Incremental Role of Pancreatic Magnetic Resonance Imaging after Staging Computed Tomography to Evaluate Patients with Pancreatic Ductal Adenocarcinoma

Pancreatic ductal adenocarcinoma: the latest on diagnosis, molecular profiling, and systemic treatments

Pancreatic ductal adenocarcinoma (PDAC) is currently the fourth leading cause of death in the United States and is expected to be ranked second in the next 10 years due to poor prognosis and a rising incidence. Distant metastatic PDAC is associated with the worst prognosis among the different phases of PDAC. The diagnostic options for PDAC are convenient and available for staging, tumor response evaluation, and management of resectable or borderline resectable PDAC. However, imaging is crucial in PDAC diagnosis, monitoring, resectability appraisal, and response evaluation. The advancement of medical technologies is evolving, hence the use of imaging in PDAC treatment options has grown as well as the utilization of ctDNA as a tumor marker. Treatment options for metastatic PDAC are minimal with the primary goal of therapy limited to symptom relief or palliation, especially in patients with low functional capacity at the point of diagnosis. Molecular profiling has shown promising potential solutions that would push the treatment boundaries for patients with PDAC. In this review, we will discuss the latest updates from evidence-based guidelines regarding diagnosis, therapy response evaluation, prognosis, and surveillance, as well as illustrating novel therapies that have been recently investigated for PDAC, in addition to discussing the molecular profiling advances in PDAC.

The value of 18F-fluorodeoxyglucose positron emission tomography/magnetic resonance whole-body scans and local enhancement scans in the preoperative staging and resectability assessment of pancreatic adenocarcinoma

Background

In addition to contrast-enhanced multiphase computed tomography (CT) and magnetic resonance imaging (MRI), integrated positron emission tomography (PET)/magnetic resonance (MR) is increasingly being used for the preoperative evaluation of pancreatic cancer. The purpose of this study was to explore the value of hybrid ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) PET/MR imaging in preoperative assessment and treatment decision-making.

Methods

A retrospective data collection (of imaging, clinical, and pathological information) was conducted on patients who underwent ¹⁸F-FDG PET/MR with clinically diagnosed or suspected pancreatic cancer from March 2018 to March 2022 in Ruijin Hospital. The data of 76 patients were initially included, with 1 of the 76 patients eventually being excluded due to a misdiagnosis of inflammatory disease. Of the 75 patients, 38 underwent pancreatic tumor resection and 10 underwent laparoscopic exploration. The accuracy of ¹⁸F-FDG PET/MR for pancreatic cancer staging and the assessment of pancreatic resectability was evaluated based on pathological results, intraoperative findings, and documented final clinical stages of illness. The adjustments to patient treatment plans were also analyzed before and after ¹⁸F-FDG PET/MR examination.

Results

The accuracy of clinical tumor node metastasis (TNM) staging of pancreatic cancer by ¹⁸F-FDG PET/MR was 73.3% (55/75). The area under the curve (AUC) of ¹⁸F-FDG PET/MR for diagnosing the advanced stage (III-IV) versus the nonadvanced stage (I-II) of disease was 0.922 [95% confidence interval (CI): 0.852-0.993]. The treatment regimen of 20.0% (15/75) of patients was impacted. The accuracy of the evaluation of the resectability of pancreatic cancer with ¹⁸F-FDG PET/MR was 91.9% (34/37). With the surgical and pathological results being used as a reference, the overall accuracy of preoperative ¹⁸F-FDG PET/MR for T staging was 62.2%, and the AUC for diagnosing T4 versus T1-3 was 0.872 (95% CI: 0.660-1.000).

Conclusions

¹⁸F-FDG PET/MR performs well in diagnosing advanced pancreatic cancer and thus may impact the treatment decisions for a considerable number of patients. ¹⁸F-FDG PET/MR has a high level of accuracy in evaluating the resectability of pancreatic cancer before surgery.

Pancreatic adenocarcinoma: imaging techniques for diagnosis and management

Pancreatic cancer is a leading cause of death from cancer but only a minority of patients with pancreatic ductal adenocarcinomas are eligible for curative resection. The increasing role of neoadjuvant therapy provides hope of improving outcomes. However, progress is also reliant on advances in imaging that can identify disease earlier and accurately assess treatment response. Computed tomography remains the cornerstone in evaluation of resectability, offering excellent spatial resolution. However, in high-risk patients, additional magnetic resonance imaging and positron emission tomography-computed tomography may further guide treatment decisions. Conventional computed tomography can be limited in its ability to determine disease response after neoadjuvant therapy. Dual-energy computed tomography and computed tomography or magnetic resonance imaging perfusion studies emerging as potentially better alternatives. Combined with pioneering advances in radiomic analysis, these modalities also show promise in analysing tumour heterogeneity and thereby more accurately predicting outcomes. This article reviews these imaging techniques.

[Diagnostic Imaging of pancreatic carcinoma-Update of the new guideline]

The new German S3 guidelines on ductal pancreatic adenocarcinoma were published for the first time on the homepage of the Association of the Scientific Medical Societies in Germany (AWMF) in December 2021 as a new update and thus the second update (first update 2013) and contain a large number of innovations in terms of diagnostics and treatment. The guidelines were organized and led by the German Society for Digestive and Metabolic Diseases (DGVS). In this article we would like to present the central content and innovations related to the radiological diagnostics of ductal pancreatic adenocarcinoma. The most important innovations are the highest recommendation strength in favor of computed tomography (CT) when assessing tumor spread as well as the adaptation of the European guidelines for cystic tumors by magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP) as the method of first choice. A further innovation is the implementation of a structured reporting of CT findings for describing the anatomical tumor resectability on the basis of the publication presented by the Abdominal Imaging Working Group and the Oncological Imaging Working Group of the German Radiological Society. There is no evidence for the implementation of radiological imaging in the field of aftercare or in the field of screening.

Tumor-Specific miRNA Signatures in Combination with CA19-9 for Liquid Biopsy-Based Detection of PDAC

Pancreatic ductal adenocarcinoma (PDAC) is considered one of the most aggressive malignancies and has high mortality and poor survival rates. Therefore, there is an urgent need to discover non-invasive biomarkers for early detection before PDAC reaches the incurable stage. We hypothesized that liquid biopsy of PDAC-derived extracellular vesicles (PDEs) containing abundant microRNAs (miRNAs) could be used for early diagnosis of PDAC because they can be selectively enriched and because they are biologically stable. We isolated PDEs by immunocapture using magnetic beads, and we identified 13 miRNA candidates in 20 pancreatic cancer patients and 20 normal controls. We found that expression of five miRNAs, including miR-10b, miR-16, miR-155, miR-429, and miR-1290, was markedly higher in PDEs. Furthermore, the miRNA signatures along with serum carbohydrate antigen 19-9 (CA19-9) were optimized by logistic regression, and the miRNA signature and CA19-9 combination markers (CMs) were effective at differentiating PDAC patients from normal controls. As a result, the CMs represented a high sensitivity (AUC, 0.964; sensitivity, 100%; specificity, 80%) and a high specificity (AUC, 0.962; sensitivity, 85.71%; specificity, 100%). These findings suggest that five miRNAs expressed in PDEs and CA19-9 are valuable biomarkers for screening and diagnosis of pancreatic cancer by liquid biopsy.

Additional MRI for initial M-staging in pancreatic cancer: a cost-effectiveness analysis

OBJECTIVE

Pancreatic cancer is portrayed to become the second leading cause of cancer-related death within the next years. Potentially complicating surgical resection emphasizes the importance of an accurate TNM classification. In particular, the failure to detect features for non-resectability has profound consequences on patient outcomes and economic costs due to incorrect indication for resection. In the detection of liver metastases, contrast-enhanced MRI showed high sensitivity and specificity; however, the cost-effectiveness compared to the standard of care imaging remains unclear. The aim of this study was to analyze whether additional MRI of the liver is a cost-effective approach compared to routinely acquired contrast-enhanced computed tomography (CE-CT) in the initial staging of pancreatic cancer.

METHODS

A decision model based on Markov simulation was developed to estimate the quality-adjusted life-years (QALYs) and lifetime costs of the diagnostic modalities. Model input parameters were assessed based on evidence from recent literature. The willingness-to-pay (WTP) was set to $100,000/QALY. To evaluate model uncertainty, deterministic and probabilistic sensitivity analyses were performed.

RESULTS

In the base-case analysis, the model yielded a total cost of $185,597 and an effectiveness of 2.347 QALYs for CE-MR/CT and $187,601 and 2.337 QALYs for CE-CT respectively. With a net monetary benefit (NMB) of $49,133, CE-MR/CT is shown to be dominant over CE-CT with a NMB of $46,117. Deterministic and probabilistic survival analysis showed model robustness for varying input parameters.

CONCLUSION

Based on our results, combined CE-MR/CT can be regarded as a cost-effective imaging strategy for the staging of pancreatic cancer.

KEY POINTS

• Additional MRI of the liver for initial staging of pancreatic cancer results in lower total costs and higher effectiveness. • The economic model showed high robustness for varying input parameters.

Management of Primary Squamous Cell Carcinoma of the Pancreas: A Case Report

Introduction: Primary squamous cell carcinoma of the pancreas (SCCP) is a rare malignant tumor that has been reported in individual case reports only. The clinical data on primary SCCP treatment are limited. Therefore, the appropriate management strategy for this disease should be standardized. Case Presentation: We present the case of a 63-year-old man admitted to our hospital for upper left abdominal pain for 2 months without weight loss or jaundice. Enhanced computed tomography (CT) and magnetic resonance imaging (MRI) of the abdomen revealed a mixed solid and cystic lesion in the pancreatic tail, measuring 35 × 37 mm in maximum diameter with enhancement. The patient was diagnosed with primary SCCP without metastasis, based on radiological and pathological findings. He did not receive neoadjuvant therapy postoperatively and was followed up by CT and MRI for 18 months without recurrence or metastasis. Result: Complete resection is the most effective treatment for early stage primary SCCP. Abdominal MRI is an effective imaging tool for preoperative evaluation and postoperative follow-up of primary SCCP. The need for neoadjuvant therapy depends on various factors. Conclusion: Primary SCCP is a tumor with poor prognosis. Risk factor control, early accurate radiologic evaluation, and individualized treatment strategies improve the quality of life and prolong the overall survival period of patients.

ISOlation Procedure vs. conventional procedure during Distal Pancreatectomy (ISOP-DP trial): study protocol for a randomized controlled trial

BACKGROUND

Radical antegrade modular pancreatosplenectomy (RAMPS) is an isolation procedure in pancreatosplenectomy for pancreatic body/tail cancer. Connective tissues around the bifurcation of the celiac axis are dissected, followed by median-to-left retroperitoneal dissection. This procedure has the potential to isolate blood and lymphatic flow to the area of the pancreatic body/tail and the spleen to be excised. This is achieved by division of the inflow artery, transection of the pancreas, and then division of the outflow vein in the early phases of surgery. In cases of pancreatic ductal adenocarcinoma (PDAC), the procedure has been shown to decrease intraoperative blood loss and increase R0 resection rate by complete clearance of the lymph nodes. This trial investigates whether the isolation procedure can prolong the survival of patients with pancreatic ductal adenocarcinoma who undergo distal pancreatosplenectomy (DPS) compared with those that undergo the conventional approach.

METHODS/DESIGN

Patients with PDAC scheduled to undergo DPS are randomized before surgery to undergo either a conventional procedure (arm A) or to undergo the isolation procedure (arm B). In arm A, the pancreatic body, tail, and spleen are mobilized, followed by removal of the regional lymph nodes. The splenic vein is transected at the end of the procedure. The timing of division of the splenic artery (SA) is not restricted. In arm B, regional lymph nodes are dissected, then we transect the root of the SA, the pancreas, then the splenic vein. At the end of the procedure, the pancreatic body/tail and spleen are mobilized and removed. In total, 100 patients from multiple Japanese high-volume centers will be randomized. The primary endpoint is 2-year recurrence-free survival by intention-to-treat analysis. Secondary endpoints include intraoperative blood loss, R0 resection rate, and overall survival.

DISCUSSION

If this trial shows that the isolation procedures can improve survival with a similar R0 rate and with a similar number of lymph node dissections to the conventional procedure, the isolation procedure is expected to become a standard procedure during DPS for PDAC. Conversely, if there were no significant differences in endpoints between the groups, it would demonstrate justification of either procedure from surgical and oncological points of view.

TRIAL REGISTRATION

UMIN Clinical Trials Registry UMIN000041381 . Registered on 10 August 2020. ClinicalTrials.gov NCT04600063 . Registered on 22 October 2020.

European Cancer Organisation Essential Requirements for Quality Cancer Care (ERQCC): Pancreatic Cancer

European Cancer Organisation Essential Requirements for Quality Cancer Care (ERQCC) are written by experts representing all disciplines involved in cancer care in Europe. They give patients, health professionals, managers and policymakers a guide to essential care throughout the patient journey. Pancreatic cancer is an increasing cause of cancer mortality and has wide variation in treatment and care in Europe. It is a major healthcare burden and has complex diagnosis and treatment challenges. Care must be carried out only in pancreatic cancer units or centres that have a core multidisciplinary team (MDT) and an extended team of health professionals detailed here. Such units are far from universal in European countries. To meet European aspirations for comprehensive cancer control, healthcare organisations must consider the requirements in this paper, paying particular attention to multidisciplinarity and patient-centred pathways from diagnosis, to treatment, to survivorship.

A Comparative Study of Survivor Outcomes between Preoperative Evaluation Using CT Alone and Combined CT and MRI in Patients with Pancreatic Ductal Adenocarcinoma

Purpose

Materials and Methods

Results

Conclusion

The Role of Imaging in Current Treatment Strategies for Pancreatic Adenocarcinoma

In pancreatic cancer, imaging plays an essential role in surveillance, diagnosis, resectability evaluation, and treatment response evaluation. Pancreatic cancer surveillance in high-risk individuals has been attempted using endoscopic ultrasound (EUS) or magnetic resonance imaging (MRI). Imaging diagnosis and resectability evaluation are the most important factors influencing treatment decisions, where computed tomography (CT) is the preferred modality. EUS, MRI, and positron emission tomography play a complementary role to CT. Treatment response evaluation is of increasing clinical importance, especially in patients undergoing neoadjuvant therapy. This review aimed to comprehensively review the role of imaging in relation to the current treatment strategy for pancreatic cancer, including surveillance, diagnosis, evaluation of resectability and treatment response, and prediction of prognosis.

Imaging and Management of Pancreatic Cancer

Pancreatic cancer is an aggressive disease with rising incidence and high mortality despite advances in imaging and therapeutic options. Surgical resection is currently the only curative treatment, with expanding roles for adjuvant and neoadjuvant chemoradiation. Accurate detection, staging, and post-treatment monitoring of pancreatic cancer are critical to improving survival and imaging plays a central role in the multidisciplinary approach to this disease. This article will provide a broad overview of the imaging and management of pancreatic cancer with a focus on diagnosis and staging, operative and nonoperative treatments, and post-therapeutic appearances after surgery and chemoradiation therapy.