Ultrasound has limited diagnostic utility in children with acute lymphoblastic leukemia developing pancreatitis

Abstract

Purpose: Acute pancreatitis (AP) due to chemotherapy-induced pancreatic injury is a common side effect of treatment for acute lymphoblastic leukemia (ALL), the most common childhood malignancy. The American College of Radiology recommends ultrasound (US) for initial imaging of AP in all populations to assess for ductal obstruction. However, US may be insensitive to diagnose and assess chemotherapy-associated AP. Methods and Materials: The institutional review board approved this retrospective study. Patients with ALL and AP were identified from protocol databases, using Common Terminology Criteria for Adverse Events (CTCAE) version 3. Chemotherapy dosing, amylase/lipase levels, clinical symptoms, and US/computed tomography (CT) reports within 10 days of diagnosis were recorded. All CT images were reviewed for revised Atlanta classification and CT severity index (CTSI). Results: Sixty-nine patients, aged 2-21 years, experienced 88 episodes of AP, undergoing 98 US and 44 CT. Seventy-two events (82%) occurred within 30 days of asparaginase administration. Sixty-nine episodes (78%) were initially diagnosed by the presence of abdominal pain and pancreatic enzyme elevation. Overall sensitivities for AP detection were 47% using US and 98% for CT. US sensitivity was greatest in CTCAE grade 4 (86%) and necrotizing pancreatitis (67%). Conclusions: Most cases of AP in children with ALL can be diagnosed with clinical history and labs. US has limited sensitivity in detecting pancreatitis in this population. Imaging to diagnose AP in this patient population could be limited to clinically equivocal cases.

Current State of Imaging of Pediatric Pancreatitis: AJR Expert Panel Narrative Review

“…This consensus reflects ultrasound's high sensitivity for gallstones and biliary obstruction, the modality's availability, and likely overemphasis on lack of ionizing radiation exposure. This consensus belies the moderate sensitivity and specificity of ultrasound for AP, with recent studies suggesting 47-52% sensitivity [8,9].…”

Severe complications in the induction phase of therapy in a pediatric patient with T-cell acute lymphoblastic leukemia: A case report

“…Richardson study of clinically equivocal cases showed that a contrast-enhanced computed tomography or magnetic resonance imaging of the abdomen should be performed. [25] The accurate mechanism of AAP is unknown. The genetic risk factors associated with asparaginase-associated pancreatitis in pediatrics that have been found are PRSS1, Unc-51 like autophagy activating kinase 2, regulator of g protein signaling 6, Carboxypeptidase A2, 4-hydroxy-2-oxoglutarate aldolase 1, metallopeptidase with thrombospondin type 1 motif 17, Myb-binding protein 1A, sperm antigen with calponin homology and coiled-coil domains 1, asparagine synthetase (glutamine-hydrolyzing) and cystic fibrosis transmembrane conductance regulator.…”

Contrast-Enhanced Ultrasound in Children: Implementation and Key Diagnostic Applications

“…CEUS may help establish the diagnosis of early chronic pancreatitis, as areas of parenchymal fibrosis show decreased enhancement compared to the superior mesenteric artery [75]. However, a limitation of ultrasound in general for the assessment of pancreatitis is the frequent presence of overlying bowel gas that can obscure areas of necrosis and surrounding inflammatory changes [76]. Further study remains needed in children…”