*Łukasz Durko1, Magdalena Barańska1, Aleksandra Kaczka2, Ewa Małecka-Panas1
The evaluation of sensitivity and specificity of selected imaging techniques in diagnosing pancreatic lesions
Ocena czułości i swoistości wybranych badań obrazowych w diagnostyce chorób trzustki
1Department of Digestive Tract Diseases, Medical University of Łódź
Head of Department: Professor Ewa Małecka-Panas, MD, PhD
2Department of Clinical Nutrition and Gastroenterological Diagnostics, Medical University of Łódź
Head of Department: Cezary Chojnacki, MD, PhD
Streszczenie
Wstęp. Endosonografia (EUS) stanowi najbardziej precyzyjną metodę w obrazowaniu trzustki (pozwala uwidocznić małe zmiany ogniskowe, zwapnienia, torbiele, poszerzenie przewodu trzustkowego oraz przewodu żółciowego). Przezbrzuszna ultrasonografia (US) oraz tomografia komputerowa (CT) pozostają nadal badaniami pierwszego rzutu w związku z ich większą dostępnością.
Cel pracy. Ocena czułości i swoistości US i CT w rozpoznawaniu nieprawidłowości w miąższu trzustki w porównaniu do EUS.
Materiał i metody. Wykonano analizę statystyczną wyników badań US, CT i EUS 60 pacjentów diagnozowanych z powodu podejrzenia zmiany ogniskowej trzustki oraz 29 pacjentów z podejrzeniem przewlekłego zapalenia trzustki.
Wyniki. W porównaniu do wyników EUS czułość i swoistość rozpoznawania guza trzustki wynosiła dla CT odpowiednio 96,4 i 92,3%, dla US – 85,7 i 80%. Czułość i swoistość TK dla oceny poszerzenia przewodu Wirsunga wynosiła 72,2 i 84,4%, zaś dla US – 38,9 i 79,2%. Czułość i swoistość TK dla oceny poszerzenia PŻW wynosiła w niniejszej analizie 100%, zaś dla US odpowiednio 95,0 i 97,6%.
W przewlekłym zapaleniu trzustki, w porównaniu do wyników EUS, czułość i swoistość TK dla rozpoznawania zwapnień w miąższu trzustki wynosiła odpowiednio 45,4 i 29,4%, dla US – 26,1 i 27,0%. Czułość i swoistość TK dla oceny zrazikowej struktury trzustki wynosiła 69,2 i 20,0%, dla US – 33,3 i 10,0%. Czułość i swoistość TK dla oceny nieprawidłowości w przebiegu przewodu Wirsunga i obecności złogów w jego świetle wynosiła 75,0 i 58,3%, dla US – 42,8 i 40,0%. Czułość i swoistość TK dla uwidocznienia torbieli trzustki wynosiła 88,9 i 93,7%, dla US – 77,8 i 90,9%.
Wnioski. Czułość US dla oceny miąższu trzustki jest ograniczona. Badanie CT odznacza się względnie wysoką czułością w rozpoznawaniu nieprawidłowości w miąższu trzustki, choć jest mniej dokładne niż EUS. Czułość US i CT może być niewystarczająca do rozpoznania przewlekłego zapalenia trzustki.
Summary
Introduction. Endosonography (EUS) remains the most accurate method in detecting pancreatic abnormalities (presence of tumor, calcifications, cysts, dilation of pancreatic duct, dilation of common bile duct). Transabdominal ultrasound (US) and computed tomography (CT) are however first line imaging techniques, and still remain more accessible.
Aim. The aim of the study was the evaluation of sensitivity and specificity of US and CT for detecting selected pancreatic abnormalities in comparison to EUS.
Material and methods. We performed statistical analysis of the results of US, CT and EUS of 60 patients who were suspected of pancreatic mass and of 29 patients with chronic pancreatitis.
Results. In comparison to EUS, the sensitivity and specificity of diagnosing pancreatic tumor in CT was respectively 96.4 and 92.3%, for US 85.7 and 80%. For visualising PD dilatation CT 72.2 and 84.4%, US 38.9 and 79.2%. For evaluating CBD dilatation CT 100 and 100%, for US 95.0 and 97.6%.
In chronic pancreatitis in comparison to EUS the sensitivity and specificity of CT for detecting calcifications in pancreatic parenchyma in CT was 45.4 and 29.4%, US 26.1 and 27.0% and for detecting lobular structure of pancreas: CT – 69.2 and 20.0%, US – 33.3 and 10.0%. Sensitivity and specificity for detecting PD abnormalities were: for CT – 75.0 and 58.3%, for US – 42.8 and 40.0% and for visualising pancreatic cysts: CT – 88.9 and 93.7%, US – 77.8 and 90.9%.
Conclusions. The sensitivity of US is limited. CT presents relatively high sensitivity in detecting pancreatic abnormalities, however is less accurate than EUS. The sensitivity of US and CT in diagnosing CP might be insufficient in comparison to EUS.
Introduction
Endosonography (EUS) is a highly accurate technique for imaging pancreas. In 99% procedures the whole pancreatic parenchyma can be visualised. The sensitivity of this method for detecting focal lesions in the pancreas reaches 94-98% with specificity of 86%. EUS is also efficient in detecting small pancreatic lesions (< 2 cm) – its sensitivity is higher than contrast computed tomography (CT) – 93 vs 53%. Additionally, negative result of EUS examination rules out the presence of focal pancreatic lesion with high probability (1, 2).
Among solid focal lesions in the pancreas, the majority are pancreatic adenocarcinoma (PDAC) – 85%, pancreatic neuroendocrine tumors (PNET) are diagnosed in 7-10% cases and inflammatory lesions are found – in 15-18% patients. Other solid lesions are rare (lymphoma, mesenchymal neoplasms, metastases) (3, 4).
In retrospective analysis by Lahat et al. of the group of 475 patients who underwent pancreatic resection due to the detected pancreatic lesions, 86.5% individuals had symptoms and 13.5% were asymptomatic. Among symptomatic patients 69% had malignant lesions, 26% potentially malignant lesions (mainly mucinous cystadenomas) and 2% – benign lesions. In the group of asymptomatic patients malignant lesion were found in 34%, potentially malignant in 60% and benign in 6% (5).
Transabdominal ultrasonography (US) is a first line diagnostic tool in patients presenting with abdominal pain or jaundice. The method is non-invasive and widely available. Pancreatic head tumors, presenting as a hypoechoic mass are often accompanied by dilatation of common bile duct (CBD) and dilatation of pancreatic duct (PD). Lesions in the body and tail of the pancreas might be difficult to detect in US due to lack of CBD dilation and the presence of gas in surrounding intestinal loops, stomach or colon. Additionally, the accuracy of US is highly dependent on the operator’s experience. The sensitivity of US for detecting pancreatic masses among different observers reaches 50-90% (6, 7). Performing US without contrast media often does not allow for differentiation between PDAC, PNET and inflammatory lesions. Nevertheless, US is an acceptable first imaging method but does not allow for exclusion of small pancreatic tumors (< 2 cm) which might have better prognosis than advanced lesions (8). As the accuracy of US constantly improves due to technical development and regarding the fact that there is few recent data regarding US sensitivity and specificity in detecting pancreatic masses, we believe that diagnostic value of this method should be reexamined.
The sensitivity of contrast enhanced computer tomography (CT) for detecting pancreatic tumors has improved over the last years and reaches 75-100% with specificity of 70-100% (9). As sensitivity of CT for diagnosing large pancreatic tumors reaches 98%, small lesions (< 2 cm) are diagnosed by CT only with 68-77% sensitivity (10, 11).
EUS as a highly sensitive method for evaluating pancreatic parenchyma is a recommended tool for diagnosing chronic pancreatitis (CP). Close proximity of the transducer to the pancreas allows the whole parenchyma visualisation, and is more accurate for detecting small lesions than US and CT (12). In 2007 Rosemont Criteria which describe endosonographic features of CP were introduced. CP diagnosis is certain, suggestive or undetermined depending on the combination of detected features (13).
Aim
The aim of the study was to evaluate the sensitivity and specificity of US and CT for evaluating selected pancreatic abnormalities (presence of tumor, calcifications, cysts, dilation of pancreatic duct, secondary dilation of common bile duct) in comparison to EUS.
Material and methods
We analysed 60 individuals in whom the presence of pancreatic mass was suspected (subtle to gross abnormalities in pancreatic parenchyma, dilatation of CBD in ultrasound or CT examination, elevated Ca 19-9 levels, cholestasis, weight loss, family history of pancreatic tumors). Patients underwent EUS examination in the Department of Digestive Tract Diseases, Medical University of Łódź in the years 2015-2016. For the purpose of the study we selected patients who had the results of US and contrast CT within the previous 3 months (the examinations were performed in random centers). Regarding short observation period we used the result of EUS examination as the reference. We performed a retrospective analysis of the sensitivity and specificity of CT and US in detecting the presence of pancreatic mass (the size of masses were 1-5 cm), dilatation of PD and dilatation of CBD.
We also analysed a group of 29 patients in whom we diagnosed chronic pancreatitis (CP) with the use of EUS. Similarly, all these patients had previous contrast CT and USG examinations performed in random centers within previous 3 months. EUS was considered as a reference examination as it allowed for precise identification of CP Rosemont Criteria. We analysed the sensitivity and specificity of CT and USG for detecting Rosemont criteria features in CP.
Results
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Piśmiennictwo
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