Pancreatic adenocarcinoma: CT versus MR imaging in the evaluation of resectability--report of the Radiology Diagnostic Oncology Group

Hidden in plain sight: commonly missed early signs of pancreatic cancer on CT

Pancreatic ductal adenocarcinoma (PDAC) has poor prognosis mostly due to the advanced stage at which disease is diagnosed. Early detection of disease at a resectable stage is, therefore, critical for improving outcomes of patients. Prior studies have demonstrated that pancreatic abnormalities may be detected on CT in up to 38% of CT studies 5 years before clinical diagnosis of PDAC. In this review, we highlight commonly missed signs of early PDAC on CT. Broadly, these commonly missed signs consist of small isoattenuating PDAC without contour deformity, isolated pancreatic duct dilatation and cutoff, focal pancreatic enhancement and focal parenchymal atrophy, pancreatitis with underlying PDAC, and vascular encasement. Through providing commentary on demonstrative examples of these signs, we demonstrate how to reduce the risk of missing or misinterpreting radiological features of early PDAC.

Staging Computed Tomography Parameters Predict the Need for Vein Resection during Pancreaticoduodenectomy in Resectable Pancreatic Ductal Adenocarcinoma

BACKGROUND

Surgery-first approach is the current standard of care for resectable pancreatic ductal adenocarcinoma (PDAC), and a proportion of these cases will require venous resection. This study aimed to identify parameters on staging computed tomography (CT) that predict the need for venous resection during pancreaticoduodenectomy (PD) for resectable PDAC.

METHODS

We conducted a retrospective analysis of prospectively collected data on patients who underwent PD for resectable staged PDAC (as per NCCN criteria) between 2011 and 2020. Staging CTs were independently reviewed by two specialist radiologists blinded to the clinical outcomes. Univariate and multivariate risk analyses were performed.

RESULTS

In total, 296 PDs were included. Venous resection was performed in 62 (21%) cases. There was a higher rate of resection margin positivity in the vein resection group (72.6% vs. 48.7%, p = 0.001). Tumour at the neck of the pancreas, superior mesenteric vein involvement of ≥10 mm and pancreatic duct dilatation were identified as independent predictors for venous resection.

DISCUSSION

Staging CT parameters can predict the need for venous resection during PD for resectable cases of PDAC. This may assist in surgical planning, patient selection and counselling. Future efforts should concentrate on validating these results or identifying additional predictors in a multicentre and prospective setting.

Technical options in surgery for artery-involving pancreatic cancer: Invasion depth matters

Background

The artery involvement explains the majority of primary unresectability of non-metastatic pancreatic cancer patients and both arterial resection and artery-sparing dissection techniques are utilized in curative-intent pancreatectomies for artery-involving pancreatic cancer (ai-PC) patients.

Methods

This narrative review summarized the history of resectability evaluation for ai-PC and attempted to interpret its current pitfalls that led to the divergence of resectability prediction and surgical exploration, with a focus on the rationale and the surgical outcomes of the sub-adventitial divestment technique.

Results

The circumferential involvement of artery by tumor currently defined the resectability of ai-PC but insufficient to preclude laparotomy with curative intent. The reasons behind could be: 1. The radiographic involvement of tumor to arterial circumference was not necessarily resulted in histopathological artery wall invasion; 2. the developed surgical techniques facilitated radical resection, better perioperative safety as well as oncological benefit. The feasibility of periadventitial dissection, sub-adventitial divestment and other artery-sparing techniques for ai-PC depended on the tumor invasion depth to the artery, i.e., whether the external elastic lamina (EEL) was invaded demonstrating a hallmark plane for sub-adventitial dissections. These techniques were reported to be complicated with preferable surgical outcomes comparing to arterial resection combined pancreatectomies, while the arterial resection combined pancreatectomies were considered performed in patients with more advanced disease.

Conclusions

Adequate preoperative imaging modalities with which to evaluate the tumor invasion depth to the artery are to be developed. Survival benefits after these techniques remain to be proven, with more and higher-level clinical evidence needed.

Key message

The current resectability evaluation criteria, which were based on radiographic circumferential involvement of the artery by tumor, was insufficient to preclude curative-intent pancreatectomies for artery-involving pancreatic cancer patients. With oncological benefit to be further proven, periarterial dissection and arterial resection have different but overlapping indications, and predicting the tumor invasion depth in major arteries was critical for surgical planning.

Pancreatic colloid adenocarcinoma arising from intraductal papillary mucinous neoplasm: Radiologic-pathologic correlation with cinematic rendering

Intraductal papillary mucinous neoplasms (IPMN) of the pancreas have the potential for malignant progression into adenocarcinoma. Colloid or mucinous non-cystic carcinoma of the pancreas is an uncommon variant neoplasm that can arise within an intestinal type IPMN and have a relatively improved prognosis but may mimic the more lethal tubular or ductal adenocarcinoma. Colloid carcinoma is an infiltrating ductal epithelial neoplasm containing primarily extracellular stromal mucin pools and scant amount of centrally floating neoplastic cells. While several reports have evaluated the unique pathologic and immunohistochemical profile of colloid carcinomas, there has been limited radiologic-pathologic correlation in the literature. We report a case of an 83-year-old female who presented for evaluation of slowly progressive abdominal pain and was found to have colloid carcinoma arising from an IPMN. This is one of the first reports to correlate the multimodality radiology including cinematic rendering (CR) and histopathology features associated with this tumor. An enhanced understanding of the correlation between imaging appearance and specific histopathologic findings may aid in the early recognition and treatment of this rare neoplasm. Emphasis is placed on CR as this may help guide surgical management.

Cinematic Rendering: Novel Tool for Improving Pancreatic Cancer Surgical Planning

Pancreatic ductal adenocarcinoma is the third-leading cause of all cancer-related deaths in the US. While 20% of patients have resectable disease at diagnosis, improved control of systemic disease using effective chemotherapeutic regimens allows for aggressive operations involving complex vascular resection and reconstruction. A pancreas protocol computed tomography (PPCT) is the gold standard imaging modality in determining local resectability (degree of tumor-vessel involvement), however, it is limited by the inter-operator variability. While post-processing-3D-rendering helps, it does not allow for real-time dynamic assessment of resectability. A recent development in post-process-rendering called cinematic rendering (CR) overcomes this by utilizing advanced light modeling to generate photorealistic 3D images with enhanced details. Cinematic rendering allows for nuanced visualization of areas of interest. Our preliminary experience, as one of the first centers to incorporate the routine use of CR, has proven very useful in surgical planning. For local determination of resectability, vascular mapping allows for accurate assessment of major arteries and the portovenous system. For the portovenous anatomy it assists in determining the optimal surgical approach (extent of resection, appropriate technique for reconstruction, and need for mesocaval shunting). For arterial anatomy, vessel encasement either represents dissectible involvement via periadventitial dissection or true vessel invasion that is unresectable. CR could potentially provide superior ability than traditional PPCT to discern between the two. Additionally, CR allows for better 3D visualization of arterial anatomic variants which, if not appreciated preoperatively, increases risk of intraoperative ischemia and postoperative complications. Lastly, CR could help avoid unnecessary surgery by enhanced identification of occult metastatic disease that is metastatic disease that is otherwise not appreciated on a standard PPCT.

Regional lymph node metastasis detected on preoperative CT and/or FDG-PET may predict early recurrence of pancreatic adenocarcinoma after curative resection

The objective of this study was to evaluate the role of regional lymph node (LN) metastasis detected on preoperative CT and/or ¹⁸F-fluoro-2-deoxyglucose-positron emission tomography (FDG-PET) scans in the prediction of early tumor recurrence after curative surgical resection of pancreatic ductal adenocarcinoma (PDAC). This retrospective study included 137 patients who underwent upfront surgery with R0 resection of PDAC between 2013 and 2016. Regional LN metastasis was identified using two criteria: positive findings for regional LN metastasis on either preoperative CT or FDG-PET scans (LN_OR), or on both preoperative CT and FDG-PET scans (LN_AND). A total of 55 patients had early tumor recurrence within 12 months after curative resection. Univariable and multivariable Cox proportional hazard regression analysis showed that preoperative carbohydrate antigen 19-9 (CA19-9) levels, preoperative locally advanced status, and regional LN metastasis (both LN_OR and LN_AND criteria) were significant risk factors for early recurrence. Positive LN_OR and LN_AND showed significantly poorer recurrence-free survival compared to negative regional LN metastasis groups (p = 0.048 and p = 0.020, respectively). Compared with the LN_AND criteria, the LN_OR criteria provided higher sensitivity (22.4% vs. 15.5%, p = 0.046) and a higher negative predictive value (61.9% vs. 59.8%, p = 0.046). The LN_OR definition provided more sensitive and accurate performance in diagnosing preoperative regional LN metastasis.

Development and validation of an ultrasound-based prediction model for differentiating between malignant and benign solid pancreatic lesions

OBJECTIVE

To identify the diagnostic ability of precontrast and contrast-enhanced ultrasound (CEUS) in differentiating between malignant and benign solid pancreatic lesions (MSPLs and BSPLs) and to develop an easy-to-use diagnostic nomogram.

MATERIALS AND METHODS

This study was approved by the institutional review board. Patients with pathologically confirmed solid pancreatic lesions were enrolled from one tertiary medical centre from March 2011 to June 2021 and in two tertiary institutions between January 2015 and June 2021. A prediction nomogram model was established in the training set by using precontrast US and CEUS imaging features that were independently associated with MSPLs. The performance of the prediction model was further externally validated.

RESULTS

A total of 155 patients (mean age, 55 ± 14.6 years, M/F = 84/71) and 78 patients (mean age, 59 ± 13.4 years, M/F = 36/42) were included in the training and validation cohorts, respectively. In the training set, an ill-defined border and dilated main pancreatic duct on precontrast ultrasound, CEUS patterns of hypoenhancement in both the arterial and venous phases of CEUS, and hyperenhancement/isoenhancement followed by washout were independently associated with MSPLs. The prediction nomogram model developed with the aforementioned variables showed good performance in differentiating MSPLs from BSPLs with an area under the curve (AUC) of 0.938 in the training set and 0.906 in the validation set.

CONCLUSION

Hypoenhancement in all phases, hyperenhancement/isoenhancement followed by washout on CEUS, an ill-defined border, and a dilated main pancreatic duct were independent risk factors for MSPLs. The nomogram constructed based on these predictors can be used to diagnose MSPLs.

KEY POINTS

• An ill-defined border and dilated main pancreatic duct on precontrast ultrasound, hypoenhancement in all phases of CEUS, and hyperenhancement/isoenhancement followed by washout were independently associated with MSPLs. • The ultrasound-based prediction model showed good performance in differentiating MSPLs from BSPLs with an AUC of 0.938 in the training set and 0.906 in the external validation set. • An ultrasound-based nomogram is an easy-to-use tool to differentiate between MSPLs and BSPLs with high efficacy.

The Role of Endoscopic Ultrasonography in the Diagnosis and Staging of Pancreatic Cancer

Pancreatic cancer is the fourth leading cause of cancer-related death and the second gastrointestinal cancer-related death in the United States. Early detection and accurate diagnosis and staging of pancreatic cancer are paramount in guiding treatment plans, as surgical resection can provide the only potential cure for this disease. The overall prognosis of pancreatic cancer is poor even in patients with resectable disease. The 5-year survival after surgical resection is ~10% in node-positive disease compared to ~30% in node-negative disease. The advancement of imaging studies and the multidisciplinary approach involving radiologists, gastroenterologists, advanced endoscopists, medical, radiation, and surgical oncologists have a major impact on the management of pancreatic cancer. Endoscopic ultrasonography is essential in the diagnosis by obtaining tissue (FNA or FNB) and in the loco-regional staging of the disease. The advancement in EUS techniques has made this modality a critical adjunct in the management process of pancreatic cancer. In this review article, we provide an overall description of the role of endoscopic ultrasonography in the diagnosis and staging of pancreatic cancer.

Optimal value of CA19-9 determined by KRAS-mutated circulating tumor DNA contributes to the prediction of prognosis in pancreatic cancer patients

Despite the acceptance of carbohydrate antigen 19-9 (CA19-9) as a valuable predictor for the prognosis of pancreatic ductal adenocarcinoma (PDAC), its cutoff value remains controversial. Our previous study showed a significant correlation between CA19-9 levels and the presence of KRAS-mutated ctDNA in the blood of patients with PDAC. Based on this correlation, we investigated the optimal cutoff value of CA19-9 before surgery. Continuous CA19-9 values and KRAS-mutated ctDNAs were monitored in 22 patients with unresectable PDAC who underwent chemotherapy between 2015 and 2017. Receiver operating characteristic curve analysis identified 949.7 U/mL of CA19-9 as the cutoff value corresponding to the presence of KRAS-mutated ctDNA. The median value of CA19-9 was 221.1 U/mL. Subsequently, these values were verified for their prognostic values of recurrence-free survival (RFS) and overall survival (OS) in 60 patients who underwent surgery between 2005 and 2013. Multivariate analysis revealed that 949.7 U/mL of CA19-9 was an independent risk factor for OS and RFS in these patients (P = 0.001 and P = 0.010, respectively), along with lymph node metastasis (P = 0.008 and P = 0.017), unlike the median CA19-9 level (P = 0.150 and P = 0.210). The optimal CA19-9 level contributes to the prediction of prognosis in patients with PDAC before surgery.

Current controversies and advances in the management of pancreatic adenocarcinoma

Pancreatic adenocarcinoma is a lethal disease with a mortality rate that has not significantly improved over decades. This is likely due to several challenges unique to pancreatic cancer. Most patients with pancreatic cancer are diagnosed at a late stage of disease due to the lack of specific symptoms prompting an early investigation. A small subset of patients who are diagnosed at an early stage have a better chance at survival with curative surgical resection, but most patients still succumb to the disease in a few years. The dismal overall prognosis is due to suspected micro-metastasis at an early stage. Due to this reason, there is a recent interest in treating all patients with pancreatic cancers with systemic therapy upfront (including the ones that are surgically resectable). This approach is still not the standard of care due to the lack of robust prospective data available. Recent advancements in treatment regimens of chemotherapy, radiation and immunotherapy have improved the overall short-term survival but the long-term survival still remains poor. Novel approaches in diagnosis and treatment have shown promise in clinical studies but long-term clinical data is lacking. The following manuscript presents an overview of the epidemiology, diagnosis, staging, recent advances, novel approaches and controversies in the management of pancreatic adenocarcinoma.

A review of response in neoadjuvant therapy for exocrine pancreatic cancer

Despite overall advances in cancer therapy, patients with pancreatic ductal adenocarcinoma continue to have a poor prognosis. While adjuvant therapy is still considered standard, there is mounting evidence that neoadjuvant therapy confers similar benefits in patients with locally advanced disease. The primary measures of response are radiographic, biochemical, margin status, and pathologic. Given overall low response rates and the need for new treatment strategies, standard metrics remain important to the investigation of new systemic agents.

Determining the CA19-9 concentration that best predicts the presence of CT-occult unresectable features in patients with pancreatic cancer: A population-based analysis

BACKGROUND

Serum CA19-9 concentration may be useful in triaging patients with pancreatic cancer for more intensive staging investigations. Our aim was to identify the CA19-9 cut-point with the greatest accuracy for detecting unresectable features not identified by CT scan, and to examine the performance of this and other cut-points in predicting the outcome of staging laparoscopy (SL).

METHODS

Patients with pancreatic cancer were drawn from two state-wide cancer registries between 2009 and 2011. We used classification and regression tree (CART) analysis to identify the CA19-9 cut-point which best predicted the presence of imaging-occult unresectable features, and compared its performance with that of a number of alternative cut-points. We then used logistic regression to test the association between CA19-9 concentration and detection of unresectable features in patients who underwent SL.

RESULTS

From the CART analysis, the optimal CA19-9 cut-point was 440 U/mL. CA19-9 ≥ 150 U/mL had a similar Youden Index, but greater sensitivity (69% versus 47%). This remained true for those who had obstructive jaundice at the time of CA19-9 sampling. CA19-9 concentration greater than or equal to 110 U/mL, 150 U/mL and 200 U/mL was associated with significantly greater odds of unresectable features being detected during SL.

CONCLUSION

Elevated serum CA19-9 concentration is a valid marker for CT-occult unresectable features; the most clinically appropriate cut-point appears to be ≥ 150 U/mL irrespective of the presence of jaundice. Clinical trials which evaluate the value of CA19-9 in the staging algorithm for pancreatic cancer are needed before it is routinely used in clinical practice.

Pancreatic Cancer Imaging: A New Look at an Old Problem

Computed tomography is the most commonly used imaging modality to detect and stage pancreatic cancer. Previous advances in pancreatic cancer imaging have focused on optimizing image acquisition parameters and reporting standards. However, current state-of-the-art imaging approaches still misdiagnose some potentially curable pancreatic cancers and do not provide prognostic information or inform optimal management strategies beyond stage. Several recent developments in pancreatic cancer imaging, including artificial intelligence and advanced visualization techniques, are rapidly changing the field. The purpose of this article is to review how these recent advances have the potential to revolutionize pancreatic cancer imaging.

Lymph node size and its association with nodal metastasis in ductal adenocarcinoma of the pancreas

Background

Although lymph node metastasis is a poor prognostic factor in patients with pancreatic ductal adenocarcinoma (PDAC), our understanding of lymph node size in association with PDAC is limited. Increased nodal size in preoperative imaging has been used to detect node metastasis. We evaluated whether lymph node size can be used as a surrogate preoperative marker of lymph node metastasis.

Methods

We assessed nodal size and compared it to the nodal metastatic status of 200 patients with surgically resected PDAC. The size of all lymph nodes and metastatic nodal foci were measured along the long and short axis, and the relationships between nodal size and metastatic status were compared at six cutoff points.

Results

A total of 4,525 lymph nodes were examined, 9.1% of which were metastatic. The mean size of the metastatic nodes (long axis, 6.9±5.0 mm; short axis, 4.3±3.1 mm) was significantly larger than that of the non-metastatic nodes (long axis, 5.0±4.0 mm; short axis, 3.0±2.0 mm; all p<.001). Using a 10 mm cutoff, the sensitivity, specificity, positive predictive value, overall accuracy, and area under curve was 24.8%, 88.0%, 17.1%, 82.3%, and 0.60 for the long axis and 7.0%, 99.0%, 40.3%, 90.6%, and 0.61 for the short axis, respectively.

Conclusions

The metastatic nodes are larger than the non-metastatic nodes in PDAC patients. However, the difference in nodal size was too small to be identified with preoperative imaging. The performance of preoperative radiologic imaging to predict lymph nodal metastasis was not good. Therefore, nodal size cannot be used a surrogate preoperative marker of lymph node metastasis.

Pitfalls in the MDCT of pancreatic cancer: strategies for minimizing errors

Multidetector computed tomography (MDCT) is a widely used cross-sectional imaging modality for initial evaluation of patients with suspected pancreatic ductal adenocarcinoma (PDAC). However, diagnosis of PDAC can be challenging due to numerous pitfalls associated with image acquisition and interpretation, including technical factors, imaging features, and cognitive errors. Accurate diagnosis requires familiarity with these pitfalls, as these can be minimized using systematic strategies. Suboptimal acquisition protocols and other technical errors such as motion artifacts and incomplete anatomical coverage increase the risk of misdiagnosis. Interpretation of images can be challenging due to intrinsic tumor features (including small and isoenhancing masses, exophytic masses, subtle pancreatic duct irregularities, and diffuse tumor infiltration), presence of coexisting pathology (including chronic pancreatitis and intraductal papillary mucinous neoplasm), mimickers of PDAC (including focal fatty infiltration and focal pancreatitis), distracting findings, and satisfaction of search. Awareness of pitfalls associated with the diagnosis of PDAC along with the strategies to avoid them will help radiologists to minimize technical and interpretation errors. Cognizance and mitigation of these errors can lead to earlier PDAC diagnosis and ultimately improve patient prognosis.

Ultrasound diagnosis of pancreatic solid tumors

INTRODUCTION

Advances and widespread use of various diagnostic imaging modalities have dramatically improved our ability to visualize and diagnose pancreatic diseases. In particular, ultrasonography in pancreatic diseases plays an important role from screening to diagnosis as a simple and safe examination method.

METHODS

The basic scanning method of transabdominal pancreatic ultrasonography, characterization, and differential diagnosis by ultrasonography including contrast-enhanced ultrasonography (CEUS) for solid pancreatic tumors are reviewed with reference to various papers.

RESULTS

In recent years, the ability to visualize and diagnose pancreatic mass lesions has been dramatically improved with advances in ultrasound equipment. In particular, CEUS using an ultrasound contrast agent has made it possible to evaluate hemodynamics in organs or lesions as well as in the flow signal of arterial blood vessels, and it has played an important role not only in diagnosis of the presence of a lesion but also in the qualitative diagnosis. The enhancement behavior and pattern with CEUS of pancreatic solid tumors is shown in text and Fig. 9. Moreover, the flow chart for diagnosing pancreatic solid tumors with CEUS classifying the enhancement behavior and pattern for pancreatic solid tumors on CEUS is shown (Fig. 10). In meta-analyses, the pooled sensitivity in the differential diagnosis of pancreatic adenocarcinomas and other pancreatic focal masses with CEUS was 86-90%, and the pooled specificity was 75-88%.

CONCLUSION

CEUS is a minimally invasive and useful diagnostic method that can be used to make a simple and quick qualitative diagnosis of pancreatic diseases. CEUS provides a lot of information important for diagnosis, and has led to changes in the conventional diagnostic systems in pancreatic diseases.

Diagnostic Ability of Convex-Arrayed Endoscopic Ultrasonography for Major Vascular Invasion in Pancreatic Cancer

Background/Aims

This study aimed to examine the diagnostic ability of endoscopic ultrasonography (EUS) for major vascular invasion in pancreatic cancer and to evaluate the relationship between EUS findings and pathological distance.

Methods

In total, 57 consecutive patients who underwent EUS for pancreatic cancer before surgery were retrospectively reviewed. EUS image findings were divided into four types according to the relationship between the tumor and major vessel (types 1 and 2: invasion, types 3 and 4: non-invasion). We also compared the EUS findings and pathologically measured distances between the tumors and evaluated vessels.

Results

The sensitivity, specificity, and accuracy of EUS diagnosis for vascular invasion were 89%, 92%, and 91%, respectively, in the veins and 83%, 94%, and 93%, respectively, in the arteries. The pathologically evaluated distances of cases with type 2 EUS findings were significantly shorter than those of cases with type 3 EUS findings in both the major veins (median [interquartile range], 96 [0–742] µm vs. 2,833 [1,076–5,694] µm, p=0.012) and arteries (623 [0–854] µm vs. 3,097 [1,396–6,000] µm, p=0.0061). All cases with a distance of ≥1,000 µm between the tumors and main vessels were correctly diagnosed.

Conclusions

Tumors at a distance ≥1,000 µm from the main vessels were correctly diagnosed by EUS.

Anaplastic pancreatic cancer diagnosed with endoscopic ultrasound guided fine needle aspiration showing hypervascular tumor: A case report

RATIONALE

Pancreatic ductal carcinoma is a hypovascular tumor, and characteristic findings are observed on imaging modalities, such as computed tomography (CT) and magnetic resonance imaging (MRI), in most cases.

PATIENT CONCERNS

Here we report a case of anaplastic carcinoma of the pancreas (ACP) with characteristics of hypervascular tumor diagnosed by endoscopic ultrasound guided fine needle aspiration (EUS-FNA). A 70-year-old woman was admitted to hospital because of exacerbation of diabetes. Contrast-enhanced CT revealed a hypervascular tumor at the head of the pancreas.

DIAGNOSIS

EUS-FNA was performed. Osteoclast-like giant cells and tumor cells with polymorphic nuclei were found on pathological examination and she was diagnosed with ACP.

INTERVENTIONS

Although it was a surgical indication at the time of diagnosis, the tumor rapidly worsened. Oral administration of TS-1 (tegafur/gimeracil/oteracil) was initiated. Chemotherapy was discontinued after the end of 2 courses because the tumor had increased prominently on CT.

OUTCOMES

She died approximately a year since the onset of the illness.

LESSONS

ACP occasionally exhibits the characteristics of a hypervascular tumor and may require differentiation from other pancreatic tumors, such as neuroendocrine tumor. Therefore, pathological diagnosis by EUS-FNA at an early stage is important to determine treatment strategies.

Cinematic rendering of pancreatic neoplasms: preliminary observations and opportunities

Pancreatic cancer is the third most common cause of cancer death and CT is the most commonly used modality for the initial evaluation of suspected pancreatic cancer. Post-processing of CT data into 2D multiplanar and 3D reconstructions has been shown to improve tumor visualization and assessment of tumor resectability compared to axial slices, and is considered the standard of care. Cinematic rendering is a new 3D-rendering technique that produces photorealistic images, and it has the potential to more accurately depict anatomic detail compared to traditional 3D reconstruction techniques. The purpose of this article is to describe the potential application of CR to imaging of pancreatic neoplasms. CR has the potential to improve visualization of subtle pancreatic neoplasms, differentiation of solid and cystic pancreatic neoplasms, assessment of local tumor extension and vascular invasion, and visualization of metastatic disease.

Diagnosis and Detection of Pancreatic Cancer

Computed tomography is the first-line imaging modality for suspected pancreatic cancer. Magnetic resonance cholangiopancreatography is a second-line modality for suspected pancreatic cancer and is usually reserved for equivocal cases. Both computed tomography and MR are highly sensitive in the detection of pancreatic cancer, with up to 96% and 93.5% sensitivity, respectively. Computed tomography is superior to MR in the assessment of tumor resectability, with accuracy rates of up to 86.8% and 78.9%, respectively. Close attention to secondary signs of pancreatic cancer, such as pancreatic duct dilatation, abrupt pancreatic duct caliber change, and parenchymal atrophy, are critical in the diagnosis of pancreatic cancer. Emerging techniques such as radiomics and molecular imaging have the potential of identifying malignant precursors and lead to earlier disease diagnosis. The results of these promising techniques need to be validated in larger clinical studies.

Does Second Reader Opinion Affect Patient Management in Pancreatic Ductal Adenocarcinoma?

RATIONALE AND OBJECTIVES

To determine the impact of second-opinion assessment on cancer staging and patient management in patients with pancreatic ductal adenocarcinoma.

METHODS AND MATERIALS

This retrospective study was approved by our institutional review board with a waiver of informed consent. Second-opinion reports between January 1, 2009 and December 31, 2013, alongside outside reports for 65 consecutive cases of biopsy-proven pancreatic adenocarcinomas, were presented in random order to two experienced abdominal surgeons who independently reviewed them blinded to the origin of the report, images of the examinations, and patient identifier. Each surgeon filled in a questionnaire for each report recommending cancer staging and patient management. Recommended patient management and staging were evaluated against reference standards (actual patient management at 6 months following second-opinion assessment, and pathology or other clinical and imaging reference standards at 6 months or longer, respectively) using Cohen kappa.

RESULTS

Cancer staging differed in 13% (9 of 65) of cases for surgeon 1 and in 18.4% (12 of 65) for surgeon 2. Patient management changed in 38.4% (25 of 65) of cases for surgeon 1 and in 20% (13 of 65) for surgeon 2. When compared to the pathologic staging gold standard, second opinion was correct in 85.7% (six of seven) of the time for both surgeons. Recommended patient management from second-opinion reports showed good agreement with the reference standard (weighted k = 0.6467 [0.4014-0.892] and weighted k = 0.6262 [0.3954-0.857] for surgeon 2).

CONCLUSION

Second-opinion review by subspecialized oncologic radiologists can impact patient care, specifically in terms of management decision.

A new mild hyperthermia device to treat vascular involvement in cancer surgery

Surgical margin status in cancer surgery represents an important oncologic parameter affecting overall prognosis. The risk of disease recurrence is minimized and survival often prolonged if margin-negative resection can be accomplished during cancer surgery. Unfortunately, negative margins are not always surgically achievable due to tumor invasion into adjacent tissues or involvement of critical vasculature. Herein, we present a novel intra-operative device created to facilitate a uniform and mild heating profile to cause hyperthermic destruction of vessel-encasing tumors while safeguarding the encased vessel. We use pancreatic ductal adenocarcinoma as an in vitro and an in vivo cancer model for these studies as it is a representative model of a tumor that commonly involves major mesenteric vessels. In vitro data suggests that mild hyperthermia (41-46 °C for ten minutes) is an optimal thermal dose to induce high levels of cancer cell death, alter cancer cell's proteomic profiles and eliminate cancer stem cells while preserving non-malignant cells. In vivo and in silico data supports the well-known phenomena of a vascular heat sink effect that causes high temperature differentials through tissues undergoing hyperthermia, however temperatures can be predicted and used as a tool for the surgeon to adjust thermal doses delivered for various tumor margins.

Diagnostic accuracy of different imaging modalities following computed tomography (CT) scanning for assessing the resectability with curative intent in pancreatic and periampullary cancer

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.

Chronic pancreatic inflammatory granuloma caused by foreign body presenting as a pancreatic pseudotumor: A case report and literature review

In clinical practical work, a rare kind of chronic pancreatic inflammatory granuloma which is caused by the foreign body of gastrointestinal perforation could be misdiagnosed and treated as pancreatic neoplasm sometimes, and even brings irreparable harm to patients. Here, we depict a male presenting recurrent upper abdominal pain and gradual weight loss, besides, the computer tomography suggested pancreatic tumor strongly. Fortunately, it has been proved to be a chronic pancreatic inflammatory granuloma caused by fish bone through laparotomy finally. To our knowledge, this case is the first case about the chronic pancreatic inflammatory granuloma caused by foreign body which successfully avoids unnecessary pancreatectomy.

Anatomical, Physiological, and Molecular Imaging for Pancreatic Cancer: Current Clinical Use and Future Implications

Pancreatic adenocarcinoma is one of the deadliest human malignancies. Early detection is difficult and effective treatment is limited. Verifying the presence of micrometastatic dissemination and vessel invasion remains elusive, limiting radiological staging once this diagnosis is made. Diagnostic imaging provides independent tools to evaluate and characterize the biologic behavior of pancreatic cancer. Conventional anatomic imaging alone with either CT or MRI yields useful information on organ involvement but is limited in providing molecular and physiological information. Molecular imaging techniques such as PET or MRS provide information on metabolic and signaling pathways. Advanced MR sequences that target physiological parameters expand imaging options to characterize these tumors. By considering the parametric data from these three imaging approaches (anatomic, molecular, and physiological) we can better define specific tumor signatures. Such parametric characterization can provide insight into tumor metabolism, cellular density, protein expression, focal perfusion, and vascular permeability of these tumors. Radiogenomics research has already demonstrated ability to obtain information about cancer's genotype and phenotype; this is without invasive procedures or surgery. Further advances in these areas of experimental imaging hold promise to enable future clinical advances in detection and therapy of pancreatic cancer.

Low-dose whole organ CT perfusion of the pancreas: preliminary study

OBJECTIVES

To investigate the feasibility of low-dose whole pancreas CT perfusion in the clinical practice.

METHODS

Sixty-one patients suspected pancreatic disease underwent low-dose whole pancreas CT perfusion scan (by body weight, group A: 70 kV, 120 mAs; group B: 80 kV, 100 mAs) and the individualized pancreas scan. Forty-six patients were enrolled. Perfusion characteristics, such as, blood flow, blood volume and permeability, were analyzed. The effective radiation dose of the whole pancreas CT perfusion and the total CT scan protocol were recorded. CT findings were histologically confirmed by surgical intervention or diagnostic puncture.

RESULTS

Of the 46 cases, 33 were pancreatic adenocarcinoma, 5 were solid-pseudo-papillary tumors of pancreas, 8 cases of pancreatic endocrine tumors on the perfusion study. There was significant interobserver agreement on the measurement of normal pancreatic CT perfusion parameters of group A (n = 28)and group B (n = 18), respectively (p > 0.05). For the normal pancreas, there was no significant difference on CT perfusion parameters between group A and group B (p > 0.05). There were significant differences on blood flow as well as blood volume between the pancreatic adenocarcinomas and the normal pancreas (p < 0.001), whereas no difference on the permeability (p > 0.05). The time to peak of the normal pancreas is 28.94 ± 4.37 s (range from 24 to 38 s). Different pancreatic tumors had different types of time attenuation curve (TAC). TACs were different between pancreatic adenocarcinomas and normal pancreas. The effective radiation dose of the whole pancreas CT perfusion of Group A and Group B were 3.60 and 4.88 mSv (DLP 246 and 325 mGy cm), respectively, and the total radiation dose was around 8.01-16.22 mSv.

CONCLUSIONS

Low-dose whole pancreatic CT perfusion can effectively reduce radiation dose, and provide the best phase for the individualized pancreas scan, which has great value in the clinical practice.

Resectability of the pancreatic adenocarcinoma: A study from Iran

Background:

Definite treatment of pancreatic adenocarcinoma is surgical resection. Absence of early symptoms in most patients leads to late diagnosis and treatment. This study aims to evaluate resectability of the pancreatic adenocarcinoma at the time of the diagnosis in Iran.

Materials and Methods:

The present study which is of a descriptive, prospective and case series nature, has been studying the resectability of the pancreatic adenocarcinoma by multi-detector computerized tomography, endoscopic ultrasonography, laparoscopy and/or laparotomy in 157 patients for the duration of 2 years since November 2009.

Results:

A total of 157 patients were enrolled in this study. Majority of them (68%) were male. The mean age was 67 years. Final diagnosis obtained 1-12 (2.7 ± 1.6) months after beginning of the symptoms. The lesion situated in the head of the pancreas in 127 cases (81%). Vascular invasion, lymphadenopathy, liver metastasis and peritoneal involvement were seen in 88%, 57%, 43% and 19% of the patients, respectively. According to imaging, tumor was resectable in 10 (6%) patients but laparoscopy and/or laparotomy revealed that only five cases (3%) were actually resectable. After 24 months, only 8 patients were alive; 5 cases of them had been treated by Whipple surgery and other 3 cases were under the chemotherapy. At 1 and 2 year survival rate of the patients was 11% and 5%, respectively.

Conclusion:

Majority (97%) of the pancreatic adenocarcinomas are unresectable at the time of diagnosis. Thus, meticulous preoperative assessment of patients is essential in patients to avoid major surgery in unresectable cases.

Diagnostic accuracy of EUS and CT of vascular invasion in pancreatic cancer: a systematic review

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.

Clinical evaluation, imaging studies, indications for cytologic study and preprocedural requirements for duct brushing studies and pancreatic fine-needle aspiration: The Papanicolaou Society of Cytopathology Guidelines

The Papanicolaou Society of Cytopathology has developed a set of guidelines for pancreaticobiliary cytology including indications for endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) biopsy, techniques for EUS-FNA, terminology and nomenclature to be used for pancreaticobiliary disease, ancillary testing and postbiopsy management. All documents are based on expertise of the authors, literature review, discussions of the draft document at national and international meetings and synthesis of online comments of the draft document. This document selectively presents the results of these discussions. This document summarizes recommendations for the clinical and imaging work-up of pancreatic and biliary tract lesions along with indications for cytologic study of these lesions. Prebrushing and FNA requirements are also discussed.

Guidelines for pancreaticobiliary cytology from the Papanicolaou Society of Cytopathology: A review

The newest installment on state-of-the-art standards of practice in cytopathology from the Papanicolaou Society of Cytopathology (PSC) focuses on the pancreaticobiliary system. Similar to the National Cancer Institute recommendations for aspiration cytology of the thyroid, the PSC guidelines for pancreaticobiliary cytology addresses indications, techniques, terminology and nomenclature, ancillary studies, and postprocedure management. Each committee was composed of a multidisciplinary group of experts in diagnosing, managing, and treating patients with pancreaticobiliary disease. Draft documents were posted on an interactive Web-based forum hosted by the PSC Web site (www.papsociety.org) and the topics of terminology, ancillary testing, and management were presented at national and international meetings over an 18-month period for discussion and feedback from practicing pathologists around the world. This review provides a synopsis of these guidelines.

Is arterial infiltration still a criterion for unresectability in pancreatic adenocarcinoma?

As surgical resection remains the only hope for cure in pancreatic cancer (PC), more aggressive surgical approaches have been advocated to increase resection rates. Venous resection demonstrated to be a feasible technique in experienced centers, increasing survival. In contrast, arterial resection is still an issue of debate, continuing to be considered a general contraindication to resection. In the last years there have been significant advances in surgical techniques and postoperative management which have dramatically reduced mortality and morbidity of major pancreatic resections. Furthermore, advances in multimodal neo-adjuvant and adjuvant treatments, as well as the better understanding of tumor biology and new diagnostic options have increased overall survival. In this article we highlight some of the important points that a modern pancreatic surgeon should take into account in the management of PC with arterial involvement in light of the recent advances.

Clinical evaluation, imaging studies, indications for cytologic study, and preprocedural requirements for duct brushing studies and pancreatic FNA: the Papanicolaou Society of Cytopathology recommendations for pancreatic and biliary cytology

The Papanicolaou Society of Cytopathology has developed a set of guidelines for pancreaticobiliary cytology including indications for endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) biopsy, techniques for EUS-FNA, terminology and nomenclature to be used for pancreaticobiliary disease, ancillary testing, and post-biopsy management. All documents are based on expertise of the authors, literature review, discussions of the draft document at national and international meetings, and synthesis of online comments of the draft document. This document selectively presents the results of these discussions. This document summarizes recommendations for the clinical and imaging work-up of pancreatic and biliary tract lesions along with indications for cytologic study of these lesions. Prebrushing and FNA requirements are also discussed.

Efficacy of multi-detector computerized tomography scan, endoscopic ultrasound, and laparoscopy for predicting tumor resectability in pancreatic adenocarcinoma

BACKGROUND

Definitive treatment for pancreatic adenocarcinoma is surgical resection. Endoscopic ultrasound (EUS), multi-detector computerized tomography scan (MDCT), and laparoscopy are current preoperative methods for assessing the resectability in this malignancy. This study compared the efficacy of these methods in predicting the resectability of pancreatic adenocarcinoma.

METHODOLOGY

One hundred and fifty-seven patients considered for resection of pancreatic adenocarcinoma in two centers in Iran were evaluated. All of the patients were evaluated by MDCT and/or EUS; ones that had resectable tumor in imaging were assessed by laparoscopy/laparotomy. Patients undergoing pancreaticoduodenectomy were followed for 2 years.

RESULTS

The majority (67%) were male. The mean age was 66 years. The lesion was situated in the head of pancreas in 127 cases (81%). Tumor resectability rate according to the MDCT scan/EUS, laparoscopy, and laparotomy was 6%, 5%, and 3%, respectively. Only 3% of the pancreatic adenocarcinoma cases were resectable at the time of diagnosis. Fifty percent of patients predicted to have resectable tumor according to MDCT/EUS and 37.5% of cases that had resectable disease in laparoscopy were found to have unresectable lesions at laparotomy and or postsurgical follow up.

CONCLUSIONS

Prognosis continues to be dismal for pancreatic adenocarcinoma, and better methods to assess tumor resectability are needed.

Preoperative imaging for resectable periampullary cancer: clinicopathologic implications of reported radiographic findings

BACKGROUND

High-resolution, multiphase, computed tomography (CT) is a standard preoperative test prior to pancreatectomy, yet the clinical significance of routinely reported findings remains unknown.

METHODS

We identified patients who underwent a pancreaticoduodenectomy for a periampullary adenocarcinoma (PA) over the previous 5 years and had a pancreas protocol CT at our institution. Clinicopathologic implications of reported CT findings were evaluated.

RESULTS

There were 155 pancreatic ductal adenocarcinomas (PDA) and 47 non-pancreatic PAs. No mass was visualized on CT in 6 % of PDAs and 23 % of non-pancreatic PA. A size discrepancy of ≥1 cm between radiographic and pathologic tumor diameters was observed in 40 % of PAs, with CT underestimating the size in most instances (75 %). Radiographically enlarged lymph nodes were not associated with true lymph node metastases in PDAs (70 % lymph node positive cases were enlarged on CT vs 74 % lymph node negative, p = 0.5), but were associated with a preoperatively placed biliary endoprosthesis (63 % with endoprosthesis were enlarged vs 37 % no endoprosthesis, p = 0.013). Major visceral vessel involvement on CT was not associated with a vascular resection (3 % with CT vessel involvement vs 2 % without, p = 0.8) or a positive uncinate resection margin (24 vs 20 %, respectively, p = 0.6).

DISCUSSION

While dedicated pancreas protocol CT provides unprecedented detail, the test may lead to overinterpretation of the extent of disease in some instances. A radiographic suggestion of enlarged lymph nodes and vascular involvement does not necessarily preclude exploration with curative intent. CTs with local disease should be reported in an objective template and carefully reviewed by a multidisciplinary group of surgeons, radiologists, and oncologists to avoid missing an opportunity for neoadjuvant therapy or cure by resection.

Liver blood supply after a modified Appleby procedure in classical and aberrant arterial anatomy

Reported here are two cases of a modified Appleby operation for borderline resectable ductal adenocarcinoma of the pancreatic body, in one of which a R0 distal resection was attended to by excision, not only of the celiac axis, but also of the common and left hepatic arteries in the presence of arterial anatomic variation Michels, type VIIIb. The possibility and avenues of the maintenance of the blood supply to the left hepatic lobe after surgical aggression of this kind are demonstrated employing computed tomography (CT) and 3-D CT angiography. Furthermore, both cases highlight all important worrisome aspects of pancreatic cancer resectability prediction.

Multimodality imaging of pancreatic ductal adenocarcinoma: a review of the literature

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.

Hereditary pancreatic cancer: molecular bases and their application in diagnosis and clinical management: a guideline of the TTD group

Pancreatic carcinoma (PC) represents the fourth leading cause of cancer death in Spain with a death rate of 2,400 males and 2,000 females per year. Poor outcome related to its silent nature and the lack of reliable secondary prevention measures translate into advanced-stage diagnosis, 75 % of deaths within the first year of diagnosis and 5-year survival rate of <5 %. Family history was first recognized as a risk factor for PC. Further population-based and case-control studies subsequently found that 7.8 % of patients with PC have a family history of the same tumor and individuals with a first-degree relative with PC have a 3.2-fold increased risk of developing PC. Overall, it is estimated that up to 10 % of PC have a familial component. However, known genetic syndromes account for <20 % of the observed familial aggregation of PC. We review the most important aspects in epidemiology, molecular biology and clinical management of familial PC.

Staging laparoscopy for proximal pancreatic cancer in a magnetic resonance imaging-driven practice: what's it worth?

BACKGROUND

Preoperative imaging is often inadequate in excluding unresectable pancreatic cancer. Accordingly, many groups employ staging laparoscopy (SL), although none have evaluated SL after preoperative magnetic resonance imaging (MRI). We performed a retrospective, indirect cost-effectiveness analysis of SL after MRI for pancreatic head lesions.

METHODS

All MRI scans administered for proximal pancreatic cancer between 2004 and 2008 were reviewed and the clinical course of each patient determined. We queried our billing database to render average total costs for all inpatients with proximal pancreatic cancer who underwent pancreaticoduodenectomy, palliative bypass or an endoscopic stenting procedure. We then performed an indirect evaluation of the cost of routine SL.

RESULTS

The average costs of hospitalization for patients undergoing pancreaticoduodenectomy, open palliative bypass and endoscopic palliation were: US$26, 122.43, US$21, 957.18 and US$11, 304.00, respectively. The calculated cost of SL without laparotomy was US$2966.25 or US$1538.61 prior to laparotomy. The calculated cost of treating unresectable disease by outpatient laparoscopy followed by endoscopy was US$5943.17. Routine SL would increase our costs by US$76, 967.46 (3.6%).

CONCLUSIONS

Staging laparoscopy becomes cost-effective by diverting unresectable patients from operative to endoscopic palliation. Given the paucity of missed metastases on MRI, the yield of SL is marginal and its cost-effectiveness is poor. Future studies should address the utility of SL by both examining this issue prospectively and investigating the cost-effectiveness of endoscopic vs. surgical palliation in a manner that takes account of survival and quality of life data.

Pancreas-protocol imaging at a high-volume center leads to improved preoperative staging of pancreatic ductal adenocarcinoma

BACKGROUND

High-quality preoperative cross-sectional imaging is vital to accurately stage patients with pancreatic ductal adenocarcinoma (PDAC). We hypothesized that imaging performed at a high-volume pancreatic cancer center with pancreatic imaging protocols more accurately stages patients compared with pre-referral imaging.

METHODS

We retrospectively reviewed data from all patients with PDAC who presented to the surgical oncology clinic at our institution between June 2005 and August 2009. Detailed preoperative imaging, staging, and operative data were collected for each patient.

RESULTS

A total of 230 patients with PDAC were identified, of which 169 had pre-referral imaging. Patients were selectively reimaged at our institution based on the quality and timing of imaging at the outside facility: 108 (47%) patients were deemed resectable, 54 (23.5%) were deemed borderline-resectable, and 68 (29.5%) were deemed unresectable. Of the resectable patients, 99 opted for resection. Eighty-two of those 99 patients underwent preoperative imaging at our institution, and of these 27% had unresectable disease at the time of surgery compared with 47% of patients who only had pre-referral imaging (p = 0.14). Reimaging altered staging and changed management in 56% of patients. Among that group were 55 patients, categorized as resectable on pre-referral imaging, who on repeat imaging were deemed to be borderline resectable (n = 27) or unresectable (n = 28).

CONCLUSIONS

Pancreas-protocol imaging at a high-volume center improves preoperative staging and alters management in a significant proportion of patients with PDAC who undergo pre-referral imaging. Thus, repeat imaging with pancreas protocols and dedicated radiologists is justified at high-volume centers.

Advances in diagnosis, treatment and palliation of pancreatic carcinoma: 1990-2010

Several advances in genetics, diagnosis and palliation of pancreatic cancer (PC) have occurred in the last decades. A multidisciplinary approach to this disease is therefore recommended. PC is relatively common as it is the fourth leading cause of cancer related mortality. Most patients present with obstructive jaundice, epigastric or back pain, weight loss and anorexia. Despite improvements in diagnostic modalities, the majority of cases are still detected in advanced stages. The only curative treatment for PC remains surgical resection. No more than 20% of patients are candidates for surgery at the time of diagnosis and survival remains quite poor as adjuvant therapies are not very effective. A small percentage of patients with borderline non-resectable PC might benefit from neo-adjuvant chemoradiation therapy enabling them to undergo resection; however, randomized controlled studies are needed to prove the benefits of this strategy. Patients with unresectable PC benefit from palliative interventions such as biliary decompression and celiac plexus block. Further clinical trials to evaluate new chemo and radiation protocols as well as identification of genetic markers for PC are needed to improve the overall survival of patients affected by PC, as the current overall 5-year survival rate of patients affected by PC is still less than 5%. The aim of this article is to review the most recent high quality literature on this topic.

Pancreatic neoplasia: a practical cross-sectional imaging primer for the nonradiologist

PURPOSE

The purpose of this article is to provide a practical review of basic pancreatic imaging protocols and key cross-sectional imaging findings of the more common pancreatic neoplasms.

METHODS

We performed a literature search and reviewed numerous cases archived in the radiology department of a large university hospital to find examples which illustrate the key cross-sectional imaging findings of pancreatic neoplasms.

RESULTS

We reviewed the literature and provided several practical examples of common cross-sectional imaging findings in patients with pancreatic neoplasms.

CONCLUSIONS

Cross-sectional imaging plays a pivotal role in the evaluation of pancreatic neoplasms and allows proper triage of patients for conservative, medical or surgical management due to its ability to reliably detect and characterize pancreatic lesions, determine involvement of local structures, and assess metastatic disease. Familiarity with the key imaging findings will allow the clinician to better implement imaging data into daily practice.

Pancreatic and hepatobiliary cancers

Morphology-based imaging modalities have replaced classical conventional nuclear medicine modalities for detection of liver or pancreatic lesions. With positron emission tomography and the glucose analog F-18 fluorodeoxyglucose (FDG), a sensitive and specific modality for the detection of hepatic metastases and extrahepatic tumor deposits from hepatocellular or pancreatic cancer is available. F-18 FDG PET can increase the accuracy of staging primary tumors of the liver or the pancreas, and can be used for response monitoring. Radiopharmaceuticals such as Ga-68 DOTATOC and F-18 DOPA allow the specific detection of neuroendocrine pancreatic tumors and their metastatic deposits. Hybrid scanners such as PET-CT integrate morphologic and metabolic information, and allow to increase the sensitivity and specificity of noninvasive imaging in many tumor entities. The development of specific radiopharmaceuticals and technical innovations such as SPECT-CT has increased the reliability of conventional scintigraphic imaging. This chapter focuses on the use of PET-CT in hepatobiliary and pancreatic cancers.

An MRI-driven practice: a new perspective on MRI for the evaluation of adenocarcinoma of the head of the pancreas

OBJECTIVES

The purpose of the study was to describe the MRI-driven management of masses at the head of the pancreas.

MAIN OUTCOME MEASURES

The main outcome measure was tumor resectability.

METHODS

A retrospective review of prospective radiographic diagnoses was undertaken.

RESULTS

Between 2004 and 2008, we have treated 124 patients for a radiographic diagnosis of adenocarcinoma of the head of the pancreas. This diagnosis was correct in 96.0% of the time. MRI was 100% sensitive in determining resectability, 73.2-78.9% specific, and had an overall accuracy of 86.3-87.5%. MRI could detect venous and arterial involvement with 95% and 95.9% accuracy, respectively, and missed only six metastases.

CONCLUSION

MRI is a useful tool in the preoperative imaging of pancreatic head lesions that is highly sensitive and very specific for resectable disease. Prospective trials of MRI in this setting are indicated.

Functional magnetic resonance imaging in an animal model of pancreatic cancer

AIM

To test the hypotheses that diffusion weighed (DW)- and transcatheter intraarterial perfusion (TRIP)-magnetic resonance imaging (MRI) can each be used to assess regional differences in tumor function in an animal pancreatic cancer model.

METHODS

VX2 tumors were implanted in pancreata of 6 rabbits. MRI and digital subtraction angiography (DSA) were performed 3 wk following implantation. With a 2-French catheter secured in the rabbit's gastroduodenal artery, each rabbit was transferred to an adjacent 1.5T MRI scanner. DW- and TRIP-MRI were performed to determine if necrotic tumor core could be differentiated from viable tumor periphery. For each, we compared mean differences between tumor core/periphery using a 2-tailed paired t-test (alpha = 0.05). Imaging was correlated with histopathology.

RESULTS

Tumors were successfully grown in all rabbits, confirmed by necropsy. On DW-MRI, mean apparent diffusion coefficient (ADC) value was higher in necrotic tumor core (2.1 +/- 0.3 mm(2)/s) than in viable tumor periphery (1.4 +/- 0.5 mm(2)/s) (P < 0.05). On TRIP-MRI, mean perfusion values was higher in tumor periphery (110 +/- 47 relative units) than in tumor core (66 +/- 31 relative units) (P < 0.001).

CONCLUSION

Functional MRI can be used to differentiate necrotic from viable tumor cells in an animal pancreatic cancer model using ADC (DW-MRI) and perfusion (TRIP-MRI) values.

Vascular invasion in pancreatic cancer: Imaging modalities, preoperative diagnosis and surgical management

Pancreatic cancer is associated with a poor prognosis, and surgical resection remains the only chance for curative therapy. In the absence of metastatic disease, which would preclude resection, assessment of vascular invasion is an important parameter for determining resectability of pancreatic cancer. A frequent error is to misdiagnose an involved major vessel. Obviously, surgical exploration with pathological examination remains the “gold standard” in terms of evaluation of resectability, especially from the point of view of vascular involvement. However, current imaging modalities have improved and allow detection of vascular invasion with more accuracy. A venous resection in pancreatic cancer is a feasible technique and relatively reliable. Nevertheless, a survival benefit is not achieved by curative resection in patients with pancreatic cancer and vascular invasion. Although the discovery of an arterial invasion during the operation might require an aggressive management, discovery before the operation should be considered as a contraindication. Detection of vascular invasion remains one of the most important challenges in pancreatic surgery. The aim of this article is to provide a complete review of the different imaging modalities in the detection of vascular invasion in pancreatic cancer.

Extrapancreatic neural plexus invasion by pancreatic carcinoma: characteristics on magnetic resonance imaging

BACKGROUND

Our objective is to study the characteristics of extrapancreatic neural plexus invasion by pancreatic carcinoma on MR imaging.

METHODS

20 patients with both pancreatic carcinoma and extrapancreatic neural plexus invasion confirmed by pathology were recruited in this study. MR imaging was performed within 1 month before surgery. On MR images, signal intensity at the site of potential extrapancreatic neural plexus invasion, lymph nodes and tumor size were noted. The relationship of extrapancreatic neural plexus invasion to these findings was analyzed.

RESULTS

Signs of extrapancreatic neural plexus invasion were depicted on MR imaging in 80% of patients, which included streaky and strand-like signal intensity structure in fat tissue in 50% of patients and irregular masses adjacent to tumor in 30%. Signal intensity at invasion site was similar to that of pancreatic carcinoma. The frequencies of patients with vascular invasion and with lymph nodes larger than 5 mm were, respectively, 50% and 55%. Tumor diameter was 24 +/- 7 mm on MR imaging. Extrapancreatic neural plexus invasion was correlated with vascular invasion (r = 0.58, P < 0.005), slightly related with lymphadenopathy (r = 0.35, 0.1 > P > 0.05), but not related with tumor size.

CONCLUSION

MR imaging is useful to depict extrapancreatic neural plexus invasion by pancreatic carcinoma.