Department of Medical Imaging, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.
Department of Surgery, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.
Abdom Radiol (NY). 2022 Oct;47(10):3436-3445. doi: 10.1007/s00261-022-03589-z. Epub 2022 Jul 21.
Adequate TNM-staging is important to determine prognosis and treatment planning of duodenal adenocarcinoma. Although current guidelines advise contrast-enhanced CT (CECT) for staging of duodenal adenocarcinoma, literature about diagnostic tests is sparse.
In this retrospective single-center cohort study, we analyzed the real life performance of routine CECT for TNM-staging and the assessment of resectability of duodenal adenocarcinoma. Intraoperative findings and pathological staging served as reference standard for resectability, T-, and N-staging. Biopsies, FDG-PET-CT, and follow-up were used as the reference standard for M-staging.
Fifty-two consecutive patients with duodenal adenocarcinoma were included, 26 patients underwent resection. Half of the tumors were isodense to normal duodenum on CECT. The tumor was initially missed in 7/52 patients (13%) on CECT. The correct T-stage was assigned with CECT in 14/26 patients (54%), N-stage in 11/26 (42%), and the M-stage in 42/52 (81%). T-stage was underestimated in (27%). The sensitivity for detecting lymph node metastases was only 24%, specificity was 78%. Seventeen percent of patients had indeterminate liver or lung lesions on CECT. Surgery with curative intent was started in 32 patients, but six patients (19%) could not be resected due to unexpected local invasion or metastases.
Radiologists and clinicians have to be aware that routine CECT is insufficient for staging and determining resectability in patients with duodenal adenocarcinoma. CECT underestimates T-stage and N-stage, and M-stage is often unclear, resulting in futile surgery in 19% of patients. Alternative strategies are required to improve staging of duodenal adenocarcinoma. We propose to combine multiphase hypotonic duodenography CT with MRI.
充分的 TNM 分期对于确定十二指肠腺癌的预后和治疗计划至关重要。尽管目前的指南建议使用对比增强 CT（CECT）进行十二指肠腺癌分期，但关于诊断测试的文献却很少。
在这项回顾性单中心队列研究中，我们分析了常规 CECT 对十二指肠腺癌分期和可切除性评估的实际表现。术中发现和病理分期作为可切除性、T 分期和 N 分期的参考标准。活检、FDG-PET-CT 和随访被用作 M 分期的参考标准。
52 例连续的十二指肠腺癌患者被纳入研究，其中 26 例患者接受了手术。半数肿瘤在 CECT 上与正常十二指肠等密度。CECT 最初漏诊了 7/52 例患者（13%）的肿瘤。26 例患者中，14 例（54%）通过 CECT 正确分期 T 期，11 例（42%）正确分期 N 期，42/52 例（81%）正确分期 M 期。T 期被低估了（27%）。检测淋巴结转移的敏感性仅为 24%，特异性为 78%。CECT 发现 17%的患者有肝或肺转移的不确定病变。32 例患者开始进行有治愈意图的手术，但由于意外的局部侵犯或转移，有 6 例患者（19%）无法切除。
放射科医生和临床医生必须意识到，常规 CECT 不足以对十二指肠腺癌患者进行分期和确定可切除性。CECT 低估了 T 期和 N 期，M 期通常不明确，导致 19%的患者进行了无效的手术。需要采取替代策略来提高十二指肠腺癌的分期水平。我们建议将多相低张十二指肠造影 CT 与 MRI 相结合。
