Date post: | 10-Apr-2018 |
Category: |
Documents |
Upload: | gizelle-valim-dos-santos |
View: | 220 times |
Download: | 0 times |
8/8/2019 Adenocarcinoma Pancreas able Qx.
http://slidepdf.com/reader/full/adenocarcinoma-pancreas-able-qx 1/5
David A . B lu em ke , M D , P hD #{149}ohn L . C am eron , M D #{149}a lph H . H ruban , M D #{149} en ry A . P itt, M D
S tanley S . S iege lm an , M D #{149}h ilipp e Soy er, M D2 #{149}llio t K . F ishm an , M D
Poten tia lly R esec tab le Pancrea tic
A denocarc in om a: Sp ira l C T A ssessm en t
w ith Surg ica l and P atho log ic C orre la tion ’
38 1
PURPOSE : To eva lu ate th e a ccu racy
of sp ira l com pu ted tom ography (CT )
in asse ssin g th e resec tab ility o f sm all
p an creatic duc ta l ad eno ca rc in om a
and to co rre la te th e CT find in g s w ith
his topatho log ic an d su rg ical f ind ings.
MATER IALS AN D METHOD S : Spi-
ra l C T scan s ob ta in ed in 64 patientsw ho underw en t su rgery for poten -
tia lly resec tab le pan crea tic ad enocar -
c in om a w ere p rosp ec tive ly a sse ssed
fo r tum or resec tab ility . C T find in gs
w ere correla ted w ith su rg ica lly a s-
ses sed exten t o f tum or and patho-
log ic f in din gs.
RESULTS : F ifty -seven (8 9% ) of 64
carcin om as w ere de tec ted w ith sp ira l
C T . Tw en ty-fou r ca rc in om as w ere
resec tab le a t su rg ery and 40 w ere not.
T h e avera ge size o f resec tab le tum ors
w as 3 .1 cm (range , 1 .0 -7 .5 cm ). T he
ov era ll accu ra cy of sp ira l C T for as-
sessin g resectab ility w as 70% . O f re-
sec ted tum ors, 1 4 w ere hypoa ttenuat-
in g com pared w ith th e rem ain in g
pancrea s and 10 w ere iso a ttenuatin g .
E leven tum ors show ed neo in tim al
p ro lifera tion in ar ter io le s a t h isto -
lo gic e xa min at io n.
CONCLUS ION : Further p rogress in
p reop era tiv e stag in g of pan creatic
du c ta l ad enocarc in om a w ith sp ira l
C T shou ld b e d irected tow ard im -
p rov in g d e tec tion o f sm a ll p an creatic
tum ors and asses sm en t o f ear ly m eta -
sta t ic d ise ase .
In dex term s: C om pu ted tom og raphy (C T ) ,
helical, 770. 12115 #{149}P ancreas, C T, 770 .12 115
P an cr ea s, n eo pla sm s, 770. 321
Radio l o g y 1 99 5; 1 97 :3 81 -3 85
C OMI ’UTED tom og raph y (CT ) is the
dom inan t im ag in g m oda lity
u sed fo r th e d iag nos is an d stag ing of
p an c rea tic du cta l ad en ocarc inom a,
w ith an overa ll accu ra cy of m ore than
90% (1 ,2 ) fo r d ynam ic CT . T h is h igh
accu racy is in pa rt due to th e ad -
vanced sta ge of m ost tum ors at in itia l
p resen ta tion . O n ly 1 0% -15% o f pa -
tien ts have po ten tia lly resec tab le pan -
c rea tic adenoca rc inom a at in itia l d iag -
nosis . A lthough the pro gnos is fo r
m ost pa tien ts w ith panc rea tic adeno -
ca rcin om a is d ism a l (o ve ra ll 3 -y ea r
su rv iva l ra te ap prox im ate ly 2% ) (3 ,4 ) ,
subs tan tia l p rogress has b een m ade
in treatin g a subgroup of patien ts
w ith ca rc in om a lim ited to th e head
of th e panc reas w ho unde rg o panc re -
aticod uod en ectom y . Fu rth er , pa tien ts
w ith sm a ll tum ors ( < 2 c m dia me ter),
w ith tum o rs th at d id n o t encase m a jo r
vesse ls, and w ith tum o rs tha t haveno t m e ta stas ized to lym ph nod es had
5-yea r su rv iva ls o f 30% , 36% , an d 57% ,
re spec tive ly (5 ). M o reov er , in c rea sed
su rg ical expe rtise h as redu ced th e
m orb id ity an d m orta lity p rev ious ly
assoc ia ted w ith p an c rea tic su rge ry (6 ) ,
m ak in g such trea tm en t an op tion fo r
m ore pa tien ts .
T h e CT fea tu res o f re sec tab le p an -
c rea tic tum ors have b een d escribed
in a ser ies o f 13 tum ors ( 7) , a lt ho ug h
CT technology ha s prog ressed con-
side rab ly since tha t a rtic le . S p ira l CT
has been rep orted to p rov id e h igh -
qu ality im ages o f th e panc reas d uring
a s ing le b reath h o ld (8 ,9 ) , w ith ex ce l-
len t reso lu tion of fin e deta il su ch a s
the panc rea tic d uc t (10 ). T h is stu dy
w as the re fo re p erfo rm ed to eva lua te
the accu racy of sp ira l C T in asse ssing
the nesectab ility o f p an c rea tic du cta l
adeno carc inom a and to co rrela te sp i-
ra l C T find in gs w ith h isto pa tho lo g ic
an d su rg ical f ind ings.
MATER IAL S A N D M ETHOD S
B etw een F eb ru ary 1992 an d A ugust
19 94 , w e eva lua ted th e sp iral C T scans
from pa tien ts w ith po ten tially re sectab le
pan cre atic du cta l ad en oca rcin om a. Pa -
tien ts w ere inc luded in the s tudy if the
fo llow in g criter ia w ere m et: (a ) pa tien t
und erw en t at tem pted surg ica l re sec tion
of a p an crea tic m ass iden tif ied at p reop -
e ra tive im ag in g eva lua tion , inc lud in g CT ,
endo scop ic retrog rade cho lan g iop an c rea -
to g raphy and /o r ang iograph y ; (b ) patien t
und erw en t preop era tiv e sp ira l C T o f the
abdom en w ith in trav en ous con tra st m a te-
ria l a t T he John s H opk in s H osp ita l, and
(c ) p ath o log ic ex am ina tion of su rg ica lly
b iop sied or resec ted tum or and /o r ad -
enop ath y sh ow ed pan creatic ad en oca rc i-
nom a. R esectab le cancer w as d ef in ed as
any tum or judged to have been to ta lly
rem oved a t su rg e ry , w ithou t m acrosco p ic
ev idence o f res idua l tum o r and w itho u t
ev idence o f inv o lvem en t o f ne ighb oring
organ s (o th er th an the du odenum ) or h e-
m atogenou s or d is tan t lym ph nod e m etas -
tases (o th er than p er ip an crea tic nod es).
P atien ts w ith adenocarc inom as of the am -
pu lla o f V ate r , the d uodenum , o r the d is -
ta l b ile du ct w ere ex clu ded , a s w ere pa -
tie n ts w ith is le t cel l tum o rs, cys tic tum ors ,
and o th er rare tum ors o f th e pancreas. A
to ta l o f 6 4 p a tien ts m e t the in clu sion c rite -
ria . T h e ave rag e pa tien t age w as 66 yea rs
(range, 44-82 y ear s). T h irty -fiv e pat ien ts
w ere m en and 29 w ere w om en .
S p ira l CT scan s w ere prospec tive ly eva l-
ua ted fo r tum or resectability an d w ere com -
pared w ith su rg ica l find ings , inc lu d ing
those o b tained a t b iopsy an d /o r resec tion .
F ind ings o n sp iral C T scan s in pa tien ts
w ith surg ica lly resec tab le ca rc inom as w ere
fu r th e r com pared w ith th e h is to lo g ic find -
in gs of the resected specim en .
I From T he Ru sse ll H . M organ D epar tm ent of R ad io log y and Rad io log ica l Science (DA B ., 5 .5 .5 . ,
P .S ., E .K .F .) and the D epartm en ts o f S urgery (J .L .C ., H A P.) and P a tho logy (R .H .H .), T he Jo hns H op-
k ins M ed ica l In stitu tions , 60 0 N W o lfe S t, B altim o re, M D 21287 . F rom th e 1994 R SN A sc ien tific a s-
sem bly . R eceived A pril 2 8 , 1995 ; rev is io n req uested M ay 30 ; rev ision rece ived Jun e 8 ; accep ted Jun e
1 2. A d dr es s rep r in t requests to D AB .
2 Cu rren t ad dre ss: C entre M #{233 }d ico -Ch iru rg ical F och , S erv ice d e R adio to g ie , Suresn es, F ran ce .
© R SN A , 1995
Sp ira l C T T echniqu e
A ll CT scan s w ere o b ta ined w ith a So -
m a tom P lus scanne r w ith a sp iral C T op -
t ion (S iem ens, Ise lin , N J). S can n ing tim e
w as 24 second s. T he fie ld o f v iew w as ch o-
sen to in clu de the en tire abdom en . CT
8/8/2019 Adenocarcinoma Pancreas able Qx.
http://slidepdf.com/reader/full/adenocarcinoma-pancreas-able-qx 2/5
1 . 2 .
F igures 1 , 2 . (1 ) U n rese ctab le p an creatic ad eno carcin om a. S p ira l C T scan show s a hypoatten -
ua ting tum o r (la rge arrow ) a rising f rom th e head and un cin ate p roc ess o f th e p anc rea s and
ex ten d ing p os teriorly and caudally to su rround th e sup er ior m esen teric a rte ry as it branches
(sm all a rrow ). T he fa t p lane be tw een the artery and tum or is ob lite ra ted . T he tum or w as pre -
d ic ted to b e u nresec tab le o n the basis o f th e f in d ings in th e sp ira l C T exam ina tion . A t su rgery ,
the m ain bu lk of the tum or w as resec ted bu t g ross tum or arou nd th e su perio r m esen te ric a rte ry
was lef t beh in d . (2 ) R e sec tab le p anc rea tic aden oca rcinom a. S pira l C T scan show s the tum or
in the pan crea tic h ead (a rrow ) to have sim ila r a ttenu a tion to the rem aind er o f the pancreas.
T he pancrea tic duc t is d ila ted . A t su rgery , a 2 .5 -cm m odera te ly d ifferen tia ted adenocarc in om a
was presen t, w ith inv as ion of the perip ancrea tic fa t and tum or in tw o o f eigh t penp ancrea tic
38 2 #{149}adio logy N ovem ber 1995
scans w ere o b ta in ed w ith 12 0 kV p, 165
mA , and 360#{176}inear in terpo lation axia l re-
con stru ction s fo r exam inat ion s p erfo rm ed
from Feb ru ary 19 92 to N ovem ber 1992 (1 6
p atien ts ). F rom D ecem ber 1 992 to S ep tem -
b er 199 4 , scans w ere ob ta in ed w ith 1 20
kV p, 210 mA , and 180#{176}i ne ar i nt er po la ti on
(48 pa tien ts ). C o llim ation w as 8 mm for
a ll ex am ina tion s. S can s began a t th e d ia -
ph ragm to com ple tely im age th e live r an d
continu ed cau dally th ro ug h th e pancreas .B efo re the s tar t o f sp ira l C T , n on io n ic
iod ina ted co n trast m ate ria l (12 0 m L of io -
hexo l a t 30 0 m g of iod ine per m illilite r o r
10 0 mL of io hexo l at 35 0 m g of io d ine p er
m illilite r) w as in jec ted in trav en ous ly a t a
ra te o f 2-3 m L /sec. Pa tien ts w ere ins truc ted
to hyp e rven tila te fo r seve ra l b rea ths d ur-
ing the in jec tion . S p ira l CT scann in g w as
begun imm edia tely af te r th e com ple tio n
of the con tra st in jec tion . P a tien ts w ere in -
s truc ted to ho ld the ir b reath fo r the du ra -
tion of the sp ira l C T scan .
T ran sax ia l im ag es from th e sp iral CT
scan w ere recons truc ted at ov er lapp in g
4-m m in te rva ls . A ll reco nstruc ted im ag es
w ere film ed at b o th so ft tissue se tting s
(w id th , 41 0 H U ; cen te r, 7 H U ) and narrow
“live r” se ttin gs (w id th , 176 H U ; cen te r,
7 6HU ) .
Im ag e In te rp re ta tio n
P rospec tive im ag e in te rp re ta tion w as
p erfo rm ed to p reope rativ ely assess tum o r
resec tab ility by us in g the crite ria o f F reen y
et al (1 ,2 ). P a tien ts w ere ju dged to have
unresec tab le pan crea tic duc tal ca rc inom a
i f any of the fo llow in g f ind ing s w ere iden -
tif ied on the sp ira l C T scan : a sc ite s , m eta s-
tase s in th e live r o r m esen tery , v ascu la r
invo lvem en t (encasem en t o f the su pe rio r
m esen ter ic a rte ry o r ce liac ax is , o cc lus ion
of the po rta l ve in o r sup erio r m esen te ric
ve in ) , o r loca l tum or ex ten sion to ad jacen t
o rg ans o the r than the d uod en um . A ll
o the r pa tien ts w ere judg ed to h av e po ten -
tia lly resec tab le ca rc inom a. C arc in om a w as
no t ju dged to be u nre sec tab le o n the basis
o f the p re sence of ad en opa th y a lo ne (de -
sc ribed fu rthe r be low ).
Fo r pa tien ts fo und to hav e re sectab le
tum ors a t su rge ry , re tro spec tive rev iew of
sp iral C T scans w as pe rfo rm ed and the
fin d ings corre lated w ith those f rom histo -
pa tho lo g ic exam in atio n . Th ree rad io log ists
r etrosp ect ive ly r ev iew ed these CT scan s in
co nsensus w ithou t k now led ge o f pa tho l-
ogy resu lts . T um or s ize, a ttenua tion re la -
tive to su rrou nd in g panc reas, and loca tionw ere an a ly zed . T he pre sence of ad en opa -
th y m easuring at leas t 5 mm in the peri-
pancrea tic o r periporta l tis sues o r 10 mm
in th e paraaortic -pa racava l cha ins w as
no ted . T he pe rip anc rea tic tissues an d m a-
jo r vessels w ere ev a lu ated fo r in filtra tion
and en casem en t, respectiv ely .
Spira l CT scan s w ere ob ta ined w ith in 30
days of surgery . A ll pa tien ts und erw en t
su rg ica l exp lora tio n for a ttem p ted resec-
tion of a pancrea tic m ass . In all cases, su r-
ge ry in vo lv ed e ithe r re sectio n of th e p ri-
many tum or m ass or b iopsy o f tissues to
estab lish the d iagn osis o f u nresec tab le
d isease .
lym ph nodes .
S tandard o f R eferen ce
For pa tien ts w ho had unresec tab le tu -
m ors a t su rgery , the opera tive record w as
the s tandard o f re fe rence . Fo r pa tien ts
w ith su rg ica lly resec tab le tum ors , the
pa tho log ic sp ecim en w as the s tan dard of
re fe rence . P a th o log ic spec im ens from the
resec ted tum ors w ere eva lua ted by one
pa tho log is t. Spec ific fea tu res tha t w ere
ana lyzed inc lu ded tum o r s ize , deg ree o f
d iffe ren tia tio n of the tum or, an d lym ph
node invo lvem en t by tum o r. A lso , d uo-dena l, comm on bile duc t, m ic ro vascu la r,
and perineura l invasion by tum or w ere
sea rched fo r. E x tens io n to the peripancre -
at ic fat w a s no ted if p resen t .
S ens itiv ity w as de fined as the pe rcen t-
age of co rrec tly d iagnosed unresectab le
le sio ns. S pe cific ity w as d efin ed a s the pe r-
c en tage o f corr ect ly d iagnosed resec tab le
le sio ns. S tat ist ica l a na lysis w as perfo rm ed
by us ing S tatv iew 4 .1 (A bacus C oncep ts ,
B erk e ley , C alif). T h e F ishe r R to Z trans-
fo rm ation fo r pa ired d ata w as used to
eva lua te th e re la tionsh ip be tw een nom i-
na t variab les. A na ly sis o f v ar iance w as
used to eva lua te th e re la tio nsh ip be tw een
tum or s ize , pe ripancrea tic fa t inv as ion ,and p an creatic a trop hy and a tten ua tion .
The F isher exac t tes t w as used to eva lua te
the rela tionsh ip b etw een tum or a ttenua-
tion and pa tho log ic f ind ing s. S ta tist ica l
m ea sures w ere cons ide red sign ifican t for
P < .05.
RESULTS
O f th e 6 4 pa tien ts , 40 (62% ) w ere
fou nd to have unnesectab le d isea se a t
su rg ery (F ig 1 ) . O f these 40 pa tien ts ,
sp ina l C T enab led the co rrec t d iagno -
s is o f unresec tab le d isease in 21 (53% )
(sensitiv ity , 53% ). N in eteen pa tien ts
(47% ) cons idered to have nesec tab le
d isease a t sp ira l C T had unresec tab le
d isease a t su rgery . Tw en ty -four pa-
tien ts (38% ) had re sectab le tum o rs a t
su rg e ry ; sp iral C T en ab led the co rrec t
d iag nos is in all 24 (spec if ic ity , 10 0% ).
Thu s, th e o ve ra ll accu racy o f sp ira l C T
fo r p red ictin g resec tab ility w as 7 0%
(95% confidence in te rv al, 59% , 81% ).
S p ira l CT dep ic ted a pancrea tic m ass
in 5 7 (89% ) o f the 6 4 pa tien ts . In f ive
o f the seven pa tien ts w ithou t a m ass
id en tified a t C T , panc rea tic and /on
b ile duc t d ilatio n w as p re sen t. In th ree
p atien ts in w hom the tum or w as no t
iden tif ied w ith sp ira l C T , ch ro n ic (n =
1) o r acu te ( = 2) pancrea titis w as
iden tif ied a t C T , ob scu rin g th e tum or.
F our o f seven tum o rs no t iden tif ied
w ith sp ina l C T w ere un re sec tab le a s a
resu lt o f d iffuse carc in om atosis (n =
1), live r m eta sta sis (ii = 1), and loca l
tum or ex tensio n (n = 2). T he s ize of
th ese tum ors w as no t specif ically a s-
sessed a t su rgery . T h ree of seven tu -m ors n o t iden tif ied a t sp ira l C T w ere
re sec tab le; the se a re d escr ibed fu rth e r
b e low .
In the subg ro up of 19 p atien ts w ho
w ere con side red to have resec tab le
d isease a t C T bu t u nresec tab le d isease
at su rge ry , e igh t pa tien ts (42% ) had
sm all live r m etas tases less than 10 mm
in d iam ete r . O n e of these pa tien ts
an d tw o add ition al pa tien ts a lso had
sm all pen itonea l m etastases . Seven
pa tien ts had porta l v ein an d /on sup e-
nor m esen ten ic v ein in vo lv em en t by
tum or (po rtal ve in in vasion , n = 2;
8/8/2019 Adenocarcinoma Pancreas able Qx.
http://slidepdf.com/reader/full/adenocarcinoma-pancreas-able-qx 3/5
8/8/2019 Adenocarcinoma Pancreas able Qx.
http://slidepdf.com/reader/full/adenocarcinoma-pancreas-able-qx 4/538 4 #{149}adio logy N ovem ber 1995
su rg ery (neg ativ e p red ic tive va lue ,
5 6% ). Th is is som ew hat b ette r than
th e find ings from a m u lti-ins titu t io na l
stu dy (1 3) , w h ich reported a nega tive
p red ic tive va lue fo r d ynam ic CT of
28% .
CT F ind ings o f R esec tab le
P an crea tic A denocarc in om a
O f ou r 24 cases w ith rad io lo g ic-
pa th o log ic co rre latio n , 10 (42% ) tu -
m ons w ere isoa ttenua ting com pared
w ith th e norm al pancreas and 14
(5 8% ) w ere hypoa ttenua ting . Th is is
su bstan tia lly d ifferen t than the re su lts
repo rted p rev ious ly b y F reeny et a l
(1 ), a lth ough the ir stud y popu la tion
w as prim arily com po sed of pa tien ts
w ith un re sectab le tum ors (1 54 of 1 61
pa tien ts ). In th at se ries , 83% of tum ors
d isp lay ed fo ca l a rea s o f h ypo atten ua -
t ion com pared w ith the norm a l pan -
c rea s. A n earlier s er ie s desc rib in g CT
fea tu re s o f 13 nesec tab le panc rea tictum ors u sing early CT techn o log y
a lso desc ribed isoa tten ua ting tum ors,
bu t no d istin c tio n w as m ad e be tw een
pa tien ts w ho rece ived in trav en ous
con tra st and tho se w ho d id n o t (7 ).
T he re la tive a ttenua tion of th e tum o r
to th e p ancreas is re la ted to its v ascu -
la rity com pared w ith tha t o f the sun -
ro und ing p an creas . T h is re la tive a tten -
ua tion is th ere fo re a fu nc tion of th e
p re sen ce o f un de rly ing pa ren ch ym a l
disease in th e p an creas and changes
as a func tion of tim e a fte r in trav en ous
con tra st adm in istra tion . In our se r ies
and tha t o f F reeny e t a l (1 ), im ages o f
the p an creas w ere like ly ob ta ined a f-
ten th e peak lev els o f p ancreatic en -
han cem en t (th e arter ia l phase). It
seem s like ly th at tum o rs tha t a re iso -
a ttenua ting to the p an creas at “no u-
tine” sp ira l scann ing m ay b ecom e
hypoa tten ua ting re la tiv e to th e p an -
c rea s du rin g the a rter ia l p hase and
the ir consp icu ity w ou ld subseq uen tly
be increased (14).
Seconda ry sig ns o the r than a foca l
m ass a re u sua lly h e lp fu l in th e d iag -
nos is o f p an creatic cancer . T hese sign s
inc lud e p an creatic an d comm on b ile
du ct d ila tion an d a troph y of the pan-
c rea s d ista l to th e tum o r. In o ur study ,
no pancreatic on com m on bile du ct
d ila tion w as presen t in 1 1 of 24 tu -
m ons prov ed to b e su rg ically re sect-
ab le . P an creatic a tro phy w as pre sen t
in on ly seven of the 24 cases ; h ow -
even , there w as assoc ia ted pancreatic
du ct d ila t io n (P < .000 1). I t is the re-
fo re im portan t to recogn ize tha t the se
sm a ll, resec tab le tum o rs m ay have a
sub stan tia lly d ifferen t ap pea rance
than m ay o th erw ise be ex pected . A
h ig h degree o f susp ic ion fo r a m alig -
nan t neop lasm m u st b e p re sen t in the
case o f “a typ ica l” panc rea tic m asses
tha t m ay be isoa ttenua tin g and d e -
tec ted on ly as a b u lge in the p an cre -
a tic con tou r , w itho u t ev idence of p an -
c rea tic o r b ile duc t d ila tion .
Tum or S tag in g
The m o st comm on reaso n fo r m ac -
cu rate p reop era tive as ses sm en t w ith
sp iral C T w as lack o f de tectio n of live r
m e tas tase s. In th e 1 9 cases th a t w ere
inaccu ra te ly asse ssed w ith sp iral C T ,
live r m e tasta se s w ere p re sen t in e igh t
(42% ). T hese m etas tases w ere sm all,
rang ing in s ize from 2 to 1 0 m m , bu t
w ere im m edia tely o bv io us a fte r su n -
g ical in spec tion and p alp atio n of the
liven . S p ira l C T w ith ove rlap p ing re-
co nstruc tion in te rv als ev ery 4 m m has
been show n to inc rea se th e de tectio n
of sm a ll les ions in th e live r com pared
w ith tha t o f con tig uou s 8 -mm trans-
ax ial im ag ing (15) . H ow eve r , in add i-tio n to les ion de tectio n , it is necessary
to cha rac te rize these focal abno rm a li-
tie s . T h is is lik ely to p rov e to b e d iff i-
cu lt. Jon es e t a l (16 ) have sh ow n th at
app ro x im a te ly 5 0% of sm a ll le sions in
th e liven le ss than on equa l to 15 mm
in d iam ete r are ben ig n . T he re fo re ,
sm a ll le sion s de tec ted w ith sp in al C T ,
p articu la rly if on ly a few les ions are
p re sen t, s till req u ire con firm a tion of
m alig nancy if pa tien ts a re to b e ex -
c lud ed from surge ry .
O ur re su lts fo r stag ing sm a ll p an -
c rea tic tum ors a re sim ila r to th ose o f
W arshaw e t a l (17 ) , w ho eva lua ted 4 0
pa tien ts w ith po ten tially resec tab le
tum ors a sse ssed w ith dy nam ic C T
and ang iog raphy . In tha t s er ie s , 1 4
p atien ts (3 5% ) h ad add itiona l h epa tic
o r peritonea l m etastases de tec ted
w ith lapa roscop y tha t ex clu ded th em
from surge ry . N od al stag ing w ith sp i-
ra l C T w as in accu rate , re f lec ting ea rly
m eta sta tic in vo lv em en t in no rm al-size
lym ph nod es . T he stag ing resu lts o f
F reen y et a l (1 ) w ith use o f d ynam ic
C T w ere som ew hat d ifferen t. O f 1 8
p atien ts w ith po ten tially resec tab le
tum ors w ho und e rw en t su rg ery ,
no ne o f the fiv e case s fou nd to b e
un re sec tab le a t su rg ery w ere d ue to
liv er o r p eriton ea l m eta sta se s. Th e
d iffe rences in re su lts a re p ro bab ly
d ue to d ifferences in pa tien t se lec -
tion c rite r ia an d d iffe ren ces in the
s ize o f th e pa tien t po pu la tion .
T um or size has been corre lated
w ith pa tien t o u tcom e (1 8) , and in th is
se ries tum or s ize as dep ic ted a t sp ira l
C T correla ted w e ll w ith tum o r size at
pa th o log ic exam ina tio n (r = .82 ) . A c-
cura te as se ssm en t o f tum or size w as
a ided by ob tain ing o ve rlapp ing ax ia l
reco nstruc tions eve ry 4 mm . In th e
seven cases in w hich a tum or m ass
w as no t id en tified , it is p ossib le th at
reduc ing co llim a tion to 3 -4 mm w ou ld
fu rthe r im p ro ve th e d etec tion of th e
tum or m ass (11 ,1 9 ) . H ow ev er , o u r
scann ing p ro to co l w as design ed to
cov er th e en tire c ran io cau da l ex ten t
o f the liv er an d panc reas on th e sp ira l
C T scan obta ined du rin g a sing le
b rea th ho ld . W ith th e sp iral C T scan-
ne r tech no lo gy tha t w as av ailab le
ov er the cou rse o f th e study , w e w ere
no t ab le to pe rfo rm add itiona l scan -
n ing un til 5 -10 m in u te s la te r d ue to
x -ray tub e hea t load in g lim ita tions .
R ad io lo g ic -P atho log ic C orre la tion
O f th e 24 resected tum ors, loca l tu -
m or ex ten sion inv o lv in g the du ode -
num , comm on b ile du ct, and pe ripan -
c rea tic fat w as p re sen t in 17 , 1 6 , and
17 cases, respec tive ly . L o ca l ex tens ion
to these tissu es w as n o t d irectly re -la ted to tum or size . T he re w ere tw o
cases in w hich loca l tum or ex ten sion
a ro und the p eripanc rea tic tissues p re-
c luded su rg ica l resec tion . In b o th
cases, lack of resec tab ility d ue to tu -
m on ex tensio n w as n o t sugg ested pro -
spec tive ly , a lthou gh one p atien t had
concurren t p an creatitis .
P an creatic ad enocanc inom a is m o st
frequen tly hy poa ttenua ting corn -
pa red w ith no rm al p anc reas a f ter ad -
m in istra tion of in trav enou s co n tra st.
In a m inor ity o f cases (one of 24 tu -
m ors in th is se ries ), th is w as due to
cen tra l tum or nec ro sis , a s w as p rev i-
ous ly sug gested (1 ). M ore comm only ,
tum o r h ypo atten ua tion is re lated to
d iffe ren tia l co n tras t enhan cem en t o f
the tum or and the norm a l panc reas.
Pancrea tic aden ocarcinom a ten ds to
have ea rly vascu la r in vasion (12 o f 24
cases in th is se ries ); tum or in vasion of
vesse ls m ay resu lt in decreased b lood
flow . H ow eve r, o f th e 12 tum o rs w ith
vascu la r inv asio n , six w ere h ypo atten -
ua ting and six w ere isoa tten ua ting ,
so tha t ea rly vascu la r invas io n w as a
poo r p red ic to r o f tum or atten ua tion .
P an creatic ad enoca rc ino rn a a lso
ten ds to inc ite a lo ca l f ib ro tic tissue
re spo nse . P re sum ab ly , the b loo d sup -
p ly to the tum or is frequen tly d iffe r-
en t than th at to th e no rm al panc reas,
an d th is d iffe ren ce accou n ts fo r re la -
tive tum or hypoa tten ua tion . In add i-
tio n , eleven o f 24 nesec ted tum ors (4 6% )
w ere assoc ia ted w ith n eo in tim a l p ro -
lifena tion in sm a ll a r ter io le s ad jacen t
to th e tum o r m ass. T um o rs w ith asso -
cia ted n eo in tim a l p ro life ra tion w ere
m ore frequ en tly h ypo attenu a tin g
(e igh t o f 11 cases) than isoa ttenua t-
ing com pared w ith no rm a l panc reas.
8/8/2019 Adenocarcinoma Pancreas able Qx.
http://slidepdf.com/reader/full/adenocarcinoma-pancreas-able-qx 5/5
Neoin tim a l p ro life ra tion is a lo ca l tis-
sue re spon se n ea r the tum or; it is in -
te res tin g to sp ecu la te th a t the vascu -
lan scle rosis iden tif ied h is to log ica lly
also in d icate s a vascu la r re sp onse to
the tum or th at re su lts in h ypoa tten u -
atio n o n CT scans.
S tudy L im ita tion s
Seve ral lim itatio ns o f th is stu dy
m ay be addre ssed as sp iral C T scan -
nin g technolog y p rogresses. Th e C T
scan ne r u sed du ring the stu dy cou ld
be co nside red a “ firs t-g ene ra tion ”
sp iral scan ne r: S cann in g w as lim ited
to 24 seco nds and the re w as an ap-
p rox im a tely 5 -m in u te de lay be tw een
the end o f the sp ira l s can and su bse -
qu en t s cans . S cann ing w as pe rfo rm ed
a fte r the early ar te ria l ph ase o f pan -
creatic enhancem en t (ie , d u rin g the
porta l ph ase o f liv er en hancem en t) .
B ecau se the panc reas is an ex trem e ly
vascu la r o rgan an d has a rich arte ria l
supp ly , a rte r ial phase scann ing w ou ld
like ly have b een m o re op tim a l fo r
panc rea tic tum or ev a lua tion bu t less
op tim a l fo r de tec tion of liv e r m e ta sta-
ses. D ua l-phase arte rial and porta l
phase scann ing o f the p an creas and
live r, re sp ec tive ly , w ill like ly p ro ve
ad van tageou s fo r s tag ing panc rea tic
neop la sm s (14) . W ith a rte ria l phase
scann in g of th e panc reas, a ttenua tion
d iffe ren ces b e tw een the tum or and
the n orm a l panc reas m ay be in -
c rea sed , rende ring th e tum or m ore
consp icuou s. A n add itiona l lim itatio nw as th at on -lin e ana lysis o f the C T
im ages w as no t ava ilab le, so th at w e
w ere unable to determ in e a ttenuation
va lues o f th e tum ors and norm a l p an -
creas .
In con clu sion , m o st sm a ll, p o ten -
tia lly re sec tab le p an creatic tum o rs can
b e id en tified w ith sp ira l C T . T um o rs
ju dged to be un re sec tab le on th e basis
o f the sp ira l C T exam in atio n are in -
v a riab ly un re sec tab le a t su rge ry . H ow -
eve r, in th is se r ies , m ore than 4 0% of
tum ors judg ed resec tab le at sp iralC T w ere unresec tab le a t su rg ery , fre-
q uen tly due to sm a ll live r m eta sta se s.
F u rth er p ro g re ss in p reop era tive tu -
m or stag ing fo r panc rea tic d uc tal ad -
en ocarc inom a sh ou ld be d irected to -
w ard im p rov ing the d e tec tion of sm a ll
p anc rea tic tum ors and asse ssing ea rly
m eta sta tic d is ea se . #{149}
A cknow ledgm ent: W e thank John P . E n ter -
l ine , M S. fo r sta tis tica l r ev iew of the da ta .
Referen ces
1 . F re eny PC , M ark s W M , R yan JA , T rave rso
LW . Pancreat ic d uc ta l aden ocarc inom a:diagnosis and s tag ing w ith dyn am ic CT .
R adio lo gy 1988; 1 66 :12 5-1 33 .
2. F reeny PC , T rav erso W , R y an JA . D iagno-
sis an d stag ing of p anc rea tic adenocarci-
nom a w ith d ynam ic com puted tom og ra-
p hy . A m J S urg 1 993; 1 65 :60 0-6 06 .
3 . W a rsh aw AL , F ern and ez-del C as tillo C .
P an creatic car cin om a. N E ng l J M ed 1992;
326:455-465.
4 . Conno lly M M , D aw son PJ, M ichelass i F , e t
at. Su rv iva l in 1 001 pa tien ts w ith carc i-
n om a of the p ancrea s. A nn Surg 1987 ; 2 06:
366-373.
5 . T su ch iya R , N od a T , H a rad a M , et a t. C o t-
le ctive rev iew o f sm all c arc inom as of the
p anc rea s. A nn Su rg 1986; 203:77-81 .
6 . C am eron JL , P it t HA , Y eo C J, L il lem oe K D ,
Kaufman H S, Co lem an J . O n e hundredan d fo rty -five consecu tiv e p anc rea tico du o-
den ectom ies w ith ou t m o rta lity . A nn S urg
1 9 93 ; 2 17 :4 3 0- 43 5 .
7. Ita i Y , A rak i T , T asaka A , M a ruy am a M .
Com puted tom ograph ic app earanc e o f re -
sec tab le pan cre atic c arc inom a . R adio log y
1 9 82 ; 1 4 3: 7 19 - 72 6 .
8. D upuy DE , C os tello P . E cke r CP . S piral
CT of th e pan creas . R ad io logy 1992; 1 83 :
815-818 .
9 . F ishm an EK , W yatt SH , N ey D R , K uhlm an
JE , S iege lm an 55 . S piral CT of th e p an-
crea s w ith m u ltip lan ar d isp lay . A JR 1992;
159:1209-1215.
10 . Z em an RK , Ze ibe rg AS , D avro s W J, e t a t.
R ou tine he lic al CT o f th e ab dom en : im age
q uality cons ide rations . R adio log y 1993 ;
189:395-400.
11 . M eg ibow A J. Pancreat ic aden oca rcinom a:des ign ing the exam ination to eva lua te the
clin ica l q ue stio ns. R adio lo gy 1992 ; 1 83:297 -
303.
12 . N ordback IH , H ruban R H , B oitn ott JK , Pit t
HA , C am eron JL . C a rcinom a o f the body
an d ta il of th e p anc rea s. A m J Surg 1 992;
164:26-31 .
1 3 . M egib ow A J, Zhou XH , R otte rdam H , et at .
P an creatic adeno carcin om a: CT ver sus M R
im agin g in th e evalu ation of re sec tab i lity -
r epo rt of the rad io lo gy d ia gn ost ic onco log y
gro up . R ad io lo gy 1995; 1 95:327 -3 32 .
1 4 . H olle tt M D , Jo rgensen M J, Jeff rey R B Jr.
Q uanti ta tive ev alu atio n of pancreat ic en-
h anc em ent d urin g du al ph ase he lica l CT .
R ad io lo gy 1995; 195 :35 9-3 61 .
15 . U rban BA , F ishm an EK , K uh lm an JE , K a -
w ash im a A , H enn es sey JC , S iege lm an 55 .D etect ion of foca l h epa tic le sion s w ith sp i-
ra t C T : com par iso n of 4 - an d 8-m m in ter -
s c a n s p a ci n g . A JR 1 99 3; 1 60 :7 83 -7 85 .
1 6 . Jo nes EC , Ch ezm arJL , N elso n R C , B ern ar-
d in o M E . Th e frequency and sig n ifican ce
of s ma ll ( 15 mm ) h epa tic le sio ns detecte d
by CT. A JR 1 99 2; 1 58 :5 35 -5 39 .
17 . W arsh aw AL , T epper JE , Sh ip ley W U . L a-
paroscopy in the s tag ing and plann ing of
therapy for pan cre atic cance r. Am J S urg
1 98 6; 1 51 :7 6- 80 .
1 8 . C am eron JL , C rist DW , S itzm ann JV , e t at.
Fac tors in fluenc ing surv iva l af ter p anc re-
at icod uodenec tom y fo r p ancrea tic cancer.
Am J S urg 1 991 ; 1 61:120 -12 4 .
1 9 . Culliv er D J , B ake r M E , C heng CA , M eyers
WC , Papp as TN . M a lig nant b ilia ry ob -
stru ctio n : e ffic acy of th in -se ctio n dynam ic
CT in d eterm in in g resecta b il ity . A JR 1992;
159:503-507.