Diagnostic accuracy of contrast-enhanced diffusion-weighted MRI for liver metastases of pancreatic cancer: towards adequate staging and follow-up of pancreatic cancer – DIA-PANC study: study protocol for an international, multicenter, diagnostic trial

Abstract

Background: At the time of surgery, approximately 10-20% of the patients with pancreatic cancer are considered unresectable because of unexpected liver metastasis, peritoneal carcinomatosis or locally advanced disease. This leads to futile surgical treatment with all the associated morbidity, mortality and costs. More than 50% of all liver metastases develop in the first six months postoperatively. These (subcentimeter) liver metastases are most likely already present at the time of diagnosis and have not been identified pre-operatively, due to the poor sensitivity of routine preoperative contrast-enhanced CT (CECT). Methods: The DIA-PANC study is a prospective, international, multicenter, diagnostic cohort study investigating diffusionweighted, contrast-enhanced MRI for the detection of liver metastases in patients with all stages of pancreatic cancer. Indeterminate or malignant liver lesions on MRI will be further investigated histopathologically. For patients with suspected liver lesions without histopathological proof, follow up imaging with paired CT and MRI at 3-, 6-and 12-months will serve as an alternative reference standard. Discussion: The DIA-PANC trial is expected to report high-level evidence of the diagnostic accuracy of MRI for the detection of liver metastases, resulting in significant value for clinical decision making, guideline development and improved stratification for treatment strategies and future trials. Furthermore, DIA-PANC will contribute to our knowledge of liver metastases regarding incidence, imaging characteristics, their number and extent, and their change in time with or without treatment. It will enhance the worldwide implementation of MRI and consequently improve personalized treatment of patients with suspected pancreatic ductal adenocarcinoma. Trial registration: ClinicalTrials.gov Identifier: NCT03469726. Registered on March 19th 2018-Retrospectively registered.

Magnetic Fields and Cancer: Epidemiology, Cellular Biology, and Theranostics

“…MRI and CT show similar performance in the presurgical evaluation of pancreatic cancer [386,387]. Preoperative MRI is instrumental to detect the stage and resectability of pancreatic cancer [388] and preoperative gadoxetic acid-enhanced liver MRI has a high diagnostic performance in detecting liver metastasis from pancreatic ductal adenocarcinoma [389,390]. Gadolinium-enhanced MRI with DWI detected synchronous liver metastases [391], whereas [F-18]-FDG PET/MRI provides an imaging tool to improve the staging of pancreatic cancer and for the identification of Sister Mary Joseph nodules [392].…”

Chemokine Receptor 2 Targeted PET/CT Imaging Distant Metastases in Pancreatic Ductal Adenocarcinoma

“…Due to a lack of effective screening tools and early warning symptoms, approximately 52% of all PDAC patients have distant metastasis at diagnosis, and 30% of all patients have locally advanced disease with tumor invasion of surrounding vessels or organs, neither of which allows curative surgical resection. Furthermore, of the 10–15% of patients who are eligible for surgery and adjuvant chemotherapy, more than 50% relapse within 2 years, accompanied by distant metastases, rendering the surgical intervention futile. − These facts underscore the importance of developing a tool for the early, sensitive, and specific detection of PDAC metastasis.…”

Diffusion-weighted imaging for the detection of liver metastases in the preoperative evaluation of pancreatic cancer — are we really at the end of the road?

“…The potential for curative treatment in pancreatic cancer depends on two factors: the feasibility of operating on the localized tumor and the absence of distant metastases. During surgery, around 10–20% of patients are deemed unresectable due to unforeseen liver metastasis, peritoneal carcinomatosis, or locally advanced disease [ 1 ]. Over 50% of liver metastases occur within the initial 6 months following the surgery [ 2 ].…”

“…Over 50% of liver metastases occur within the initial 6 months following the surgery [ 2 ]. It is presumed that these liver metastases existed at the time of diagnosis but remained undetected before surgery either because they were too small or due to limitations in the imaging technique [ 1 ].…”

“…On the other hand, MRI surpasses CT in accurately evaluating liver metastases. While the sensitivity of CT ranges from 38 to 76%, the sensitivity of MRI in connection diffusion-weighted imaging (DWI) sensitivity levels between 86 and 97% [ 1 – 4 ]. When discussing liver metastases that go unnoticed or are inaccurately assessed before pancreatic cancer surgery, we typically refer to lesions in the subcentimeter range [ 1 ].…”