The role of dual-phase helical CT in assessing resectability of carcinoma of the gallbladder

Our objective was to assess the ability of dual-phase helical CT (DHCT) to predict resectability of carcinoma of gallbladder (CaGB). Thirty-two consecutive patients suspected of having CaGB on clinical examination and sonography presented to our centre over 10-month period. All these 32 patients underwent DHCT. Fifteen patients were considered inoperable and 2 had xanthogranulomatous cholecystitis. The remaining 15 patients (10 women, 5 men; age range 33-72 years) underwent surgery and had histopathological confirmation of CaGB and were included in the study based on the following criteria: presence of mass in gallbladder fossa on sonography and DHCT, and confirmation at surgery and histopathological examination. Axial reconstructions of 2 mm were obtained (collimation 3 mm, table speed 4.5 mm/s) for arterial (scan delay 20 s) and venous (scan delay 60 s) phases on a helical scanner. The criteria used for unresectability were: distant metastasis (liver, peritoneum, lymph nodes), extensive local contiguous organ spread, involvement of secondary biliary confluence of both lobes of liver, tumoral invasion of main portal vein, or proper hepatic artery or simultaneous invasion of one side hepatic artery and the other side portal vein. The CT findings related to unresectability were correlated with surgical findings. On the basis of CT findings, 10 patients were unresectable and 5 were resectable. Of the 10 patients considered unresectable, 9 had tumours that were unresectable at surgery (sensitivity 100%, positive predictive value 90%). Five patients had more than one reason and 4 had one reason alone for being unresectable (lymph nodes, n=2; hepatic metastasis, n=1; and vascular invasion, n=1). All 5 patients considered resectable based on CT findings had resectable tumours at surgery (negative predictive value 100%). The overall accuracy of CT was 93.3%. Dual-phase helical CT comprehensively evaluates CaGB and may be a useful tool in preoperative staging of this tumour in determining resectability.     

Diagnostic Accuracy of CT for Evaluating Circumferential Resection Margin Status in Resectable or Borderline Resectable Pancreatic Head Cancer: A Prospective Study Using Axially Sliced Surgical Pathologic Correlation

ObjectiveCT plays a central role in determining the resectability of pancreatic cancer, which directs the use of neoadjuvant therapy. This study aimed to assess the diagnostic accuracy of CT in predicting circumferential resection margin (CRM) involvement in patients with resectable or borderline resectable pancreatic head cancer.Materials and MethodsSeventy-seven patients who were scheduled for upfront surgery for resectable or borderline resectable pancreatic head cancer were prospectively enrolled, and 75 patients (38 male and 37 female; mean age ± standard deviation, 68 ± 11 years) were finally analyzed. The CRM status was evaluated separately for the superior mesenteric artery (SMA) and posterior and superior mesenteric vein/portal vein (SMV/PV) margins. Three independent radiologists reviewed the preoperative CT images and evaluated the resection margin status. The reference standard for CRM status was pathologic examination of pancreaticoduodenectomy specimens in an axial plane perpendicular to the axis of the second portion of the duodenum. The diagnostic accuracy of CT was assessed for overall CRM involvement, defined as involvement of the SMA or posterior margins (per-patient analysis), and involvement of each of the three resection margins (per-margin analysis). The data were pooled using a crossed random effects model.ResultsForty patients had pathologically confirmed overall CRM involvement in pancreatic cancer, while CRM involvement was not seen in 35 patients. For overall CRM involvement, the pooled sensitivity and specificity were 15% (95% confidence interval: 7%–49%) and 99% (96%–100%), respectively. For each of the resection margins, the pooled sensitivity and specificity were 14% (9%–54%) and 99% (38%–100%) for the SMA margin, 12% (8%–46%) and 99% (97%–100%) for the posterior margin; and 37% (29%–53%) and 96% (31%–100%) for the SMV/PV margin, respectively.ConclusionCT showed very high specificity but low sensitivity in predicting pathological CRM involvement in pancreatic cancer.     

Teardrop superior mesenteric vein: CT sign for unresectable carcinoma of the pancreas

OBJECTIVE: Our objective was to investigate whether a tethered, teardrop-shaped superior mesenteric vein (SMV) is a reliable CT indicator of unresectable adenocarcinoma of the head of the pancreas. MATERIALS AND METHODS: CT scans of 92 patients with high suspicion for pancreatic head adenocarcinoma were retrospectively reviewed by two radiologists who were unfamiliar with the patients' outcomes. The reviewers were asked to assess whether the teardrop SMV sign was present or not; agreement was reached by consensus. Teardrop SMV was considered absent in patients with an obstructed vessel. RESULTS: Of 92 patients, 30 had a normal pancreas without a teardrop SMV. A mass in the head of the pancreas was seen in all 62 patients with cancer. Of these 62 patients, 30 (seven with teardrop SMV) were deemed to have inoperable disease by standard CT or clinical criteria. The remaining 32 patients underwent surgery; only 15 of these 32 had successful pancreatoduodenectomies. No patient with resectable tumor had an unequivocal teardrop SMV sign. In 17 patients (13 with teardrop SMV), resection of the tumor could not be accomplished because of vascular encasement (n = 12) or metastasis (n = 5). Added to conventional signs, teardrop SMV significantly increased CT's sensitivity (from 60% to 91%) and accuracy (from 79% to 95%) without significantly changing its specificity (from 100% to 98%) for resectability of pancreatic head cancer. CONCLUSION: The teardrop SMV is a reliable sign for predicting unresectability of adenocarcinoma of the head of the pancreas and can significantly contribute to preoperative planning.     

Adenocarcinoma of the head of the pancreas: determination of surgical unresectability with thin-section pancreatic-phase helical CT

OBJECTIVE: This study was conducted to evaluate newly introduced criteria for unresectability of pancreatic cancer with thin-section pancreatic-phase helical CT. MATERIALS AND METHODS: Twenty-five patients with adenocarcinoma in the head of the pancreas underwent thin-section pancreatic-phase helical CT. The major peripancreatic vessels were categorized on a scale of 1-4, according to the degree of circumferential involvement by tumor. The maximum diameters of the small peripancreatic veins--gastrocolic trunk, anterosuperior pancreaticoduodenal vein, and posterosuperior pancreaticoduodenal vein--were recorded. Findings on CT were compared with the results of surgery in each patient. RESULTS: Sixteen patients had surgically resectable tumors, and nine patients had surgically unresectable tumors. CT and surgical correlation was available for 98 major peripancreatic vessels; 85 were resectable and 13 were unresectable. Of category 1 vessels, 72 (97%) of 74 were resectable at surgery. Of category 2 vessels, 12 (71%) of 17 were resectable. One (50%) of two category 3 vessels and none (0%) of five category 4 vessels were resectable at surgery. CT showed a dilated gastrocolic trunk in two patients; one of these patients had a surgically resectable tumor, but the other patient had a surgically unresectable tumor. CONCLUSION: In patients with adenocarcinoma in the head of the pancreas, the degree of circumferential vessel involvement by tumor as shown by CT is useful in predicting which patients will have surgically unresectable tumors. A dilated gastrocolic trunk should not be used as an independent sign of surgical unresectability.     

Pancreatic adenocarcinoma: the different CT criteria for peripancreatic major arterial and venous invasion

OBJECTIVE: To establish preliminarily the different diagnostic criteria for peripancreatic arterial and venous invasion in pancreatic carcinoma by comparing their multidetector-row computed tomography (MDCT) appearances with surgical exploration. METHODS: Among 101 patients with pancreatic carcinoma examined by MDCT, 54 candidates accepting surgery were preoperatively evaluated for vascular invasion based on CT signs (A-E): arterial embedment in tumor or venous obliteration; tumor involvement exceeding one-half of the circumference of the vessel; vessel wall irregularity; vessel caliber stenosis; teardrop superior mesenteric vein (SMV). The peripancreatic major vessels (n = 224) were examined carefully by surgeons during the operation. RESULTS: During surgical exploration, 78 vessels were found to be invaded. With sign A (B, C, or D) as the CT criterion for peripancreatic vascular invasion, the sensitivity of arterial and venous invasion was 66% (97%, 45%, or 41%) and 14% (49%, 63%, or 55%), respectively; the specificity of absence of arterial and venous invasion was 100% (91%, 99%, or 100%) and 100% (all 100%). In this study, there were 3 SMVs appearing teardrop (sign E), which were all confirmed to be invaded. CONCLUSIONS: It is recommended that the CT diagnostic criteria for arterial and venous invasion should be dealt with differently. The criteria of arterial invasion are the presence of sign A or the combination of sign B with one of signs C and D. The criteria of venous invasion are the presence of one of the following signs: sign A, sign B, sign C, sign D, and sign E.     

Assessment of vascular invasion in pancreatic carcinoma by MDCT

Background

Pancreatic cancer is one of the aggressive cancers with poor resectability and survival rates. The relationship to adjacent vessels must be assessed before deciding the choice of treatment.

Aim

Assessment of the MDCT signs of arterial and venous invasion in pancreatic carcinoma.

Subjects and methods

Total of 179 of the major peripancreatic vessels (CA; CHA; SMA; PV; SMV) in 47 patients who underwent surgery for pancreatic cancer after MDCT were assessed at surgery and compared with CT findings. Statistical analysis of the findings was done using Chi square test.

Results

115 vessels were not invaded at surgery, while the remaining 64 vessels were invaded (22 arteries and 42 veins). There was over all statistically significant difference between arterial and venous invasion regarding stenosis, occlusion, infiltration and circumferential involvement of the vessel wall.

Conclusion

Assessment of vascular invasion is crucial in the evaluation of resectability for pancreatic cancer. MDCT is an accurate diagnostic tool for peripancreatic vascular invasion in cancer pancreas.     

胰腺癌侵犯胰周主要血管的CT表现分析

目 的分析多层螺旋CT(MSCT)胰腺检查，胰腺癌侵及胰周主要动、静脉的不同CT表现特征。方法 MSCT诊断胰腺癌68例患者中，33例行手术治疗(其中12例行胰十二指肠切除术，21例剖腹探查发现不可切除)，病理结果均证实为胰腺导管细胞癌。术中由手术者仔细探查胰周主要血管[肠系膜上动脉(SMA)、腹腔干(CA)、肝动脉(HA)、肠系膜上静脉(SMV)及门静脉主干(PV)]。结果 165支受检血管中，手术探查发现103支血管未受侵犯，其余62支血管受侵，MSCT术前检查，8．1％(5／62)受侵血管误判为未受侵犯(假阴性)。其余受侵的胰周主要动、静脉(57支)具有不同的CT表现特征：胰周主要动脉受侵时，均被肿瘤包绕大于管周的1／2或完全包埋于肿瘤中。胰周主要静脉受侵时，部分静脉血管被肿瘤包绕小于管周的1／2：SMV为4支(4／17)，PV为2支(2／13)，但同时均出现管壁受浸润或管腔狭窄或管腔形态改变；胰周静脉受侵犯时出现管腔狭窄或闭塞的机会较胰周动脉大：SMV为11支(11／17)，PV为12支(12／13)，而CA为3支(3／8)，HA为4支(4／7)，SMA为4支(4／12)；胰周静脉受侵犯时管壁呈浸润性改变的比例较胰周动脉高：SMV为11支(11／17)，PV为7支(7／13)，而CA为3支(3／8)，HA为2支(2／7)，SMA为6支(6／12)。结论 胰周动、静脉受侵及时，其CT表现具有不同特征。     

Preoperative assessment of resectability of hepatic hilar cholangiocarcinoma: combined CT and cholangiography with revised criteria

PURPOSE: To retrospectively assess the accuracy of combined multiphasic computed tomography (CT) and direct cholangiography for evaluation of the resectability of hilar cholangiocarcinoma, on the basis of revised criteria for unresectability, by using surgery as the reference standard. MATERIALS AND METHODS: Institutional review board approval was obtained, and informed consent was waived. From 1998 to 2003, 55 patients (37 men, 18 women; mean age +/- standard deviation, 59 years +/- 12) with surgically proved hilar cholangiocarcinomas who underwent preoperative CT (single-detector row CT, n = 26; multi-detector row CT, n = 29) and cholangiography were included for study. The authors' revised criteria for unresectable tumor were contralateral hepatic artery invasion; main or contralateral portal vein invasion longer than 2 cm; biliary extension to the contralateral secondary confluence, farther than 2 cm from hepatic hilum; enlarged lymph nodes at the celiac, portacaval, and paraaortic area; and other ancillary findings. Tumor resectability based on these parameters was determined at imaging by two radiologists in consensus. Mann-Whitney U test and weighted kappa coefficient of agreement were used for accuracy determination. RESULTS: For depiction of portal vein invasion (in 26 patients), CT yielded an accuracy of 85.5%. Arterial invasion was found at surgery in 19 patients, with CT providing an accuracy of 92.7%. For prediction of node involvement (15 patients, 27%), CT yielded an accuracy of 83.6%. The extent of ductal involvement could be accurately predicted in 46 patients (84%) (weighted kappa = 0.767). In 30 of 42 patients with disease classified as resectable according to revised criteria, disease was found to be resectable at surgery (71.4% positive predictive value). In 11 of 13 patients with disease classified as unresectable according to revised criteria, unresectable disease was confirmed (84.6% negative predictive value). Overall accuracy of resectability was 74.5%. CONCLUSION: Combined interpretation of CT and direct cholangiographic images by using our revised criteria resulted in overall accuracy of 74.5% for prediction of resectability for hilar cholangiocarcinoma.     

直肠癌术前CT扫描的价值

目的：评估直肠癌术前ＣＴ扫描的价值。材料与方法：１０４例直肠癌（Ｔ２期１１例、Ｔ３期９０例、Ｔ４期３例）的ＣＴ扫描与手术病理这缘改变、浸润周径、淋巴结大小对Ｔ、Ｎ分期的价值。结果：以肿瘤石头居齿状和结节改变作为Ｔ３的诊断指标,其准确率分别为９４．０％、９０．４％、８８．４％;Ｔ分期的准确率是８９．４％,Ｔ３的准确率是９４．０％。将肿瘤侵犯肠管周径〉１／２与≤１／２作为Ｔ３期的诊断指标,有显著统计学     

Indeterminate mediastinal invasion in bronchogenic carcinoma: CT evaluation

The computed tomographic (CT) scans of 80 patients with bronchogenic carcinoma classified as indeterminate for direct mediastinal invasion were retrospectively reviewed after the patients had undergone thoracotomy. Forty-eight (60%) of the masses were resectable, without invasion of the mediastinum, 18 (22%) focally invaded the mediastinum but were technically resectable, and 14 (18%) invaded the mediastinum and were not technically resectable. Although in most circumstances in this relatively small subset of patients CT was not helpful in differentiating masses with and without mediastinal invasion, CT was able to separate a large group of masses that were likely to be technically resectable. Thirty-six (97%) of 37 masses with one or more of these CT findings were considered technically resectable: contact of 3 cm or less with mediastinum, less than 90 degrees of contact with aorta, and mediastinal fat between mass and mediastinal structures. Of these 36 masses, 28 were resectable without mediastinal invasion, and eight were resectable with focal limited mediastinal invasion.     

Assessment of vascular invasion in pancreatic head cancer with multislice spiral CT: value of multiplanar reconstructions

The use of multiplanar reconstructions (MPRs) generated from multislice spiral CT (MSCT) data sets in the preoperative assessment of vascular invasion in pancreatic cancer was evaluated. Forty patients underwent biphasic high-resolution MSCT prior to surgery for pancreatic head cancer. Image reconstruction included thin-slice axial, sagittal and coronal MPRs as well as an MPR perpendicular to the course of a major peripancreatic vessel in proximity to the tumor. CT criteria for vascular invasion were: (1) circumferential involvement >180° and (2) vessel narrowing. Imaging findings of 52 vessels were correlated with surgical and histopathological reports. Regarding the CT criterion circumferential involvement, vascular invasion was demonstrated on axial MPRs with a sensitivity and specificity of 58 and 97%. For the assessment with coronal and sagittal MPRs sensitivity was only 47%. Vascular invasion was recognized best on perpendicular MPRs with a sensitivity, specificity and accuracy of 74, 97 and 88%, respectively. Vessel narrowing was a less reliable CT criterion for vascular invasion, mainly due to the lower specificity of 91% obtained with each available MPR. Thin-slice MPRs oriented perpendicularly to a possibly invaded vessel exactly depict the grade of circumferential involvement and thus have the capability to improve the assessment of vascular invasion in pancreatic cancer.     

Intravascular ultrasound for evaluation of portal venous involvement in pancreatic cancer

The aim of this study was to evaluate the accuracy of intravascular ultrasound (IVUS) in diagnosing tumour involvement of the portal vein in patients with exocrine cancer of the head of the pancreas. Seven consecutive patients with a preoperative diagnosis of carcinoma, preoperatively deemed to be resectable, were examined with IVUS of the portal vein during surgery. The IVUS catheters were 6.2 F (2.0 mm) in diameter with a 20-MHz transducer and were introduced into the portal vasculature through the mesenteric superior vein. All patients had tumour extending to the portal vein as demonstrated at histopathological examinations in six cases and at surgical dissection in one case. The IVUS technique correctly identified all these patients, whereas five patients were incorrectly deemed at surgery not to have tumour involvement of the portal vein. These results indicate that IVUS is a very sensitive method for the evaluation of tumour involvement of the portal vein. Received 4 October 1995; Revision received 12 February 1996; Accepted 14 February 1996     

Percutaneous CT-guided superior mesenteric vein access for portal vein recanalization-transjugular intrahepatic portosystemic shunt

Portal vein recanalization-transjugular intrahepatic portosystemic shunt (PVR-TIPS) is a valuable technique in the treatment cirrhosis and portal vein (PV) thrombosis. Only a few studies have reported cases of utilizing the transmesenteric approach in the procedure''s initial portal access. Here, we report the successful utilization of a CT-guided percutaneous puncture of the superior mesenteric vein (SMV) for PVR-TIPS in a patient with splenic vein thrombosis. A 54-year-old male with a history of morbid obesity (BMI: 44.67), hepatitis C, NASH cirrhosis, esophageal varices, and complete PV thrombosis presented for PVR-TIPS. An initial percutaneous transplenic approach was attempted, but was aborted due to the discovery of a splenic vein thrombosis. Subsequently, the patient was brought back into the hybrid-angio CT suite, and the SMV was accessed percutaneously with a 21-gauge needle under 4D CT-guidance. A 5-Fr micropuncture sheath was then placed. Additional portal venogram confirmed PV thrombosis. Right internal jugular vein (IJV) access was then obtained, and the right hepatic vein was catheterized. A loop snare was advanced from the SMV access into the right PV. A Colapinto needle was later positioned in the right hepatic vein, and the right PV was accessed using the loop snare as a target. A wire was then advanced and captured by the snare, and brought down through the PV. The tract was dilated with a 10 mm balloon, and a Viatorr stent was deployed. Balloon embolectomy of the SMV, splenomesenteric vein, and TIPS were then performed with a CODA balloon with improvement in flow through the TIPS on final portal venogram. Portosystemic gradient was 11 mmHg initially and 10 mmHg post-TIPS. Follow-up TIPS venogram in 3 weeks showed a widely patent TIPS. CT-guided percutaneous SMV access may serve as valuable technique in PVR-TIPS when traditional modes of initial portal access for recanalization are unobtainable.     

胰腺癌血管侵犯的不同CT诊断标准的研究

目的:研究胰腺癌血管侵犯的不同CT诊断标准的优劣。材料和方法:回顾性收集我院经多层螺旋CT三期动态增强扫描并经手术病理证实为胰腺导管细胞癌的36例患者。CT轴位图像结合CTA(以MIP和VR方法重建)以及多平面重建(MPR)分别对这些血管以Loyer和Lu血管分级CT标准进行分级,并和手术结果进行对照,分别作出受试者工作特性曲线(ROC),比较曲线下面积的差异。另外,运用Lu的CT诊断标准分别评价胰周动脉和静脉受侵的准确性、灵敏度、特异度、阳性预测值、阴性预测值、Youden指数,研究Lu的CT诊断标准对动静脉分级的差异。结果:Loyer和Lu的CT诊断标准所得的灵敏度、特异度分别为84.5%、86.0%、81.4%、91.8%,两个诊断标准的ROC曲线下面积分别为0.886、0.912,经统计学检验无明显差异。应用Lu的CT诊断标准,胰周动静脉受侵的阳性预测值分别为57.1%和71.0%。结论:分别以Loyer和Lu血管分级CT标准对胰腺癌胰周血管侵犯进行分级,两者的诊断价值相同,Lu的CT诊断标准的最佳诊断分界点应在90°-180°之间,此外,它对胰周动脉的价值要比静脉差。     

Streamlined flow in the portal vein: demonstration with MR angiography

PURPOSE: To demonstrate whether streamlining of the portal vein flow exists by evaluating the relative distribution of blood flowing from the superior mesenteric vein (SMV) and splenic vein (SV) into the portal venous system. MATERIALS AND METHODS: Fifteen healthy adult volunteers underwent MR angiography of the main portal vein (PV) and portal vein branches after an overnight fast. Transverse two dimension time-of-flight gradient echo sequences were obtained three times, in suspended expiration and inspiration, respectively, as follows: 1) No presaturation slab, 2) presaturation slab across the SMV, 3) presaturation slab across the SV. Signal intensity (SI) measurements were obtained for all acquisitions. using regions of interest traced manually within the PV and portal branches. RESULTS: After presaturation of the SMV and SV during expiration, the overall SI average in the PV decreased by 47% +/- 8 (mean +/- SD) and 17% +/- 9, respectively. Right to left portal branch SI ratio and right-anterior to left-posterior SI ratio in the PV were 0.91 +/- 0.09 and 1.02 +/- 0.08 at baseline, respectively. They decreased significantly (P < 0.05) to 0.87 +/- 0.09 and to 0.95 +/- 0.09 after saturation of the SMV, and increased significantly to 0.95 +/- 0.08 and to 1.07 +/- 0.10 after saturation of the SV. CONCLUSION: MR angiography with selective saturation of the SMV and SV provided reproducible assessment of the respective contributions of the SMV and SV to portal flow, and allows demonstration that streamlining of splanchnic blood occurs in the portal vein of normal subjects.     

Pancreatic adenocarcinoma: signs of vascular invasion determined by multi-detector row CT

The purpose of this study was to analyse multi-detector row CT (MDCT) signs of peripancreatic arterial and venous invasion in pancreatic carcinoma. Among 101 patients with pancreatic carcinoma examined by MDCT, 54 candidates for surgery were pre-operatively evaluated for vascular invasion based on MDCT signs. The peripancreatic major vessels (including superior mesenteric artery, coeliac artery, common hepatic artery, superior mesenteric vein and portal vein) were examined carefully by surgeons during the operation. At surgical exploration, 78 of 224 vessels were invaded by tumour. The invaded peripancreatic major arteries (n = 29) and veins (n = 49) presented different MDCT signs: 43% of invaded veins (18/42, except for 7 occluded veins) were surrounded by tumour less than 50% of the vessel circumference compared with 97% (28/29) of the invaded arteries, which were surrounded by tumour more than 50% of the vessel circumference or were embedded in tumour (p<0.001). 69% (34/49) of the invaded veins had vascular stenosis or obliteration, compared with 41% (12/29) of the invaded arteries (p<0.05). Irregularity of the vein wall, 74% (31/42, except for 7 occluded veins); occurred more often than that of the artery wall, 45% (13/29) (p<0.05). In conclusion, the MDCT signs of peripancreatic arterial and venous invasion have different characteristics, which should be considered in pre-operative evaluation.     

Pre- and postprandial alterations of portal venous flow: evaluation with single breath-hold three-dimensional half-Fourier fast spin-echo MR imaging and a selective inversion recovery tagging pulse

PURPOSE: To evaluate the influence of food intake on portal flow using unenhanced magnetic resonance imaging (MRI). MATERIALS AND METHODS: The study population included 29 healthy subjects. A selective inversion recovery tagging pulse was used on the superior mesenteric vein (SMV) and splenic vein (SpV) to study the correlation of tagged blood in the portal vein (PV). MRI was performed before and 60-90 min after a meal. RESULTS: The flow signal from the SMV increased in 97% of the subjects after the meal. Before the meal the portal flow was dominated by flow from the SpV in 59% of the subjects, while it was dominated by flow from the SMV in 76% of the subjects after the meal. The most common distribution pattern of the flow signal from the SpV before the meal was in the central part of the main PV (55%), while it was in the left side (45%) after the meal. The most common distribution pattern of the flow signal from the SMV was in the bilateral sides of the main PV both before and after the meal (62%). CONCLUSION: This technique shows potential for evaluating pre- and postprandial alterations of flow from the SpV and SMV in the PV under physiological conditions.     

CT assessment of the inferior peripancreatic veins: clinical significance

OBJECTIVE: The purpose of this study was to evaluate and clarify the clinical significance of CT scans of the inferior peripancreatic veins. MATERIALS AND METHODS: Forty-three patients with suspected pancreatic disease underwent three-phase helical CT (collimation, 5 mm; reconstruction, 2.5 mm; scan delay, 30, 60, and 150 sec). The frequency of visualization on CT of the anterior and posterior inferior pancreaticoduodenal veins, inferior pancreaticoduodenal vein, and first jejunal trunk was assessed and correlated with angiographic and pathologic findings. RESULTS: The frequency of visualization of normal inferior peripancreatic veins in patients (n = 22) with a normal portomesenteric vein was 36% for the anteroinferior pancreaticoduodenal vein, 36% for the posteroinferior pancreaticoduodenal vein, 59% for the inferior pancreaticoduodenal vein, and 100% for the first jejunal trunk. The smaller inferior peripancreatic veins were frequently not visualized when normal. In patients (n = 13) with pancreatic carcinoma involving the portosuperior mesenteric vein, all of the inferior peripancreatic veins were dilated and easily recognizable. When the tumor did not involve the portosuperior mesenteric vein but did involve the anteroinferior pancreaticoduodenal, posteroinferior pancreaticoduodenal, and inferior pancreaticoduodenal veins (n = 8), some of the other peripancreatic veins (first jejunal trunk, anterior and posterior superior pancreaticoduodenal veins, and gastrocolic trunk) were dilated. Dilatation indicated tumor extension to the third portion of the duodenum. In patients (n = 7) with involvement of the inferior pancreaticoduodenal vein, the first jejunal trunk, or both without the involvement of the portosuperior mesenteric vein, dilatation of the other peripancreatic veins (anteroinferior pancreaticoduodenal vein, posteroinferior pancreaticoduodenal vein, anterosuperior pancreaticoduodenal vein, posterosuperior pancreaticoduodenal vein, and gastrocolic trunk) indicated tumor invasion of only the second portion of the extrapancreatic nerve plexus (n = 4) and tumor invasion of both the second portion of the extrapancreatic nerve and the mesenteric root (n = 3). CONCLUSION: Dilatation of peripancreatic veins with nonvisualization of inferior peripancreatic veins suggests tumor invasion of peripancreatic tissue.     

Radiological staging in patients with hilar cholangiocarcinoma: a systematic review and meta-analysis

Objective To obtain diagnostic performance values of CT, MRI, ultrasound and 18-fludeoxyglucose positron emission tomography (PET)/CT for staging of hilar cholangiocarcinoma. Methods A comprehensive systematic search was performed for articles published up to March 2011 that fulfilled the inclusion criteria. Study quality was assessed with the quality assessment of diagnostic accuracy studies tool. Results 16 articles (448 patients) were included that evaluated CT (n=11), MRI (n=3), ultrasound (n=3), or PET/CT (n=1). Overall, their quality was moderate. The accuracy estimates for evaluation of CT for ductal extent of the tumour was 86%. The sensitivity and specificity estimates of CT were 89% and 92% for evaluation of portal vein involvement, 83% and 93% for hepatic artery involvement, and 61% and 88% for lymph node involvement, respectively. Data were too limited for adequate comparisons of the different techniques. Conclusion Diagnostic accuracy studies of CT, MRI, ultrasound or PET/CT for staging of hilar cholangiocarcinoma are sparse and have moderate methodological quality. Data primarily concern CT, which has an acceptable accuracy for assessment of ductal extent, portal vein and hepatic artery involvement, but low sensitivity for nodal status.     

Assessing resectability of lung cancer: the role of computed tomography of the mediastinum, upper abdomen and head

In order to assess the value of computed tomography (CT) of the mediastinum, upper abdomen and head in the assessment of resectability of lung cancer, the CT findings of 262 patients, of whom 198 underwent thoracotomy, were analyzed retrospectively and the stagings obtained at CT and thoracotomy were compared. Mediastinal CT reliably predicted resectability when there was no evidence of mediastinal involvement. However, it was often impossible to determine whether tumour with apparent mediastinal infiltration on CT was resectable or not. The sole finding of lymph node enlargement did not permit differentiation of benign from malignant lymphadenopathy when the lymph node diameter was less than 25 mm and the lymphadenopathy was confined to one lymph node station. Upper abdominal metastases were found in 6.1% and brain metastases in 4.6% of patients and neither the histological type nor other features of the tumour were found to be useful predictors of their presence. The large number of non-specific findings decreased the utility of abdominal CT. The appropriate strategy for the pre-operative evaluation of patients with lung cancer is discussed.