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Pancreatic duct adenocarcinoma (PDAC) typically presents as a low-enhancement mass on contrast-enhanced ambulatory CT with upstream main pancreatic duct (MPD) dilation, thereby facilitating the identification of the cause of
MPD dilation.
However, PDAC with equal density is often encountered in clinical practice, which cannot be accurately distinguished from the adjacent pancreatic parenchyma, and thus manifests only as isolated MPD dilation
.
Isodense PDACs have been reported to account for 5.
4% to 11%
of total cases.
At the same time, the sudden truncation and dilation of MPD is not specific for the diagnosis of PDAC, and can also occur in
lesions without identifiable cause or chronic pancreatitis.
Therefore, clinicians who encounter sudden amputation and dilation of MPD without visible pancreatic lesions can determine whether to perform pancreatic MRI, MRCP, and endoscopic ultrasound (EUS) for further evaluation
.
Recently, a study published in the journal European Radiology developed a CT-based nomogram to reliably predict occult pancreatic malignancy in cases of sudden amputation and dilation of MPD without obvious pancreatic lesions on CT, so as to quantify the probability of occult pancreatic malignancy and facilitate further diagnostic work
.
This retrospective study included 92 patients (mean age, 63.
4 ± 10.
6 years, 63 men and 29 women) with sudden amputation and dilation of MPD and no visible pancreatic lesions on enhanced CT between 2009 and 2021.
Two radiologists independently evaluated CT imaging features
.
Multivariate logistic regression analysis was performed to identify clinical and CT imaging features
of hidden pancreatic malignancies.
Based on these results, a nomogram is developed and its performance
evaluated.
Thirty-eight (41.
3%) and 54 (58.
7%) were placed in the malignant and benign groups
, respectively.
In multivariate analysis, elevated CA19-9 (probability [OR] 7.
5, p = 0.
003), catheter truncation at the head/neck (OR 7.
6, p = 0.
006), abnormal parenchymal contour at catheter truncation (OR 13.
7, p < 0.
001), and presence of acute pancreatitis (OR 11.
5, p = 0.
005) were independent predictors of
pancreatic malignancy.
Any combination of two important features shows 77.
2% accuracy, and any combination of three features shows 100% specificity
.
The CT-based nomogram shows the area under the curve (AUC) of 0.
84 (95% confidence interval, 0.
77-0.
90).
Figure A 78-year-old woman pathologically proven to be benign stenosis and intraductal papillary myxoma with low-grade dysplasia in the tail of the pancreas
.
a Axial portal vein phase CT images performed for breast cancer metastasis work show truncated main pancreatic duct (MPD), body dilation (arrowhead), and no identifiable lesions
.
The maximum diameter of the pancreatic duct is 3.
9 mm
.
No contour abnormalities or pancreatitis
are seen.
A 14 mm lobulated cystic lesion (arrowhead)
was also observed in the tail of the pancreas.
CA 19-9 is within normal range
.
B There are no obvious variables
in patients.
The total score in the nomogram model is 0, and the corresponding estimated probability is 0.
07 (7%)
.
The patient underwent a distal pancreatectomy
.
Pathologic evidence of benign stenosis at the incision and branch IPMN at the tail
This study suggests that in patients with abrupt amputation and dilation of MPD but no pancreatic lesions visible on CT, the combination of three CT features (parenchymal contour abnormalities, head/neck location at the site of duct amputation, and presence of pancreatitis) and elevated CA19-9 can help assess the likelihood of occult pancreatic malignancy and can be used as a decision support tool to assist in clinical identification of further treatment options
.
Original source:
Chae Young Lim,Ji Hye Min,Jeong Ah Hwang,et al.
Assessment of main pancreatic duct cutoff with dilatation, but without visible pancreatic focal lesion on MDCT: a novel diagnostic approach for malignant stricture using a CT-based nomogram.
DOI:10.
1007/s00330-022-08928-8