Chest computed tomography in the staging of pancreatic and periampullary carcinoma

Korean clinical practice guideline for pancreatic cancer 2021: A summary of evidence-based, multi-disciplinary diagnostic and therapeutic approaches

Pancreatic cancer is the eighth most common cancer and the fifth most common cause of cancer-related death in Korea. To enable standardization of management and facilitate improvements in outcome, a total of 53 multi-disciplinary experts in gastroenterology, surgery, medical oncology, radiation oncology, radiology, nuclear medicine, and pathology in Korea developed new recommendations that integrate the most up-to-date, evidence-based research findings and expert opinions. Recommendations were made on imaging diagnosis, endoscopic management, surgery, radiotherapy, palliative chemotherapy, and specific management procedures, including neoadjuvant treatment or adjuvant treatment for patients with resectable, borderline resectable, and locally advanced unresectable pancreatic cancer. This is the English version of the Korean clinical practice guideline for pancreatic cancer 2021. This guideline includes 20 clinical questions and 32 statements. This guideline represents the most standard guideline for the diagnosis and treatment of patients with pancreatic ductal adenocarcinoma in adults at this time in Korea. The authors believe that this guideline will provide useful and informative advice.

The yield of chest computed tomography in patients with locally advanced pancreatic cancer

OBJECTIVE

To evaluate the incidence of pulmonary metastases on chest computed tomography (CT) in patients with locally advanced pancreatic cancer (LAPC).

METHODS

All patients diagnosed with LAPC in a single tertiary center (Erasmus MC) between October 2011 and December 2017 were reviewed. The staging chest CT scan and follow-up chest CT scans were evaluated. Pulmonary nodules were divided into three categories: apparent benign, too small to characterize, and apparent malignant.

RESULTS

In 124 consecutive patients diagnosed with LAPC, 119 (96%) patients underwent a staging chest CT scan at the initial presentation. In 88 (74%) patients no pulmonary nodules were found; in 16 (13%) patients an apparent benign pulmonary nodule was found, and in 15 (13%) patients a pulmonary nodule too small to characterize was found. Follow-up chest CT scan(s) were performed in 111 (93%) patients. In one patient with either no pulmonary nodule or an apparent benign pulmonary nodule at initial staging, an apparent malignant pulmonary nodule was found on a follow-up chest CT scan. However, a biopsy of the nodule was inconclusive. Of 15 patients in whom a pulmonary nodule too small to characterize was found at staging, 12 (80%) patients underwent a follow-up CT scan; in 4 (33%) of these patients, an apparent malignant pulmonary nodule was found.

CONCLUSION

In patients with LAPC in whom at diagnosis a chest CT scan revealed either no pulmonary nodules or apparent benign pulmonary nodules, routine follow-up chest CT scans is not recommended. Patients with pulmonary nodules too small to characterize are at risk to develop apparent malignant pulmonary nodules during follow-up.

Routine Chest Computed Tomography for Staging of Pancreatic Head Carcinoma

OBJECTIVES

The diagnostic value of routine chest computed tomography (CT) in addition to abdominal CT in workup for pancreatic head carcinoma is unclear. The aim of this study was to determine if routine chest CT revealed significant lesions that altered the management of patients with suspected pancreatic head carcinoma.

METHODS

All Dutch pancreatic cancer centers were surveyed on the use of chest CT in preoperative staging. In addition, a single-center retrospective cohort study was performed including all patients referred with suspected pancreatic head malignancy without chest CT between 2005 and 2016. The primary end point was the proportion of patients in which chest CT revealed clinically significant lesions, leading to a change in management.

RESULTS

In 7 of 18 Dutch pancreatic cancer centers (39%), a preoperative chest CT is not routinely performed. In the study cohort, 170 of 848 patients (20%) were referred without chest CT and underwent one by local protocol. Chest CT revealed new suspicious lesions in 17 patients (10%), of whom 6 had metastatic disease (3.5%).

CONCLUSIONS

Routine use of chest CT in diagnostic workup for pancreatic head carcinoma reveals clinically significant lesions in 10% of patients, being metastases in up to 4%.

Lung Metastases in Patients with Stage IV Pancreatic Cancer: Prevalence, Risk Factors, and Survival Impact

The aim of this study was to evaluate the prevalence, the clinicopathological variables associated with probability of lung metastases, and the impact of lung metastases on survival outcome in patients with stage IV pancreatic cancer (PC) treated with palliative chemotherapy. A total of 654 patients with stage IV PC who underwent palliative chemotherapy from 2010–2016 were retrospectively enrolled in this study. Possible clinical variables associated with lung metastases and survival outcome were examined by univariate and multivariate analysis. Lung metastases were detected in 15.0% (3.4% with isolated lung metastases and 11.6% with synchronic metastases to lung and other organs). Female gender, poorly differentiated tumor grade, and large primary tumor size were independent risk factor in multivariate analysis. The median overall survival (OS) time was 6.5 months in the entire cohort, while the median OS was 11.8, 6.9, 7.7, 10.1, and 5.0 months for patients with isolated lung, isolated liver, isolated peritoneum, isolated distant lymph nodes, and multiple sites metastases, respectively. Isolated lung metastases were a better prognosticator for OS in univariate and multivariate analysis. This study utilized real-world clinical practice data to assess the prevalence, risk factors, and survival impact of lung metastases in patients with stage IV pancreatic cancer.

Diagnostic Accuracy of a 64-Slice Multi-Detector CT Scan in the Preoperative Evaluation of Periampullary Neoplasms

Periampullary tumors are highly malignant masses with poor prognosis. Surgical resection is the only treatment for patients with this disease. The preoperative evaluation of masses is essential to determine the tumor resectability and vascular invasion. The aim of this study was to determine the diagnostic accuracy of 64-slice multi-detector computed tomography (MDCT) in detecting the resectability of periampullary masses. A cross-sectional study was conducted on patients with a definite diagnosis of periampullary cancer. All the participants underwent an MDCT scan before the surgical pancreaticoduodenectomy. The preoperative results were compared to the intraoperative findings and the diagnostic accuracy was determined based on the sensitivity and specificity of the MDCT. From June 2015 until June 2016, 32 patients with periampullary carcinoma were enrolled in the study. Of 32 masses, one of them considered nonresectable because of the gross vascular invasion in th CT images. After the operation, the overall resectability rate was 81.3%. The sensitivity and specificity of MDCT for tumor resectability was 100% and 16.7%, respectively, with an overall accuracy of 84.4%. To sum up, MDCT had high sensitivity but low specificity in the preoperative evaluation of preampullary carcinomas. The low specificity resulted from the low accuracy of the CT scan in detecting vascular involvement.

Pearls and pitfalls of imaging metastatic disease from pancreatic adenocarcinoma: a systematic review

Pancreatic adenocarcinoma is a systemic disease due to the presence of metastatic disease at the time of diagnosis and local recurrence as well as distant metastatic disease after treatment in a majority of patients. Recognition of these metastatic sites may help in accurate staging and assessment of therapeutic response. The authors discuss and illustrate imaging findings of metastatic disease from pancreatic adenocarcinoma in different organ systems with emphasis on entities that can mimic metastatic pancreatic cancer.

Staging chest computed tomography and positron emission tomography in patients with pancreatic adenocarcinoma: utility or futility?

OBJECTIVES

This study was conducted to determine if routine staging chest computed tomography (CT) or positron emission tomography (PET) scanning alters the clinical management of patients with newly diagnosed pancreatic adenocarcinoma.

METHODS

All new pancreas cancers seen in medical oncology, radiation oncology and surgery from 1 June 2008 to 20 June 2010 were retrospectively reviewed. Patients with metastatic disease on chest CT or PET, that had been unsuspected on initial imaging, were identified.

RESULTS

Pancreatic adenocarcinoma was present in 247 consecutive patients. Abdominal CT demonstrated metastases in 108 (44%) and localized disease in 139 (56%) patients. Chest CT and PET were not performed in 15 (11%) of these 139 patients. In the remaining 124 patients, CT imaging suggested resectable disease in 46, borderline resectable disease in 52 and locally advanced disease in 26 patients. Chest CT demonstrated an unsuspected lymphoma in one patient with borderline resectable disease and PET identified extrapancreatic disease in two patients with locally advanced disease. Chest CT and PET added no information in 121 (98%) of the 124 patients.

CONCLUSIONS

The addition of chest CT and PET to high-quality abdominal CT is of little clinical utility; additional sites of metastasis are rarely found. As the quality of abdominal imaging declines, the yield from other imaging modalities will increase. Dedicated pancreas-specific abdominal CT remains the cornerstone of initial staging in suspected or biopsy-proven pancreatic cancer.

Ultrasonography of the pancreas. 4. Contrast-enhanced imaging

The introduction of contrast-enhanced ultrasonography (CEUS) has lead to great developments in the diagnostic capabilities of ultrasound. Second generation contrast media, characterized by harmonic responses at low mechanical index of the ultrasound beam, have already proven usefulness in the study of the liver but other abdominal organs can take advantage from the dynamic study during continuous ultrasonographic scans. The dynamic observation of the enhancement allows the perfect evaluation of the abdominal organs perfusion. The perfusion of the pancreas is well correlated to the semeiology of the gland parenchymography at CEUS. The study of the pancreas is a new and promising application of CEUS. CEUS can be used to better identify pancreatic lesions respect to conventional Ultrasound (US) or to characterize pancreatic lesions already visible at US. Moreover the staging of some pancreatic lesions can be improved by the use of contrast media. This article will review the clinical application of CEUS in the different pancreatic pathologies.

Evidence-based diagnosis and staging of pancreatic cancer

Only 20% of patients who present with pancreatic cancer will be amenable to potentially curative resection. Therefore, it is necessary to reliably identify patients who might benefit from major surgical intervention by employing the appropriate staging methods. In this review, the pros and cons of each imaging technique are discussed and an algorithm for single and combined use of the different imaging modalities is proposed. To date, contrast-enhanced multi-detector row helical CT (MDR-CT) together with endoscopic ultrasound (EUS) remain the first staging methods of choice. MDR-CT has a high sensitivity for identifying vascular invasion and EUS is able to detect lesions as small as 2-3 mm. ERCP is performed mainly in patients with biliary obstruction with the option for therapeutic intervention during the same session. MRI with MR-angiography, MRCP, PET/CT and staging laparoscopy are additional modalities which might give further information in cases of equivocal findings by MDR-CT and EUS. The role of tumour markers such as CA 19-9 and CEA is reserved for monitoring and diagnosing post-surgery recurrence. Cytological or histological confirmation should usually be performed in patients that are not eligible for surgery prior to the commencement of palliative radio- or chemotherapy. In the routine clinical setting, MDR-CT and EUS play the predominant roles by providing the most cost-effective and accurate means for diagnosing and staging most cases of pancreatic cancer.