Poor Glycemic Control Is Associated with Failure to Complete Neoadjuvant Therapy and Surgery in Patients with Localized Pancreatic Cancer.

BACKGROUND: The impact of glycemic control in patients with pancreatic cancer treated with neoadjuvant therapy is unclear. METHODS: Glycated hemoglobin (HbA1c) values were measured in patients with localized pancreatic cancer prior to any therapy (pretreatment) and after neoadjuvant therapy prior to surgery (preoperative). HbA1c levels greater than 6.5% were classified as abnormal. Patients were categorized based on the change in HbA1c levels from pretreatment to preoperative: GrpA, always normal; Gr B, worsened; GrpC, improved; and GrpD, always abnormal. RESULTS: Pretreatment HbA1c levels were evaluable in 123 patients; there were 67 (55%) patients in GrpA, 8 (6%) in GrpB, 22 (18%) in GrpC, and 26 (21%) in GrpD. Of the 123 patients, 92 (75%) completed all intended therapy to include surgery; 57 (85%) patients in GrpA, 4 (50%) patients in GrpB, 16 (72%) patients in GrpC, and 15 (58%) patients in GrpD (p = 0.01). Elevated preoperative carbohydrate antigen 19-9 (CA19-9) (OR 0.22;[0.07-0.66]), borderline resectable (BLR) disease stage (OR 0.20;[0.01-0.45]) and abnormal preoperative HbA1c (OR 0.30;[0.11-0.90]) were negatively associated with completion of all intended therapy. Abnormal preoperative HbA1c was associated with a 2.74-fold increased odds of metastatic progression during neoadjuvant therapy (p = 0.08). CONCLUSIONS: Elevated preoperative HbA1c is associated with failure to complete neoadjuvant therapy and surgery and a trend for increased risk of metastatic progression.

Misdiagnosis of pericardial cyst by echocardiography and computed tomography scanning.

We saw a patient who had clinical features of right-sided heart failure. Echocardiography and computed tomography findings were incorrectly interpreted as demonstrating an intracardiac mass. At surgery, a pericardial cyst externally compressing the right ventricular cavity was found. We conclude that, although noninvasive tests may play a valuable role in evaluating intracardiac masses, interpretation may be difficult and misdiagnoses are possible.

Gallium citrate Ga 67 scanning: clinical usefulness in lymphoma patients.

Gallium citrate Ga 67 (67Ga) scans were performed in 50 consecutive lymphoma patients who underwent routine staging. The overall accuracy of 67Ga scans was greater than 80% for all nodal sites except the spleen (68%). Sensitivity was greater than 88% in the neck and mediastinum, 67% in the abdomen-pelvis, and 33% for the spleen. Specificity was greater than 85% for all nodal sites except for the mediastinum (67%). The accuracy of pedal lymphangiograms was 75%, sensitivity 87%, and specificity 68%. Gallium 67 scans complemented the lymphogram in the abdomen-pelvis but, due to limited sensitivity and high number of equivocal studies (16%), did not replace it. Infraclavicular, pectoral, and mediastinal lesions were detected by 67Ga scans when missed by other means. In 20% to 25% of patients, 67Ga scans provided information not afforded by other diagnostic studies and are therefore considered an important staging procedure for lymphoma patients.

Computed tomography in the staging of small cell lung cancer: implications for combined modality therapy.

Computed tomography of the thorax and abdomen, from the thoracic inlet to the renal hila, was performed as part of initial staging in 51 patients with small cell carcinoma of the lung (SCCL). The computed tomographic (CT) scans were repeated after completion of chemotherapy, as part of routine restaging and assessment of response to therapy. To identify the ways in which CT scanning uniquely benefited evaluation of initial disease extent in comparison to other diagnostic studies exclusive of CT scan, all diagnostic and clinical data were reviewed. CT scan identified more advanced intrathoracic disease than chest radiography in 82% of patients. Mediastinal node involvement not appreciated by chest radiography was seen in 61% of patients. Adrenal and retroperitoneal node involvement, not suspected by other studies, was identified by CT scan in 31% and 12% of patients, respectively. Thirty percent of the patients staged as limited disease (LD) were advanced to extensive disease (ED) by CT scan findings. While confirmation, by biopsy, of positive CT findings was not consistently accomplished, restaging CT scans provided indirect confirmation by displaying improvement or worsening that correlated with disease regression or progression. Thoraco-abdominal CT scanning more accurately identifies the extent of small cell carcinoma than other imaging procedures. This has important implications for reporting results by extent of disease. In addition, CT more accurately identifies the magnitude of intrathoracic primary and nodal tumors, which may influence the choice and conduct of local treatment--surgery and/or radiation therapy--in combination with systemic chemotherapy.

Current imaging strategies for colorectal cancer.

Endoscopy and barium enema examinations are used to identify the primary site of disease in patients with clinical suspicion of colorectal cancer. Once colorectal cancer has been confirmed by imaging studies and biopsy, preoperative evaluation is directed toward accurate disease staging. Most currently available imaging techniques are inaccurate for detecting transmural extension, perienteric spread of tumors and distant lymph node involvement. Although both computed tomography (CT) and magnetic resonance imaging (MRI) have an unacceptably low sensitivity for accurate staging, CT is clearly superior to MRI for detecting extrahepatic metastases. Transrectal ultrasonography, however, is a promising new method for detecting perirectal spread of disease. The diagnostic efficacy of MRI and intravenous dynamic hepatic CT for detecting liver metastases is approximately equal. CT during arterial portography is recommended before resection of solitary liver metastases. Chest radiography is also part of the routine preoperative evaluation. Bone scans are rarely performed in patients without the skeletal pain suggestive of bone metastases. During the years following surgery for colorectal cancer, many patients undergo special imaging studies to identify local tumor recurrence, secondary tumor growth elsewhere within the large bowel and both regional and distant spread of disease. Thus, for the patient with a sharply increasing carcinoembryonic antigen level, CT of the abdomen and liver is the current recommendation. Immunoscintigraphy is a new imaging modality that addresses some of the limitations of current diagnostic procedures for colorectal cancer. This procedure gives whole body information on disease extent, especially in the extrahepatic abdomen and pelvis, and can therefore contribute to patient management decisions.

The effect of varying high pass filter parameters on the detectability of isolated pulmonary nodules in digitized chest images.

The effect of image processing of digital radiographic data on lesion detectability in clinical images has not been systematically studied. In this experiment, we evaluated a low frequency suppression filter program applied to CT digital radiographic localization images (General Electric Scoutview). Three different filter parameters affecting edge enhancement and local image contrast were applied to a set of digital chest images. A standard observer detection experiment comparing the variously filtered digital images and standard chest radiographs in the detection of lung nodules (11 peripheral lung fields, one superimposed on aortic arch) was performed. Standard chest radiography was more sensitive than the digital chest images, although some improvement was noted with increase in local image contrast and edge enhancement. Both image formats were equally specific. Image processing would be better evaluated using a digital imaging system with better performance parameters.

Abdominal computed radiography: evaluation of low-constrast lesions.

Computed radiography has proved useful as a localization device for computed tomography. In an attempt to evaluate computed radiography as a primary diagnostic device, 16 patients were evaluated with various degrees of gallbladder opacification following standard oral cholecystograms, and 15 patients were evaluated with renal masses, identified on standard excretory urography. Subjective evaluation of computed radiographs as compared to the standard radiographs demonstrated no diagnostic advantage to computed radiography. The poor spatial resolution of the computed radiographs was not overcome by the improvement in contrast resolution.

Patient evaluation. Laboratory and imaging studies.

The evaluation of urolithiases, in terms of calculus detection and evaluation of the morphology and function of the kidneys, continues to be refined with advances in imaging technology. The most significant recent advance is use of helical or spiral CT scan for the accurate delineation of renal and ureteral calculi in the acute setting. This may provide an accurate, rapid, and cost-effective method of patient evaluation. The alternative approach is to use plain abdominal radiography to detect renal or ureteral calculi. Noncontrast-enhanced helical or spiral CT scanning has its greatest impact in patients with negative abdominal radiographs or in those patients with suspected urinary colic in whom renal but not ureteral calculi are seen. A supplemental intravenous urogram can be used, as appropriate, to evaluate renal function and degree of obstruction on both the involved and uninvolved side. Combined abdominal radiography and sonography may be used for calculus detection and demonstration of obstruction. Sonography is an operator-dependent technique requiring expertise, experience, and adequate imaging equipment for satisfactory results. Physiologic study of renal blood flow and urinary dynamics using Doppler techniques are possible, though considered to be in the realm of clinical investigation at this time. Sonography has a valuable role in the serial evaluation of chronic stone formers with a history of recurrent urinary infections related to obstruction or reflux. Radiography, fluoroscopy, and sonography are the imaging, methods used in ESWL treatment in preprocedure and postprocedure.

Computed tomography. Focal and diffuse liver disease.

Contrast enhanced CT is very accurate in the detection of focal hepatic disease. Lesion characterization is a more complex issue, in some instances requiring a combination of CT and other diagnostic tests or biopsy for accurate diagnosis. Although CT remains the modality of choice in the evaluation of suspected focal hepatic disease, this role may change if progress in MR imaging leads to further improvements in lesion detection and characterization.

Intra-arterial digital subtraction angiography.

DSA is an imaging technique that should be integrated into a state-of-the-art angiographic system for proper application and utilization. This results in improvements in both efficiency and diagnostic accuracy. However, from the physician's viewpoint, the proper use of a DSA imaging facility mandates not only an understanding of angiographic principles as applied with conventional film-screen systems but also an in-depth understanding of the factors that affect DSA performance. In particular, factors affecting spatial resolution and contrast sensitivity are crucial. This knowledge has to be applied interactively and "on-line" to achieve optimal IA-DSA image quality.

Ultrasound evaluation of pelvic infections.

Sonography is used infrequently for diagnosing acute pelvic inflammatory disease because the physical examination is highly sensitive, because the sonogram lacks specificity, and because the patient is often scheduled for surgery or laparoscopy or treated medically based on clinical findings, obviating the need for diagnostic studies. Sonography is usually reserved for identifying, localizing, and following pelvic abscesses complicating pelvic inflammatory disease. The sonogram is valuable in identifying the location of intrauterine devices because of the increased incidence of inflammatory pelvic disease in these patients. Postoperative and posttraumatic abscesses and abscesses of gastrointestinal origin may require the concomitant use of computed tomography and radionuclide studies, with ultrasonography performing a complementary function. The ultrasound examination may be valuable both in improving diagnostic confidence and providing guidance for aspiration. Because of the limited spectrum of appearances of numerous pelvic diseases, the most accurate diagnoses are obtained when the sonogram is interpreted in light of the detailed clinical information.

Ablation of liver metastasis: is preoperative imaging sufficiently accurate?

The recent introduction of cryotherapy and radiofrequency ablation of liver metastasis has expanded the indications for treatment. As technology has advanced, a percutaneous approach has been developed. Percutaneous treatment, however, requires accurate preoperative imaging. From 1993 to 1999, 179 patients underwent operative exploration for treatment of suspected hepatic metastases from colorectal carcinoma. One hundred seventy-seven patients were staged by preoperative CT, two patients were staged by MRI, and complete data were available in 176. Hepatic tumor count by preoperative imaging was compared to intraoperative tumor count obtained by inspection, palpation, ultrasonographic examination using a 3.5/7.5 MHz T probe, and careful gross sectioning of the resected specimen. Post hoc analysis was performed on 35 CT scans by two radiologists who specialize in abdominal CT. These radiologists were blinded to the intraoperative findings. Their interpretations were compared to the intraoperative counts and to each other. Thirty-four (19%) of 179 patients were deemed untreatable at operation because of unsuspected overwhelming liver involvement in 11 (6%) or extrahepatic metastases in 23 (13%). For the group, CT was accurate in 80 patients (45%), showed more lesions than were found in 16 (9%), and showed fewer metastases than were found in 80 (45%). When the preoperative scan predicted a solitary metastasis, it was correct in 45 (65%) of 69 patients and underestimated disease in 24 (35%). In the post hoc analysis, the mean numbers of lesions reported by the two radiologists did not differ from the mean number of tumors found; however, the radiologists' counts agreed on 16 (59%) and disagreed on 11 (41%) of the scans. The accuracy of CT decreased with increasing numbers of lesions. Regardless of the type of preoperative imaging, intraoperative findings altered the course of the operation in 96 (55%) of 176 patients. Preoperative imaging is not sufficiently accurate to permit adequate percutaneous treatment of hepatic metastases from colorectal carcinoma.

Mesenteric ischemia.

Mesenteric ischemia is an important clinical condition becoming more prevalent with aging of the population. Mesenteric ischemia may be manifest in an acute presentation, usually secondary to thromboembolism or cardiac insufficiency. Patients have abdominal pain, lactic acidosis, benign abdominal examination, and, often, coexistent multisystem organ dysfunction. Chronic mesenteric ischemia is secondary to proximal arterial stenosis or occlusions inadequately compensated by collateral flow. Clinical presentation may simulate occult malignancy. In this review article, the role of Doppler sonography and other diagnostic imaging tests in suspected acute mesenteric ischemia and mesenteric arterial insufficiency are evaluated with emphasis on diagnostic criteria and appropriate use in each clinical context.

Patency rates of portal vein/superior mesenteric vein reconstruction after pancreatectomy for pancreatic cancer.

BACKGROUND: Pancreatectomy with venous reconstruction (VR) for pancreatic cancer (PC) is occurring more commonly. Few studies have examined the long-term patency of the superior mesenteric-portal vein confluence following reconstruction. METHODS: From 2007 to 2013, patients who underwent pancreatic resection with VR for PC were classified by type of reconstruction. Patency of VR was assessed using surveillance computed tomographic imaging obtained from date of surgery to last follow-up. RESULTS: VR was performed in 43 patients and included the following: tangential resection with primary repair (7, 16%) or saphenous vein patch (9, 21%); segmental resection with splenic vein division and either primary anastomosis (10, 23%) or internal jugular vein interposition (8, 19%); or segmental resection with splenic vein preservation and either primary anastomosis (3, 7%) or interposition grafting (6, 14%). All patients were instructed to take aspirin after surgery; low molecular weight heparin was not routinely used. An occluded VR was found in four (9%) of the 43 patients at a median follow-up of 13 months; median time to detection of thrombosis in the four patients was 72 days (range 16-238). CONCLUSIONS: Pancreatectomy with VR can be performed with high patency rates. The optimal postoperative pharmacologic therapy to prevent thrombosis requires further investigation.

Image quality in dynamic CT: a clinical discussion.

Modern state-of-the-art computed tomographic (CT) scanners emphasize three capabilities: image quality, dynamic scan capability, and a high-resolution thin-section technique. Image quality is fundamental and dependent on optimum performance and the interrelationship of all system components. Variables that affect the performance of the scanner include x-ray tube output and rate of heat dissipation; quantum detection efficiency; electronic noise in the acquisition system; speed, accuracy, and integration of mechanical motion in the gantry and table; and the algorithm used for image reconstruction. System design must allow for dynamic scan operation, either in the single-scan or cluster mode, with short interscan or intergroup delays or, as more recently developed, with helical acquisition. Dynamic scanning is frequently used for nonneurologic applications, including diagnosis of vascular and perivascular diseases and multifocal organ disease, particularly hepatic disease. Efficient operation depends on rapid reconstruction and display capability. Modern systems have been engineered to provide flexible modes of operation, particularly in dynamic scanning, and rapid on-line review and analysis, all of which serve to improve the quality of images produced with dynamic CT scanning.

Vascular ultrasound: a radiologist perspective.

Color Doppler flow imaging (CDFI) is an evolutionary technical development that has considerably improved the diagnostic efficacy and clinical role of vascular ultrasound. The appropriate use of CDFI rests on an understanding of the instrumentation, factors affecting image quality and artifact, as well as the pathophysiology of the central and peripheral circulation. The modality has reached a relative plateau of performance. In this review, applications of CDFI for studies of the neck, abdomen, and extremities are evaluated.

Dynamic hepatic CT.

A technique for incremental dynamic computed tomography (CT) of the liver with boluses of contrast material (with a 50-g iodine load) administered intravenously is described. For most focal liver lesions, which are hypovascular in relation to normal hepatic parenchyma, bolus contrast material enhancement and incremental dynamic scanning improve detectability, compared with that yielded by nondynamic, contrast material infusion techniques. The bolus contrast-enhanced dynamic scan technique is reproducible and of value in patients undergoing sequential CT for assessment of tumor bulk response to chemotherapy. Patients who are potential candidates for resection of focal hepatic lesions should preoperatively undergo intraarterial contrast-enhanced CT. Intravenous bolus enhanced dynamic hepatic CT can be extended to cover more than one anatomic region (eg, abdomen and thorax), as in patients undergoing CT for staging lung carcinoma. In these patients, incremental scan sequences are programmed caudad to cephalad. Incremental dynamic CT is also an appropriate technique to use in cooperative patients who have suffered blunt abdominal trauma.