperative on pancreatic cancer. EUS could provide other additional information when compared with CT.
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Affiliation(s)
- RenBao Yang
- Department of General Surgery, Anhui Medical University Affiliated HeFei Hospital, Hefei Second People's Hospital, Hefei, 230011, China,
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Okano K, Suzuki Y. Strategies for early detection of resectable pancreatic cancer. World J Gastroenterol 2014; 20:11230-11240. [PMID: 25170207 PMCID: PMC4145761 DOI: 10.3748/wjg.v20.i32.11230] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 02/14/2014] [Accepted: 04/16/2014] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer is difficult to diagnose at an early stage and generally has a poor prognosis. Surgical resection is the only potentially curative treatment for pancreatic carcinoma. To improve the prognosis of this disease, it is essential to detect tumors at early stages, when they are resectable. The optimal approach to screening for early pancreatic neoplasia has not been established. The International Cancer of the Pancreas Screening Consortium has recently finalized several recommendations regarding the management of patients who are at an increased risk of familial pancreatic cancer. In addition, there have been notable advances in research on serum markers, tissue markers, gene signatures, and genomic targets of pancreatic cancer. To date, however, no biomarkers have been established in the clinical setting. Advancements in imaging modalities touch all aspects of the clinical management of pancreatic diseases, including the early detection of pancreatic masses, their characterization, and evaluations of tumor resectability. This article reviews strategies for screening high-risk groups, biomarkers, and current advances in imaging modalities for the early detection of resectable pancreatic cancer.
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Lee ES, Lee JM. Imaging diagnosis of pancreatic cancer: A state-of-the-art review. World J Gastroenterol 2014; 20:7864-7877. [PMID: 24976723 PMCID: PMC4069314 DOI: 10.3748/wjg.v20.i24.7864] [Citation(s) in RCA: 244] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 12/13/2013] [Accepted: 01/05/2014] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer (PC) remains one of the deadliest cancers worldwide, and has a poor, five-year survival rate of 5%. Although complete surgical resection is the only curative therapy for pancreatic cancer, less than 20% of newly-diagnosed patients undergo surgical resection with a curative intent. Due to the lack of early symptoms and the tendency of pancreatic adenocarcinoma to invade adjacent structures or to metastasize at an early stage, many patients with pancreatic cancer already have advanced disease at the time of their diagnosis and, therefore, there is a high mortality rate. To improve the patient survival rate, early detection of PC is critical. The diagnosis of PC relies on computed tomography (CT) and/or magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP), or biopsy or fine-needle aspiration using endoscopic ultrasound (EUS). Although multi-detector row computed tomography currently has a major role in the evaluation of PC, MRI with MRCP facilitates better detection of tumors at an early stage by allowing a comprehensive analysis of the morphological changes of the pancreas parenchyma and pancreatic duct. The diagnosis could be improved using positron emission tomography techniques in special conditions in which CT and EUS are not completely diagnostic. It is essential for clinicians to understand the advantages and disadvantages of the various pancreatic imaging modalities in order to be able to make optimal treatment and management decisions. Our study investigates the current role and innovative techniques of pancreatic imaging focused on the detection of pancreatic cancer.
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Liles JS, Katz MHG. Pancreaticoduodenectomy with vascular resection for pancreatic head adenocarcinoma. Expert Rev Anticancer Ther 2014; 14:919-29. [PMID: 24833085 DOI: 10.1586/14737140.2014.919860] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Traditionally, pancreatic ductal adenocarcinoma with regional vascular involvement was thought to represent unresectable disease and was associated with disease progression and death within 1 year of diagnosis. Recent evidence demonstrates that pancreaticoduodenectomy with vascular resection and reconstruction can be safely performed in select patients with 5-year survival rates as high as 20%. In order to safely treat and to optimize survival in these complex patients, it is essential to accurately identify vascular involvement preoperatively, to utilize a multidisciplinary treatment approach, and to emphasize meticulous surgical technique with awareness of the critical margins of resection.
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Affiliation(s)
- Joe Spencer Liles
- Department of Surgical Oncology, Division of Surgery, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, FCT17.6000, Houston, TX 77030, USA
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Sabater L, García-Granero A, Escrig-Sos J, Gómez-Mateo MDC, Sastre J, Ferrández A, Ortega J. Outcome Quality Standards in Pancreatic Oncologic Surgery. Ann Surg Oncol 2014; 21:1138-46. [DOI: 10.1245/s10434-013-3451-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Indexed: 12/16/2022]
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Tamm EP, Bhosale PR, Vikram R, de Almeida Marcal LP, Balachandran A. Imaging of pancreatic ductal adenocarcinoma: State of the art. World J Radiol 2013. [PMID: 23671746 DOI: 10.4329/wjr.v5.i3.9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Significant advances in imaging technology have changed the management of pancreatic cancer. In computed tomography (CT), this has included development of multidetector row, rapid, thin-section imaging that has also facilitated the advent of advanced reconstructions, which in turn has offered new perspectives from which to evaluate this disease. In magnetic resonance imaging, advances including higher field strengths, thin-section volumetric acquisitions, diffusion weighted imaging, and liver specific contrast agents have also resulted in new tools for diagnosis and staging. Endoscopic ultrasound has resulted in the ability to provide high-resolution imaging rivaling intraoperative ultrasound, along with the ability to biopsy via real time imaging suspected pancreatic lesions. Positron emission tomography with CT, while still evolving in its role, provides whole body staging as well as the unique imaging characteristic of metabolic activity to aid disease management. This article will review these modalities in the diagnosis and staging of pancreatic cancer.
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Affiliation(s)
- Eric Peter Tamm
- Eric Peter Tamm, Priya Ranjit Bhosale, Raghu Vikram, Leonardo Pimentel de Almeida Marcal, Aparna Balachandran, Department of Diagnostic Radiology, Division of Diagnostic Imaging, University of Texas, MD Anderson Cancer Center, Houston, TX 77230-1402, United States
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Tumor Size on Abdominal MRI Versus Pathologic Specimen in Resected Pancreatic Adenocarcinoma: Implications for Radiation Treatment Planning. Int J Radiat Oncol Biol Phys 2013; 86:102-7. [DOI: 10.1016/j.ijrobp.2012.11.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 10/26/2012] [Accepted: 11/11/2012] [Indexed: 02/07/2023]
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Tamm EP, Bhosale PR, Vikram R, de Almeida Marcal LP, Balachandran A. Imaging of pancreatic ductal adenocarcinoma: State of the art. World J Radiol 2013; 5:98-105. [PMID: 23671746 PMCID: PMC3650210 DOI: 10.4329/wjr.v5.i3.98] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Revised: 09/22/2012] [Accepted: 09/29/2012] [Indexed: 02/06/2023] Open
Abstract
Significant advances in imaging technology have changed the management of pancreatic cancer. In computed tomography (CT), this has included development of multidetector row, rapid, thin-section imaging that has also facilitated the advent of advanced reconstructions, which in turn has offered new perspectives from which to evaluate this disease. In magnetic resonance imaging, advances including higher field strengths, thin-section volumetric acquisitions, diffusion weighted imaging, and liver specific contrast agents have also resulted in new tools for diagnosis and staging. Endoscopic ultrasound has resulted in the ability to provide high-resolution imaging rivaling intraoperative ultrasound, along with the ability to biopsy via real time imaging suspected pancreatic lesions. Positron emission tomography with CT, while still evolving in its role, provides whole body staging as well as the unique imaging characteristic of metabolic activity to aid disease management. This article will review these modalities in the diagnosis and staging of pancreatic cancer.
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Abstract
Accurate staging of pancreatic cancer is essential in order to select patients, which are candidates for curative resection. Multidetector computed tomography is the best imaging for determination of pancreatic cancer loco regional and distal resectability. Endoscopic ultra sonography has complementary role in small tumours. It can guide regional lymph node puncture for accurate staging. Magnetic resonance with MR angiography can be helpful in determining vascular respectability of pancreatic cancer. The use of laparoscopy with laparoscopic ultrasound has been increased last years in order to avoid unnecessary laparotomy. Positron emission tomography may be useful tool for diagnosing occult metastatic disease. It is still in evaluation.
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Shrikhande SV, Barreto SG, Goel M, Arya S. Multimodality imaging of pancreatic ductal adenocarcinoma: a review of the literature. HPB (Oxford) 2012; 14:658-668. [PMID: 22954001 PMCID: PMC3461371 DOI: 10.1111/j.1477-2574.2012.00508.x] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Accepted: 05/16/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Accurate pre-operative imaging in pancreatic cancer helps avoid unsuccessful surgical explorations and forewarns surgeons regarding aberrant anatomy. This review aimed to determine the role of current imaging modalities in the diagnosis and determination of resectability of pancreatic and peri-ampullary adenocarcinomas. METHODS A systematic search of the scientific literature was carried out using EMBASE, PubMed/MEDLINE and the Cochrane Central Register of Controlled Trials for the years 1990 to 2011 to obtain access to all publications, especially randomized controlled trials, reporting on the diagnostic accuracy of ultrasonography, multi-detector computed tomography (MDCT), magnetic resonance imaging (MRI), endoscopic ultrasonography (EUS) or positron emission tomography (PET)-computed tomography (CT) and the evaluation of resectability of pancreatic and peri-ampullary adenocarcinomas. RESULTS Based on 66 articles analysed in the review, MDCT and MRI/MRCP have comparable sensitivity and specificity rates for diagnosis and staging of pancreatic cancers. EUS offers the best sensitivity and specificity rates for lesions <2 cm. Improved staging has been noted when PET-CT scans are added to pre-operative evaluation. CONCLUSIONS MDCT with angiography or MRI/MRCP should constitute the first imaging modality in suspected pancreatic adenocarcinomas. EUS is recommended for assessing lesions not clearly detected, but suspected, on CT/MRI and in tumours considered 'borderline resectable' on MDCT to assess vascular involvement. PET-CT in locally advanced lesions will help rule out distant metastases.
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Affiliation(s)
- Shailesh V Shrikhande
- Departments of Hepato-Pancreato-Biliary Surgical Oncology Radiology, Tata Memorial Hospital, Mumbai, India.
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Conrad C, Fernández-Del Castillo C. Preoperative evaluation and management of the pancreatic head mass. J Surg Oncol 2012; 107:23-32. [PMID: 22674403 DOI: 10.1002/jso.23165] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2012] [Accepted: 05/01/2012] [Indexed: 12/16/2022]
Abstract
The differential diagnosis of a pancreatic head mass encompasses a wide range of clinical entities that include both solid and cystic lesions. This chapter focuses on our approach to the patient presenting with a newly found pancreatic head mass with the main goals of determining the risk of the lesion being malignant or premalignant, resectability if the patient is appropriate for surgical intervention, assessment of need for multimodality treatment and determination the patient's surgical risk.
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Affiliation(s)
- Claudius Conrad
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 021114, USA.
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Truty MJ, Thomas RM, Katz MH, Vauthey JN, Crane C, Varadhachary GR, Wolff RA, Abbruzzese JL, Lee JE, Fleming JB. Multimodality therapy offers a chance for cure in patients with pancreatic adenocarcinoma deemed unresectable at first operative exploration. J Am Coll Surg 2012; 215:41-51; discussion 51-2. [PMID: 22608401 DOI: 10.1016/j.jamcollsurg.2012.03.024] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 03/21/2012] [Accepted: 03/21/2012] [Indexed: 12/18/2022]
Abstract
BACKGROUND Patients identified at surgical exploration with unresectable pancreatic ductal adenocarcinoma receive palliative, noncurative therapy. We hypothesized that accurate radiographic restaging, multimodality treatment, and advanced surgical technique can offer patients deemed unresectable at previous exploration the possibility for curative salvage pancreatectomy. STUDY DESIGN Review of a prospectively maintained pancreatic ductal adenocarcinoma database identified all patients (1990 to 2010) evaluated after being deemed unresectable at first exploration elsewhere. Referring hospitals were categorized per National Cancer Data Base criteria as academic, community, or international. Patients were restaged using objective imaging (CT) criteria and classified based on anatomic resectability. Clinicopathologic factors and cancer-related outcomes were assessed. RESULTS We evaluated 88 patients who underwent previously unsuccessful resection attempts at academic (n = 50), community (n = 25), and international (n = 13) centers. Radiographic restaging confirmed that 7 (8%) patient tumors were locally advanced and unresectable, but 81 (92%) were resectable (n = 61) or borderline resectable (n = 20). Using a surgery first (9%) or preoperative chemoradiation (91%) approach, successful reoperative pancreatectomy was performed in 66 (81%) patients, with 94% receiving R0 resections. Vascular resection/reconstruction was required in 30 (46%) patients and 50 (76%) required complex revision of previously created biliary/gastrointestinal bypass. The major complication rate was 20% and 3 (4.5%) patients died perioperatively. Median overall survival was 29.6 months for successfully resected patients vs 10.6 and 5.1 months (p < 0.0001) for those patients with locally advanced unresectable disease at initial referral or in whom metastatic disease developed before resection, respectively. CONCLUSIONS In this very selected cohort of high-risk patients, the majority had anatomically resectable tumors on restaging. Accurate radiographic restaging, a multimodality treatment strategy, and advanced surgical techniques can provide an opportunity for cure in a substantial proportion of select patients who were deemed unresectable at exploration.
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Affiliation(s)
- Mark J Truty
- Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX 77030, USA
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Truty MJ, Thomas RM, Katz MH, Vauthey JN, Crane C, Varadhachary GR, Wolff RA, Abbruzzese JL, Lee JE, Fleming JB. Multimodality therapy offers a chance for cure in patients with pancreatic adenocarcinoma deemed unresectable at first operative exploration. J Am Coll Surg 2012. [PMID: 22608401 DOI: 10.1016/j.jamcollsurg.2012.03.024.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2022]
Abstract
BACKGROUND Patients identified at surgical exploration with unresectable pancreatic ductal adenocarcinoma receive palliative, noncurative therapy. We hypothesized that accurate radiographic restaging, multimodality treatment, and advanced surgical technique can offer patients deemed unresectable at previous exploration the possibility for curative salvage pancreatectomy. STUDY DESIGN Review of a prospectively maintained pancreatic ductal adenocarcinoma database identified all patients (1990 to 2010) evaluated after being deemed unresectable at first exploration elsewhere. Referring hospitals were categorized per National Cancer Data Base criteria as academic, community, or international. Patients were restaged using objective imaging (CT) criteria and classified based on anatomic resectability. Clinicopathologic factors and cancer-related outcomes were assessed. RESULTS We evaluated 88 patients who underwent previously unsuccessful resection attempts at academic (n = 50), community (n = 25), and international (n = 13) centers. Radiographic restaging confirmed that 7 (8%) patient tumors were locally advanced and unresectable, but 81 (92%) were resectable (n = 61) or borderline resectable (n = 20). Using a surgery first (9%) or preoperative chemoradiation (91%) approach, successful reoperative pancreatectomy was performed in 66 (81%) patients, with 94% receiving R0 resections. Vascular resection/reconstruction was required in 30 (46%) patients and 50 (76%) required complex revision of previously created biliary/gastrointestinal bypass. The major complication rate was 20% and 3 (4.5%) patients died perioperatively. Median overall survival was 29.6 months for successfully resected patients vs 10.6 and 5.1 months (p < 0.0001) for those patients with locally advanced unresectable disease at initial referral or in whom metastatic disease developed before resection, respectively. CONCLUSIONS In this very selected cohort of high-risk patients, the majority had anatomically resectable tumors on restaging. Accurate radiographic restaging, a multimodality treatment strategy, and advanced surgical techniques can provide an opportunity for cure in a substantial proportion of select patients who were deemed unresectable at exploration.
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Affiliation(s)
- Mark J Truty
- Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX 77030, USA
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Zhang Y, Huang J, Chen M, Jiao LR. Preoperative vascular evaluation with computed tomography and magnetic resonance imaging for pancreatic cancer: a meta-analysis. Pancreatology 2012; 12:227-33. [PMID: 22687378 DOI: 10.1016/j.pan.2012.03.057] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Revised: 03/28/2012] [Accepted: 03/29/2012] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Vascular invasion (VI) is the most important factor in assessing operability for pancreatic cancer. The accuracy of preoperative vascular staging with computed tomography (CT) and magnetic resonance imaging (MRI) was examined using meta-analysis. METHODS Published articles in pancreatic cancer comparing diagnostic accuracy of CT with MRI for VI confirmed on histology were searched from MEDLINE, EMBASE and ISI Web of Science databases. Pooled sensitivity, specificity, likelihood ratio, summary receiver operating characteristic (SROC) curve and area under curve (AUC) were analysed by SPSS 13.0 and Revmen 5.1. RESULTS Eight studies (n = 296) met the inclusion criteria. The pooled sensitivity of CT and MRI in diagnosing VI was 71% (95% CI, 64-78) and 67% (95% CI, 59-74), pooled specificity 92% (95% CI, 89-95) and 94% (95% CI, 91-96), positive likelihood ratio 6.33 (95% CI, 4.51-8.87) and 6.58 (95% CI, 4.62-9.37), negative likelihood ratio 0.34 (95% CI, 0.27-0.43) and 0.38 (95% CI, 0.30-0.47), and AUCs 0.87 and 0.76 (p = 0.63), respectively. There was no significant difference between CT and MRI for preoperative diagnosis of VI. Subgroup analysis of 4 studies (n = 143) showed no significant difference between CT and MRI in preoperative diagnosis of venous or arterial invasion (p = 0.73 and p = 0.81, respectively). When CT was compared with MRA in 3 studies (n = 110), again there was no significant difference for preoperative staging of VI (p = 0.54). CONCLUSIONS Both CT and MRI are underreporting vascular invasion preoperatively in pancreatic cancer. MRA does not add any additional information on vascular staging when compared with CT and MRI.
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Affiliation(s)
- Yaojun Zhang
- Department of Surgery and Cancer, Imperial College London, Du Cane Road, London W12 0NN, United Kingdom
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Tamm EP, Balachandran A, Bhosale PR, Katz MH, Fleming JB, Lee JH, Varadhachary GR. Imaging of pancreatic adenocarcinoma: update on staging/resectability. Radiol Clin North Am 2012; 50:407-28. [PMID: 22560689 DOI: 10.1016/j.rcl.2012.03.008] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Because of the evolution of treatment strategies staging criteria for pancreatic cancer now emphasize arterial involvement for determining unresectable disease. Preoperative therapy may improve the likelihood of margin negative resections of borderline resectable tumors. Cross-sectional imaging is crucial for correctly staging patients. Magnetic resonance (MR) imaging and computed tomography (CT) are probably comparable, with MR imaging probably offering an advantage for identifying liver metastases. Positron emission tomography/CT and endoscopic ultrasound may be helpful for problem solving. Clear and concise reporting of imaging findings is important. Several national organizations are developing templates to standardize the reporting of imaging findings.
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Affiliation(s)
- Eric P Tamm
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1473, Houston, TX 77030, USA.
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Glant JA, Waters JA, House MG, Zyromski NJ, Nakeeb A, Pitt HA, Lillemoe KD, Schmidt CM. Does the interval from imaging to operation affect the rate of unanticipated metastasis encountered during operation for pancreatic adenocarcinoma? Surgery 2011; 150:607-16. [DOI: 10.1016/j.surg.2011.07.048] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2011] [Accepted: 07/11/2011] [Indexed: 01/14/2023]
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