Secretin-Assisted Computed Tomography Scan and Magnetic Resonance Imaging in Improving Pancreatic Tumor Conspicuity

Accurate preoperative tumor detection and staging are fundamental for treating patients with
pancreatic adenocarcinoma. Patients with unresectable tumors can benefit from being spared
an extensive operation associated with substantial morbidity and mortality, cost, and pain.
On the other hand, patients with localized disease, which is amenable to surgical removal,
have the option of operation. Therefore, accurate staging of pancreatic cancer requires the
detection of the tumor, and evaluation of its size, its relationship to major
peri-pancreatic vascular structures and portal venous system, locoregional lymph nodes, and
distant metastases. Multiple imaging techniques have been used to evaluate the pancreas.
Although, at this point, no consensus exists as to the best staging algorithm, multidetector
(MD) computed tomogrophy (CT) and Magnetic resonance imaging (MRI) provide sufficient
information for the management of most patients.

Patients with a tumor larger than 3 cm are characterized as non-surgical. CT sensitivity in
detecting small pancreatic tumors of less than 2 cm is low. Multiple methods have been
suggested to increase the sensitivity of CT. The sensitivity of CT increases with using
multidetector CT which now has an accuracy rate of about 95-97% for initial detection and
approximating that of 100% for staging.

Secretin (a natural hormone produced by the duodenal mucosal cells) is known to increase
blood flow to the pancreas. The principal use of secretin in imaging today is in exocrine
function of the pancreas or morphological evaluation of the pancreatic duct under ultrasound
or MRI. Theoretically, pancreatic contrast enhancement should also increase after secretin
administration. This would imply that tumor conspicuity might also be increased if contrast
enhancement of the normal pancreas increases. Secretin CT has been advocated by other
centers to improve depiction of the ampulla and periampullary/duodenal diseases and to
improve contrast enhancement. O'Connell et al, used secretin in patients suspected or with
known pancreatic mass and concluded that administration of intravenous secretin leads to
greater enhancement of the pancreas with greater tumor conspicuity, than imaging without
secretin.

MRI of the pancreas has undergone a major change because it can provide noninvasive images
of the pancreatic ducts and the parenchyma. MR cholangiopancreatography (MRCP) enables
detection of anatomic variants such as pancreas divisum. Although contrast material-enhanced
CT is still considered the gold standard in acute pancreatitis and for the detection of
calcifications in chronic pancreatitis, MR imaging and secretin-enhanced MRCP are useful in
evaluating pseudocysts and pancreatic disruption.

The role of MR is still debated in pancreatic neoplasms except the cystic lesions where MR
imaging provides critical information regarding the lesion's content and a possible
communication with the pancreatic ducts. Although some articles have shown that MRI was
equivalent to CT in diagnosis and staging, others have shown the opposite. Nishiharu et al.
found comparable tumor detection but a benefit with CT, notably for peripancreatic and
vascular invasion. Comparing CT, echoendoscopy, and MRI, Soriano et al. demonstrated that CT
showed the highest level of precision in primary tumor staging, local-regional staging,
vascular invasion, distant metastases, Tumor, node, metastasis (TNM) staging, and tumor
resectability. MRI retains its originality in imaging the parenchyma, the pancreatic and
biliary ducts, and vascular structures; however, in many institutions, CT remains the
reference imaging choice for diagnosing and staging pancreatic cancer. Other than CT's
advantages for the tumor, its excellent spatial resolution also provides detailed
reconstructions in all planes and arterial mapping and therefore makes it possible to search
for surgical contraindications such as celiac trunk stenosis. MRI is still used today as a
second-intention tool when there is doubt or when CT and echoendoscopy are not sufficiently
conclusive; it is not currently recommended to use MRI in first-intention diagnosis of
pancreatic cancer.

The aim of this pilot study is to determine whether the administration of intravenous
secretin before contrast-enhanced CT and MRI improves pancreatic enhancement and pancreatic
tumor conspicuity and to evaluate which technique is more appropriate for pancreatic tumor
detection, staging and evaluation of resectability.