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Assessment of Pancreatic Tumor Resectability with Multidetector Computed Tomography

Posted Jul 31, 2008 Updated Apr 7, 2023
By An K. Singh DMRD , Dushyant V. Sahani MD , Michael A. Blake MD , Mukta C. Joshi MS , Jennifer A. Wargo MD , Carlos Fernez-del Castillo MD
10 min read

Rationale and Objectives

The purpose of this retrospective study was to compare the maximum intensity projection (MIP) images generated at a multidetector computed tomography (MDCT) scanner console using advanced tools at a three-dimensional (3D) workstation for assessment of pancreatic tumor resectability.

Materials and Methods

Institutional review board approval and informed consent wavier were obtained for this retrospective study. The intraoperative findings were used as reference standard. Two radiologists assessed console MIPs that were created using computed tomographic (CT) data sets of 30 patients (17 men and 13 women; age range, 35–79 years; mean age, 58 years) operated for pancreatic tumors. Semi-automated MIP images were created on a separate MDCT console. Two blinded radiologist (R1, R2) and surgeons (S1, S2) evaluated the image data independently for vascular involvement and tumor resectability. The image quality and diagnostic confidence for MIPs were graded on a 5-point scale (1 = poor, 2 = suboptimal, 3 = intermediate, 4 = good; 5 = excellent) and comparison was made with 3D workstation image scores.

Results

The findings revealed greater than 90% sensitivity, specificity, and accuracy for detecting involvement of peripancreatic vessels by pancreatic tumor with an excellent interobserver agreement (κ = 0.87–1.00). The findings of console-generated MIPs were same as the findings of 3D workstation images. The mean of image quality and diagnostic confidence grading for console MIPs by assessors were 4.4 and 4.2, respectively. The average time to generate simple MIPs at the console was 3.4 minutes (range, 2.3–4.4) compared to 26 minutes (range, 18–33) to create images at the 3D workstation.

Conclusion

Semi-automated MIPs generated from an MDCT scanner console is an excellent alternative to 3D workstation images for assessing resectability of pancreatic tumor based on vascular involvement. Console MIPs can be quickly generated during the time of scan and thus can improve CT workflow.

Computed tomography (CT) is highly reliable for tumor staging and the determination of resectability and prognosis of pancreatic carcinoma ( ). It is critical to ensure that potentially resectable or unresectable tumors be correctly identified to appropriately present either surgical options in resectable patients or curative alternatives in unresectable cases.

Multidetector computed tomography (MDCT) provides technical advantages such as shorter image acquisition time and isotropic voxel resolution ( ). In addition, post-processed two- and three-dimensional (2D and 3D) images, such as maximum intensity projection (MIP) and volume rendering (VR) from MDCT scans, are superior and facilitate more accurate assessment of tumor resectability ( ). Previous studies have revealed that greater than 50% encasement of the portal vein (PV) or the superior mesenteric vein (SMV) by the pancreatic tumor with or without its compression is suggestive of vessel involvement, and MIP images obtained perpendicular to the axis of the PV provides a better plane to assess vessel involvement ( ).

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Materials and methods

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MDCT Technique

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Image Postprocessing

Console MIPs

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Table 1

Reconstruction Protocol for MIPs Created at the MDCT Scanner Console

View Slice Thickness (mm) Overlap (mm) Field of View (cm) No. of Images Axial (with decreased field of view) 5 2.5 27 23 Coronal 5 2.5 30 26 Oblique coronals (perpendicular to PV) 5 2.5 32 26 Oblique coronals (parallel to pancreatic body) 5 2.5 36 26 Sagittal (for celiac trunk and SMA origin) 5 2.5 36 26

MDCT: multidetector computed tomography; MIP: maximum intensity projection; PV: portal vein; SMA: superior mesenteric artery.

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Image Processing: 3D Workstation

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Image Analysis

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Standard of Reference

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Time for Image Generation

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Statistical Analysis

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Results

Surgery and Histopathology

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Console MIP Evaluation

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Figure 1, A 73-year-old female patient with unresectable pancreatic adenocarcinoma. (a) Console-generated axial maximum intensity projection (MIP) image shows greater than 50% circumferential encasement of the superior mesenteric vein ( thin arrow ) and duodenal infiltration is seen ( curved arrow ). (b) Console-generated coronal MIP image displaying involvement of superior mesenteric vein ( black arrow ) by the pancreatic mass.

Figure 2, (a) Image showing slab placement for axial oblique console maximum intensity projection (MIP) image acquisition perpendicular to the course of the portal vein. (b) On this axial oblique MIP image, involvement and compression of portal vein ( thick arrow ) by pancreatic mass ( thin arrows ) are well appreciated. (c) Axial oblique MIP image showing involvement of the superior mesenteric vein ( curved arrow ) by the pancreatic mass. A metallic stent is present in the common bile duct ( arrowhead ).

Figure 3, Console-generated axial maximum intensity projection (MIP) images from a 64-year-old woman with resectable adenocarcinoma of pancreatic head. (a) Sagittal MIP image from console displaying tumor-portal vein relationship that shows an intact intervening fat plane between tumor and portal vein ( thin arrow ). A metallic stent is seen in the common bile duct ( arrowhead ). (b) Console generated coronal MIP shows close tumor-vessel relationship with intact intervening fat plane ( thin arrow ). (c) Oblique coronal volume MIP snapshot generated on a 3D workstation showing the same finding.

Table 2

Evaluation of Vascular Involvement on Review of Console MIP Images Generated from Preoperative 16-Slice MDCT Data Sets of 30 Patients with Pancreatic Malignancies (involved vessels = 21/161)

Blood Vessel Surgery Radiologist 1 ⁎ Radiologist 2 † No. of R/U on Surgery GDA 3 3 3 R ( n = 2); U ( n = 1) Hepatic artery 5 5 5 U ( n = 5) SMA 2 2 0 U ( n = 2) Celiac Trunk 0 0 0 — SMV 5 6 ‡ 5 U ( n = 4); R ( n = 1) Portal vein 5 6 ‡ 5 U ( n = 4) Splenic artery 0 0 0 — Splenic vein 1 1 1 R ( n = 1) Total 21 23 19 —

GDA: gastroduodenal artery; MDCT: multidetector computed tomography; MIP: maximum intensity projection; R: resectable; SMA: superior mesenteric artery; SMV: superior mesenteric vein; U: unresectable.

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Figure 4, A 55-year-old female patient with resectable pancreatic adenocarcinoma. (a) Coronal maximum intensity projection (MIP) generated from console displaying tumor-vessel relationship. Note a distinct fat plane is seen between the pancreatic mass and the superior mesenteric vein ( thin arrow ). (b) Console-generated axial MIP image shows close tumor-vessel relationship with preserved intervening fat plane ( thin arrow ).

Figure 5, (a) Image showing slab placement for console maximum intensity projection (MIP) image acquisition in oblique coronal plane parallel to pancreatic body axis. (b) Console-generated oblique coronal MIP image in a 79-year-old woman showing involvement and compression of common hepatic artery ( thick arrow ) by pancreatic mass. The superior mesenteric artery is also compressed ( curved arrow ). (c) Snapshot of volume MIP obtained at 3D workstation in sagittal plane showing involvement of common hepatic artery by the pancreatic mass ( arrowhead ).

Figure 6, (a) Sagittal console maximum intensity projection (MIP) showing involvement of the gastroduodenal artery (GDA) by the pancreatic mass in a 50-year-old woman ( thin arrow ). A metallic stent is seen in the common bile duct (CBD) ( arrowhead ). (b) Console-generated coronal MIP showing involvement of the common hepatic artery ( thin arrow ) and GDA ( curved arrow ) in a 69-year-old male patient with a large pancreatic head mass. The portal vein is also involved ( thick arrow ). A metallic stent ( asterisk ) is seen in the CBD.

Table 3

Interobserver Agreement of Both Radiologists for Evaluation of Tumor Resectability and Important Vessel Involvements on Review of Console MIPs ⁎

Criterion κ Value 95% Confidence Interval Resectability 1.00 Not estimable Portal vein 0.87 0.62–1.00 Superior mesenteric vein 0.89 0.68–1.00 Hepatic artery 1.00 Not estimable

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Qualitative Analysis

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Time Spent in Image Generation

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Statistical Analysis

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Table 4

Statistical Evaluation of Vascular Involvement Detection on Console MIPs in 30 Patients with Pancreatic Malignancies ⁎

Variable R1, % 95% CI R2, % 95% CI Sensitivity 100 (21/21) 83.9–100 90.4 (19/21) 69.6–98.8 Specificity 98.5 (138/140) 94.9–99.8 100 (140/140) 97.3–100 Accuracy 98.7 (159/161) — 98.7 (159/161) — PPV 91 (21/23) — 100 (19/19) — NPV 100 (138/138) — 98 (140/142) —

CI: confidence interval; NPV: negative predictive value; PPV: positive predictive value.

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Discussion

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Conclusion

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Academic Radiology, Volume 15, Issue 8
Journals General Radiology
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