Assessment of resectability of pancreatic carcinoma by color Doppler sonography

Efficacy of color Doppler ultrasound and contrast-enhanced ultrasound in identifying vascular invasion in pancreatic ductal adenocarcinoma

OBJECTIVES

To compare color Doppler ultrasound and contrast-enhanced ultrasound (CEUS) in evaluating vascular invasion in pancreatic ductal adenocarcinoma (PDAC).

MATERIALS AND METHODS

This retrospective study included 210 patients with PDAC who were evaluated by color Doppler ultrasound, CEUS, and contrast-enhanced computed tomography (CECT) at our institution between January 2017 and December 2020. Pathologic results were used as the gold standard in patients who underwent surgical and intraoperative exploration. For nonsurgical patients, CECT results were used as the reference standard. The vessels evaluated included those in the peripancreatic arterial system and venous system. The diagnostic performances of color Doppler ultrasound and CEUS for vascular invasion were compared.

RESULTS

In 51 patients who underwent surgery and intraoperative exploration, color Doppler ultrasound and CEUS differed only in assessing venous system invasion in patients with PDAC of the pancreatic body and tail, with the former being superior to the latter. In 159 nonsurgical patients, there was no difference between CEUS and color Doppler ultrasound in assessing superior mesenteric arteriovenous invasion. CEUS was superior to color Doppler ultrasound in evaluating the celiac artery and its branches, with an accuracy of up to 97.8% for some vessels. Color Doppler ultrasound was ideal for evaluating the splenic and portal veins.

CONCLUSION

CEUS is more suitable for the evaluation of peripancreatic arteries than color Doppler. CEUS combined with color Doppler ultrasound can be used as a potential supplement to CECT and is also expected to be used to evaluate vascular invasion of PDAC after chemotherapy.

CRITICAL RELEVANCE STATEMENT

Contrast-enhanced US and color Doppler in the assessment of vascular invasion in pancreatic ductal adenocarcinoma have their respective advantages, through standardized ultrasound processes are expected to improve the efficiency of inspection.

KEY POINTS

Contrast-enhanced US has unique advantages in assessing pancreatic ductal adenocarcinoma invasion of the celiac artery. Doppler imaging is of high value in assessing venous system invasion. Standardization of ultrasound imaging procedures for pancreatic ductal adenocarcinoma is expected to improve efficiency.

Establishment and Verification of a Scoring Model for the Differential Diagnosis of Pancreatic Cancer and Chronic Pancreatitis

OBJECTIVES

The aims of this study were to establish a scoring model for the differential diagnosis of pancreatic cancer (PC) and chronic pancreatitis (CP) and to evaluate its diagnostic efficacy.

METHODS

The data of 502 patients with PC and 210 patients with CP at the Peking Union Medical College Hospital from January 1999 to December 2013 were retrospectively analyzed. Binary logistic regression was applied to establish the prediction model for the differential diagnosis. The model was verified using the method of leave-one-out cross-validation.

RESULTS

The scoring system was established with 5 variables including age, carbohydrate antigen 19-9 level, splenic vein invasion, irregular dilatation of the pancreatic duct, and nontruncated pancreatic duct stenosis. The score range was from -2 to 3. The area under the receiver operating characteristic curve of the objects was 0.779 (95% confidence interval, 0.744-0.814) (P < 0.01), indicating that the scoring system is good at differentiation of PC with CP. With a score of 1 as the diagnostic cut-off value, the diagnostic sensitivity, specificity, positive predictive value, negative predictive value, and accuracy rate were 71.3%, 69.0%, 70.0%, 71.4%, and 70.2%, respectively.

CONCLUSIONS

The scoring model may improve the differential diagnosis of PC and CP and be useful in clinical practice.

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.

Role of endoscopic ultrasound in the diagnosis and staging of pancreatic cancer

Early diagnosis of pancreatic cancer remains a difficult task, and multiple imaging tests have been proposed over the years. The aim of this review is to describe the current role of endoscopic ultrasound (EUS) for the diagnosis and staging of patients with pancreatic cancer. A detailed search of MEDLINE between 1980 and 2007 was performed using the following keywords: pancreatic cancer, endoscopic ultrasound, diagnosis, and staging. References of the selected articles were also browsed and consulted. Despite progress made with other imaging methods, EUS is still considered to be superior for the detection of clinically suspected lesions, especially if the results of other cross-sectional imaging modalities are equivocal. The major advantage of EUS is the high negative predictive value that approaches 100%, indicating that the absence of a focal mass reliably excludes pancreatic cancer. The introduction of EUS-guided fine needle aspiration allows a preoperative diagnosis in patients with resectable cancer, as well as a confirmation of diagnosis before chemoradiotherapy for those that are not. This comprehensive review highlighted the diagnostic capabilities of EUS including the newest refinements such as contrast-enhanced EUS, EUS elastography, and 3-dimensional EUS. The place of EUS-guided biopsy is also emphasized, including the addition of molecular marker techniques.

Ultrasonography of the pancreas. 3. Doppler imaging

Ultrasonography is probably the most widely used medical imaging technique. In fact, its non-invasivity, portability, widespread distribution and good clinical results have made it the preferred method for a first imaging approach to patients in a large variety of clinical settings. Ultrasound technology is advancing rapidly, aimed to increase image quality. In particular, increased color-Doppler sensitivity is contributing to the diagnosis and staging of pancreatic disease. Doppler studies are in fact integral part of ultrasound examination of the pancreas evaluating the peripancreatic vascular structures enclose portal vein, splenic artery and vein, superior mesenteric artery and vein, aorta, and inferior vena cava. While flows in all peri-pancreatic vessels are well recognized, only few parenchymal vessels are usually appreciable in normal conditions. Anyway the increased Doppler sensitivity allows the visualization of smaller peri-pancreatic and intra-pancreatic vessels. This article will review the technical background underlying the clinical application of Doppler ultrasonography in pancreatic imaging, with particular emphasis to normal vascular anatomy of the pancreas, and to the main applications of Doppler techniques in the different pancreatic pathologies.

Significance of color doppler ultrasonography in the assessment of pancreatic carcinoma vascular invasion

Background/Aim. It is highly appreciated to provide exact data on vascular invasion of pancreatic carcinoma relying as much as possible on non-invasive diagnostic procedures. Color Doppler ultrasonography has been proven as an efficient method for clinical staging of pancreatic carcinoma essential for therapeutic decisions. The aim of this study was to provide an analysis of the sensitivity and specificity for color Doppler ultrasonography in patients suffering from pancreatic carcinoma. Methods. We performed color Doppler ultrasonography examination in 43 patients with pancreatic carcinoma prior to the surgery. The findings of ultrasonography on neoplasm vascular invasion were correlated to the findings obtained during the subsequent surgical procedures. An estimation of neoplastic invasion of certain blood vessels including portal vein, celiac trunk, and superior mesenteric artery and vein is critical for decision making regarding surgical treatment. The patients with metastases of pancreatic carcinoma were excluded from the study. Results. Comparing color Doppler and the surgical findings we estimated the sensitivity for detection of neoplastic vascular invasion ranging from 79?93%, whereas the specificity range was from 83?93%. Conclusion. Color Doppler ultrasonography is a sufficiently sensitive and specific method for evaluation of vascular invasion in pancreatic carcinoma patients. Since color Doppler ultrasonography is a non-invasive, radiation free, and inexpensive diagnostic tool, considering also the results of this and similar studies we could strongly recommend its use for an initial presurgical evaluation of vascular invasion in pancreatic carcinoma patients.

Ultrasonography, computed tomography and magnetic resonance imaging for diagnosis and determining resectability of pancreatic adenocarcinoma: a meta-analysis

OBJECTIVE

To compare ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI) in the diagnosis and determination of resectability of pancreatic adenocarcinoma.

METHODS

Articles reporting US, CT, or MRI data of patients with known or suspected pancreatic adenocarcinoma and at least 20 patients verified with histopathology, surgical findings, or follow-up were included. A bivariate random effects approach was used to calculate sensitivity and specificity for diagnosis and resectability of pancreatic adenocarcinoma.

RESULTS

Sixty-eight articles fulfilled all inclusion criteria. For diagnosis, sensitivities of helical CT, conventional CT, MRI, and US were 91%, 86%, 84%, and 76% and specificities were 85%, 79%, 82%, and 75% respectively. Sensitivities for MRI and US were significantly lower compared with helical CT (P = 0.04 and P = 0.0001). For determining resectability, sensitivities of helical CT, conventional CT, MRI, and US were 81%, 82%, 82, and 83% and specificities were 82%, 76%, 78%, and 63% respectively. Specificity of US was significantly lower compared with helical CT (P = 0.011).

CONCLUSIONS

Helical CT is preferable as an imaging modality for the diagnosis and determination of resectability of pancreatic adenocarcinoma.

Assessment of portal vein invasion in pancreatic cancer by fusion 3-dimensional ultrasonography

OBJECTIVE

The purpose of this study was to assess the usefulness of a newly developed imaging technique, fusion 3-dimensional ultrasonography (3DUS) in the diagnosis of portal vein (PV) invasion in patients with pancreatic cancer (PC).

METHODS

Fourteen patients with proven PC were examined by fusion 3DUS presented as shaded volume-rendering and multiplanar reconstruction images. The surgical findings were obtained in all patients (12 with resection and 2 without). The findings were compared with those of 2-dimensional ultrasonography (2DUS), contrast-enhanced computed tomography (CT), dynamic CT (DCT), angiography, and surgical findings. Portal vein invasion was assessed by 3 independent radiologists for each modality, and objectivity of the assessment was examined by interobserver variability analysis (kappa value).

RESULTS

On the basis of surgical findings, the accuracy rates of 2DUS, fusion 3DUS, DCT, and angiography were 78.6%, 92.9%, 85.3%, and 66.7%, respectively. The kappa values of 2DUS, fusion 3DUS, DCT, and angiography for PV invasion were 0.57, 0.90, 0.63, and 0.49, respectively, being most objective in fusion 3DUS.

CONCLUSIONS

Fusion 3DUS is useful for diagnosis of PV invasion of PC.

Imaging for the diagnosis and staging of periampullary carcinomas

Multiple imaging modalities are available for investigating patients with a suspected periampullary neoplasm. The relative utility of each imaging modality is discussed regarding its role in diagnosis and staging. A general imaging approach to patients with a distal biliary obstruction also is presented.

The role of ultrasound in biliary and pancreatic diseases

The possibilities and the limits of transabdominal ultrasonography (US) in the diagnosis of bilio-pancreatic diseases are reviewed here in the light of the last 10 years' research. US remains the method of choice for the diagnosis of gallstones and is generally accepted as an initial imaging technique in gallstone complications, such as acute cholecystitis. Moreover the method can be useful for the detection of the biliary complications after laparoscopic cholecystectomy and after liver transplantation. US is still considered the first diagnostic procedure when stones are suspected in the common bile duct. The use of color Doppler can provide a differential diagnosis of gallbladder cancer with respect to other benign inflammatory or polypoid lesions. Color Doppler US allows to detect vascular complications of acute pancreatitis such as pseudoaneurysms. US is still considered useful for the initial screening of the pancreatic cancer. However, for staging other imaging techniques must be employed. With US useful informations are obtained in the diagnosis of cystic tumors of the pancreas and of pancreatic metastases. US is generally of little use for the diagnosis of endocrine tumors.