Staging of pancreatic adenocarcinoma by imaging studies

Imaging preoperatively for pancreatic adenocarcinoma

Pancreatic cancer is a highly lethal malignancy which is increasing in incidence and mortality. The fourth leading cause of cancer death in the U.S., pancreatic cancer is projected to become the second leading cause of cancer death by 2020. Patients with pancreatic cancer have an abysmal 5-year survival of 6%, and 90% of these patients eventually die from the disease. This is in large part due to the commonly advanced stage of disease at the time of diagnosis. Currently, the only potentially curative therapy for pancreatic carcinoma is complete surgical resection. Patients who undergo incomplete resection with residual disease have similar survival rates to those patients with metastatic disease and should be spared this relatively morbid surgery. Thus, the key to impacting prognosis is the detection of smaller and earlier stage lesions, and the key to optimal management is accurately determining which patients have potentially resectable surgery and which patients would not benefit from surgery. Cross-sectional imaging plays an essential role in both the diagnosis and appropriate staging of pancreatic carcinoma. The diagnosis and staging of pancreatic adenocarcinoma is performed with cross-sectional imaging. Multi-detector computed tomography (MDCT) is the most commonly used, best-validated imaging modality for the diagnosis and staging of pancreatic cancer. Modern contrast-enhanced magnetic resonance imaging (MRI) has been demonstrated to be equivalent to MDCT in detection and staging of pancreatic cancer. Endoscopic ultrasound (EUS) is very sensitive for detecting pancreatic masses; however, due to limitations in adequate overall abdominal staging, it is generally used in addition to or after MDCT. Transabdominal ultrasound and positron emission tomography/computed tomography (PET/CT) have limited roles in the diagnosis and staging of pancreatic cancer. Preoperative imaging is used to characterize patients as having resectable disease, borderline resectable disease, locally advanced disease (unresectable) and metastatic disease (unresectable). As the definitions of borderline resectable and unresectable may vary from institution to institution and within institutions, it is essential to accurately assess and describe the factors relevant to staging including: local extent of tumor, vascular involvement, lymph node involvement and distant metastatic disease. To facilitate this, standardized reporting templates for pancreatic ductal adenocarcinoma have been created and published. Structured reporting for pancreatic cancer has been reported to provide superior evaluation of pancreatic cancer, facilitate surgical planning, and increase surgeons' confidence about tumor resectability.

Objective Assessment of Surgical Restaging after Concurrent Chemoradiation for Locally Advanced Pancreatic Cancer

The role of neoadjuvant chemoradiation therapy in locally advanced pancreatic cancer (LAPC) is still controversial. The aim of this study was to evaluate surgical downstaging after concurrent chemoradiation therapy (CCRT) for LAPC by measuring the objective changes after treatment. From January 2003 through July 2011, 54 patients with LAPC underwent neoadjuvant CCRT. Computed tomography findings of the tumor size, including major vessel invasion, were analyzed before and after CCRT. Among the total recruited patients, 14 had borderline resectable malignancy and another 40 were unresectable before CCRT. After CCRT, a partial response was achieved in four patients. Stable disease and further disease progression were achieved in 36 and 14 patients, respectively. Tumor size showed no significant difference before and after CCRT (3.6 ± 1.1 vs. 3.6 ± 1.0 cm, P = 0.61). Vessel invasion showed improvement in two patients, while 13 other patients showed further tumor progression. Thirty-nine patients with unresectable malignancy and 11 patients with borderline resectable malignancy at time of initial diagnosis remained unchanged after CCRT. Four patients with borderline pancreatic malignancy progressed to an unresectable stage, whereas one unresectable pancreatic malignancy improved to a borderline resectable stage. Only one patient with borderline resectable disease underwent operation after CCRT; however, curative resection failed due to celiac artery invasion and peritoneal seeding. The adverse events associated with CCRT were tolerable. In conclusion, preoperative CCRT in LAPC rarely leads to surgical downstaging, and it could lower resectability rates.

Metastases of pancreatic adenocarcinoma: A systematic review of literature and a new functional concept

INTRODUCTION

Pancreatic cancer, especially Pancreatic Adenocarcinoma, is still associated with a high mortality and morbidity for affected patients notwithstanding considerable progresses in diagnosis and both surgical pharmacological therapy. Despite metastases from colorectal, gastric and neuroendocrine primary tumor and their treatment are widely reported, the literature has been rarely investigated the impact of localization and numbers of pancreatic metastases. This study performed a systematic analysis of the most recent scientific literature on the natural history of Pancreatic Adenocarcinoma focusing attention on the role that the "M" parameter has on a possible prognostic stratification of these patients.

MATERIAL AND METHODS

PubMed and Science Direct databases were searched for relevant articles on these issue.

RESULTS

Initial database searches yielded 7231 studies from PubMed and 29101 from Science Direct. We evaluated 1031 eligible full text articles.

CONCLUSIONS

An updated insight into the world of Pancreatic Tumors might help physicians in better evaluating mechanisms of metastases, patients selection and survival and in programming appropriate interventions to modify the worst outcomes of advanced disease.

Pancreatic cancer: Patient and caregiver perceptions on diagnosis, psychological impact, and importance of support

BACKGROUND/OBJECTIVES

Pancreatic cancer (PC) can have an enormous psychological toll on those affected by it. This study evaluated patient and caregiver perceptions about diagnosis and daily life with PC.

METHODS

The Pancreatic Cancer Action Network (PanCAN) administered a 25-min online survey (funded by Celgene) between July 30 and September 18, 2013 to patients with PC and caregivers whose loved ones were alive or had died within the past 6 months.

RESULTS

There were 397 respondents (all in the US) including 184 patients (81 with metastatic disease) and 213 caregivers (145 with loved ones with metastatic disease); 80% of patients reported having a primary caregiver. Over 90% reported symptoms before diagnosis, the most common of which being acute abdominal pain, pain radiating into the back, and fatigue. Gastroenterologists were the diagnosing physician in 36.3% of cases. The mean duration from symptom onset to diagnosis was 2.4 months. The most common action taken by diagnosing physicians was referral to another physician (57.7%). No treatments were offered for 9% of patients with nonmetastatic disease and 17% of patients with metastatic disease. The most commonly reported caregiver roles were providing support on treatment days and talking to physicians. A greater percentage of caregivers than patients recognized the various roles played by caregivers. Patients aware of the PanCAN Patient and Liaison Services (PALS) program reported fewer negative emotions than PALS-unaware patients.

CONCLUSIONS

This study provides insights into the issues patients and caregivers in the US face and the importance of support services for both.

[Pancreatic cancer. Evidence based management guidelines of the Hungarian Pancreatic Study Group]

Pancreatic cancer is a disease with a poor prognosis usually diagnosed at a late stage. Therefore, screening, diagnosis, treatment and palliation of pancreatic cancer patients require up-to-date and evidence based management guidelines. The Hungarian Pancreatic Study Group proposed to prepare an evidence based guideline based on the available scientific evidence and international guidelines. The preparatory and consultation board appointed by the Hungarian Pancreatic Study Group translated and complemented/modified the recent international guidelines. 37 clinical statements in 10 major topics were defined (Risk factors and genetics, Screening, Diagnosis, Staging, Surgical care, Pathology, Systemic treatment, Radiation therapy, Palliation and supportive care, Follow-up and recurrence). Evidence was graded according to the National Comprehensive Cancer Network (NCCN) grading system. The draft of the guideline was presented and discussed at the consensus meeting in September 12, 2014. Statements were accepted with either total (more than 95% of votes, n = 15) or strong agreement (more than 70% of votes, n = 22). The present guideline is the first evidence-based pancreatic cancer guideline in Hungary that provides a solid ground for teaching purposes, offers quick reference for daily patient care and guides financing options. The authors strongly believe that these guidelines will become a standard reference for pancreatic cancer treatment in Hungary.

Pancreatic cancer: diagnosis and treatments

Pancreatic cancer is one of the deadliest cancers, with exceptionally high mortality. Despite the relatively low incidence rate (10th), it is the fourth leading cause of cancer-related deaths in most developed countries. To improve the early diagnosis of pancreatic cancer and strengthen the standardized comprehensive treatment are still the main focus of pancreatic cancer research. Here, we summarized the rapid developments in the diagnosis and treatments of pancreatic cancer. Regarding diagnosis, we reviewed advances in medical imaging technology, tumor markers, molecular biology (e.g., gene mutation), and proteomics. Moreover, great progress has also been made in the treatments of this disease, including surgical resection, chemotherapy, targeted radiotherapy, targeted minimally invasive treatment, and molecular targeted therapy. Therefore, we also recapitulated the development, advantages, and disadvantages of each of the treatment methods in this review.

Tips and tricks of the surgical technique for borderline resectable pancreatic cancer: mesenteric approach and modified distal pancreatectomy with en-bloc celiac axis resection

Borderline resectable (BR) pancreatic cancer involves the portal vein and/or superior mesenteric vein (PV/SMV), major arteries including the superior mesenteric artery (SMA) or common hepatic artery (CHA), and sometimes includes the involvement of the celiac axis. We herein describe tips and tricks for a surgical technique with video assistance, which may increase the R0 rates and decrease the mortality and morbidity for BR pancreatic cancer patients. First, we describe the techniques used for the "artery-first" approach for BR pancreatic cancer with involvement of the PV/SMV and/or SMA. Next, we describe the techniques used for distal pancreatectomy with en-bloc celiac axis resection (DP-CAR) and tips for decreasing the delayed gastric emptying (DGE) rates for advanced pancreatic body cancer. The mesenteric approach, followed by the dissection of posterior tissues of the SMV and SMA, is a feasible procedure to obtain R0 rates and decrease the mortality and morbidity, and the combination of this aggressive procedure and adjuvant chemo(radiation) therapy may improve the survival of BR pancreatic cancer patients. The DP-CAR procedure may increase the R0 rates for pancreatic cancer patients with involvement within 10 mm from the root of the splenic artery, as well as the CHA or celiac axis, and preserving the left gastric artery may lead to a decrease in the DGE rates in cases where there is more than 10 mm between the tumor edge and the root of the left gastric artery. The development of safer surgical procedures is necessary to improve the survival of BR pancreatic cancer patients.

Borderline resectable pancreatic cancer: Definitions and management

Pancreatic cancer is the fourth leading cause of cancer death in the United States. While surgical resection remains the only curative option, more than 80% of patients present with unresectable disease. Unfortunately, even among those who undergo resection, the reported median survival is 15-23 mo, with a 5-year survival of approximately 20%. Disappointingly, over the past several decades, despite improvements in diagnostic imaging, surgical technique and chemotherapeutic options, only modest improvements in survival have been realized. Nevertheless, it remains clear that surgical resection is a prerequisite for achieving long-term survival and cure. There is now emerging consensus that a subgroup of patients, previously considered poor candidates for resection because of the relationship of their primary tumor to surrounding vasculature, may benefit from resection, particularly when preceded by neoadjuvant therapy. This stage of disease, termed borderline resectable pancreatic cancer, has become of increasing interest and is now the focus of a multi-institutional clinical trial. Here we outline the history, progress, current treatment recommendations, and future directions for research in borderline resectable pancreatic cancer.

The role of (18)fluoro-deoxyglucose positron emission tomography/computed tomography in resectable pancreatic cancer

BACKGROUND

The role of (18)fluoro-deoxyglucose positron emission tomography/computed tomography in pancreatic ductal adenocarcinoma is debated. We retrospectively assessed the value of (18)fluoro-deoxyglucose positron emission tomography/computed tomography in addition to conventional imaging as a staging modality in pancreatic cancer.

METHODS

(18)Fluoro-deoxyglucose positron emission tomography/computed tomography was performed in 72 patients with resectable pancreatic carcinoma after multi-detector computed tomography positron emission tomography was considered positive for a maximum standardized uptake value >3.

RESULTS

Overall, 21% of patients had a maximum standardized uptake value ≤ 3, and 60% of those had undergone neoadjuvant treatment (P=0.0001). Furthermore, 11% of patients were spared unwarranted surgery since positron emission tomography/computed tomography detected metastatic disease. All liver metastases were subsequently identified with contrast-enhanced ultrasound. Sensitivity and specificity of positron emission tomography/computed tomography for distant metastases were 78% and 100%. The median CA19.9 concentration was 48.8 U/mL for the entire cohort and 292 U/mL for metastatic patients (P=0.112).

CONCLUSIONS

The widespread application of (18)fluoro-deoxyglucose positron emission tomography/computed tomography in patients with resectable pancreatic carcinoma seems not justified. It should be considered in selected patients at higher risk of metastatic disease (i.e. CA19.9>200 U/mL) after undergoing other imaging tests. Neoadjuvant treatment is significantly associated with low metabolic activity, limiting the value of positron emission tomography in this setting.

Optimal Pancreatic Phase Delay with 64-Detector CT Scanner and Bolus-tracking Technique

RATIONALE AND OBJECTIVES

To assess the optimal pancreatic phase delay in terms of parenchymal enhancement and tumor-to-pancreas contrast with a bolus-tracking method.

MATERIALS AND METHODS

Patients referred for suspicion of pancreatic tumor and undergoing 64-detector computed tomography scanner were randomized to an individualized scan delay of 10, 20, or 30 seconds of nonionic contrast material (370 mg I/mL) after aortic enhancement above 150 Hounsfield units. The volume of contrast was adjusted to patient weight. Pancreatic and tumor enhancements were measured. Statistical analysis included analysis of variance and post hoc Tukey tests.

RESULTS

One hundred and fifty patients were randomized to individualized scan delays of 10, 20, or 30 seconds. Pancreatic parenchymal enhancement in all patients (n = 150) was significantly higher with a delay of 20 or 30 seconds than that with 10 seconds (P < .001 for both). Tumor-to-pancreas contrast for solid tumors (n = 59) was significantly higher with a delay of 30 seconds than that with 10 seconds (P = .015). Adenocarcinoma-to-pancreas contrast during pancreatic phase was significantly higher for a 20- or 30-second delay than for a 10-second delay (P = .027 and .011, respectively) for one reader.

CONCLUSIONS

With a flow rate of 4 mL/s and weight-adjusted contrast volume, an individualized scan delay of 30 seconds after aortic transit time revealed higher pancreatic enhancement and tumor-to-pancreas contrast than that with a delay of 10 seconds.

Early diagnosis of pancreatic cancer

Pancreatic cancer is a common malignancy of the pancreas, with about 90% originating in the glandular epithelium. As a highly malignant gastrointestinal tumor, pancreatic cancer is difficult to diagnose and treat. The silent nature of the clinical manifestations and the difficulty of early diagnosis lead to a poor prognosis. In recent years, the incidence rate and mortality rate have increased significantly, with the 5-year survival rate being less than 1%. It is evident that early diagnosis is an effective strategy to improve the prognosis and therefore has become a hotspot of research. This article reviews the progress in early diagnosis of pancreatic cancer in terms of imageological diagnosis, serological examinations and genomic testing as well as the screening of high-risk populations.

Borderline resectable pancreatic cancer: a consensus statement by the International Study Group of Pancreatic Surgery (ISGPS)

BACKGROUND

This position statement was developed to expedite a consensus on definition and treatment for borderline resectable pancreatic ductal adenocarcinoma (BRPC) that would have worldwide acceptability.

METHODS

An international panel of pancreatic surgeons from well-established, high-volume centers collaborated on a literature review and development of consensus on issues related to borderline resectable pancreatic cancer.

RESULTS

The International Study Group of Pancreatic Surgery (ISGPS) supports the National Comprehensive Cancer Network criteria for the definition of BRPC. Current evidence supports operative exploration and resection in the case of involvement of the mesentericoportal venous axis; in addition, a new classification of extrahepatic mesentericoportal venous resections is proposed by the ISGPS. Suspicion of arterial involvement should lead to exploration to confirm the imaging-based findings. Formal arterial resections are not recommended; however, in exceptional circumstances, individual therapeutic approaches may be evaluated under experimental protocols. The ISGPS endorses the recommendations for specimen examination and the definition of an R1 resection (tumor within 1 mm from the margin) used by the British Royal College of Pathologists. Standard preoperative diagnostics for BRPC may include: (1) serum levels of CA19-9, because CA19-9 levels predict survival in large retrospective series; and also (2) the modified Glasgow Prognostic Score and the neutrophil/lymphocyte ratio because of the prognostic relevance of the systemic inflammatory response. Various regimens of neoadjuvant therapy are recommended only in the setting of prospective trials at high-volume centers.

CONCLUSION

Current evidence justifies portomesenteric venous resection in patients with BRPC. Basic definitions were identified, that are currently lacking but that are needed to obtain further evidence and improvement for this important patient subgroup. A consensus for each topic is given.

Upper gastrointestinal complications associated with gemcitabine-concurrent proton radiotherapy for inoperable pancreatic cancer

BACKGROUND

Little is known about acute upper gastrointestinal (GI) complications associated with gemcitabine-concurrent proton radiotherapy (GPT) for inoperable pancreatic cancer. We investigated acute GI complications following GPT in patients with inoperable pancreatic cancer using small-bowel endoscopy.

METHODS

This prospective single center observational study was conducted at the Hyogo Ion Beam Medical Center from January 2010 to January 2012. Ninety-one patients who had clinically and medically inoperable pancreatic cancer treated by GPT were analyzed. Endoscopic examinations were performed before and after GPT to clarify the incidence rates of radiation-induced ulcers, GI hemorrhage, and GI perforation associated with GPT.

RESULTS

Post-treatment endoscopic examinations revealed that 45 (49.4 %) patients had radiation-induced ulcers in the stomach and duodenum. Of those, many ulcerative lesions were found in the lower stomach (51 %) and horizontal part of the duodenum (39 %), regardless of the primary tumor site in the pancreas. Neither GI hemorrhage, nor perforation, was found in post-treatment endoscopy examinations.

CONCLUSION

Approximately half of the patients treated with GPT for inoperable pancreatic cancer exhibited radiation-induced ulcers in the stomach and duodenum.

Sensitivity of alternative testing for pancreaticobiliary cancer: a 10-y review of the literature

BACKGROUND

Biliary strictures present a diagnostic challenge to differentiate benign disease from hepatopancreaticobiliary (HPB) malignancies. Endoscopic retrograde cholangiopancreatography cytology is commonly performed in these patients; however, its sensitivity for diagnosis of HPB malignancy is poor (41.6%). Many adjunctive tests have been investigated to improve the sensitivity of HPB biopsies. To determine the best tests available, however, we reviewed the literature and performed a comparative analysis of all recently investigated tests and their sensitivities.

METHODS

A PubMed search identified articles published between 2003 and 2014, describing alternate methods for diagnosing HPB malignancies, reported sensitivity, final pathology, and had data available online. Meta-analysis was conducted for tests with multiple articles. Tests with the highest sensitivity and specificities were reported.

RESULTS

A total of 77 studies were identified. Meta-analysis was performed on the sensitivity of EUS-FNA (74.2%), fluorescence in situ hybridization (54.2%), immunostain of insulin-like growth factor 2 mRNA-binding Protein 3 (IMP3; 80.4%), IMP3 + cytology (86.4%), K homology domain containing protein overexpressed in cancer (KOC; 85.9%), S100P (77.8%), serum CA19-9 (69.3%), and K-ras mutations (47.0%) to detect malignancy. Ultimately, 12 tests were identified with superior sensitivity (85.3%-100%) and specificities (81.6%-100%) including stricture scrapping, brush sectioning, IMP3 stain + cytology, IMP3+S100A4, bile carcinoembryonic cell adhesion molecule 6 protein (±CA19-9), bile micro RNA (miRNA)-135b, serum miRNA-RNU2-1f, serum miRNA-21 (+CA19-9), peripheral blood mononuclear cells miRNA-27a-3p (+CA19-9), serum miRNA-16 + miRNA-196a (+CA19-9), peripheral blood mononuclear cells mRNAs h-TERT + CK20 + CEA + C-MET.

CONCLUSIONS

We recommend immunostaining with a panel of IMP3+KOC + S100A4 + cytology to achieve maximum sensitivity and specificity from HPB biopsies. One biliary protein (carcinoembryonic cell adhesion molecule 6) and several RNAs (bile and blood) offer exceptional sensitivity and specificity and should be tested prospectively in larger populations. Overall, this review identifies several tests to improve the sensitivity of diagnostic algorithms to identify HPB malignancies.

Pancreatic ductal adenocarcinoma radiology reporting template: consensus statement of the Society of Abdominal Radiology and the American Pancreatic Association

Pancreatic ductal adenocarcinoma is an aggressive malignancy with a high mortality rate. Proper determination of the extent of disease on imaging studies at the time of staging is one of the most important steps in optimal patient management. Given the variability in expertise and definition of disease extent among different practitioners as well as frequent lack of complete reporting of pertinent imaging findings at radiologic examinations, adoption of a standardized template for radiology reporting, using universally accepted and agreed on terminology for solid pancreatic neoplasms, is needed. A consensus statement describing a standardized reporting template authored by a multi-institutional group of experts in pancreatic ductal adenocarcinoma that included radiologists, gastroenterologists, and hepatopancreatobiliary surgeons was developed under the joint sponsorship of the Society of Abdominal Radiologists and the American Pancreatic Association. Adoption of this standardized imaging reporting template should improve the decision-making process for the management of patients with pancreatic ductal adenocarcinoma by providing a complete, pertinent, and accurate reporting of disease staging to optimize treatment recommendations that can be offered to the patient. Standardization can also help to facilitate research and clinical trial design by using appropriate and consistent staging by means of resectability status, thus allowing for comparison of results among different institutions.

Pancreatic ductal adenocarcinoma radiology reporting template: consensus statement of the society of abdominal radiology and the american pancreatic association

Pancreatic ductal adenocarcinoma is an aggressive malignancy with a high mortality rate. Proper determination of the extent of disease on imaging studies at the time of staging is one of the most important steps in optimal patient management. Given the variability in expertise and definition of disease extent among different practitioners as well as frequent lack of complete reporting of pertinent imaging findings at radiologic examinations, adoption of a standardized template for radiology reporting, using universally accepted and agreed on terminology for solid pancreatic neoplasms, is needed. A consensus statement describing a standardized reporting template authored by a multi-institutional group of experts in pancreatic ductal adenocarcinoma that included radiologists, gastroenterologists, and hepatopancreatobiliary surgeons was developed under the joint sponsorship of the Society of Abdominal Radiologists and the American Pancreatic Association. Adoption of this standardized imaging reporting template should improve the decision-making process for the management of patients with pancreatic ductal adenocarcinoma by providing a complete, pertinent, and accurate reporting of disease staging to optimize treatment recommendations that can be offered to the patient. Standardization can also help to facilitate research and clinical trial design by using appropriate and consistent staging by means of resectability status, thus allowing for comparison of results among different institutions.

Aggressive surgery for borderline resectable pancreatic cancer: evaluation of National Comprehensive Cancer Network guidelines

OBJECTIVES

The objective of this study was to evaluate the relevance of defining borderline resectable (BR) pancreatic cancer as a distinct entity in the treatment scheme of pancreatic cancer as proposed by the National Comprehensive Cancer Network.

METHODS

Among 375 patients with pancreatic cancer, 137 patients were deemed to have resectable disease (R) by preoperative imaging studies, whereas 96 were found to have an unresectable disease during surgery. The remaining 142 patients fulfilled the definition of BR and were further classified into 3 subgroups based on the National Comprehensive Cancer Network guidelines: portal vein invasion (PV[+]), common hepatic artery invasion (CHA[+]), and superior mesenteric artery invasion (SMA[+]). PV(+) was subdivided into types B, C, and D according to the degree of portal vein invasion.

RESULTS

Patients in the R group had significantly better survival than those in the PV(+) group (P = 0.0038), who in turn survived significantly longer than those classified as SMA(+) (P = 0.041). Type B patients survived significantly longer than did types C and D patients (P = 0.013 and P = 0.030, respectively). In PV(+) patients, compliance with postoperative chemotherapy at 3 and 6 months was 56.9% and 44.6%, respectively, substantially inferior to patients with resectable disease (72.6% and 54.7%, respectively).

CONCLUSIONS

The optimal treatment strategy may differ among various subgroups within the BR category.

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.

Abdominal ultrasonography in detecting and surgical treatment of pancreatic carcinoma

THE AIM OF THE STUDY

was to asses the clinical value of percutaneous abdominal ultrasonography in diagnosis, staging and surgical treatment of patients with pancreatic carcinoma.

MATERIAL AND METHODS

Prospective clinical trial on diagnostic accuracy of percutaneous abdominal ultrasonography was conducted in 409 consecutive patients with pancreatic cancer which were operated on at the I Dept. of General Surgery in Cracow between 2000 and 2010.

RESULTS

Diagnostic accuracy of percutaneous abdominal ultrasonography in pancreatic cancer was 91,1%. The accuracy in detecting different stages of local advancement according to TNM classification was assessed respectively 92.3%-T1, 91.3%-T2, 89.4%-T3, 92.1%-T4, a whole T1-T4 on 91.3%. Diagnostic accuracy of percutaneous abdominal ultrasonography in diagnosis of metastasis to lymph nodes, vascular infiltration, and resectability was respectively 80.7%, 86%, 91.4%.

CONCLUSIONS

Percutaneous abdominal ultrasonography has high diagnostic accuracy in diagnosis, staging and predicting surgical treatment of patients with pancreatic carcinoma.

Pancreatic Adenocarcinoma, version 2.2012: featured updates to the NCCN Guidelines

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Pancreatic Adenocarcinoma discuss the workup and management of tumors of the exocrine pancreas. These NCCN Guidelines Insights provide a summary and explanation of major changes to the 2012 NCCN Guidelines for Pancreatic Adenocarcinoma. The panel made 3 significant updates to the guidelines: 1) more detail was added regarding multiphase CT techniques for diagnosis and staging of pancreatic cancer, and pancreas protocol MRI was added as an emerging alternative to CT; 2) the use of a fluoropyrimidine plus oxaliplatin (e.g., 5-FU/leucovorin/oxaliplatin or capecitabine/oxaliplatin) was added as an acceptable chemotherapy combination for patients with advanced or metastatic disease and good performance status as a category 2B recommendation; and 3) the panel developed new recommendations concerning surgical technique and pathologic analysis and reporting.

Tumor size as measured at initial X-ray examination, not length of bile duct stricture, predicts survival in patients with unresectable pancreatic cancer

Background

The survival of unresectable pancreatic cancer patients is extremely poor. The aim of this study was to examine if tumor size could predict survival length in order to optimize patient care.

Methods

A retrospective observational study was performed on 185 consecutive patients with unresectable pancreatic cancer (ICD10: C250-2 and C258) who were diagnosed from 2003 to May 2010. The patients' initial radiographs at presentation of symptoms were reviewed by the same radiologist, and tumor extent was determined.

Results

The largest tumor diameter of the primary tumor was measured in 132 patients, 22 by an ultrasound and the other patients by a CT scan. In 53 patients, the tumor size could not be delimited and measured. Seventy-five patients (41%) had liver metastases at presentation of symptoms. Median survival for the entire patient group was only 119 days. The median diameter of the patient’s largest tumor was 4.35 cm, while the sample groups ranged from 1.2 to 14 cm. Patients were divided into two groups: those with a largest tumor diameter of ≤ 4.3 cm (66 patients) and those with a largest tumor diameter of > 4.3 cm (66 patients). Median survival for these groups was 149 and 94 days (p = 0.019), respectively. Cox regression showed a hazard ratio for tumor size of 1.48 (95% CI 1.02, 2.07) (p = 0.038), adjusted for the gemcitabine treatment which had been given to 49 patients and the presence of liver metastasis. In 88 patients, stricture length could be measured at ERCP. When comparing stricture lengths of ≤ 2 cm and > 2 cm, no difference in survival time was noted within a Kaplan-Meier analysis.

Conclusion

The size of the maximum tumor diameter of the primary tumor during the initial X-ray examination of patients with pancreatic cancer may predict survival time for those patients who had no surgical resection. Stricture length at ERCP gave no information on survival.

Diagnostic value of EUS elastography in differentiation of benign and malignant solid pancreatic masses: a meta-analysis

BACKGROUND/AIMS

EUS elastography is a novel technique that can be used for distinguishing benign from malignant lymph nodes and focal pancreatic masses. However, the studies pertaining to EUS elastography for differential diagnosis of solid pancreatic masses have reported widely varied sensitivities and specificities. A meta-analysis of all relevant articles was performed to estimate the overall diagnostic accuracy of EUS elastography for differentiating benign and malignant solid pancreatic masses.

METHODS

The literatures were identified by searching in PubMed and Embase databases. Two reviewers independently extracted the information from the literatures for constructing 2 × 2 table. A random-effect model or a fixed-effect model was used to estimate the sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio. A summary receiver operating characteristic curve (SROC) also was constructed. Meta-regression and subgroup analysis were used to explore the sources of heterogeneity.

RESULTS

13 studies including a total of 1042 patients with solid pancreatic masses were selected for meta-analysis. The pooled sensitivity and specificity of EUS elastography for differentiating benign and malignant solid pancreatic masses were 95% (95% confidence interval [CI], 93%-96%), 69% (95% CI, 63%-75%), respectively. The area under SROC (AUC) was 0.8695. Two significant variables were associated with heterogeneity: color pattern and blinding.

CONCLUSION

As a less invasive modality, EUS elastography is a promising method for differentiating benign and malignant solid pancreatic masses with a high sensitivity, and it can prove to be a valuable supplement to EUS-FNA.

Pancreatic Adenocarcinoma, version 2.2012: featured updates to the NCCN Guidelines

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Pancreatic Adenocarcinoma discuss the workup and management of tumors of the exocrine pancreas. These NCCN Guidelines Insights provide a summary and explanation of major changes to the 2012 NCCN Guidelines for Pancreatic Adenocarcinoma. The panel made 3 significant updates to the guidelines: 1) more detail was added regarding multiphase CT techniques for diagnosis and staging of pancreatic cancer, and pancreas protocol MRI was added as an emerging alternative to CT; 2) the use of a fluoropyrimidine plus oxaliplatin (e.g., 5-FU/leucovorin/oxaliplatin or capecitabine/oxaliplatin) was added as an acceptable chemotherapy combination for patients with advanced or metastatic disease and good performance status as a category 2B recommendation; and 3) the panel developed new recommendations concerning surgical technique and pathologic analysis and reporting.

Value of diffusion-weighted imaging for the discrimination of pancreatic lesions: a meta-analysis

OBJECTIVE

We aimed to explore the role of diffusion-weighted imaging (DWI) in the discrimination of pancreatic lesions through meta-analysis.

METHODS

The MEDLINE, EMBASE, Cancerlit, and Cochrane Library databases, from January 2001 to August 2011, were searched for studies evaluating the diagnostic performance of DWI in the discrimination of pancreatic lesions. We determined sensitivities and specificities across studies, calculated positive and negative likelihood ratios (LR+ and LR-), and constructed summary receiver operating characteristic curves.

RESULTS

A total of 11 studies with 586 patients, who fulfilled all of the inclusion criteria, were considered for the analysis. No publication bias was found. The pooled sensitivity of DWI was 0.86 [95% (confidence interval (CI), 0.78, 0.91] and the pooled specificity was 0.91 (95% CI, 0.81, 0.96). Overall, LR+ was 9.8 (95% CI, 4.1, 23.3) and LR- was 0.15 (95% CI, 0.09, 0.26). The area under the curve of the summary receiver operating characteristic was 0.94 (95% CI, 0.91-0.96). In subgroup analysis, prospectively designed studies had the highest pooled sensitivity (0.87, 95% CI 0.75, 0.94) and specificity (0.96, 95% CI 0.91, 0.99) (P<0.05). Study sensitivity was not correlated with the prevalence of pancreatic lesions (R=0.1076, P=0.3247).

CONCLUSION

A limited number of small studies suggest that DWI is a potentially technically feasible measure to differentiate malignant from benign pancreatic lesions. However, it is still controversial and is limited in that it can only distinguish certain lesions. High-quality prospective studies on DWI for the discrimination of pancreatic lesions still need to be conducted.

Clinical usefulness of diffusion-weighted MR imaging for detection of pancreatic cancer: comparison with enhanced multidetector-row CT

PURPOSE

The aim of this study was to compare diffusion-weighted magnetic resonance imaging (DWI) and multidetector-row computed tomography (MDCT) for detection of primary pancreatic cancer by reviewing images of patients at high risk for pancreatic cancer with main pancreatic duct (MPD) dilatation shown by magnetic resonance cholangiopancreatography (MRCP).

METHODS

From October 2007 to September 2009, 83 patients who had undergone both DWI and MDCT with MPD dilatation were identified and were reviewed by four readers (2 radiologists and 2 gastroenterology fellows). Diagnostic performance in pancreatic cancer detection was evaluated with 95% confidence intervals. Statistically significant differences in the detection of pancreatic cancer between DWI and MDCT were compared by receiver operating characteristics and the confidence of the diagnosis by the paired t test.

RESULTS

Thirty-two of 83 patients were diagnosed with primary pancreatic cancer by histological evaluation of 15 surgical and 2 endoscopic ultrasound-guided fine needle aspiration samples, and by the clinical course for 15 lesions. Overall average accuracies of pancreatic cancer detection by the four readers were 84% with DWI and 86% with MDCT.

CONCLUSION

Performance of DWI and MDCT was equivocal for detection of pancreatic cancer in a high-risk population with MPD dilatation. The combination of MRCP and DWI for detection of pancreatic cancer allowed identification of a high-risk population and tumor detection with a single imaging modality with no need for contrast medium.

Pancreatic cancer tumor size on CT scan versus pathologic specimen: implications for radiation treatment planning

PURPOSE

Pancreatic cancer primary tumor size measurements are often discordant between computed tomography (CT) and pathologic specimen after resection. Dimensions of the primary tumor are increasingly relevant in an era of highly conformal radiotherapy.

METHODS AND MATERIALS

We retrospectively evaluated 97 consecutive patients with resected pancreatic cancer at two Boston hospitals. All patients had CT scans before surgical resection. Primary endpoints were maximum dimension (in millimeters) of the primary tumor in any direction as reported by the radiologist on CT and by the pathologist for the resected gross fresh specimen. Endoscopic ultrasound (EUS) findings were analyzed if available.

RESULTS

Of the patients, 87 (90%) had preoperative CT scans available for review and 46 (47%) had EUS. Among proximal tumors (n = 69), 40 (58%) had pathologic duodenal invasion, which was seen on CT in only 3 cases. The pathologic tumor size was a median of 7 mm larger compared with CT size for the same patient (range, -15 to 43 mm; p < 0.0001), with 73 patients (84%) having a primary tumor larger on pathology than CT. Endoscopic ultrasound was somewhat more accurate, with pathologic tumor size being a median of only 5 mm larger compared with EUS size (range, -15 to 35 mm; p = 0.0003).

CONCLUSIONS

Computed tomography scans significantly under-represent pancreatic cancer tumor size compared with pathologic specimens in resectable cases. We propose a clinical target volume expansion formula for the primary tumor based on our data. The high rate of pathologic duodenal invasion suggests a risk of duodenal under-coverage with highly conformal radiotherapy.

Accuracy of differential diagnosis for pancreatic cancer is improved in the combination of RCAS1 and CEA measurements and cytology in pancreatic juice

Improvement of diagnostic accuracy for pancreatic cancer in pancreatic disease patients was investigated by examining the combination of three diagnostic methods, i.e., measurements of RCAS1 and CEA levels in pancreatic juice and pancreatic juice cytology. Pancreatic juice was collected from 12 pancreatic cancer (PC) and 26 non-PC patients. RCAS1 and CEA levels were measured by using ELISA. RCAS1 expression on surgically resected tissue was immunohistochemically examined for 2 PC patients. By setting the cutoff level of RCAS1 at 10 U/ml and that of CEA at 18.5 μg/ml, sensitivity of RCAS1 was 42% and that of CEA was 50%. On the other hand, sensitivity and specificity increased from 42% and 85% of RCAS1 alone to 75% and 85% in the examination of RCAS1 + CEA + cytology, and the false-negative rate was also reduced to 25% in this combination. Immunohistochemically, a patient with a high RCAS1 level in pancreatic juice had numerous RCAS1-positive tumor cells in the pancreatic juice. We concluded that RCAS1 and CEA measurements together with cytology in pancreatic juice would be a useful combination method for making a differential diagnosis of PC from non-PC.

Intraoperative ultrasonography of the pancreas

Intraoperative ultrasonography (US) of the pancreas is a versatile technique that provides excellent spatial and contrast resolution and real-time imaging capabilities, making it useful for diagnostic imaging as well as for guidance of laparoscopic and open operative procedures. Intraoperative US may be used for applications such as staging and localizing tumors; performing regional metastatic surveys; documenting arterial and venous patency; identifying endocrine tumors; distinguishing pancreatitis from a neoplasm; and guiding biopsy, duct cannulation, and drainage of abscesses or cysts. The scanning approach and technique vary according to the application, with many different equipment and transducer options and sterilization methods available. With increasing clinical demands for intraoperative US, it is essential that radiologists be familiar with its uses and technique. In addition, to properly perform intraoperative US and accurately interpret the images, knowledge of normal and variant pancreatic and vascular anatomy and relevant landmarks is needed. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.307105051/-/DC1.

Diagnostic management of pancreatic cancer

Pancreatic cancer is one of the most deadly solid tumors, with an overall 5-year survival rate of less than 5%. Due to a non-specific clinical presentation, it is often diagnosed at an advanced stage and is rarely amenable for curative treatment. Therefore early diagnosis and appropriate staging are still essential to define the best care and to improve patient survival. Several imaging modalities are currently available for the evaluation of pancreatic cancer. This review focuses on different techniques and discusses the diagnostic management of patients with pancreatic cancer. This review was conducted utilizing Pubmed and was limited to papers published within the last 5 years. The search key words pancreatic cancer, pancreatic adenocarcinoma, pancreatic tumors, diagnosis, radiology, imaging, nuclear imaging, endoscopy, endoscopic ultrasound and biochemical markers were used.

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.

Evidence-based imaging of pancreatic malignancies

A high-quality pancreatic protocol computed tomography (CT) is the primary imaging modality for diagnosing and staging pancreatic malignancy. The main limitation of CT is the lack of sensitivity for early pancreatic lesions. Endoscopic ultrasound (EUS) provides an excellent complement to CT for both diagnosis and staging of pancreatic cancer, and allows easy access for needle aspiration and tissue diagnosis. Magnetic resonance (MR) can be helpful for evaluating small hepatic nodules or cystic lesions of the pancreas, but in general, the role of MR and positron emission tomography remains limited to special situations when the results of CT and EUS are equivocal.

Pancreatic adenocarcinoma in a patient with situs inversus: a case report of this rare coincidence

Background

Situs inversus (SI) is a relatively rare occurrence in patients with pancreatic adenocarcinoma. Pancreatic resection in these patients has rarely been described. CT scan imaging is a principle modality for detecting pancreatic cancer and its use in SI patients is seldom reported.

Case Presentation

We report a 48 year old woman with SI who, despite normal CT scan 8 months earlier, presented with obstructive jaundice and a pancreatic head mass requiring a pancreaticoduodenectomy. The surgical pathology report demonstrated pancreatic adenocarcinoma.

Conclusion

SI is a rare condition with concurrent pancreatic cancer being even rarer. Despite the rarity, pancreaticoduodenectomy in these patients for resectable lesions is safe as long as special consideration to the anatomy is taken. Additionally, radiographic imaging has significantly improved detection of early pancreatic cancer; however, there continues to be a need for improved detection of small neoplasms.

Can preoperative CA19-9 and CEA levels predict the resectability of patients with pancreatic adenocarcinoma?

BACKGROUND

We aimed to explore the predictive ability of preoperative carbohydrate antigen 19-9 (CA19-9) and carcinoembryonic antigen (CEA) levels for assessing tumor resectability (R0 resection) in patients with pancreatic adenocarcinoma.

METHODS

The present study included 72 patients who had been treated surgically for potentially resectable pancreatic adenocarcinoma and 42 patients who had been treated surgically for palliation (bypass surgery) at our institution. Pancreatic adenocarcinoma was histologically confirmed by pathological examination of the resected specimen or, if unresected, by intraoperative biopsy.

RESULTS

For resectable disease, the mean and median values of CA19-9 were significantly lower than for R1/2 or unresectable disease. The best cut-off points for CEA, CA19-9, and tumor size to predict resectability were 2.47 ng/mL, 92.77 U/mL and 11.85 cm(3), respectively. A CA19-9 > or = 92.77 U/mL and both tumor markers no less than the cut-off levels predicted the possibility of R1/2 or unresectability with 90.6% and 88.6% accuracy, respectively. However, either tumor marker or both tumor markers less than the cut-off levels predicted the probability of R0 resection only with 27.1% and 40.6% accuracy, respectively. The independent contributing factors to resectability (R0 resection) by multivariate regression analysis were a CA 19-9 < 92.77 U/mL, a tumor size < 11.85 cm(3), and a less advanced AJCC stage.

CONCLUSION

The present study demonstrates that preoperative serum CA19-9 and CEA levels can be used for the prediction of resectability (R0 resection) in patients with pancreatic adenocarcinoma, which may enable a simple and cost-effective exclusion of such patients who are unlikely to benefit from surgery.

Radical resection and outcome for malignant tumors of the pancreatic body and tail

AIM: To analyze the factors influencing radical (R0) resection rate and surgical outcome for malignant tumor of the pancreatic body and tail.

METHODS: The clinical and operative data and follow-up results of 214 pancreatic body and tail cancer patients were analyzed retrospectively.

RESULTS: One hundred and twenty/214 pancreatic body and tail cancer patients underwent surgical treatment; the overall resection rate was 59.2% (71/120), and the R0 resection rate was 40.8% (49/120). Compared with non-R0 treatment, the patients receiving an R0 resection had smaller size tumor (P < 0.01), cystadenocarcinoma (P < 0.01), less lymph node metastasis (P < 0.01), less peri-pancreatic organ involvement (P < 0.01) and earlier stage disease (P < 0.01). The overall 1-, 3- and 5-year survival rates for pancreatic body and tail cancer patients were 12.7% (25/197), 7.6% (15/197) and 2.5% (5/197), respectively, and ductal adenocarcinoma patients had worse survival rates [15.0% (9/60), 6.7% (4/60) and 1.7% (1/60), respectively] than cystadenocarcinoma patients [53.8% (21/39), 28.2% (11/39) and 10.3% (4/39)] (P < 0.01). Moreover, the 1-, 3- and 5-year overall survival rates in patients with R0 resection were 55.3% (26/47), 31.9% (15/47) and 10.6% (5/47), respectively, significantly better than those in patients with palliative resection [9.5% (2/21), 0 and 0] and in patients with bypass or laparotomy [1.2% (1/81), 0 and 0] (P < 0.01).

CONCLUSION: Early diagnosis is crucial for increasing the radical resection rate, and radical resection plays an important role in improving survival for pancreatic body and tail cancer patients.

A systematic review of resectability and survival after concurrent chemoradiation in primarily unresectable pancreatic cancer

PURPOSE

The objective of this study was to determine the effect on resection rate and survival of neoadjuvant chemoradiotherapy for primarily unresectable locally advanced pancreatic carcinoma.

METHODS

A systematic review of recently published literature was performed. Resection rates and survival data were derived from reports published from 2000 onwards. Only recent studies, based on radiotherapy with standard dose and fractionation, have been analyzed.

RESULTS

Thirteen studies with a total of 510 patients met selection criteria. A resection rate of 8.3-64.2% was reported (median, 26.5%). Of the operated patients, 57.1-100% (median, 87.5%) had R0 tumor resection. Most papers reported occasional pathological complete responses (CR, 3.0-8.8%). When outcome in all patients was considered, median survival ranged from 9 to 23 (median, 13.3) months, comparing favorably with literature data based on concurrent chemoradiation alone (range, 8.6-13 months). Surprisingly, in patients with unresectable tumor at presentation, median survival after surgery ranged from 16.4 to 32.3 (median, 23.6) months.

CONCLUSIONS

The finding of a high proportion of R0 resection among all resections performed confirms the activity of neoadjuvant radiochemotherapy and should not be neglected. Based on these data, patients with unresectable pancreatic cancer without disease progression after chemoradiotherapy should be considered for radical surgery.

Role of endoscopic ultrasound in pancreatic cancer

Pancreatic cancer (PC) is the fourth most common cause of cancer deaths in Western societies. It is an aggressive tumor with an overall 5-year survival rate of less than 5%. Surgical resection offers the only possibility of cure and long-term survival for patients suffering from PC; however, unfortunately, fewer than 20% of patients suffering from PC have disease that is amendable to surgical resection. Therefore, it is important to accurately diagnose and stage these patients to enable optimal treatment of their disease. The imaging modalities involved in the diagnosis and staging of PC include multidetector CT scanning, endoscopic ultrasound (EUS), endoscopic retrograde cholangiopancreaticography and MRI. The roles and relative importance of these imaging modalities have changed over the last few decades and continue to change owing to the rapid technological advances in medical imaging, but these investigations continue to be complementary. EUS was first introduced in the mid-1980s in Japan and Germany and has quickly gained acceptance. Its widespread use in the last decade has revolutionized the management of pancreatic disease as it simultaneously provides primary diagnostic and staging information, as well as enabling tissue biopsy. This article discusses the potential benefits and drawbacks of EUS in the primary diagnosis, staging and assessment of resectability, and EUS-guided fine-needle aspiration in PC. Difficult diagnostic scenarios and pitfalls are also discussed. A suggested management algorithm for patients with suspected PC is also presented.