adenocarcinoma pancreas able qx

8/8/2019 Adenocarcinoma Pancreas able Qx.

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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



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;


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.



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 .

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adenocarcinoma pancreas able qx

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