Imaging of pancreatic neoplasms.

Ductal adenocarcinoma accounts for 85% to 90% of all solid pancreatic neoplasms, is increasing in incidence, and is the fourth leading cause of cancer-related deaths. There are currently no screening tests available for the detection of ductal adenocarcinoma. The only chance for cure in pancreatic adenocarcinoma is surgery. Imaging has a crucial role in the identification of the primary tumor, vascular variants, identification of metastases, disease response assessment to treatment, and prediction of respectability. Pancreatic neuroendocrine neoplasms can have a distinctive appearance and pattern of spread, which should be recognized on imaging for appropriate management of these patients.

Pancreatic neuroendocrine neoplasms: diagnosis and management.

Pancreatic neuroendocrine neoplasms are uncommon but rising in incidence. There have been recent changes in the WHO nomenclature and a newly proposed American Joint Committee on Cancer TNM staging, which complement each other. These neoplasms are of great medical and radiological interest because of their diverse presenting features and imaging appearances. There is an increased role for both anatomic and functional imaging in the assessment of these neoplasms. A review of the nomenclature, staging, and imaging is presented in this paper.

Complications of Whipple surgery: imaging analysis.

BACKGROUND/AIMS: The purpose of this article is to describe and illustrate anatomic findings after the Whipple procedure, and the appearance of its complications, on imaging. CONCLUSION: Knowledge of the cross-sectional anatomy following the Whipple procedure, and clinical findings for associated complications, are essential to rapidly and accurately diagnose such complications on postoperative studies in order to optimize treatment.

Venous tumor thrombus in nonfunctional pancreatic neuroendocrine tumors.

OBJECTIVE: We sought to determine the incidence of venous tumor thrombus in nonfunctioning pancreatic neuroendocrine tumors. MATERIALS AND METHODS: We reviewed CT images of patients with a diagnosis of nonfunctional pancreatic neuroendocrine tumors over a 4-year period. For patients who underwent surgery, changes to surgical plans related to the tumor thrombus were also recorded. RESULTS: CT showed venous tumor thrombi in 29 of the 88 patients (33%; 95% CI, 23-44%). This CT finding was not accurately reported in 18 of the 29 patients (62%; 95% CI, 42-79%). Of the 39 patients who underwent surgery, venous tumor thrombi were detected in 11 patients (28%; 95% CI, 15-45%) and were confirmed by pathology. Microscopic venous tumor thrombi in 10 patients were not detected by CT. Pathologic results showed venous tumor thrombi in 21 of the 39 patients (54%; 95% CI, 37-70%) who underwent surgery. The surgical plan was significantly changed in two of the 11 patients with gross thrombi (18%; 95% CI, 2-52%) who underwent surgery. There was no change in the surgical plan for the 10 patients with microscopic tumor thrombi. CONCLUSION: The incidence of venous tumor thrombus detected by imaging was 33% in our study. This imaging finding was not accurately reported on the radiology report in 62% of the patients. In 18% of the patients with gross venous tumor thrombi, there was a significant alteration in the surgical plan. It is critical for the radiologist to be aware of the association of venous tumor thrombi in patients with nonfunctioning pancreatic neuroendocrine tumors and to report these findings.

Perfusion CT findings in patients with metastatic carcinoid tumors undergoing bevacizumab and interferon therapy.

OBJECTIVE: The purpose of this article is to assess tumor changes on perfusion CT with bevacizumab and interferon (IFN) therapy in patients with metastatic carcinoid tumors and to evaluate perfusion CT differences between the two therapies. SUBJECTS AND METHODS: In a phase 2 clinical trial, 44 patients were randomized to receive monotherapy with bevacizumab or IFN for 18 weeks (stage 1), followed by dual-therapy with both drugs (stage 2). Twenty-four patients consented to have optional perfusion CT examinations, which were undertaken at baseline and 18 weeks and at intervening 2 days (bevacizumab arm) or 9 weeks (IFN arm), and subsequently at 2 days after the addition of bevacizumab (IFN arm) and 9 weeks after the addition of IFN (bevacizumab arm). Tumor blood flow, blood volume, and permeability were evaluated. RESULTS: In the bevacizumab arm (n = 12), mean (± SD) blood flow reduced significantly after 2 days compared with baseline (16.2 ± 6.9 vs 32.3 ± 21.3 mL/min/100 g; p = 0.02), a 41.4% reduction (p < 0.0001) that was relatively fixed. Blood volume was similarly reduced from baseline values (2.8 ± 1.3 vs 4.3 ± 2.1 mL/100 g; p = 0.02), a 27.9% reduction (p < 0.02). Both measures remained essentially unchanged at 18 weeks. Similar changes in blood flow and blood volume were observed with the addition of bevacizumab in stage 2. No significant changes in blood flow or blood volume were detected in the IFN arm (n = 12), and no significant changes in permeability were detected in either arm. CONCLUSION: Perfusion CT detects significant changes in perfusion parameters in metastatic carcinoid tumors treated with bevacizumab. Such changes are apparent just 2 days into therapy, are sustained, and are significantly different from those associated with IFN treatment. Tumor blood flow decreased with bevacizumab treatment by a relatively fixed percentage relative to baseline measurements.

Correlation of computed tomography and positron emission tomography in patients with metastatic gastrointestinal stromal tumor treated at a single institution with imatinib mesylate: proposal of new computed tomography response criteria.

PURPOSE: Response Evaluation Criteria in Solid Tumors (RECIST) are insensitive in evaluating gastrointestinal stromal tumors (GISTs) treated with imatinib. This study evaluates whether computed tomography (CT) findings of GIST after imatinib treatment correlate with tumor responses by [18F]fluorodeoxyglucose (FDG) positron emission tomography (PET) and develops reliable, quantitative, CT response criteria. PATIENTS AND METHODS: A total of 172 lesions selected by RECIST were evaluated in 40 patients with metastatic GISTs treated with imatinib. All patients had pretreatment and 2-month follow-up CTs and FDG-PETs. Multivariate analysis was performed using tumor size and density (Hounsfield unit [HU]) on CT and maximum standardized uptake value (SUVmax) on FDG-PET. Patients were observed up to 28 months. RESULTS: Mean baseline tumor size and density on CT were 5.3 cm and 72.8 HU, respectively, and mean baseline SUVmax on FDG-PET was 5.8. Thirty-three patients had good response on FDG-PET. A decrease in tumor size of more than 10% or a decrease in tumor density of more than 15% on CT had a sensitivity of 97% and a specificity of 100% in identifying PET responders versus 52% and 100% by RECIST. Good responders on CT at 2 months had significantly longer time to progression than those who did not respond (P = .01). CONCLUSION: Small changes in tumor size or density on CT are sensitive and specific methods of assessing the response of GISTs. If the prognostic value of our proposed CT response criteria can be confirmed prospectively, the criteria should be employed in future studies of patients with GIST.

We should desist using RECIST, at least in GIST.

PURPOSE: Response Evaluation Criteria in Solid Tumors (RECIST) are insensitive in evaluating imatinib-treated gastrointestinal stromal tumors (GISTs). Response by Choi criteria, a 10% decrease in size or a 15% decrease in density on contrast-enhanced CT, correlated well in a small training set of patients who showed response as measured by positron emission tomography, and was more predictive of time to tumor progression (TTP) than response by RECIST. This study was designed to validate these observations in an independent data set. PATIENTS AND METHODS: Fifty-eight patients with imatinib-treated GISTs were evaluated by RECIST and Choi criteria. TTP was compared with TTP in the training set. Patients were analyzed initially with follow-up to 28 months, extended to 60 months for survival analysis. RESULTS: Patients who met Choi response criteria on CT at 2 months had significantly better TTP than those who did not (P = .0002), whereas response group by RECIST was not significantly correlated with TTP. Even when the 98 patients from both sets were analyzed together, the response group by RECIST did not correlate significantly with TTP, whereas response group by Choi criteria did correlate significantly with TTP. Disease-specific survival (DSS) was also significantly correlated with response group by Choi criteria (P = .04), but not with response group by RECIST. CONCLUSION: Choi response criteria are reproducible, more sensitive, and more precise than RECIST in assessing the response of GISTs to imatinib mesylate. Response by Choi criteria, unlike response by RECIST, correlates significantly with TTP and DSS. Response by Choi criteria should be incorporated routinely into future studies of GIST therapy. We should desist using RECIST, at least in GIST.

Accuracy of preoperative imaging of hepatic tumors with helical computed tomography.

BACKGROUND: The accuracy of preoperative computed tomography (CT) scans in the era of modern imaging techniques with helical, high-resolution CT has not been adequately assessed. We reviewed the data from our departmental prospective database with the hypothesis that intraoperative ultrasonography (IOUS) still detects more hepatic tumors than are evident on preoperative helical CT scans. METHODS: All patients who underwent surgical resection and/or radiofrequency ablation of primary or metastatic hepatic tumors between January 2001 and July 2002 were included in the review. All patients had preoperative helical CT imaging followed by hepatic IOUS. The number of malignant lesions and evidence of local disease identified by the preoperative CT scan versus IOUS and surgical exploration were compared. RESULTS: In this time period, 250 patients underwent surgical resection and/or radiofrequency ablation of hepatic tumors. In 67 (27%) of these patients, IOUS identified more hepatic tumors than were seen on preoperative helical CT scan. In eight patients (3%), CT underestimated local extension of the disease into the diaphragm. The incidence of inaccurate preoperative prediction of the extent of disease increased significantly with a greater number of hepatic tumors. CONCLUSIONS: IOUS identified additional hepatic tumors in 27% of patients who underwent hepatic resection after state-of-the-art preoperative CT imaging. This study provides evidence that IOUS remains an essential part of the complete assessment of hepatic malignancies in patients who receive surgical treatment.

CT evaluation of the response of gastrointestinal stromal tumors after imatinib mesylate treatment: a quantitative analysis correlated with FDG PET findings.

OBJECTIVE: We correlated changes in tumor density on CT with changes in glucose metabolism, or the maximum standardized uptake value (SUV(max)), on FDG PET and sought to develop CT imaging criteria that can be used to objectively evaluate tumor response in patients with metastatic gastrointestinal stromal tumors (GISTs) who undergo treatment with imatinib mesylate. MATERIALS AND METHODS: Using the criteria established by the Response Evaluation Criteria in Solid Tumors (RECIST) group, we selected 173 tumors (in 36 patients) for study. Tumor size and density were determined objectively, and overall tumor response (OTR) was evaluated subjectively on CT images. The changes in these parameters before and after treatment were correlated with changes in SUV(max). RESULTS: Significant decreases were seen in both tumor density (mean, 12.3 H [16.5%]; p < 0.0001) and SUV(max) (mean, 3.43 [64.9%]; p < 0.0001). OTR evaluated subjectively, correlated well with changes in SUV(max) (p < 0.0001). No statistically significant association was found between changes in tumor density and changes in SUV(max) (p = 0.3088), but 70% (14/20) of the patients with tumors that showed response on FDG PET exhibited at least a partial response by a change in tumor density. Tumor size was found to have decreased significantly 2 months after treatment (p = 0.0070). However, in 75% of the patients, the disease was stable according to the traditional tumor response criteria of RECIST. CONCLUSION: FDG PET is sensitive and specific for evaluating tumor response but cannot be used in patients whose baseline FDG PET results are negative for tumors. Although subjective evaluation was a better indicator of treatment response than was tumor density alone, the tumor density measurement is a good indicator and provides a reliable quantitative means of monitoring the tumor. RECIST, using only tumor size, was unreliable for monitoring GISTs during the early stage of imatinib mesylate treatment.

Quality of life intervention for prostate cancer patients: design and baseline characteristics of the active for life after cancer trial.

Prostate cancer patients receiving androgen ablation therapy experience significant physical and psychological sequelae associated with their disease and treatment. Because physical activity improves physical and psychological well-being, a lifestyle physical activity intervention may help slow or reverse the associated decline in quality of life (QOL). No studies have evaluated an intervention to improve multiple QOL domains in patients receiving androgen ablation therapy. Active for Life After Cancer is a three-group randomized controlled trial designed to evaluate the effectiveness of a lifestyle physical activity intervention (Lifestyle Program) in improving QOL. The Lifestyle Program, a 6-month behavioral skills training group, is compared to an Educational Support Program and Standard Care. The purpose of this paper is to describe the design of the randomized trial and present baseline data that will characterize the QOL of the sample. Challenges to recruitment for the trial also will be presented and discussed.

Body surface area and body weight predict total liver volume in Western adults.

Computed tomography (CT) is used increasingly to measure liver volume in patients undergoing evaluation for transplantation or resection. This study is designed to determine a formula predicting total liver volume (TLV) based on body surface area (BSA) or body weight in Western adults. TLV was measured in 292 patients from four Western centers. Liver volumes were calculated from helical computed tomographic scans obtained for conditions unrelated to the hepatobiliary system. BSA was calculated based on height and weight. Each center used a different established method of three-dimensional volume reconstruction. Using regression analysis, measurements were compared, and formulas correlating BSA or body weight to TLV were established. A linear regression formula to estimate TLV based on BSA was obtained: TLV = -794.41 + 1,267.28 x BSA (square meters; r(2) = 0.46; P <.0001). A formula based on patient weight also was derived: TLV = 191.80 + 18.51 x weight (kilograms; r(2) = 0.49; P <.0001). The newly derived TLV formula based on BSA was compared with previously reported formulas. The application of a formula obtained from healthy Japanese individuals underestimated TLV. Two formulas derived from autopsy data for Western populations were similar to the newly derived BSA formula, with a slight overestimation of TLV. In conclusion, hepatic three-dimensional volume reconstruction based on helical CT predicts TLV based on BSA or body weight. The new formulas derived from this correlation should contribute to the estimation of TLV before liver transplantation or major hepatic resection.