A Pancreatic Squamous Cell Carcinoma

Silva, C.F.G, BS; Bertolazzi, P, BS; Mendes, R.E.V, BS; Oliveira, F.F.; Viana, P.C.C, MD; Horvat, N, MD
Radiology Department, Sírio Libanês Hospital, Sao Paulo, Brazil
|07/05/2019

A 67-year-old male patient, suffering from loss of appetite and weight within the last 2 months, came to the hospital for a checkup. His medical history was unremarkable. A Dual Energy (DE) CT was performed to investigate a suspected pancreatic lesion.

DECT images showed an irregular, heterogeneously enhanced lesion in the head of the pancreas, measuring 145.9 HU in density and 4.7 mg/mL in iodine uptake. The image contrast was significantly enhanced using Monoenergetic Plus (Mono+) at 45 keV. The 3D image perspective could be better demonstrated using cinematic VRT (cVRT) for improved depth and shape perceptions. A pancreas tumor was suspected and subsequently confirmed by a PET-CT. A biopsy was performed which revealed a squamous cell carcinoma.
The patient underwent a pancreatectomy, followed by chemotherapy. In a 3-month follow-up, he was in good general condition with improved symptoms.

irregular, heterogeneously enhanced lesion in the head of the pancreas
Courtesy of Sírio Libanês Hospital, Sao Paulo, Brazil

Fig. 1:
Mixed image (Fig. 1a), Mono+ image (Fig. 1b) and iodine map (Fig. 1c) show an irregular, heterogeneously enhanced lesion (arrows) in the head of the pancreas, with an iodine uptake of 4.7 mg/mL (Fig. 1c), which is almost double that in the adjacent normal pancreatic tissues (2.4 mg/mL). The measurement is normalized to the enhancement of the aorta. The enhancement is significantly improved in the Mono+ image display.

Pancreatic squamous cell carcinoma is an extremely rare subtype of pancreatic cancer of ductal origin. It is characterized by enhancement on contrast CT due to its hypervascularity. The dataset acquired by DECT can be processed to improve the contrast enhancement using syngo. CT DE Monoenergetic Plus, to both present the iodine map as well as to quantify the iodine uptake using syngo.CT DE Virtual Unenhanced. Using cVRT allows a more photo-realistic representation of the CT image data, with an enhanced and more natural depth and shape perception.

Overview of measurements and images of lesion
Courtesy of Sírio Libanês Hospital, Sao Paulo, Brazil

Fig. 2:
Quantitative measurements and graphical presentation of the CT attenuation in accordance with energy (keV) levels. Comparing 45 keV with 70 keV, the contrast difference between the lesion and the normal tissue is almost threefold.

cVRT image and PET-CT image of lesion
Courtesy of Sírio Libanês Hospital, Sao Paulo, Brazil

Fig. 3:
cVRT image (Fig. 3a) demonstrates a better 3D perspective with improved depth and shape perceptions. A PET-CT image (Fig. 3b) confirmed the lesion in the head of the pancreas.

Scanner

SOMATOM Definition Flash

Scan area

Upper abdomen

Scan mode

Dual Source Dual Energy

Scan length

302.4 mm

Scan direction

Cranio-caudal

Scan time

13 s

Tube voltage

80 / Sn140 kV

Effective mAs

145 / 67 mAs

CTDIvol

5.96 mGy

DLP

191 mGy cm

Rotation time

0.5 s

Pitch

0.6

Slice collimation

32 x 0.6 mm

Slice width

3 mm

Reconstruction increment

2.4 mm

Reconstruction kernel

D30f

Contrast

350 mg/mL

Volume

120 mL + 50 mL saline

Flow rate

5 mL/s

Start delay

Bolus tracking in the descending aorta with a threshold of 150 HU and an additional delay of 10 s