•Systematic review showed that evidence supporting radiologic surveillance after resection of PDAC is limited.•Post-operative CT has a moderate diagnostic accuracy in the detection of recurrent ...PDAC.•FDG PET-CT imaging could be of additional value when PDAC recurrence is suspected despite negative or equivocal CT findings.•Further optimization of surveillance strategies for the post-operative detection of recurrent PDAC is necessary.
Radiologic surveillance after resection of pancreatic ductal adenocarcinoma (PDAC) can provide information on the extent and location of disease recurrence. This systematic review and meta-analysis aims to give an overview of the literature on the diagnostic performance of different imaging modalities for the detection of recurrent disease after surgery for PDAC.
A systematic search was performed in PubMed, EMBASE and Cochrane Library up to 20 December 2017. All studies reporting on the diagnostic value of imaging modalities for the detection of local and/or distant disease recurrence during follow-up after resection of PDAC were eligible. Both histologic confirmation of recurrent PDAC and clinical confirmation by disease progression on follow-up imaging were considered as suitable reference standard. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool was used for critical appraisal of methodological quality. Diagnostic accuracy data were extracted or calculated and presented in forest plots. A bivariate random-effects model was used to calculate pooled estimates of sensitivity and specificity.
A total of seven retrospective studies with 333 relevant patients were ultimately eligible for data extraction. Overall, the methodological quality of the included studies was acceptable. All seven articles described test results of contrast-enhanced CT, whilst five and three articles reported outcomes on diagnostic accuracy of FDG PET-CT and FDG PET-CT combined with contrast-enhanced CT, respectively. For CT, pooled estimates for sensitivity were 0.70 (95% CI 0.61–0.78) and for specificity 0.80 (95% CI 0.69–0.88). For FDG PET-CT, pooled estimates for sensitivity and specificity were 0.88 (95% CI 0.81–0.93) and 0.89 (95% CI 0.80–0.94), respectively. For FDG PET-CT in combination with contrast-enhanced CT, pooled estimates for sensitivity were 0.95 (95% CI 0.88–0.98) and for specificity 0.81 (95% CI 0.63–0.92).
According to the current literature, post-operative CT has a moderate diagnostic accuracy in the detection of recurrent disease. FDG PET-CT imaging could be of additional value when disease recurrence is suspected despite negative or equivocal CT findings. Nevertheless, evidence supporting radiologic surveillance after resection of PDAC is limited. Future prospective studies are needed to optimize surveillance strategies after resection of pancreatic cancer.
Objective:
This study compared median OS after resection of LAPC after upfront FOLFIRINOX versus a propensity-score matched cohort of LAPC patients treated with FOLFIRINOX-only (ie, without ...resection).
Background:
Because the introduction of FOLFIRINOX chemotherapy, increased resection rates in LAPC patients have been reported, with improved OS. Some studies have also reported promising OS with FOLFIRINOX-only treatment in LAPC. Multicenter studies assessing the survival benefit associated with resection of LAPC versus patients treated with FOLFIRINOX-only are lacking.
Methods:
Patients with non-progressive LAPC after 4 cycles of FOLFIRINOX treatment, both with and without resection, were included from a prospective multicenter cohort in 16 centers (April 2015–December 2019). Cox regression analysis identified predictors for OS. One-to-one propensity score matching (PSM) was used to obtain a matched cohort of patients with and without resection. These patients were compared for OS.
Results:
Overall, 293 patients with LAPC were included, of whom 89 underwent a resection. Resection was associated with improved OS (24 vs 15 months,
P
< 0.01), as compared to patients without resection. Before PSM, resection, Charlson Comorbidity Index, and Response Evaluation Criteria in Solid Tumors (RECIST) response were predictors for OS. After PSM, resection remained associated with improved OS Hazard Ratio (HR) 0.344, 95% confidence interval (0.222–0.534),
P
< 0.01, with an OS of 24 versus 15 months, as compared to patients without resection. Resection of LAPC was associated with improved 3-year OS (31% vs 11%,
P
< 0.01).
Conclusions:
Resection of LAPC after FOLFIRINOX was associated with increased OS and 3-year survival, as compared to propensity-score matched patients treated with FOLFIRINOX-only.
Background and Aims Electromagnetic-guided placement (EMP) of a nasoduodenal feeding tube by trained nurses is an attractive alternative to EGD-guided placement (EGDP). We aimed to compare EMP and ...EGDP in outpatients, ward patients, and critically ill patients with normal upper GI anatomy. Methods In 3 centers with no prior experience in EMP, patients were randomized to placement of a single-lumen nasoduodenal feeding tube either with EGDP or EMP. The primary endpoint was post-pyloric position of the tube on abdominal radiography. Patients were followed for 10 days to assess patency and adverse events. The analyses were performed according to the intention-to-treat principle. Results In total, 160 patients were randomized to EGDP (N = 76) or EMP (N = 84). Three patients withdrew informed consent, and no abdominal radiography was performed in 2 patients. Thus, 155 patients (59 intensive care unit, 38%) were included in the analyses. Rates of post-pyloric tube position between EGDP and EMP were comparable (79% vs 82%, odds ratio 1.16; 90% confidence interval, 0.58-2.38; P = .72). Adverse events were observed in 4 patients after EMP (hypoxia, GI blood loss, atrial fibrillation, abdominal pain) and in 4 after EGDP (epistaxis N = 2, GI blood loss, hypoxia). Costs of tube placements were lower for EMP compared with EGDP: $519 versus $623, respectively ( P = .04). Conclusions Success rates and safety of EMP and EGDP in patients with normal upper GI anatomy were comparable. Lower costs and potential logistic advantages may drive centers to adopt EMP as their new standard of care. (Clinical trial registration number: NTR4286.)
Pancreatic cystic lesions are being detected with increasing frequency because of increased use and improved quality of cross-sectional imaging techniques. Pancreatic cystic lesions encompass ...non-neoplastic lesions (such as pancreatitis-related collections) and neoplastic tumors. Common cystic pancreatic neoplasms include serous cystadenomas, mucinous cystic neoplasms, intraductal papillary mucinous neoplasms, and solid pseudopapillary tumors. These cystic pancreatic neoplasms may have typical morphology, but at times show overlapping imaging features on cross-sectional examinations. This article reviews the classical and atypical imaging features of commonly encountered cystic pancreatic neoplasms and presents the limitations of current cross-sectional imaging techniques in accurately classifying pancreatic cystic lesions.
•Multiparametric MRI could be promising to distinguish between MIBC and NMIBC.•This prospective study compares mpMRI with wholemount pathology cystectomy specimen.•We found high sensitivity, but ...lower specificity than reported in previous literature.
Initial tumour staging in bladder cancer mainly relies on the histo-pathological outcome of the transurethral bladder tumour resection (TURBT) and imaging by means of a CT-scan (CT-intravenous urography; CT-IVU). The reported risk of understaging varies from 24-50%. To further improve the the evaluation of depth of invasion of the bladder tumour the application of magnetic resonance imaging (MRI) may be useful. To substantiate the additional value of this imaging modality the present observational study was designed.
This is a prospective observational study to analyse bladder tumour staging with multiparametric magnetic resonance imaging (mpMRI) in patients with a known bladder tumour, who are planned for radical cystectomy.
Patients with an invasive bladder cancer who are planned for radical cystectomy.
Patients were accrued during their visit to the outpatient department of urology. They underwent routine cystoscopy, laboratory tests (including serum Creatinin) and CT-IVU investigations and subsequently a mpMRI.
To demonstrate the value of mpMRI in the initial staging of bladder tumours using radiological bladder tumour stage (T-stage) based on mpMRI and pathological bladder tumour stage based on ‘whole-mount’ histo-pathology after radical cystectomy.
Thirty-seven participants with known bladder tumours underwent mpMRI and subsequent cystectomy. After mpMRI 10 participants were diagnosed with non-muscle-invasive bladder cancer (NMIBC) and 27 participants with muscle-invasive bladder cancer (MIBC). In the ‘whole-mount’ pathology results 12 participants had NMIBC and 25 participants had MIBC. We found a sensitivity and specificity of 0.88 en 0.58 respectively, for the evaluation of MIBC. The positive and negative predictive value were 81% and 70% respectively. The diagnostic accuracy of mpMRI to differentiate between NMIBC and MIBC was 78%.
We found a sensitivity of 88% and a specificity of 58% for mpMRI to discriminate NMIBC from MIBC.
Purpose
In patients with neuroendocrine tumor liver metastases, additional tumor reduction can be achieved by sequential treatment with
166
Ho-radioembolization after peptide receptor radionuclide ...therapy (PRRT). The aim of this study was to analyze hematotoxicity profiles, (i.e. lymphocyte and neutrophile toxicity) and the prognostic value of neutrophil-to-lymphocyte ratio (NLR) and thrombocyte-to-lymphocyte ratio (TLR).
Methods
All patients included in the prospective HEPAR PLuS study were included in this study. Blood testing was performed at baseline (before radioembolization) and at regular intervals during 1-year follow-up. Radiological response was assessed at 3, 6, 9, and 12 months according to RECIST 1.1. Logistic regression was used to analyze the prognostic value of NLR and TLR on response.
Results
Thirty-one patients were included in the toxicity analysis; thirty were included in the response analysis. Three weeks after radioembolization, a significant decrease in lymphocyte count (mean change − 0.26 × 10
9
/L) was observed. Ten patients (32.2%) experienced grade 3–4 lymphocyte toxicity. This normalized at 6 weeks and 3 months after treatment, while after 6 months a significant increase in lymphocyte count was observed. An increase in NLR and TLR at 3 weeks, compared to baseline, significantly predicted response at 3 months (AUC = 0.841 and AUC = 0.839, respectively) and at 6 months (AUC = 0.779 and AUC = 0.765). No significant relation with survival was found.
Conclusions
Toxicity after sequential treatment with PRRT and
166
Ho-radioembolization is limited and temporary, while significant additional benefit can be expected. Change in NLR and TLR at 3-weeks follow-up may be valuable early predictors of response.
Trial registration
ClinicalTrials.gov, NCT02067988. Registered 20 February 2014,
https://clinicaltrials.gov/ct2/show/record/NCT02067988
.
In multiple endocrine neoplasia type 1 (MEN1), pancreatic neuroendocrine tumors (PanNETs) have a high prevalence and represent the main cause of death. This study aimed to assess the diagnostic ...accuracy of the currently used conventional pancreatic imaging techniques and the added value of fine needle aspirations (FNAs).
Patients who had at least one imaging study were included from the population-based MEN1 database of the DutchMEN Study Group from 1990 to 2017. Magnetic resonance imaging (MRI), computed tomography (CT), endoscopic ultrasonography (EUS), FNA, and surgical resection specimens were obtained. The first MRI, CT, or EUS was considered as the index test. For a comparison of the diagnostic accuracy of MRI versus CT, patients with their index test taken between 2010 and 2017 were included. The reference standard consisted of surgical histopathology or radiological follow-up.
A total of 413 patients (92.8% of the database) underwent 3,477 imaging studies. The number of imaging studies per patient increased, and a preference for MRI was observed in the last decade. Overall diagnostic accuracy was good with a positive (PPV) and negative predictive value (NPV) of 88.9% (95% confidence interval, 76.0-95.6) and 92.8% (89.4-95.1), respectively, for PanNET in the pancreatic head and 92.0% (85.3-96.0) and 85.3% (80.5-89.1), respectively, in the body/tail. For MRI, PPV and NPV for pancreatic head tumors were 100% (76.1-100) and 87.1% (76.3-93.6) and for CT, 60.0% (22.9-88.4) and 70.4% (51.3-84.3), respectively. For body/tail tumors, PPV and NPV were 91.3% (72.0-98.8) and 87.0% (75.3-93.9), respectively, for MRI and 100% (74.9-100) and 77.8% (54.3-91.5), respectively, for CT. Pathology confirmed a PanNET in 106 out of 110 (96.4%) resection specimens. FNA was performed on 34 lesions in 33 patients and was considered PanNET in 24 all confirmed PanNET by histology (10) or follow-up (14), normal/cyst/unrepresentative in 6 (all confirmed PanNET by follow-up), and adenocarcinoma in 4 (2 confirmed and 2 PanNET). Three patients, all older than 60 years, had a final diagnosis of pancreatic adenocarcinoma.
As the accuracy for diagnosing MEN1-related PanNET of MRI was higher than that of CT, MRI should be the preferred (non-invasive) imaging modality for PanNET screening/surveillance. The high diagnostic accuracy of pancreatic imaging and the sporadic occurrence of pancreatic adenocarcinoma question the need for routine (EUS-guided) FNA.
Background
Normative data on pulmonary nodules in children without malignancy are limited. Knowledge of the frequency and characteristics of pulmonary nodules in healthy children can influence care ...decisions in children with malignant disease.
Objective
To provide normative data concerning the frequency and characteristics of pulmonary nodules on computed tomography (CT) in young children.
Materials and methods
All children ages 1 year–12 years who underwent chest CT after high-energy trauma were retrospectively investigated. Exclusion criteria were a history of malignancy, thick image slices, motion artefacts and extensive post-traumatic pulmonary changes. Two radiologists were asked to independently identify all nodules and to characterize each nodule with respect to location, size, perifissural location and calcification. Discrepancies were adjudicated by a third reader, who set the reference standard in this study. Interobserver agreement in detection and characterization was assessed using the kappa coefficient (κ).
Results
Identified were 120 patients, of whom 72 (75% male; median age: 8.0 years interquartile range: 4–11) were included. A total of 59 pulmonary nodules were present in 27 patients (38%; 95% confidence interval: 26–49%; range: 1–5 nodules per patient, with a mean diameter of 3.2 mm standard deviation: 0.9 mm). For nodule detection, the per-patient interobserver agreement was substantial (
κ
=0.78) and per-lobe agreement was moderate (
κ
=0.40). For characterization, there was fair to substantial agreement (
κ
=0.36–0.74).
Conclusion
Small pulmonary nodules on chest CT are a common finding in otherwise healthy children, but detection and characterization have only moderate interobserver agreement.
This study's aim was twofold. Firstly, to assess liver enhancement quantitatively and qualitatively in steatotic livers compared to non-steatotic livers on portal venous computed tomography (CT). ...Secondly, to determine the injection volume of contrast medium in patients with severe hepatic steatosis to improve the image quality of the portal venous phase. We retrospectively included patients with non-steatotic (
= 70), the control group, and steatotic livers (
= 35) who underwent multiphase computed tomography between March 2016 and September 2020. Liver enhancement was determined by the difference in attenuation in Hounsfield units (HU) between the pre-contrast and the portal venous phase, using region of interests during in three different segments. Liver steatosis was determined by a mean attenuation of ≤40 HU on unenhanced CT. Adequate enhancement was objectively defined as ≥50 ΔHU and subjectively using a three-point Likert scale. Enhancement of non-steatotic and steatotic livers were compared and associations between enhancement and patient- and scan characteristics were analysed. Enhancement was significantly higher among the control group (mean 51.9 ± standard deviation 11.5 HU) compared to the steatosis group (40.6 ± 8.4 HU
for difference < 0.001). Qualitative analysis indicated less adequate enhancement in the steatosis group: 65.7% of the control group was rated as good vs. 8.6% of the steatosis group. We observed a significant correlation between enhancement, and presence/absence of steatosis and grams of iodine per total body weight (TBW) (
< 0.001; adjusted R
= 0.303). Deduced from this correlation, theoretical contrast dosing in grams of Iodine (g I) can be calculated: g I = 0.502 × TBW for non-steatotic livers and g I = 0.658 × TBW for steatotic livers. Objective and subjective enhancement during CT portal phase were significantly lower in steatotic livers compared to non-steatotic livers, which may have consequences for detectability and contrast dosing.
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