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Gastrointestinal Imaging |
1 From the Department of Radiology (N.J.M., I.R.F., J.F.P., R.H.C., M.K.) and Consortium for Health Outcomes, Innovation and Cost-Effectiveness Studies, Department of Internal Medicine (A.G.), University of Michigan Hospitals, 1500 E Medical Center Dr, Box 30, Ann Arbor, MI 48109-0030. From the 1999 RSNA scientific assembly. Received August 10, 2000; revision requested September 20; final revision received December 20; accepted January 4, 2001. Address correspondence to I.R.F.
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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MATERIALS AND METHODS: Forty-nine patients with a normal-appearing pancreas but suspected of having pancreatic abnormality and 28 patients with proved pancreatic adenocarcinoma underwent multiphase, contrast-enhanced, multi–detector row CT during the arterial phase (AP), pancreatic parenchymal phase (PPP), and portal venous phase (PVP). Attenuation values of the normal pancreas, pancreatic adenocarcinoma, celiac and superior mesenteric arteries, and superior mesenteric and portal veins were measured during all three imaging phases. Quantitative analysis of these measurements and subjective qualitative analysis of tumor conspicuity were performed.
RESULTS: Maximal enhancement of the normal pancreatic parenchyma occurred during the PPP. Maximal tumor-to-parenchyma attenuation differences during the PPP and PVP were equivalent but greater than that during the AP. Subjective analysis revealed that tumor conspicuity during the PPP and PVP was equivalent but superior to that during the AP. Maximal arterial enhancement was seen during the PPP, and maximal venous enhancement was seen during the PVP.
CONCLUSION: A combination of PPP and PVP imaging is sufficient for detection of pancreatic adenocarcinoma, because it provides maximal pancreatic parenchymal and peripancreatic vascular enhancement. AP imaging can be reserved for patients in whom CT angiography is required.
Index terms: Computed tomography (CT), contrast enhancement, 77.12112, 77.12114, 77.12115 • Computed tomography (CT), helical, 77.12115 • Pancreas, CT, 77.12112, 77.12114, 77.12115 • Pancreas, neoplasms, 77.321
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Maximal enhancement of the pancreatic parenchyma is essential to ensuring that optimal tumor-to-pancreatic parenchymal contrast differences are obtained. Optimal opacification of the peripancreatic vessels is essential for the detection of vascular involvement and local tumor extension.
Several different helical CT scanning protocols have been described for pancreatic imaging (5–14). Dual phase, or biphasic, scanning protocols involve early or arterial phase imaging, performed with a scanning delay of 18–35 seconds, to maximize enhancement of the pancreas and mesenteric arteries, as well as late or portal venous phase (PVP) imaging, performed with a scanning delay 60–70 seconds, to obtain maximal mesenteric and portal venous as well as hepatic parenchymal enhancement. More recently, pancreatic parenchymal phase imaging, with a scanning delay of 40–70 seconds, instead of arterial phase imaging has been recommended, because its use results in superior pancreatic parenchymal enhancement compared with that achieved during the PVP (8,10).
With the introduction of multi–detector row (hereafter, multidetector-row) helical CT, the acquisition of a larger volume of anatomy during any phase of intravenous contrast material administration is now possible in a much shorter duration, with no sacrifice in image quality (15). Therefore, pancreatic imaging with multidetector-row helical CT has the potential to improve the detection and staging of pancreatic adenocarcinoma, because even greater arterial, pancreatic parenchymal, and portal venous enhancement can be achieved.
The purpose of our study was to determine the imaging phase to achieve maximal enhancement of the pancreatic parenchyma and the major peripancreatic arteries and veins by acquiring contrast material–enhanced multidetector-row helical CT images during the arterial phase, pancreatic parenchymal phase, and PVP. We sought to also determine the CT imaging phase with the maximal tumor-to-pancreatic parenchymal difference and thus the greatest likelihood of enabling detection of tumor.
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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All CT scans were obtained by using a multidetector-row helical CT unit (Lightspeed QX/I; GE Medical Systems, Milwaukee, Wis). One hour prior to scanning, the patients received 320 mL of dilute barium orally (Scan C: 2.1% w: w barium sulfate; Lafayette Pharmaceuticals, Yorba Linda, Calif) for bowel opacification. The patients drank 32–48 ounces of water (640–960 mL) immediately before undergoing imaging to distend the stomach and duodenum.
Nonenhanced images of the pancreas initially were obtained by using 10-mm collimation to define the craniocaudal extent of the pancreas. Then, by using a power injector, 150 mL of iohexol (300 mg of iron per milliliter) (Omnipaque 300; Nycomed Amersham, Princeton, NJ) was injected intravenously at a rate of 4 mL/sec. Arterial phase imaging was initiated following a 20-second delay from the time of initiation of contrast material injection. The entire pancreas was imaged by using a small field of view (20–25 cm, depending on body habitus), 1.25-mm collimation, a high-speed mode (pitch, 6:1), and a table speed of 1 cm/sec (7.5 mm/0.8 sec). (Thin-section collimation was selected because of the potential to perform CT angiography.) Pancreatic parenchymal phase imaging was then performed following a scanning delay of 35 seconds from the time of initiation of contrast material injection. The entire pancreas was again imaged with a small field of view—similar to that used for the arterial phase—by using 2.5-mm collimation with 5-mm reconstruction intervals in the high-quality mode (pitch, 3:1), with a table speed of 1 cm/sec (7.5 mm/0.8 sec).
The two described imaging phases were performed in a single breath hold, after which the patient was asked to make shallow breaths. The patient was then instructed to perform a second breath hold, and PVP images were acquired following a scanning delay of 60 seconds from the time of initiation of contrast material injection. For the PVP, the field of view was increased, and the abdomen was imaged from the diaphragm to the iliac crest by using 5-mm collimation with 5-mm reconstruction in the high-quality mode (pitch, 3:1) and a table speed of 1 cm/sec (7.5 mm/0.8 sec). With these parameters used for the arterial, pancreatic parenchymal, and portal venous imaging phases, the mean scanning duration for each phase was 8–12 seconds. A kilovolt peak of 120 was used, and the mean milliampere second was 354 (range, 300–440 mAs) for the arterial phase images and 202 (range, 150–250 mAs) for the pancreatic parenchymal phase and PVP images.
From December 9, 1998, to August 31, 1999, all patients underwent imaging during the arterial, pancreatic parenchymal, and portal venous phases of contrast enhancement. Following review of our preliminary data, which showed that the arterial phase images were not markedly superior for tumor detection or vascular enhancement, the protocol was amended and arterial phase imaging was not performed. Thus, in the last seven of the 28 patients with pancreatic adenocarcinoma who were included in this study (all of whom underwent imaging between September 1 and October 26, 1999), only the pancreatic parenchymal and portal venous phases of imaging were performed.
All images were reviewed on a workstation (Windows Advantage 3.1; GE Medical Systems). For quantitative analysis, attenuation measurements were obtained by using a region-of-interest cursor in every patient and during all three imaging phases. Circular region-of-interest measurements were made by one author (N.J.M.) to include at least two-thirds of the area of interest. Attenuation measurements of the following entities were obtained: (a) the most homogeneous regions of the normal pancreatic head, body, and tail; (b) pancreatic adenocarcinomas; and (c) the celiac axis, superior mesenteric artery, portal vein, and superior mesenteric vein.
The following parameters were compared across all three contrast-enhanced imaging phases in all patients: (a) pancreatic attenuation values (ie, mean attenuation of the head, body, and tail in each patient), (b) celiac axis, (c) superior mesenteric arteries, (d) portal vein, (e) superior mesenteric vein, and (f) pancreatic adenocarcinomas. In the patients with proved pancreatic adenocarcinoma, the difference between the mean normal pancreatic parenchymal attenuation value and the attenuation value of the mass—that is, the tumor-to-pancreatic parenchymal attenuation difference—was compared across all three contrast-enhanced phases.
One reader (I.R.F.) performed qualitative analysis of the tumor conspicuity during the three imaging phases in all patients with proved pancreatic adenocarcinoma. Tumor conspicuity was graded on a four-point scale in which 0 indicated not seen; 1, poor; 2, good; and 3, excellent.
The locations and sizes of 27 of the pancreatic adenocarcinomas were recorded from the CT or endoscopic ultrasonography report. One of the pancreatic adenocarcinomas was not detected at CT, and its size and location were obtained from the pathology report.
Because more than one attenuation measurement was obtained for each patient, repeated measures one-way analysis of variance was used to analyze the effect of phase on attenuation. When the phase effect was found to be significant (ie, P < .05), multiple comparisons were made by performing the Tukey-Kramer test. The ratings for phase effect on tumor conspicuity were analyzed by using the generalized estimating equations approach for repeated ordinal data. Statistical analyses were performed by using computer software (Statistical Analysis System; SAS Institute, Cary, NC). Odds ratios were calculated for the tumor conspicuity rating analysis.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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The mean attenuation values of the normal pancreas (ie, mean values in the head, body, and tail) and the tumor-to-parenchymal attenuation differences for the arterial phase, pancreatic parenchymal phase, and PVP are detailed in Table 1. The mean pancreatic parenchymal attenuation value during the pancreatic parenchymal phase was higher than that during the PVP (P = .034) (Figs 1, 2). The mean tumor-to-parenchymal attenuation difference was 16 (range, 0–40) during the arterial phase, 49 (range, 6–106) during the pancreatic parenchymal phase, and 44 (range, 2–98) during the PVP. The maximal tumor-to-pancreatic parenchymal attenuation difference in the 27 tumors seen at multidetector-row helical CT was observed during the PVP in 16 patients (range, 5.0–97.7 HU; mean, 45.5 HU) (Fig 3) and during the pancreatic parenchymal phase in 10 patients (range, 4–103 HU; mean, 50.3 HU); the differences during the two phases were equal in one patient. In no instance was the tumor-to-parenchymal attenuation difference during the arterial phase greater than that during either of the other two phases. The tumor-to-pancreatic parenchymal attenuation differences during the pancreatic parenchymal phase and PVP were significantly greater than that during the arterial phase (P < .001), but we found no significant difference between the pancreatic parenchymal phase and the PVP (P = .405).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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CT is the most widely used imaging examination for the detection and staging of pancreatic adenocarcinoma. It has a positive predictive value for tumor detection of greater than 90% (1–4). CT is also excellent for determining nonresectability, with a positive predictive value approaching 100% (1–4). However, it is not as accurate in depicting resectable tumor: The negative predictive value is only 56% with uniphasic imaging (3) and 79% with dual phase, or biphasic, helical CT (4). CT also has poor performance in the detection of small peritoneal implants, small (>1-cm) hepatic surface and parenchymal metastases, and lymph node metastases in normal-sized nodes (3,14).
Several biphasic CT scanning protocols have been used to evaluate the pancreas (5–14). The differing results in some of these studies can be attributed largely to differences in the rate and volume of intravenous contrast material administration, scanning delays, time of image acquisition, and, to some extent, scanner units.
Multidetector-row helical CT provides substantial improvement in anatomic volume coverage and in the separation of arterial from venous image acquisition phases. This improvement does not come at the sacrifice of image quality: The results of a recent study (15) show that images with diagnostic quality comparable to that of images acquired with single-detector helical CT can be obtained, even with the threefold increase in volume coverage that is achieved with multidetector-row helical CT. The multiphase imaging capabilities, increased speed of acquisition, and greater anatomic coverage achieved with multidetector-row helical CT have resulted in the need to redesign imaging protocols and pay more careful attention to bolus timing (20).
Several authors (5–7,9,12–14) have reported achieving superior pancreatic parenchymal enhancement during the arterial phase, in contrast to that achieved during the PVP, by using single-detector helical CT and scanning delays of 18–30 seconds for early or arterial phase imaging. Diehl et al (4), using computer software (Smartprep; GE Medical Systems) to calculate the optimal scanning delay (mean delay, 36 seconds), also found arterial phase imaging to be superior for depicting pancreatic adenocarcinoma. Lu et al (8) and Boland and colleagues (10) compared images obtained during the pancreatic parenchymal phase by using a scanning delay of 40 seconds (scanning duration range, 40–70 seconds), as well as PVP images obtained after a 70-second scanning delay (scanning duration range, 70–100 seconds), in patients with pancreatic adenocarcinoma. In these studies, maximal pancreatic enhancement and tumor conspicuity were seen during the pancreatic parenchymal phase.
We also observed greater pancreatic parenchymal enhancement during the pancreatic parenchymal phase (scanning delay, 35 seconds; scanning duration range, 35–47 seconds) than during the PVP (scanning delay, 60 seconds; scanning duration range, 60–74 seconds) (Table 1). However, the tumor-to-parenchymal attenuation differences during the pancreatic parenchymal phase and PVP were similar (Table 1). This difference between our study results and those of prior studies can probably be explained by the fact that the pancreatic parenchymal phase used in the prior studies overlapped with the pancreatic parenchymal phase and PVP used in our study.
Recently, Tublin et al (18) and Kim et al (19) observed that both the volume and rate of contrast material administration play a very important role in determining the degree of pancreatic enhancement. Results of the study by Tublin et al (18) demonstrate that both the peak enhancement and the time to peak enhancement of the pancreas are directly related to the rate of contrast material injection. In that study, at an injection rate of 2.5 mL/sec, peak enhancement of the pancreas (65 HU) was achieved in 69 seconds, in contrast to a peak enhancement of 84 HU achieved in 43 seconds at an injection rate of 5 mL/sec (18). Using the formula suggested by Tublin et al, with our injection rate of 4 mL/sec, the expected time to peak pancreatic enhancement should be 41 seconds. This is well within the range of 35–45 seconds used for the pancreatic parenchymal phase in our study. Kim et al (19) also found the contrast material volume and injection rate to be directly related to pancreatic parenchymal enhancement. The larger the volume and the faster the rate of injection, the better the pancreatic parenchymal enhancement (19).
In several prior studies (8,10,12), investigators have compared the effects of dual phase, or biphasic, imaging of the pancreas on peripancreatic vascular opacification. Keogan et al (12), in a study of single-detector helical CT, found that superior arterial opacification was seen during the arterial phase (scanning delay, 20 seconds). In contrast, Lu et al (8), using twin-detector helical CT, found that maximal arterial enhancement was achieved during the pancreatic parenchymal phase (scanning delay, 40 seconds).
We observed maximal arterial enhancement during the pancreatic parenchymal phase rather than during the arterial phase. This can be attributed to the greater anatomic coverage achieved in a shorter time with multidetector-row helical CT compared with that achieved with single-detector CT. The greater anatomic coverage provided by multidetector-row helical CT resulted in about 80% of the total intravenous contrast material dose being injected at the end of the arterial phase; the remaining 20% was administered at the beginning of the pancreatic parenchymal phase. Therefore, arterial enhancement does not achieve its peak until the pancreatic parenchymal phase has commenced. Because scanning of similar anatomic volumes is achieved with longer times when single- or twin-detector helical CT is used, the arterial phase used in previous studies encompasses both the arterial and pancreatic parenchymal phases used in our study (12). We believe that these differences account for the discrepant results between our and previous studies.
We observed significantly superior opacification of the superior mesenteric and portal veins during the PVP (P < .001), as compared with that achieved during the pancreatic parenchymal phase. These results differ from those of Lu et al (8), who used twin-detector CT, and Boland et al (10), who used single-detector CT; neither of these groups used arterial phase imaging, but rather they compared venous enhancement during the pancreatic parenchymal phase and PVP. These authors, by using 150 mL of iodinated intravenous contrast material injected at rates of 3 (10) and 4 mL/sec (8), respectively, achieved maximal enhancement of the superior mesenteric and portal veins during the pancreatic parenchymal phase.
With multidetector-row helical CT, our acquisition of pancreatic parenchymal phase images lasted 35–44 seconds (average scanning duration, 9 seconds) on average, and that of PVP images lasted 60.0–74.5 seconds on average (scanning duration, 14.5 seconds). In contrast, the acquisition of pancreatic parenchymal phase images reportedly lasted 40–70 seconds (scanning duration, 30 seconds) in the Lu et al (8) study and 40–63 seconds (scanning duration, 23 seconds) in the Boland et al (10) study. Therefore, the pancreatic parenchymal phase used in these studies slightly overlapped with the initial portion of the PVP used in our study. The differences in results between these prior studies and our study can be explained by the greater anatomic coverage achieved in a shorter scanning time by using multidetector-row helical CT, which resulted in an overlap of the pancreatic parenchymal and portal venous imaging phases between studies.
The limitations of our study included a small sample size, particularly the small number of patients with proved pancreatic adenocarcinoma. In addition, we used a fixed scanning delay for the arterial phase: We did not use a test bolus or an automated technique such as SmartPrep to individualize scanning delays. The use of automated techniques to initiate scanning may have resulted in more consistent and reliable enhancement of the pancreas and peripancreatic vasculature without individual variations. Furthermore, the arterial phase images were acquired by using 1.25-mm collimation, as compared with the 2.5-mm collimation used to obtain the pancreatic parenchymal phase images and the 5.0-mm collimation used to obtain the PVP images. This may have affected tumor conspicuity in favor of the arterial phase, although this was not shown to be the case in this study. This technique—with 1.25-mm collimation used for arterial phase imaging—was selected for possible use in performing CT angiography.
In summary, when the faster multidetector-row helical CT scanners are used, the scanning delays need to be modified to take into account the greater anatomic coverage achieved in a shorter time. Although maximal pancreatic parenchymal enhancement was seen during the pancreatic parenchymal phase, results of quantitative analysis showed no significant difference in tumor-to-pancreatic parenchymal attenuation differences between the pancreatic parenchymal phase and the PVP. In addition, the results of subjective qualitative analysis of tumor conspicuity were not significantly different between the pancreatic parenchymal and portal venous imaging phases.
On the basis of our study results, we have modified our protocol for performing CT of the pancreas to detect and stage tumors. Because maximal vascular and pancreatic parenchymal enhancement can be achieved by using a combination of the pancreatic parenchymal and portal venous phases, we obtain images only during these two phases; arterial phase imaging is reserved for only those cases in which CT angiography is specifically required.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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Abbreviation: PVP = portal venous phase
Author contributions: Guarantors of integrity of entire study, I.R.F., N.J.M.; study concepts, I.R.F., N.J.M.; study design, I.R.F.; literature research, I.R.F., N.J.M.; clinical studies, I.R.F., N.J.M.; data acquisition, I.R.F., N.J.M.; data analysis/interpretation, A.G., J.F.P., N.J.M.; statistical analysis, J.F.P., N.J.M.; manuscript preparation, I.R.F.; manuscript definition of intellectual content, A.G., I.R.F., N.J.M.; manuscript editing, I.R.F., J.F.P., R.H.C., M.K., A.G.; manuscript revision/review, R.H.C., M.K., I.R.F., J.F.P.; manuscript final version approval, I.R.F., R.H.C., A.G.
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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