I don’t know about you. But, for me, my least favorite CT scan has been the triple-phase CT scan to evaluate pancreatic masses. And, by most accounts in my group, many of our radiologists feel the same. For this reason, I would like to call the evaluation of the pancreas on a triple-phase CT scan a minefield. Many pitfalls in making the findings and interpretations abound. And, no one, including the physicians and patients, is ever satisfied. But, I thought this might be a good time to go through some of the issues you might encounter!
Subtle Lesions On A Triple-Phase
Pancreatic lesions tend to be some of the most subtle ones to detect. They can be hypovascular or hypervascular, infiltrative or circumscribed, versus cystic or solid. Sometimes we can see them on only one phase out of many on a triple-phase protocol. And even worse, you may only catch one of these lesions on a coronal or sagittal plane, not well confirmed by any other. There are about a billion ways that you can potentially miss one of these lesions.
Severe Consequences For Missing A Lesion
The lesions that you miss in the pancreas can be killers, literally. Both complex cystic and solid lesions can rapidly grow and kill the patient. I’ve seen significant changes over a few months or even less. Even worse, you can make the case that the patient would have significantly fewer complications if you had caught it earlier. And, these complications can include more extensive surgery, more potent chemotherapy with its consequences or broader radiation treatment plans for palliative care. And the list goes on and on.
Also, with the potential patient tragedies for missing lesions comes the potential for malpractice lawsuits in the “retrospectoscope.” Judges and juries can easily mistake “not-so-subtle” pancreatic lesions for prospectively discovered subtle ones. Along with the possibility of doing significant harm to patients for missing findings, this discrepancy can cause high-cost malpractice lawsuits/claims. If you read enough of these studies, it is only a matter of time before you receive one!
Numerous Additional Findings
In addition to the problem of finding the primary lesion, any one of many different additional findings can change a patient’s management dramatically. And, these findings can be very subtle. I’ve seen numerous permutations and combinations of different sorts of venous and arterial thromboses that folks miss all the time. Then, there is a debate about whether a lesion surrounds a vessel and to what extent. This issue necessarily affects whether or not one gets surgery. And, I can’t tell you how many times that outcome can differ depending on who is reading the study. Of course, you also have subtle lymph nodes with the porta, adjacent to the head of the pancreas and within the celiac axis. All these different additional findings that you have to think about can make your head spin. And the consequences of missing them are dire!
Finally, you have to contend with the folks that ultimately ordered the study, to begin with. In my experience, these tend to be the busiest of surgeons. And for that reason, the word “ornery” almost does not do justice. These folks are often on the edge of burnout from overworking and complex patients. They have their sets of requirements for the reader they want and how they want their studies on top of that. You will notice at your institution that they might call a study for this surgeon a Dr. “John Doe” protocol because every surgeon wants the triple-phase protocol done a slightly different way.
The Triple-Phase Protocol For The Pancreas Is A Minefield!
As you can see, when you find one of these studies coming through your department, make sure to batten down the hatches and don’t let your attention stray. Making the findings can be challenging, and there are oh so many of them potentially. Don’t forget to look at all the images and phases. And make sure to relay all the information neatly and logically. The triple-phase protocol for the pancreas is not for the faint of heart. It’s a veritable minefield of potential misses and problems!