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Gadolinium-Enhanced MRI Does Not Alter Decisions for Pancreatic Cystic Lesions

February 1, 2009
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The objective of a recent study was to determine if gadolinium administration is necessary for MRI follow-up of patients with cystic pancreatic lesions.

The study has shown that gadolinium contrast is not always required in the follow-up of cystic lesions of the pancreas.

Design
Retrospective analysis.

Participants
Fifty-six patients (17 men, 39 women) with a cystic pancreatic lesion detected on MRI.

Methodology
The initial MRI examination was obtained to investigate a suspected pancreaticobiliary abnormality. Examinations were performed with a 1.5-T MRI system. Imaging sequences included breath-hold spoiled gradient-echo T1-weighted, breath-hold T2-weighted, and breath-hold half-Fourier acquisition single-shot turbo spin-echo T2-weighted images.

Three-dimensional fat-suppressed gradient-recalled echo images were obtained prior to and during dynamic administration of IV gadolinium contrast. Arterial, portal venous, and delayed contrast-enhanced phases were obtained. Images were reviewed by two abdominal radiologists.

Unenhanced T1- and T2-weighted sequences of initial and follow-up MRI examinations were evaluated. Pancreatic cystic lesions were assessed for changes in size, changes in cyst content, and presence or absence of communication with the main pancreatic duct.

Following this assessment, one of three recommendations was made for each lesion:
(1) a probably benign lesion that required either no follow-up or follow-up in six to 12 months;
(2) an indeterminate lesion that required cyst aspiration; and
(3) a probably malignant lesion that required cyst resection. Approximately two to four weeks following the initial interpretation, cases were reevaluated, but now also included gadolinium-enhanced sequences.

The objective of a recent study was to determine if gadolinium administration is necessary for MRI follow-up of patients with cystic pancreatic lesions. The study has shown that gadolinium contrast is not always required in the follow-up of cystic lesions of the pancreas. Design Retrospective analysis. Participants Fifty-six patients (17 men, 39 women) with a cystic pancreatic lesion detected on MRI. Methodology The initial MRI examination was obtained to investigate a suspected pancreaticobiliary abnormality. Examinations were performed with a 1.5-T MRI system. Imaging sequences included breath-hold spoiled gradient-echo T1-weighted, breath-hold T2-weighted, and breath-hold half-Fourier acquisition single-shot turbo spin-echo T2-weighted images. Three-dimensional fat-suppressed gradient-recalled echo images were obtained prior to and during dynamic administration of IV gadolinium contrast. Arterial, portal venous, and delayed contrast-enhanced phases were obtained. Images were reviewed by two abdominal radiologists. Unenhanced T1- and T2-weighted sequences of initial and follow-up MRI examinations were evaluated. Pancreatic cystic lesions were assessed for changes in size, changes in cyst content, and presence or absence of communication with the main pancreatic duct. Following this assessment, one of three recommendations was made for each lesion: (1) a probably benign lesion that required either no follow-up or follow-up in six to 12 months; (2) an indeterminate lesion that required cyst aspiration; and (3) a probably malignant lesion that required cyst resection. Approximately two to four weeks following the initial interpretation, cases were reevaluated, but now also included gadolinium-enhanced sequences. [text_ad] Results There was an 87.5% concordance between readers for interpretations of MRI follow-up with, as well as without, using gadolinium. Recommendations of both readers were concordant in 95.5% of cases without and with use of gadolinium. Of 104 initial interpretations of a benign lesion, only two were changed to an indeterminate lesion classification following gadolinium administration. Two of six initial indeterminate lesions were changed to a benign category, and one of six initial indeterminate lesions was changed to a probably malignant lesion. There were no initial interpretations of a probably malignant lesion that were subsequently changed following gadolinium. Conclusions The appearance of cystic pancreatic lesions on gadolinium-enhanced MRI did not alter the management decision originally issued on the initial unenhanced study. Reviewer's Comments The results of this study are useful in that they provide certain criteria that one can use when evaluating cystic pancreatic lesions. These criteria are of comparable diagnostic utility when evaluating either unenhanced or enhanced MRI. Therefore, in the era of increased awareness of nephrogenic systemic fibrosis, these criteria can be especially practical in patients unable to receive gadolinium contrast. One of the limitations reported in this study was that the majority of lesions in the study measured 1 to 3 cm, were simple-appearing, and were consequently categorized as benign. Author: John C. Sabatino, MD, MSD Reference: Macari M, Lee T, et al. Is Gadolinium Necessary for MRI Follow-Up Evaluation of Cystic Lesions in the Pancreas? Preliminary Results. AJR Am J Roentgenol; 2009;192 (January): 159-164: [text_ad]

Results
There was an 87.5% concordance between readers for interpretations of MRI follow-up with, as well as without, using gadolinium. Recommendations of both readers were concordant in 95.5% of cases without and with use of gadolinium.

Of 104 initial interpretations of a benign lesion, only two were changed to an indeterminate lesion classification following gadolinium administration. Two of six initial indeterminate lesions were changed to a benign category, and one of six initial indeterminate lesions was changed to a probably malignant lesion. There were no initial interpretations of a probably malignant lesion that were subsequently changed following gadolinium.

Conclusions
The appearance of cystic pancreatic lesions on gadolinium-enhanced MRI did not alter the management decision originally issued on the initial unenhanced study.

Reviewer’s Comments
The results of this study are useful in that they provide certain criteria that one can use when evaluating cystic pancreatic lesions. These criteria are of comparable diagnostic utility when evaluating either unenhanced or enhanced MRI.

Therefore, in the era of increased awareness of nephrogenic systemic fibrosis, these criteria can be especially practical in patients unable to receive gadolinium contrast.

One of the limitations reported in this study was that the majority of lesions in the study measured 1 to 3 cm, were simple-appearing, and were consequently categorized as benign.

Author: John C. Sabatino, MD, MSD

Reference:
Macari M, Lee T, et al. Is Gadolinium Necessary for MRI Follow-Up Evaluation of Cystic Lesions in the Pancreas? Preliminary Results.
AJR Am J Roentgenol; 2009;192 (January): 159-164:

The objective of a recent study was to determine if gadolinium administration is necessary for MRI follow-up of patients with cystic pancreatic lesions. The study has shown that gadolinium contrast is not always required in the follow-up of cystic lesions of the pancreas. Design Retrospective analysis. Participants Fifty-six patients (17 men, 39 women) with a cystic pancreatic lesion detected on MRI. Methodology The initial MRI examination was obtained to investigate a suspected pancreaticobiliary abnormality. Examinations were performed with a 1.5-T MRI system. Imaging sequences included breath-hold spoiled gradient-echo T1-weighted, breath-hold T2-weighted, and breath-hold half-Fourier acquisition single-shot turbo spin-echo T2-weighted images. Three-dimensional fat-suppressed gradient-recalled echo images were obtained prior to and during dynamic administration of IV gadolinium contrast. Arterial, portal venous, and delayed contrast-enhanced phases were obtained. Images were reviewed by two abdominal radiologists. Unenhanced T1- and T2-weighted sequences of initial and follow-up MRI examinations were evaluated. Pancreatic cystic lesions were assessed for changes in size, changes in cyst content, and presence or absence of communication with the main pancreatic duct. Following this assessment, one of three recommendations was made for each lesion: (1) a probably benign lesion that required either no follow-up or follow-up in six to 12 months; (2) an indeterminate lesion that required cyst aspiration; and (3) a probably malignant lesion that required cyst resection. Approximately two to four weeks following the initial interpretation, cases were reevaluated, but now also included gadolinium-enhanced sequences. [text_ad] Results There was an 87.5% concordance between readers for interpretations of MRI follow-up with, as well as without, using gadolinium. Recommendations of both readers were concordant in 95.5% of cases without and with use of gadolinium. Of 104 initial interpretations of a benign lesion, only two were changed to an indeterminate lesion classification following gadolinium administration. Two of six initial indeterminate lesions were changed to a benign category, and one of six initial indeterminate lesions was changed to a probably malignant lesion. There were no initial interpretations of a probably malignant lesion that were subsequently changed following gadolinium. Conclusions The appearance of cystic pancreatic lesions on gadolinium-enhanced MRI did not alter the management decision originally issued on the initial unenhanced study. Reviewer's Comments The results of this study are useful in that they provide certain criteria that one can use when evaluating cystic pancreatic lesions. These criteria are of comparable diagnostic utility when evaluating either unenhanced or enhanced MRI. Therefore, in the era of increased awareness of nephrogenic systemic fibrosis, these criteria can be especially practical in patients unable to receive gadolinium contrast. One of the limitations reported in this study was that the majority of lesions in the study measured 1 to 3 cm, were simple-appearing, and were consequently categorized as benign. Author: John C. Sabatino, MD, MSD Reference: Macari M, Lee T, et al. Is Gadolinium Necessary for MRI Follow-Up Evaluation of Cystic Lesions in the Pancreas? Preliminary Results. AJR Am J Roentgenol; 2009;192 (January): 159-164: [text_ad]
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