CT of pancreas: minimum intensity projections

Pancreatic Trauma: Imaging Review and Management Update

Traumatic injuries of the pancreas are uncommon and often difficult to diagnose owing to subtle imaging findings, confounding multiorgan injuries, and nonspecific clinical signs. Nonetheless, early diagnosis and treatment are critical, as delays increase morbidity and mortality. Imaging has a vital role in diagnosis and management. A high index of suspicion, as well as knowledge of the anatomy, mechanism of injury, injury grade, and role of available imaging modalities, is required for prompt accurate diagnosis. CT is the initial imaging modality of choice, although the severity of injury can be underestimated and assessment of the pancreatic duct is limited with this modality. The time from injury to definitive diagnosis and the treatment of potential pancreatic duct injury are the primary factors that determine outcome following pancreatic trauma. Disruption of the main pancreatic duct (MPD) is associated with higher rates of complications, such as abscess, fistula, and pseudoaneurysm, and is the primary cause of pancreatic injury-related mortality. Although CT findings can suggest pancreatic duct disruption according to the depth of parenchymal injury, MR cholangiopancreatography and endoscopic retrograde cholangiopancreatography facilitate direct assessment of the MPD. Management of traumatic pancreatic injury depends on multiple factors, including mechanism of injury, injury grade, presence (or absence) of vascular injury, hemodynamic status of the patient, and associated organ damage. ^©RSNA, 2020 See discussion on this article by Patlas.

Imaging of Pancreatic and Duodenal Trauma

Pancreatic and duodenal injuries are rare but life-threatening occurrences, often occurring in association with other solid organ injuries. Findings of pancreatic and duodenal trauma on computed tomography and MR imaging are often nonspecific, and high levels of clinical suspicion and understanding of mechanism of injury are imperative. Familiarity with the grading schemes of pancreatic and duodenal injury is important because they help in assessing for key imaging findings that directly influence management. This article presents an overview of imaging of blunt and penetrating pancreatic and duodenal injuries, including pathophysiology, available imaging techniques, and variety of imaging features.

Imaging diagnosis of pancreatic cancer: A state-of-the-art review

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.

A tumour score with multidetector spiral CT for venous infiltration in pancreatic cancer: influence on borderline resectable

PURPOSE

A tumour score for venous invasion in patients with pancreatic adenocarcinoma was evaluated by means of computed tomography (CT), in order to improve the assessment of medical treatment and clinical outcome with special attention to borderline resectable disease.

MATERIALS AND METHODS

Fifty-six consecutive patients who underwent curative surgical resection for pancreatic cancer were analysed. On the basis of CT criteria, tumour involvement of the portal vein (PV) and superior mesenteric vein (SMV) was graded according to an adapted 4-point scale: score 1, definite absence of invasion; score 2, probable absence of invasion; score 3, probable presence of invasion; score 4, definite presence of invasion. Correlations between the venous infiltration scores and the patients' clinical features were also evaluated.

RESULTS

After radiological evaluation of PV and SMV grades of infiltration, 21/56 (37 %) and 37/56 (66 %) patients, respectively, were found to have borderline resectable disease. The 4-point scale achieved a sensitivity of 80 %, a specificity of 96 % and an accuracy of 93 % in the evaluation of the PV, and a sensitivity of 100 %, a specificity of 94 % and an accuracy of 95 % in the evaluation of the SMV. Analysis of the distribution of clinical characteristics by PV and SMV infiltration showed that both scores correlated with the presence of distal metastasis (p = 0.016 and p = 0.028, respectively), and resection margins status (p = 0.015 and p = 0.006, respectively).

CONCLUSIONS

This adapted tumour score is reliable for assessing venous invasion and might improve preoperative staging in patients with borderline resectable pancreatic cancer.

Imaging of pancreatic ductal adenocarcinoma: State of the art

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.

Imaging of pancreatic ductal adenocarcinoma: State of the art

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.

Imaging of blunt pancreatic trauma

Blunt pancreatic trauma is an exceedingly rare but life-threatening injury with significant mortality. Computed tomography (CT) is commonly employed as the initial imaging modality in blunt trauma patients and affords a timely diagnosis of pancreatic trauma. The CT findings of pancreatic trauma can be broadly categorized as direct signs, such as a pancreatic laceration, which tend to be specific but lack sensitivity and indirect signs, such as peripancreatic fluid, which tend to be sensitive but lack specificity. In patients with equivocal CT findings or ongoing clinical suspicion of pancreatic trauma, magnetic resonance cholangiopancreatography (MRCP) may be employed for further evaluation. The integrity of the main pancreatic duct is of crucial importance, and though injury of the duct may be strongly suggested upon initial CT, MRCP provides clear delineation of the duct and any potential injuries. This article aims to review and illustrate the CT and magnetic resonance imaging findings of blunt pancreatic trauma and delineate the integration of these modalities into the appropriate imaging triage of severely injured blunt trauma patients.

3D CT imaging in clinical practice

Recent technological advances in multidetector computed tomography (MDCT) have enabled 3D diagnostic imaging with superb spatial and temporal resolution. This often provides useful information on precise detail and relationships.

Pancreatic duct evaluation: accuracy of portal venous phase 64 MDCT

BACKGROUND

Many patients presenting with nonspecific signs and symptoms often receive CT scans using general protocols, not optimized to evaluate for pancreatic pathology. Therefore the purpose of this study was to evaluate portal venous phase 64 multi-row detector CT (MDCT) scans for detecting pancreatic duct strictures, stones, pancreas divisum, and communication between pancreatic ducts and cystic pancreatic lesions.

METHODS

Institutional review board approval with waived informed consent was obtained for this HIPAA-compliant study. We included all patients that underwent abdominal, portal venous phase, intravenous contrast-enhanced 64 MDCT scans between 6/7/05 and 5/01/07 and MR cholangiopancreatography (MRCP) or endoscopic retrograde pancreatography (ERCP) within 2 months of the CT. This yielded 93 patients (42 males, 51 females) with a mean age of 59 years. In addition to CT, 75 patients underwent MRCP and 37 patients underwent ERCP. Two radiologists independently evaluated the CT images, including multiplanar and minimum intensity pixel projection reformations, for pancreatic duct strictures, stones, pancreas divisum, or cystic pancreatic lesions. The latter were classified as communicating or not communicating with the pancreatic ducts. Findings on ERCP or MRCP were used to calculate diagnostic performance parameters.

RESULTS

On standard of reference examinations, 15 (16%) of the 93 patients had a pancreatic duct stricture. The sensitivity and the specificity for Observer 1 were 87% and 100%, respectively; for Observer 2, 100% and 100%, respectively. Six (6%) of the 93 patients had main pancreatic duct stones. The sensitivity and the specificity for Observer 1 were 83% and 100%, respectively; for Observer 2, 100% and 99%, respectively. Five (5%) patients had pancreas divisum; Observer 1 correctly identified four and Observer 2 correctly identified three cases. Eleven (12%) patients had cystic pancreatic lesions. Observer 1 correctly determined whether or not there was communication between the cystic pancreatic lesion and the pancreatic duct in ten cases; Observer 2 correctly made this determination in nine cases.

CONCLUSION

Portal venous phase 64 MDCT images are moderately sensitive and highly specific for detecting pancreatic duct stricture, stones, and pancreas divisum and moderately accurate for detecting communication between pancreatic ducts and cystic pancreatic lesions.

Update on 3D and multiplanar MDCT in the assessment of biliary and pancreatic pathology

The development of multidetector row computed tomography (MDCT) has led to the acquisition of true isotropic voxels that can be postprocessed to yield images in any plane of the same resolution as the original axially acquired images. This, coupled with rapid MDCT imaging during peak target organ enhancement has led to a variety of means to review imaging information beyond that of the axial perspective. Postprocessing can be utilized to identify variant biliary anatomy to guide preoperative planning of biliary-related surgery, determine the level and cause of biliary obstruction and assist in staging of biliary cancer. Postprocessing can also be used to identify pancreatic ductal variants, visualize diagnostic features of pancreatic cystic lesions, diagnose and stage pancreatic cancer, and differentiate pancreatic from peripancreatic disease.