Secretin (ChiRhoStim) Pancreas Perfusion for Pancreatic Adenocarcinoma
Secretin (ChiRhoStim) Pancreas Perfusion for Pancreatic Adenocarcinoma
The purpose of this study is to test if secretin-enhanced CT is a useful noninvasive
 screening tool for pancreatic cancer in a high-risk population.
Pancreatic cancer is the fourth most common cause of cancer death in the US. Because patients
 with pancreatic cancer rarely presents with disease specific symptoms until late in the
 course of the disease, identifying and developing surveillance strategies for early detection
 of asymptomatic pancreatic cancer is critical. EUS and fine needle aspirate (FNA) are
 currently the most accurate non-operative methods of establishing the presence or absence of
 pancreatic cancer.

 The CT findings of pancreatic cancer include an attenuation difference between the pancreatic
 mass and the surrounding pancreatic parenchyma, pancreatic ductal dilation and cutoff,
 disruption of the normal fatty marbling of the pancreatic parenchyma, rounding of the
 inferior margin of the posterior head of the pancreas, atrophy of the proximal gland, and
 signs of locally advanced or distant disease. In a case-controlled retrospective review of
 pancreatic cancers missed at CT prior to clinical presentation at the Mayo Clinic, Gangi et
 al found that CT findings definite or suspicious for pancreatic cancer were present in 50% of
 scans obtained up to 18 months before the clinical diagnosis of pancreatic cancer. Pancreatic
 duct dilation and cutoff were early CT findings indicating tumor presence, and were
 associated with near-perfect and substantial interobserver agreement. Consequently, early
 pancreatic neoplasms likely result in at least partial occlusion of the duct, leading to
 subsequent ductal dilation.

 We hypothesize that increased production of the pancreatic juice distends the otherwise small
 caliber pancreatic duct, and accentuate the secondary sign of pancreatic duct obstruction by
 a small pancreatic mass. The investigators will be able to take advantage of this physiologic
 effect of secretin, by obtaining multi-planar scans with isotropic resolution using a
 64-channel CT system.

 Secretin is a safe agent that increases pancreatic exocrine secretion. Intravenously
 administered secretin increases the pancreatic juice secretion, and magnetic resonance or CT
 scan obtained after secretin has been shown to improve visualization of the pancreatic duct.

 Day 1: Patient will fast 4 hours prior to the study. 1 L of water is given by mouth as an
 oral contrast material 30 minutes prior to the study. After placing an angiocath in the
 antecubital fossa, the patient will be placed in a supine position on the CT scanner.

 Secretin test dose will be given intravenously (0.2mcg (0.1ml). If no reaction is noted after
 one minute, then Secretin will be given intravenously (0.2 mcg/kg IV slowly over one minute).
 If an allergic reaction is noted, the patient will not have a CT scan performed as part of
 this study protocol, and that participant will be ineligible to participant with this study.
 Secretin bolus will be terminated if Systolic BP < 90mm/Hg is not corrected with IV fluids.

 Pre-contrast scan will be obtained with collimation of 0.6 x 64 mm and a pitch of 1.2 through
 the abdomen under deep inspiration. Images will be reconstructed with 1 mm slice thickness
 and 2 mm increment.

 Five minutes after administration of the intravenous Secretin, iodinated contrasted Omnipaque
 350 administered at 3-5ml/sec. Post-iodine-contrast scanning will be obtained with
 collimation of 0.6 x 64 mm and a pitch of 1.2 through the abdomen with scan delays of 40- and
 70-seconds. Total of 150 ml of intravenous iodinated contrast will be administered at the
 rate of 3 - 5 ml/ sec.

 For the 3 month (Day 2) and 18 month (Day 3) follow-up CT imaging:

 Patient will fast four hours before scan. 1 liter of water given orally 30 minutes prior to
 scan. An IV will be placed, and participant will have iodinated contrast (Omnipaque 350)
 administered at 3-5ml/sec. Post iodine scanning will be done with collimation of 0.6 x64mm
 and a pitch of 1.2 through the abdomen with scan delays of 40 and 70 seconds.

 For the optional CT scan for those who have initial positive CT:

 This exam is to be done only before endoscopic ultrasound (EUS). Patient will fast four hours
 before scan. 1 liter of water given orally 30 minutes prior to scan. An IV will be placed,
 and participant will have iodinated contrast (Omnipaque 350) administered at 3-5ml/sec. Post
 iodine scanning will be done with collimation of 0.6 x64mm and a pitch of 1.2 through the
 abdomen with scan delays of 40 and 70 seconds.

 Subjects will be followed up for 3-5 years to determine if they develop pancreatic cancer.
Inclusion Criteria:

 -  Persons 50 years or older with recently diagnosed diabetes (within 2 years), with at
 least one of the following: no family history of diabetes, abdominal discomfort,
 anorexia, weight loss, elevated serum CA 19-9, or those undergoing EUS with or without
 Fine Needle Aspiration (FNA) for pancreatic cancer screening ; OR

 -  Persons 35 years old or older with familial pancreatic cancer with 2 or more first
 degree relatives with pancreatic cancer; OR

 -  Persons 35 years old or older with Peutz-Jeghers syndrome; OR

 -  Persons 35 years old or older with suspicious clinical symptoms of pancreatic cancer,
 but had normal CT of the abdomen with iodinated contrast within 2 weeks.

 Exclusion Criteria:

 -  Persons with contraindication to iodinated contrast

 -  Allergy to iodinated contrast

 -  Renal insufficiency (serum creatinine > 1.5 mg/dl)

 -  Patients with contraindication to ionizing radiation

 -  Pregnancy

 -  Patients with previous pancreatic surgery

 -  Contraindication to secretin

 -  Allergy to secretin

 -  Acute pancreatitis