HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Figures Only Full Text (PDF) All Versions of this Article: 2453061795v1 245/3/770    most recent Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Zamboni, G. A. Articles by Raptopoulos, V. D. Search for Related Content PubMed PubMed Citation Articles by Zamboni, G. A. Articles by Raptopoulos, V. D.

Pancreatic Adenocarcinoma: Value of Multidetector CT Angiography in Preoperative Evaluation¹

¹ From the Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215. Received October 17, 2006; revision requested December 19; revision received January 22, 2007; accepted February 28; final version accepted May 7. G.A.Z. and V.D.R. supported by a grant from Toshiba America Medical Systems. Address correspondence to V.D.R. (e-mail: vraptopo{at}bidmc.harvard.edu).

	ABSTRACT

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION ADVANCES IN KNOWLEDGE IMPLICATION FOR PATIENT CARE References

 
Purpose: To retrospectively assess the sensitivity and specificity of multidetector computed tomographic (CT) angiography in the preoperative evaluation of pancreatic adenocarcinoma by using surgical findings as the reference standard.

Materials and Methods: The institutional review board approved this HIPAA-compliant study; informed consent was waived. We reviewed CT reports, surgical notes, and pathology reports from 114 patients with pancreatic or distal cholangiocarcinoma who underwent multidetector CT angiography and surgery at our institution between March 2003 and March 2006. When CT findings and surgical reports were discordant, radiologists experienced in pancreatic imaging retrospectively reviewed images for lesion resectability; four-, eight-, 16-, and 64-row CT scanners were used in 54, 19, 25, and 16 patients, respectively. Collimation of 1.25 mm was used for four- and eight-row CT and 0.5 or 0.625 mm for 16- and 64-row CT. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for resectability were calculated for initial clinical interpretation and blinded retrospective review.

Results: Eighty-eight patients had resectable lesions according to CT angiographic criteria (group A: 46 women, 42 men; mean age, 67 years; age range, 39–85 years): resection was aborted in 10 patients (11%). Twenty-six patients underwent surgery despite lesion unresectability assessed according to CT angiographic criteria (group B: 16 women, 10 men; mean age, 62 years; age range, 33–83 years); all lesions were confirmed as unresectable. The initial clinical interpretation of CT angiographic scans in all 114 patients had 100% sensitivity in the detection of resectability, 72% specificity, 89% PPV, and 100% NPV. These parameters did not appear to vary among different types of scanner. With the blinded retrospective evaluation by experienced readers, specificity increased to 94% and PPV to 98%, with no difference in sensitivity and NPV.

Conclusion: Multidetector CT angiography is an effective preoperative tool that reduces the number of aborted pancreatic resections; there is no evidence from this retrospective study suggesting varying results from the various generations of multidetector CT scanners used.

© RSNA, 2007

	INTRODUCTION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION ADVANCES IN KNOWLEDGE IMPLICATION FOR PATIENT CARE References

 
Pancreatic surgery has a mortality rate between less than 2.5% (in experienced high-volume centers) and 5%; complication rates are approximately 40% (1–5). It is therefore crucial to correctly identify patients who would most benefit from surgery (ie, those with lesions potentially responsive to curative resection) and reduce as much as possible the number of unnecessary laparotomies. Classic criteria for defining nonresectability at helical computed tomography (CT) include extrapancreatic invasion of adjacent tissues and organs other than the duodenum; occlusion, stenosis, or semicircular encasement of any major peripancreatic vessel (celiac, hepatic, or superior mesenteric artery or portal or superior mesenteric vein); hepatic metastases; peritoneal carcinomatosis; and lymph node or distant metastases (6,7).

In resectable ductal adenocarcinoma, CT is not accurate in predicting nodal involvement, and the CT depiction of peripancreatic nodes should not prevent an attempt at curative resection in patients presumed to have pancreatic carcinoma that is otherwise considered resectable (8). Predictive values for unresectability for helical CT range from 89% to 100%, and accuracies between 85% and 95% (5,9). However, predictive values for resectability are much lower, between 45% and 79% (5,10–13).

When compared with helical CT, helical CT angiography with three-dimensional reconstructions provides additional information and improves the staging for resectability of pancreatic tumors. In a retrospective study, the predictive value for vascular resectability was 70% for helical CT compared with 96% for helical CT and CT angiography (P = .021) (14).

Multidetector CT is used with increasing frequency, especially in the preoperative evaluation of patients with cancer. Although limited data are available, four-row CT has been reported in a small series to have an excellent (100%) negative predictive value (NPV) for vascular invasion and a good (87%) NPV for overall resectability for pancreatic adenocarcinoma (15,16). The purpose of our study was to retrospectively assess the sensitivity and specificity of multidetector CT angiography in the preoperative evaluation of pancreatic adenocarcinoma by using surgical findings as the reference standard.

	MATERIALS AND METHODS

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION ADVANCES IN KNOWLEDGE IMPLICATION FOR PATIENT CARE References

 
Our institutional review board approved this study and waived the need for informed consent. The study was conducted in compliance with the guidelines established by the Health Insurance Portability and Accountability Act.

Patients, Reference Standard, Record Review
One author (G.A.Z.) reviewed the medical records of all patients who underwent surgical staging or attempt at curative resection for pancreatic carcinoma at our institution between March 2003 and March 2006. We included in our study all patients who underwent scanning in our institution with multiphase multidetector CT with multiplanar reconstructions and two- and three-dimensional CT angiography and excluded all patients who underwent scanning at other institutions or with different CT protocols. CT reports, medical records, surgical notes, and pathology reports from these patients were reviewed. All patients had confirmed pancreatic adenocarcinoma (110 patients) or distal cholangiocarcinoma (four patients) according to histologic findings in surgically resected specimens or surgically performed biopsies. At the time of imaging and surgery, all masses were considered primary pancreatic carcinomas. Four tumors, however, at pathology examination turned out to be cholangiocarcinoma in the intrapancreatic portion of the common bile duct. We included these four patients in our analysis because the biological behavior of cholangiocarcinoma is aggressive, similar to that of pancreatic adenocarcinoma, and treatment and prognosis are equivalent (17).

Surgery was the reference standard. Surgery was performed by two hepatobiliary surgical fellowship–trained specialists with an average volume of 160 pancreatic surgeries per year (combined).

Patients were placed into one of two groups according to the initial clinical interpretation of the scans: Group A had lesions definitely resectable according to CT angiographic criteria (88 patients), and group B had lesions definitely or questionably unresectable according to CT angiographic criteria (26 patients).

Scanning Technique
Patients underwent CT in four-, eight-, 16-, and 64-row scanners, as available (Aquilion 16, Aquilion 64, Toshiba America Medical Systems, Tustin, Calif; LightSpeed Plus, LightSpeed Ultra, LightSpeed Pro16, LightSpeed VCT, GE Healthcare Technologies, Waukesha, Wis). Forty patients from group A underwent four-row, 15 underwent eight-row, 19 underwent 16-row, and 14 underwent 64-row CT. Fourteen patients from group B underwent four-row, four underwent eight-row, six underwent 16-row, and two underwent 64-row CT.

Patients underwent scanning with similar techniques and protocols including unenhanced, late arterial–early portal venous and venous acquisitions, timed with a bolus-tracking technique. A 1-cm² region of interest was positioned by the technologist in the abdominal aorta at the origin of the celiac axis, and this single level was scanned every 3 seconds at a low dose (50–75 mA). A 150-HU threshold of enhancement was used to determine the timing of the scan; the late arterial–early portal venous phase was performed with a 15-second delay from the threshold and the venous phase 25 seconds later. For example, if the enhancement threshold in the aorta of 150 HU was reached 20 seconds after start of the injection, late arterial–early portal venous phase would be at 35 seconds and venous phase at 60 seconds. All patients received 150–200 mL of 350 mg of iodine per milliliter contrast material (ioversol, Optiray 350; Tyco Health/Mallinckrodt, St Louis, Mo) at a rate of 4–6 mL/sec by means of automatic power injectors (EnVision; Medrad, Indianola, Pa) through an 18-gauge or 20-gauge intravenous catheter placed in an antecubital vein.

Contrast material–enhanced acquisitions were obtained craniocaudally with thin collimation: 1.25 mm for four- and eight-row CT and 0.625 or 0.5 mm, depending on the scanner, for 16- and 64-row CT. As a consequence of using the thinnest collimation possible, the scanning range for the late arterial–early portal venous contrast-enhanced phases was tailored to scan the entire pancreas, irrespective of the scanner. This range, however, was greater for the 16- and 64-row scanners, which allowed multiphasic thin-section scanning of the entire liver. Unenhanced and venous phase scans included the entire liver with all types of multidetector CT scanners.

Image Evaluation
The scans were read and clinically interpreted initially by experienced gastrointestinal radiologists on dedicated picture archiving and communication system (PACS) workstations. All scans were interpreted by two readers: one radiology resident or abdominal fellow (from a pool of 30 readers, with 2–6 years of experience) and one abdominal imaging attending radiologist (from a pool of eight readers, with 8–20 years of experience). Transverse images, multiplanar reconstruction coronal and sagittal reformations, maximum intensity projection and/or volume rendering vascular reformations, and thick-slab oblique scans along the planes of the great vessels were viewed on PACS for the initial interpretation. Vascular reformations and thick-slab oblique scans were prepared by technologists in the three-dimensional imaging laboratory and stored on PACS. Occasionally, additional image processing was required, typically performed by technologists after discussion with radiologists. Conventionally, the images stored on PACS were used for the initial interpretation and for retrospective review of images.

For each patient, one author (G.A.Z.) collected from the electronic medical records and from PACS the following information: sex, age at CT, type of multidetector CT scanner used, initial multidetector CT evaluation of resectability, time between multidetector CT and surgery, results of surgery, tumor histologic type, and size of the resected tumor or of the resected metastases.

Criteria for unresectability at pancreatic CT angiography, used at the time of initial interpretation and for the retrospective review of images, were distant disease (hepatic metastases, distant lymph node metastases, peritoneal metastases), invasion of adjacent organs other than the duodenum, and major vascular invasion. Lymph nodes were considered metastatic if the short-axis diameter was 1 cm or larger. According to the grade of vascular involvement, as used currently in our institution (14), tumors had been judged as resectable (grade 0: normal, with a fat plane or normal pancreas between tumor and vessel; grade 1: loss of fat plane between tumor and vessel, with or without smooth displacement of the vessel), questionably unresectable (grade 2: flattening and/or slight irregularity of one side of the vessel), or definitely unresectable (grade 3: encased vessel with tumor extending around at least two sides [ie, 2/3 of the perimeter], altering its contour and producing concentric or eccentric lumen narrowing; grade 4: at least one major occluded vessel) (14). The actual grade of vascular involvement, stated in the report from the initial clinical interpretation, was not individually analyzed but was used only to group patients as having lesions that were resectable (grades 0 and 1) or probably or definitely unresectable (grades 2, 3, and 4).

For the retrospective review of images, two gastrointestinal radiologists (V.D.R. and G.A.Z., with more than 20 years and 4 years of experience, respectively), blinded to the reason for unresectability, reviewed by means of consensus for lesion resectability the scans of the patients from group A whose resections were aborted and of the patients from group B whose surgical notes and CT reports were discordant. The readers reviewed the transverse images and angiographic reformations stored on PACS.

Statistical Analysis
Statistical analysis was performed by using commercially available software (SAS/STAT version 8.2; SAS Institute, Cary, NC). The sensitivity, specificity, positive predictive value (PPV), and NPV of CT angiography for the determination of resectability were calculated by using a contingency table for the initial interpretation of the scans, both according to type of scanner and overall, and for the retrospective review. The point estimates and corresponding exact Clopper-Pearson 95% confidence intervals (CIs) were reported. For the calculation of PPVs and NPVs, the prevalence of resectability within the sample was assumed to be representative of the prevalence of resectability within the population of patients who would undergo CT angiography.

	RESULTS

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION ADVANCES IN KNOWLEDGE IMPLICATION FOR PATIENT CARE References

 
Group A: Patients with Lesions Considered Resectable according to CT Angiographic Criteria
Of the 114 patients in our series (Fig 1), 88 had tumors that were initially considered to be definitely resectable according to CT angiographic criteria (Table 1): 46 women and 42 men. Mean patient age at the time of CT angiography was 67 years, and median age was 70 years (range, 39–85 years). Mean interval between CT angiography and surgery was 21 days (range, 1–73 days). Pathology examination results in the resected specimen or metastasis showed 82 ductal adenocarcinomas, four distal common bile duct carcinomas, one pancreatic clear cell carcinoma, and one mixed ductal-endocrine carcinoma; mixed ductal-endocrine carcinomas have the same prognosis as common ductal pancreatic carcinomas (18), therefore this case has been included in our analysis. Eighty-two tumors were in the pancreatic head or uncinate process and five were in the body or tail.

View larger version (16K): [in this window] [in a new window] [Download PPT slide]   Figure 1: Patient inclusion flowchart. adeno ca = adenocarcinoma, CTA = CT angiography, MDCT = multidetector CT.

Resection was aborted in 10 patients (11%): one for invasion of the porta hepatis and gastroduodenal artery, five for hepatic metastases, two for positive lymph nodes, and two for peritoneal implants. For the nine patients with distant disease, the dimensions of the metastases resected and examined on frozen sections during surgery were reviewed: The mean maximum diameter of the hepatic metastases specimens was 8.2 mm (range, 4–11 mm); the greater diameters of the peritoneal implants were 11 and 3 mm, respectively; and the greater diameters of the positive lymph nodes were 20 and 15 mm, respectively. The positive lymph nodes in these last two patients were hepatic artery nodes. Seven (13% of 55) resections were aborted in the four–eight-row CT group and three (9% of 33) in the 16–64-row group; the percentage of false-positive results did not appear to be different among the different scanners (Tables 2, 3).

View larger version (156K): [in this window] [in a new window] [Download PPT slide]   Figure 2: Transverse early portal venous phase 64-row CT angiographic image of pancreatic adenocarcinoma unresectable because of distant metastases in a 65-year-old woman. Image shows a hypoattenuating hepatic lesion (arrowhead) in the right lobe, noted at retrospective review. The abnormality was detected at intraoperative ultrasonography (US), and metastasis was confirmed at biopsy.

View larger version (191K): [in this window] [in a new window] [Download PPT slide]   Figure 3a: Pancreatic adenocarcinoma unresectable because of carcinomatosis in an 82-year-old man. (a–c) Transverse four-row CT angiographic images show that (a) the mass (arrow) in the uncinate process extends (b) to the origin of the superior mesenteric artery and (c) to the replaced hepatic artery. (d) Coronal volume rendered image depicts variant anatomy but minimal, if any, irregularity of the vessels (arrow).

View larger version (190K): [in this window] [in a new window] [Download PPT slide]   Figure 3b: Pancreatic adenocarcinoma unresectable because of carcinomatosis in an 82-year-old man. (a–c) Transverse four-row CT angiographic images show that (a) the mass (arrow) in the uncinate process extends (b) to the origin of the superior mesenteric artery and (c) to the replaced hepatic artery. (d) Coronal volume rendered image depicts variant anatomy but minimal, if any, irregularity of the vessels (arrow).

View larger version (197K): [in this window] [in a new window] [Download PPT slide]   Figure 3c: Pancreatic adenocarcinoma unresectable because of carcinomatosis in an 82-year-old man. (a–c) Transverse four-row CT angiographic images show that (a) the mass (arrow) in the uncinate process extends (b) to the origin of the superior mesenteric artery and (c) to the replaced hepatic artery. (d) Coronal volume rendered image depicts variant anatomy but minimal, if any, irregularity of the vessels (arrow).

View larger version (152K): [in this window] [in a new window] [Download PPT slide]   Figure 3d: Pancreatic adenocarcinoma unresectable because of carcinomatosis in an 82-year-old man. (a–c) Transverse four-row CT angiographic images show that (a) the mass (arrow) in the uncinate process extends (b) to the origin of the superior mesenteric artery and (c) to the replaced hepatic artery. (d) Coronal volume rendered image depicts variant anatomy but minimal, if any, irregularity of the vessels (arrow).

View larger version (148K): [in this window] [in a new window] [Download PPT slide]   Figure 4a: Pancreatic adenocarcinoma unresectable because of distant lymph node metastases in an 80-year-old woman. (a, b) Coronal reformations obtained at different levels from 64-row CT show enlarged lymph nodes (arrow) that were not appreciated at the original interpretation. The resection was aborted at laparotomy.

View larger version (147K): [in this window] [in a new window] [Download PPT slide]   Figure 4b: Pancreatic adenocarcinoma unresectable because of distant lymph node metastases in an 80-year-old woman. (a, b) Coronal reformations obtained at different levels from 64-row CT show enlarged lymph nodes (arrow) that were not appreciated at the original interpretation. The resection was aborted at laparotomy.

CT angiographic criteria for unresectability according to the initial clinical interpretation were vascular invasion (23 patients), hepatic metastases (eight patients), and lymph node metastases (five patients). Nine patients had more than one criterion for unresectability: Eight patients had two, and one patient had three.

Three patients underwent surgery for palliation of duodenal and/or biliary obstruction (Fig 5), and eight patients underwent surgery for staging (five also to evaluate the possibility of neoadjuvant chemotherapy). Fifteen patients underwent surgery with an intent to attempt curative resection, although some had a preoperative resection chance as low as 20%, as estimated by the surgeon (Fig 6).

View larger version (138K): [in this window] [in a new window] [Download PPT slide]   Figure 5: Transverse early portal venous phase 64-row CT angiographic image of pancreatic adenocarcinoma unresectable because of vascular encasement in a 66-year-old woman who underwent surgery for gastric outlet obstruction. Image shows a teardrop appearance of the superior mesenteric vein (arrow) (grade 3), a finding indicating unresectability, which was confirmed at surgery.

View larger version (151K): [in this window] [in a new window] [Download PPT slide]   Figure 6: Transverse early portal venous phase four-row CT angiographic image of pancreatic adenocarcinoma unresectable because of local vascular invasion in a 33-year-old man indicates encasement of the superior mesenteric artery (arrow) and teardrop superior mesenteric vein (arrowhead). Image shows locally unresectable disease. Heroic surgery was attempted because of the patient's young age but was aborted because of vascular invasion.

Unresectability was confirmed at surgery in all 26 patients. Surgical notes and CT reports were concordant in 21 of 26 patients. The remaining five patients had lesions considered unresectable because of vascular invasion only; hepatic metastases were found at surgery in four patients and peritoneal metastasis in one patient. Surgical confirmation of vascular unresectability was not obtained in these patients because their lesions were already judged unresectable because of the presence of distant disease. Review of the CT angiographic scans in these five patients showed that, of the four patients in whom resection was aborted because of hepatic metastases, in only one was the metastasis retrospectively recognized. In the patient whose resection was aborted for the presence of a 4 x 4 x 1-mm peritoneal implant, the implant was not visible retrospectively.

At pathologic examination, 25 patients had ductal adenocarcinoma, and one had acinar cell carcinoma.

Overall Results
Analysis of the initial clinical interpretation of all 114 CT angiographic scans (Table 2), indicates that overall sensitivity in the detection of resectability was 100% (95% CI: 95.4%, 100%), specificity was 72% (95% CI: 54.8%, 85.8%), PPV was 89% (95% CI: 80.1%, 94.4%), and NPV was 100% (95% CI: 86.8%, 100%) (Table 3). These values did not appear to be different across type of scanner (Table 3).

When the blinded retrospective evaluation by experienced readers of the CT angiographic scans for which findings were discrepant with surgical findings was taken into account (Table 4), overall sensitivity in the detection of resectability was 100% (95% CI: 95.4%, 100%), specificity was 94% (95% CI: 81.3%, 99.3%), PPV was 98% (95% CI: 91.3%, 99.7%), and NPV was 100% (95% CI: 89.7%, 100%) (Table 5). Under the same circumstances, overall sensitivity in the detection of unresectability was 94% (95% CI: 81.3%, 99.3%), specificity was 100% (95% CI: 95.4%, 100%), PPV was 100% (95% CI: 89.7%, 100%), and NPV was 98% (95% CI: 91.3%, 99.7%) (Table 6).

	DISCUSSION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION ADVANCES IN KNOWLEDGE IMPLICATION FOR PATIENT CARE References

In the two patients with lesions considered definitely resectable according to CT angiographic criteria and in whom resection was aborted due to distant lymph node metastases, the involved nodes were hepatic artery nodes (node of importance for pancreatic adenocarcinoma). These should be considered part of the celiac drainage basin, and their malignancy cannot be determined by radiographic size. However, when this node is positive for malignancy, survival is as poor as for hepatic or peritoneal metastases (21).

There were several limitations to our study. Our institution specializes in pancreatic disease. One of the consequences is that some patients whose lesions were deemed unresectable according to strict CT angiographic criteria nonetheless underwent surgery for a series of different reasons, from the necessity for tissue confirmation of the diagnosis for neoadjuvant therapy to an attempt at "heroic" surgery. The surgeons in our group perform venous resections if required because the median survival of patients with pancreatic head adenocarcinoma who require venous resection is similar to that of patients who undergo standard pancreaticoduodenectomy and superior to that of patients who do not undergo resection (22). However, venous resection was not feasible in any of the patients in our series who underwent surgery.

Another limitation is that the number of patients is small, as a result of the decision to collect the most homogeneous series possible: Only patients with adenocarcinoma who underwent surgery and preoperative CT angiography were included (participation and image-selection bias) (23). A verification bias must also be acknowledged: Not all patients with lesions deemed unresectable according to CT angiographic criteria underwent surgery. However, surgical results confirmed the CT reports in the small sample of patients with lesions defined as likely to be unresectable according to CT angiographic criteria who underwent surgery.

The readers at the initial clinical and the retrospective evaluations of the CT angiographic examinations were experienced in pancreatic imaging, which might introduce a reviewer bias. Another limitation might arise from the fact that we used the initial clinical interpretation made by a number of readers experienced in pancreatic imaging instead of having all cases reviewed by two experienced readers. We thought this was more representative of expert clinical practice and preferable to depending solely on retrospective and, therefore, inevitably biased reviews from a limited number of observers.

To reduce the test-review bias, we blinded the retrospective reviewers to the reason for unresectability at surgery. Interobserver variability was not calculated for the retrospective review of cases because the number of studies reviewed retrospectively was too small to use independent readings to demonstrate interobserver agreement.

Another possible limitation might arise from the fact that we did not evaluate if two- and three-dimensional reconstructions provided additional information when compared with the transverse images. The initial clinical and the blinded retrospective interpretations were based on a combination of all these images, as is routinely done in our institution, and the separate value of transverse images and reconstructions was not analyzed. Also, we did not assess the differences among the different versions of the workstation software used for the two- and three-dimensional reconstructions across time. However, all multiplanar and three-dimensional renderings used in this study were available in all software versions used throughout the duration of data collection for this study, the only considerable difference being the increasing speed of the newer versions. We did not think this likely to generate differences in the results.

Finally, we assessed the performance of the different generations of scanners (four- and eight-row vs 16- and 64-row) by comparing them in the evaluation of resectability by using the false-positive examinations results. False-positive and false-negative findings for resectability are most important in patient care: It is of utmost importance to prevent patients with unresectable lesions from undergoing unnecessary surgery and to not exclude any patient with a possibly resectable lesion from a surgical attempt that, currently, represents the only possibility of cure. In our series, we did not observe any false-negative findings for resectability: All patients with lesions deemed unresectable or questionably resectable according to CT angiographic criteria were confirmed to have unresectable lesions at surgery. The rate of false-positive results for resectability did not appear to be different among the different scanners.

Notwithstanding these limitations, from our results we conclude that in a specialized clinical and diagnostic setting, when using thin collimation, high contrast medium injection rate, and multiphasic imaging, multidetector CT angiography for pancreatic adenocarcinoma is a valuable preoperative tool with an effectively small number of aborted resections; there is no evidence from this retrospective study suggesting varying results from the various generations of multidetector CT scanners used. Strict adherence to technical scanning and image-processing protocols and close attention to CT signs at the time of interpretation are imperative.

	ADVANCES IN KNOWLEDGE

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION ADVANCES IN KNOWLEDGE IMPLICATION FOR PATIENT CARE References

 

• In our subspecialty clinical and diagnostic setting, when using thin collimation, high contrast medium injection rate, and multiphasic imaging, multidetector CT angiography of the pancreas is a valuable preoperative tool that effectively reduces the number of aborted resections; there is no evidence suggesting that the accuracy of preoperative staging is different across the generations of multidetector CT scanners.
  
• Initial prospective clinical interpretation of all 114 pancreatic CT angiographic scans had 100% overall sensitivity in the detection of resectability and 72% specificity; the blinded retrospective evaluation by experienced readers had 100% sensitivity in the detection of resectability and 94% specificity.
  

	IMPLICATION FOR PATIENT CARE

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION ADVANCES IN KNOWLEDGE IMPLICATION FOR PATIENT CARE References

 

• Accuracy of preoperative staging of pancreatic carcinoma with CT does not appear to depend on the type of multidetector CT scanner used for the examination, provided that thin collimation and adherence to technique are used.
  

	FOOTNOTES

 

Abbreviations: CI = confidence interval • NPV = negative predictive value • PACS = picture archiving and communication system • PPV = positive predictive value

Guarantors of integrity of entire study, G.A.Z., V.D.R.; study concepts/study design or data acquisition or data analysis/interpretation, all authors; manuscript drafting or manuscript revision for important intellectual content, all authors; approval of final version of submitted manuscript, all authors; literature research, G.A.Z., J.B.K., C.M.V., V.D.R.; clinical studies, G.A.Z., J.B.K., C.M.V., M.P.C., V.D.R.; statistical analysis, G.A.Z., J.B.K., J.B., V.D.R.; and manuscript editing, all authors

	References

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION ADVANCES IN KNOWLEDGE IMPLICATION FOR PATIENT CARE References

 

1. Trede M, Schwall G, Saeger HD. Survival after pancreatoduodenectomy: 118 consecutive resections without an operative mortality. Ann Surg 1990;211(4):447–458. [Medline]
2. Miedema BW, Sarr MG, van Heerden JA, Nagorney DM, McIlrath DC, Ilstrup D. Complications following pancreaticoduodenectomy: current management. Arch Surg 1992;127(8):945–949. [Abstract/Free Full Text]
3. Fernandez del Castillo C, Rattner DW, Warshaw AL. Standards for pancreatic resection in the 1990s. Arch Surg 1995;130(3):295–300. [Abstract/Free Full Text]
4. Yeo CJ, Cameron JL, Sohn TA, et al. Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s. Ann Surg 1997;226(3):248–257, discussion 257–260. [CrossRef][Medline]
5. Gouma DJ, van Geenen RC, van Gulik TM, et al. Rates of complications and death after pancreaticoduodenectomy: risk factors and the impact of hospital volume. Ann Surg 2000;232(6):786–795. [CrossRef][Medline]
6. Diehl SJ, Lehmann KJ, Sadick M, Lachmann R, Georgi M. Pancreatic cancer: value of dual-phase helical CT in assessing resectability. Radiology 1998;206(2):373–378. [Abstract/Free Full Text]
7. Hough TJ, Raptopoulos V, Siewert B, Matthews JB. Teardrop superior mesenteric vein: CT sign for unresectable carcinoma of the pancreas. AJR Am J Roentgenol 1999;173(6):1509–1512. [Abstract]
8. Roche CJ, Hughes ML, Garvey CJ, et al. CT and pathologic assessment of prospective nodal staging in patients with ductal adenocarcinoma of the head of the pancreas. AJR Am J Roentgenol 2003;180(2):475–480. [Abstract/Free Full Text]
9. Lu DS, Reber HA, Krasny RM, Kadell BM, Sayre J. Local staging of pancreatic cancer: criteria for unresectability of major vessels as revealed by pancreatic-phase, thin section helical CT. AJR Am J Roentgenol 1997;168(6):1439–1443. [Abstract/Free Full Text]
10. Freeny PC, Traverso LW, Ryan JA. Diagnosis and staging of pancreatic adenocarcinoma with dynamic computed tomography. Am J Surg 1993;165(5):600–606. [CrossRef][Medline]
11. Bluemke DA, Cameron JL, Hruban RH, et al. Potentially resectable pancreatic adenocarcinoma: spiral CT assessment with surgical and pathologic correlation. Radiology 1995;197(2):381–385. [Abstract/Free Full Text]
12. Tabuchi T, Itoh K, Ohshio G, et al. Tumor staging of pancreatic adenocarcinoma using early- and late-phase helical CT. AJR Am J Roentgenol 1999;173(2):375–380. [Abstract/Free Full Text]
13. Warshaw AL, Fernandez-del-Castillo C. Pancreatic carcinoma. N Engl J Med 1992;326(7):455–465.[Medline]
14. Raptopoulos V, Steer ML, Sheiman RG, Vrachliotis TG, Gougoutas CA, Movson JS. The use of helical CT and CT angiography to predict vascular involvement from pancreatic cancer: correlation with findings at surgery. AJR Am J Roentgenol 1997;168(4):971–977.[Abstract/Free Full Text]
15. Vargas R, Nino-Murcia M, Trueblood W, Jeffrey RB Jr. MDCT in pancreatic adenocarcinoma: prediction of vascular invasion and resectability using a multiphasic technique with curved planar reformations. AJR Am J Roentgenol 2004;182(2):419–425.[Abstract/Free Full Text]
16. Catalano C, Laghi A, Fraioli F, et al. Pancreatic carcinoma: the role of high-resolution multislice spiral CT in the diagnosis and assessment of resectability. Eur Radiol 2003;13(1):149–156.[Medline]
17. Yeo CJ, Sohn TA, Cameron JL, Hruban RH, Lillemoe KD, Pitt HA. Periampullary adenocarcinoma: analysis of 5-year survivors. Ann Surg 1998;227(6):821–831.[CrossRef][Medline]
18. Chatelain D, Parc Y, Christin-Maitre S, Parc R, Flejou JF. Mixed ductal-pancreatic polypeptide-cell carcinoma. Histopathology 2002;41(2):122–126.[CrossRef][Medline]
19. Pisters PW, Lee JE, Vauthey JN, Charnsangavej C, Evans DB. Laparoscopy in the staging of pancreatic cancer. Br J Surg 2001;88(3):325–337.[CrossRef][Medline]
20. Prokesch RW, Chow LC, Beaulieu CF, et al. Local staging of pancreatic carcinoma with multi–detector row CT: use of curved planar reformations initial experience. Radiology 2002;225(3):759–765. [Abstract/Free Full Text]
21. Maithel SK, Khalili K, Dixon E, et al. Impact of regional lymph node evaluation in staging patients with periampullary tumors. Ann Surg Oncol 2007;14(1):202–210. [Abstract/Free Full Text]
22. Tseng JF, Raut CP, Lee JE, et al. Pancreaticoduodenectomy with vascular resection: margin status and survival duration. J Gastrointest Surg 2004;8(8):935–949, discussion 949–950. [CrossRef][Medline]
23. Sica GT. Bias in research studies. Radiology 2006;238(3):780–789.[Abstract/Free Full Text]

This article has been cited by other articles:

				K. Strobel, S. Heinrich, U. Bhure, J. Soyka, P. Veit-Haibach, B. C. Pestalozzi, P.-A. Clavien, and T. F. Hany Contrast-Enhanced 18F-FDG PET/CT: 1-Stop-Shop Imaging for Assessing the Resectability of Pancreatic Cancer J. Nucl. Med., September 1, 2008; 49(9): 1408 - 1413. [Abstract] [Full Text] [PDF]

This Article Abstract Figures Only Full Text (PDF) All Versions of this Article: 2453061795v1 245/3/770    most recent Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Zamboni, G. A. Articles by Raptopoulos, V. D. Search for Related Content PubMed PubMed Citation Articles by Zamboni, G. A. Articles by Raptopoulos, V. D.