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Role of Abdominal Ultrasonography in Clinical Staging of Pancreatic Carcinoma: a Tertiary Center Experience

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Role of Abdominal Ultrasonography in Clinical Staging of Pancreatic Carcinoma: a Tertiary Center Experience ORIGINAL ARTICLE Role of abdominal ultrasonography in clinical staging of pancreatic carcinoma: a tertiary center experience Piotr Kulig, Radosław Pach, Jan Kulig 1st Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland KEY WORDS ABSTRACT abdominal ultrasound, INTRODUCTION Various imaging modalities are used for the diagnosis and staging of pancreatic cancer. diagnostic accuracy, Abdominal ultrasonography is the most widely available method and usually the first‑line diagnostic tool pancreatic cancer, used in patients with suspicion of pancreatic carcinoma. sensitivity, specificity OBJECTIVES The aim of the study was to assess the clinical value of abdominal ultrasonography used in a tertiary center for staging of pancreatic carcinoma. PatientS AND METHODS This prospective clinical trial included 454 consecutive patients with pancreatic cancer, who underwent a surgery between 2000 and 2012. The diagnostic accuracy of ultrasonography was established for each T category and lymph node involvement. Computed tomography and intraop‑ erative staging of the pancreatic cancer were used as reference methods. RESUltS The diagnostic accuracy of ultrasonography in cancer staging according to T categories was 94.1% for T1, 95.7% for T2, 85.4% for T3, and 81.7% for T4 tumors. The diagnostic accuracy of abdominal ultrasonography in the diagnosis of lymph node metastasis and assessment of tumor resectability was 66.1% and 74.8%, respectively. CONCLUSIONS The results of our study summarize 12 years of our experience with abdominal ultra‑ sonography in patients with pancreatic cancer and confirm that ultrasonography remains a valuable diagnostic modality in this patient group. IntroDUction Pancreatic carcinoma remains Currently, thin ‑section, contrast ‑enhanced one of the leading causes of cancer ‑related deaths multi ‑detector CT is regarded as the investiga‑ in the world. In the years from 2000 to 2009, tion of choice in patients with pancreatic cancer. the incidence rate in the United States increased The sensitivity of CT in detecting pancreatic can‑ by 0.9% per year and the death rate increased by cer is between 75% and 100% with specificity of 0.5% per year.1 The overall 5 ‑year survival rate 70% to 100%.3,4 MRI has been proved to be ef‑ reported worldwide does not exceed 5%. Even fective in the diagnosis and staging of pancreat‑ Correspondence to: dr n. med. Radoslaw Pach, I Katedra for patients with a tumor that has been surgi‑ ic cancers; therefore, it should be used in centers Chirurgii Ogólnej, Uniwersytet cally removed, the 5‑year survival is only about where these facilities are readily available. Posi‑ Jagielloński, Collegium Medicum, 20% to 25%. In 2009 in Poland, pancreatic can‑ tron emission tomography–CT is a useful com‑ ul. Kopernika 40, 31-501 Kraków, Poland, phone: +48 -12-424 -80 -07, cer was the second cause of death due to malig‑ plementary investigation to exclude metastases fax: +48 -12-424 -80 -07, nant gastrointestinal neoplasms in women and outside the abdomen. Staging laparoscopy and e -mail: [email protected] the third one in men.2 laparoscopic ultrasonography are important in Received: February 20, 2014. Revision accepted: April 1, 2014. Over the years, various radiological imaging the restaging of locally advanced lesions after neo‑ 3 Published online: April 2, 2014. modalities have been used for the diagnosis and adjuvant therapy. However, in view of wide avail‑ Conflict of interest: none declared. staging of pancreatic cancer, including abdomi‑ ability, noninvasiveness, low cost, and relatively Pol Arch Med Wewn. 2014; nal ultrasonography, computed tomography (CT), high diagnostic accuracy, abdominal ultrasonog‑ 124 (5): 225-232 Copyright by Medycyna Praktyczna, magnetic resonance imaging (MRI), laparoscopy, raphy is routinely used as the first ‑line diagnostic Kraków 2014 and endoscopic ultrasonography. modality in pancreatic cancer, and its sensitivity ORIGINAL ARTICLE Role of abdominal ultrasonography in clinical staging... 225 reaches 90%.5,6 The limitations associated with Logiq 7 (Logiq 7, General Electric, Fairfield, Con‑ abdominal ultrasound examination, such as in‑ necticut, United States), Hitachi EUB 6000, or Hi‑ sufficient experience of the operator, low quali‑ tachi EUB 550 (Hitachi, Chiyoda, Tokyo, Japan) ty of the ultrasound equipment, or incorrect pa‑ apparatus. All examinations were performed in tient preparation, result in divergent opinions on the morning, and all patients were fasting on its efficacy in pancreatic cancer staging. A signif‑ the day of the examination. Each examination icant advantage of this modality is its ability to was performed according to the established study detect liver metastases, which makes further im‑ protocol, including staging of pancreatic cancer. aging unnecessary. Morrin et al.7 demonstrated The T and N categories were established and ana‑ that grey ‑scale ultrasound combined with Dop‑ lyzed according to the TNM Classification of Ma‑ pler imaging has similar results to helical CT and lignant Tumors.8 The infiltration of the major ‑ab CT angiography in detecting venous involvement. dominal vessels (the aorta, celiac artery, superi‑ The aim of our study was to assess the diagnos‑ or mesenteric artery, common hepatic artery, he‑ tic accuracy of abdominal ultrasonography in stag‑ patic portal vein, superior mesenteric vein) was ing of pancreatic carcinoma in all patients who assessed with color Doppler and power Doppler underwent surgery between 2000 and 2012 in ultrasonography. The ultrasound criteria of vas‑ a tertiary care center. All examinations were per‑ cular invasion applied in this study were as fol‑ formed by surgeons experienced in abdominal lows: loss of normal hyperechogenic tissue be‑ ultrasonography and the results were compared tween the tumor and the vessel, obstruction, or with intraoperative findings. We attempted to encasement by tumor tissue over more than half establish the role of abdominal ultrasonography of the circumference of any vessel. The intraoper‑ performed by experienced diagnosticians in pa‑ ative finding of major artery infiltration, and, in tients with pancreatic cancer. most cases, also of major abdominal vein infiltra‑ tion, precluded resection. Local lymph nodes were PatientS anD MetHODS Patient selection The assessed as metastatic if they were hypoechogenic study involved 454 consecutive patients with pan‑ and the size of their short axis exceeded 10 mm. creatic cancer admitted to a tertiary referral hos‑ All examinations were conducted by surgeons pital, who underwent surgery between the years who verified their findings intraoperatively and 2000 and 2012. The inclusion criteria were as fol‑ performed more than 1000 abdominal ultraso‑ lows: pancreatic cancer confirmed preoperative‑ nographies per year. ly by fine ‑needle aspiration biopsy or core ‑needle The final staging of pancreatic carcinoma was biopsy performed intraoperatively or by histo‑ based on a histopathological examination of sur‑ logical examination of the specimen; preopera‑ gical specimen in resectable cases and on the re‑ tive abdominal ultrasonography and CT; signed sults of intraoperative surgical assessment. informed consent for diagnostic procedures and The assessment of retrieved lymph nodes was surgery. The exclusion criteria were as follows: dis‑ performed in patients in whom resections had tant metastases confirmed by imaging studies be‑ been performed and in some patients with unre‑ fore surgery; lack of informed consent; contrain‑ sectable tumors in whom lymph nodes had been dications for general anesthesia. collected intraoperatively for a histopathological All relevant data were collected prospective‑ study. CT was used to determine the nodal sta‑ ly using a standard electronic database (Magic2, tus when the tumor was not resected and lymph Magic Software Enterprises). The authors ana‑ nodes were not retrieved. lyzed the following variables: clinical and patho‑ In all patients, abdominal CT and chest X‑ray logical features, staging of pancreatic cancer based were required to exclude distant metastases for on preoperative abdominal ultrasonography, type clinical staging before surgery. of surgical procedures, pathomorphological stag‑ ing and staging of pancreatic carcinoma based on Surgery None of the patients received neoad‑ intraoperative findings and CT. juvant therapy prior to surgery. A Whipple or The study was performed in accordance with Traverso–Longmire procedure was used for tu‑ the ethical standards of the Declaration of Hel‑ mors located in the head of the pancreas, a dis‑ sinki and Good Clinical Practice. The approval tal pancreatectomy for those located in the body of an ethics committee was not required to con‑ or tail, and a total pancreatectomy for multifo‑ duct the present study, according to the legal sys‑ cal tumors. Regional lymph nodes were routine‑ tem in Poland. ly resected en bloc with the tumor. We did not perform vascular resection with reconstruction. Diagnostic procedures Abdominal ultrasound ex‑ In patients who had a nonresectable tumor, ex‑ aminations were performed in an outpatient clinic ploratory laparotomy or gastroenteroanastomo‑ after patients with suspicion of pancreatic cancer sis (or biliodigestive anastomosis in those with a had been consulted by a surgeon. After the ultra‑ tumor within the head of the pancreas) was per‑ sound examination, patients were scheduled for formed (TABLE 2). A bilio digestive anastomosis was CT, following which a decision on surgical
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