Received: 21 February 2020 Revised: 1 September 2020 Accepted: 2 September 2020

DOI: 10.1002/pbc.28730 Pediatric

Blood &
Cancer The American Society of
Pediatric Hematology/Oncology
O N C O LO G Y: R E S E A R C H A RT I C L E

Ultrasound has limited diagnostic utility in children with acute

lymphoblastic leukemia developing pancreatitis

Rebecca Richardson1 Cara E. Morin2 Charles A. Wheeler3 Yian Guo4

Yimei Li4 Sima Jeha5 Hiroto Inaba6 Ching-Hon Pui6 Seth E. Karol6
M. Beth McCarville2
1
Department of Radiology, Johns Hopkins School of Medicine, Baltimore, Maryland
2
Department of Diagnostic Imaging, St Jude Children’s Research Hospital, Memphis, Tennessee
3
Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
4
Department of Biostatistics, St Jude Children’s Research Hospital, Memphis, Tennessee
5
Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
6
Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee

Correspondence
Cara E. Morin, 262 Danny Thomas Pl, Mail Stop
220, Memphis, TN 38105.
Email: Cara.Morin@stjude.org
Rebecca Richardson and Cara E. Morin are
co-first authors.
Previously presented at the Society of Pedi-
atric Radiology 2019 Annual Meeting.
https://pedrad.abstractarchives.com/abstract/
pedrad2019-3106155/ultrasound-has-
limited-diagnostic-utility-in-children-with-
acute-lymphoblastic-leukemia-developing-
pancreatitis
Funding information
American Lebanese Syrian Associated Chari-
ties, Grant/Award Number: K08CA250418
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 ultra-
sound (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 retrospec-
tive 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, undergo-
ing 98 US and 44 CT. Seventy-two events (82%) occurred within 30 days of asparag-
inase administration. Sixty-nine episodes (78%) were initially diagnosed by the pres-
ence 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 his-
tory 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 equiv-
ocal cases.

Abbreviations: ALL, acute lymphoblastic leukemia; AP, acute pancreatitis; BMI, body mass index; CT, computed tomography; CTCAE, Common Terminology Criteria for Adverse Events; CTSI,
computed tomography severity index; MRI, magnetic resonance imaging; US, ultrasound

Pediatr Blood Cancer. 2020;e28730. wileyonlinelibrary.com/journal/pbc © 2020 Wiley Periodicals LLC 1 of 8

https://doi.org/10.1002/pbc.28730
2 of 8
KEYWORDS
acute lymphoblastic leukemia, asparaginase-associated pancreatitis, pancreatitis, ultrasound
1 INTRODUCTION
Acute pancreatitis (AP) is a known complication of treatment with
asparaginase, steroids, and 6-mercaptopurine for acute lymphoblastic
leukemia (ALL).1 An estimated 3-18% of patients with ALL receiving
asparaginase therapy will develop AP during treatment, usually within
the first year of asparaginase-intensive phases. This is thought to be
due to parenchymal toxicity from chemotherapy.2–4
Clinical diagnosis of AP requires two out of three of the following:
characteristic abdominal pain, serum amylase or lipase three times the
upper limit of normal, and/or imaging findings characteristic of AP.5,6
While current recommendations from the American College of
Radiology suggest ultrasound (US) as the initial imaging modality in
first episodes of AP in both adults and children; this recommendation
is based on the premise that most cases of AP are secondary to biliary
ductal obstruction, as opposed to the direct pancreatic injury believed
to cause chemotherapy-induced AP.7 Additionally, US has many known
limitations, including operator experience, frequent lack of visualiza-
tion of the entire pancreas related to overlying bowel gas or body
habitus, and variability in the appearance of a normal and abnormal
pancreas. As such we believe that US may be insensitive in the diag-
nosis of ALL-associated AP.
Furthermore, we believe that the best initial imaging modality to
identify early AP related to direct treatment toxicity is one that offers
a more thorough examination of the entire pancreas and adjacent soft
tissues with greater reproducibility and diagnostic accuracy, such as
computed tomography (CT) or magnetic resonance imaging (MRI).
In a retrospective cohort of children with ALL and known episode(s)
of AP, we evaluated the sensitivity of US in demonstrating AP findings.
Then we compared the sensitivity of US to CT imaging when available.
2 METHODS
Approval for waiver of consent was obtained from the St Jude Chil-
dren’s Research Hospital Institutional Review Board for this retrospec-
tive study.
Cases of pancreatitis in children treated for ALL that were diag-
nosed between October 26, 2007 and September 10, 2018 were iden-
tified through review of institutional databases. The Total Therapy
XVI (T16, NCT00549848) and XVII (T17, NCT03117751) protocols
include children with ALL diagnosed at ages 0-18 years and 1-18 years,
respectively. Both protocols administered pegaspargase (PEGylated L-
asparaginase) to all patients unless allergic reaction required transition
to alternative asparaginase formulations.
Diagnosis of AP based on the revised Atlanta classifica-
tion/International Study Group of Pediatric Pancreatitis: In Search for
RICHARDSON ET AL.
Cure (INSPPIRE) consortium criteria was confirmed by manual chart
review, and demographic and clinical data were collected.5,6
Clinical data were extracted from the medical record including
demographics, body mass index (BMI), complications by Common Ter-
minology Criteria for Adverse Events (CTCAE) version 3 grade of AP,
clinical symptoms, chemotherapy, and dates of events. Amylase and
lipase levels were collected from the medical record. Statistical anal-
yses were performed using Stata version 16.1 (College Station, TX) and
Graphpad Prism version 8.4.3 (San Diego, CA).
2.1 Defining the diagnostic timing
A “true” date and time of diagnosis was identified to determine how
the patient first met criteria for the diagnosis of AP (ie, met two of
three criteria including characteristic pain, amylase [total] or lipase ele-
vation, and imaging evidence of pancreatitis), the timing of the episode
of AP with respect to asparaginase administration, and the duration
from onset of pain until diagnosis. The date and time when abdominal
pain was first documented was extracted from the clinical notes. Based
on documented lab values, the first date of elevated serum amylase or
lipase levels greater than three times the upper limit of normal for each
lab was recorded. The date and time of the report from the first positive
imaging study was recorded. The date and time of the first two posi-
tive components of diagnosis were designated as the “true” diagnostic
period.
2.2 Radiological review
The first two US studies that attempted visualization of the pancreas
and the first abdominal CT performed within 10 days of the true date
of diagnosis were selected for review. In cases without an abdominal
CT, an available chest CT that included the pancreas was designated
as the corresponding CT. A board-eligible radiology resident blinded to
the original reports reviewed all US and CT images.
2.2.1 US imaging review
In addition to recording the original interpretation/report, each US
was assessed for the extent of the pancreas visualized (full, partial, or
completely obscured), diagnostic quality (diagnostic or nondiagnostic),
characteristic imaging findings of AP (pancreatic enlargement, peri-
pancreatic inflammation, peripancreatic free fluid, and ascites), and
whether a diagnosis of AP would be given in a typical clinical setting.
The pancreas was measured in the head, neck, body, and tail (if each
RICHARDSON ET AL. 3 of 8

F I G U R E 1 The entirety of the pancreas must be viewed on all imaging modalities because pancreatitis can be focal as in this example. A,
Transverse ultrasound image through the pancreas demonstrating a normal-sized pancreas without surrounding fluid or peripancreatic
inflammation (white arrow). B, Corresponding computed tomography (CT) through the pancreatic head at the same level demonstrates a normal
CT appearance (black arrow, center). C, However, a more inferiorly located slice through the pancreatic tail on the same CT study demonstrates
focal pancreatic parenchymal enlargement with regions on nonenhancement and trace peripancreatic free fluid, consistent with necrotizing
pancreatitis with an acute necrotic collection, computed tomography severity index 5 (CTSI 5) (black arrow, right)

was visualized) on all US images and in all CT cases. Enlargement was blinded to the original radiology report, clinical record, and trainee
defined as greater than two standard deviations above normal for sex interpretation.
and age per Trout et al (ref). A study was deemed of diagnostic quality
only if one of the following conditions was met: the entirety of the pan-
creas could be viewed with certainty and was normal, or the visualized 3 RESULTS
portion of the pancreas demonstrated sufficient findings to confidently
diagnose AP in a typical clinical setting (Figure 1). 3.1 Incidence of AP and demographics

Ninety-six AE reports for AP were identified in 71 patients. Of those,

2.2.2 CT imaging review
In addition to recording the original interpretation/report, each CT was
reviewed for diagnostic quality and characteristic imaging findings of
AP (focal or diffuse parenchymal enlargement, changes in pancreatic
density or enhancement, indistinct pancreatic margins, peripancreatic
fat stranding, hemorrhage, pancreatic emphysema, and peripancreatic
fluid collections). Diagnostic quality was determined based on identical
criteria used for US exams. Additionally, all CT exams were assigned a
categorization based on the revised Atlanta classification5,9 and scored
by the CT severity index (CTSI; Table S4).10 The CT scans were per-
formed with dose modulation, iterative reconstruction, and/or weight-
based dosing when appropriate to reduce the radiation dose to as
low as reasonably achievable. Radiation dosing data for each CT were
recorded.
eight episodes were excluded because incomplete data prevented
confirmation of two or three criteria for AP diagnosis.6 The analyzed
cohort consisted of 69 patients with 88 episodes of AP. Regarding
repeat episodes, 54 patients had a single episode, 12 patients had
two episodes, two patients had three episodes, and one patient
experienced four episodes, while enrolled on protocol. Patients were
predominantly male (64%) and Caucasian (77%), with a median age at
diagnosis of pancreatitis of 10 years (range 2-21). Most episodes were
documented as CTCAE grade 2 (49%) or 3 (40%) (Table 1).
One hundred forty-three imaging studies (98 US, 44 CT, and one
MRI) were performed in 70 of the 88 episodes of AP (Figure 2). Both US
and CT were available for 43% (38/88) of episodes, obtained a median
of 1 day from the onset of pain (interquartile range 1-3 days). Thirty-
four of 88 episodes (39%) underwent two or more US. Because only
one MRI was performed, this imaging modality was excluded from our
analysis.

2.2.3 Adjudication of imaging discrepancies

After all US and CT studies were reviewed, the results were com-
pared with the original imaging reports. All discrepancies in the
diagnosis of AP between the radiology trainee’s interpretation and
the original radiology report from a board-certified pediatric radi-
ologist were adjudicated by re-review of the imaging by a sin-
gle board-certified pediatric radiologist (Cara E. Morin) who was
3.2 Type of asparaginase administered and
temporal association of AP with administration
Prior to the onset of AP, patients received PEGylated L-asparaginase
(n = 73 episodes), Erwinia asparaginase (n = 12 episodes), or native
L-asparaginase (n = 2 episodes). In one episode, no asparaginase had
been administered (1/88, 1.1% of total episodes). The onset of AP was
4 of 8
FIGURE 2 Consort diagram of episode inclusion and associated imaging studies (AP, acute pancreatitis; CT, computed tomography; US,
ultrasound)
within 30 days of asparaginase administration in 72 of the 87 episodes
(83%). Onset of pancreatitis within 30 days of asparaginase adminis-
tration was higher for first episodes (88%; 58/66 episodes) compared
to recurrent episodes (66%; 14/21 episodes; P = .04).
3.3 How patients meet criteria for AP
Nearly all (86/88, 98%, 95% confidence interval [95% CI] 92-99.7%)
episodes had documentation of abdominal pain prior to lab or imaging
results. In 80/88 episodes (91%, 95% CI 83-96%), the diagnosis of AP
could have been made by elevated serum amylase or lipase concentra-
tions within 24 h of abdominal pain documentation without the use of
imaging.
Imaging was often ordered prior to or at the same time as blood
chemistries, although the diagnosis was first made in the majority of
episodes by elevated enzymes with abdominal pain (69/88, 78%, 95%
CI 68-86%). Less frequently, the diagnosis was made by imaging results
and abdominal pain prior to lab results (17/88, 19%). Out of the 69
cases that were diagnosed with labs and abdominal pain, 11 episodes
had imaging prior to diagnosis, and all of those studies were either
false-negative US examinations for the diagnosis of AP (9/11) or US
was performed to assess for an alternate diagnosis (eg, appendicitis or
colitis), and imaging of the pancreas was not obtained (2/11).
3.4 Average time to diagnosis after onset of
abdominal pain
The mean time from the onset of abdominal pain to diagnosis for all
episodes was 1.2 days (Table S1). Regardless of the severity or method
RICHARDSON ET AL.
of diagnosis, most episodes were diagnosed within 24 h (58/86, 66%)
or 48 h (73/86, 83%). When the diagnosis was made with pancreatic
enzymes prior to imaging results (n = 58, 67%), the average time from
onset of abdominal pain to diagnosis was 1.02 days. Conversely, when
a nondiagnostic US was performed prior to blood chemistry results
(n = 11, 13%), the diagnosis was made at an average of 2 days from the
onset of pain (P = .87).
Regardless of the method by which the patient met diagnostic cri-
teria, there was an inverse relationship between the clinical severity of
AP and the average number of days from onset of abdominal pain until
diagnosis: CTCAE grades 1-4 taking 3, 1.2, 1.1, and 0.8 days, respec-
tively (P = .16).
3.5 Sensitivity of US and CT
Of the 98 US studies, 47% (46/98, 95% CI 37-57%) demonstrated
sufficient imaging characteristics to diagnose AP (Figure 3). This
sensitivity was unchanged when comparing initial versus follow-
up US studies. The sensitivity of US was highest for CTAEC
grade 4 AP (6/7, 86%). No US was diagnostic for grade 1 AP
(0/3, 0%). Sensitivities were similar for grade 2 AP (22/50, 44%)
and grade 3 AP (18/38, 47%). Sensitivity of US did not vary if
it preceded (sensitivity 41%, 13/32) or followed diagnostic CT
(50%, 12/24).
The remainder of the US studies (52/98, 53%) demonstrated
incomplete visualization of the pancreas without sufficient find-
ings to diagnose AP or a completely obscured pancreas. Consider-
ing all of the US studies, the pancreas was fully visualized in none
of the cases (0/98, 0%), partially visualized in 86 studies (86/98,
88%), and nonvisualized in 12 studies (12/98, 12%). The percent
RICHARDSON ET AL.
FIGURE 3 Flowchart of imaging sensitivity (AP, acute pancreatitis; CT, computed tomography; FN, false-negative; TP, true-positive; US,
ultrasound)
of cases with nonvisualization of the pancreas was similar across
CTCAE grades 2-4 AP: 10% (5/45), 13% (5/33), and 14% (1/6),
respectively.
Every abdominal CT (or chest CT when applicable) was consid-
ered diagnostic, demonstrating the entirety of a normal-appearing
pancreas or enough of the pancreas to diagnose AP. Forty-three of
44 CTs (98%, 95% CI 88-100%) were positive for AP (P < .001 vs
US). The only false-negative CT was performed as a follow-up study
after diagnosis with pancreatic enzymes and characteristic abdominal
pain.
3.6 Severity of episodes of AP based on CTCAE,
CT, and US
Based on the revised Atlanta classification, 29 out of the 44 CTs
(66%) demonstrated interstitial edematous pancreatitis (IEP), and
14 of the studies (32%) demonstrated necrotizing pancreatitis (NP).
One of 44 CTs (2%) demonstrated a normal pancreas (CTCAE grade
2). CTSI scores increased with increasing CTCAE grades (Table 2;
P = .058).
Of those episodes in which a CT demonstrated AP and compari-
son US imaging was performed, the overall US sensitivity was 45%
(25/56), and the sensitivity by CTCAE grade was 0% (0/3) for grade
1, 36% (8/22) for grade 2, 46% (11/24) for grade 3, and 86% (6/7)
for grade 4. Furthermore, the US sensitivity was greatest when struc-
tural injury, such as necrosis and peripancreatic fluid collections, were
present, with US sensitivity of 80% for CTSI score 7-10 (severe) versus
46% for CTSI 0-3 (mild) (Figure 4).
5 of 8
3.7 Association of AP and imaging findings with
BMI and age
Consistent with prior findings, obesity limited US performance in our
patients. The median patient BMI was 18.8 kg/m2 (range 13-59 kg/m2 )
at the time of AP. Based on BMI percentile ranges for age, the patients
were underweight in three episodes (3/88, 3%), normal weight in 51
episodes (51/88, 58%), overweight in 15 episodes (15/88, 17%), and
obese in 19 episodes (19/88, 22%) (Table S2). Rates of diagnostic
US were similar for patients in the underweight, healthy weight, and
overweight categories (∼50%) compared to 33% in obese patients
(P = .25, Table S3).
US sensitivity did not differ by age: 33% in those greater than
15 years (95% CI 10-65%), 43% for ≤5 years (95% CI 23-66%), 56%
for >5-≤10 years (95% CI 35-75%), and 47% for >10-≤15 years (95%
CI 30-65%). In multivariable analysis including age and obesity, neither
was associated with US sensitivity (P = .47 and .1, respectively).
3.8 Association between type/number of US
findings and likelihood of diagnosis
We assessed four commonly reported sonographic signs of AP (pan-
creatic enlargement, peripancreatic inflammation, peripancreatic free
fluid, and ascites), and found the more US findings of pancreatitis
that were present, the more likely the study was diagnostic of AP
(3.2/4 findings on average vs 1.5/4 findings in nondiagnostic stud-
ies). Findings on US present in the studies evaluated are shown in
Table S4.
6 of 8 RICHARDSON ET AL.

F I G U R E 4 Three transverse ultrasound (US) images at the level of pancreas with corresponding axial CECT images, showing (A) nondiagnostic
US with partially visualized, normal appearing pancreas and NP/ANC on computed tomography (CT) performed 1 day earlier (computed
tomography severity index [CTSI] 8, white arrows), (B) diagnostic US with cystic pancreas and NP/ANC on CT performed 1 week later (CTSI 10,
white arrows), and (C) nondiagnostic US with nonvisualized pancreas and interstitial edematous pancreatitis (IEP) on CT performed 1 day later
(CTSI 4, white arrows)

When examining only those studies in which the pancreas was par-
tially visualized, ascites were the most common US finding, present
in 62 studies (62/86, 72%). Pancreatic enlargement was the second
most common finding present in 59 studies (59/86, 68%). Ascites and
pancreatic enlargement were only moderately associated with the
studies being considered diagnostic for AP (37/62, 60% and 43/59,
73%, respectively). Peripancreatic inflammation and peripancreatic
free fluid were the least common findings, present in only 42/86 (49%)
and 38/86 (44%) studies, respectively.
3.9 CT radiation dose data
The total average volume computed tomography dose index (CTDIvol )
across all ages was 7 mGy with a range of 1-25 mGy. Averages varied
over age ranges as follows: 3.1 mGy for ages ≤5 years, 5.4 mGy for
ages 5-10 years, 10 mGy for ages 10-15 years, and 12 mGy for ages
>15 years.
4 DISCUSSION
Our results suggest that US has limited diagnostic utility in the diag-
nosis of AP in children with ALL. In our review of 88 episodes of
pancreatitis in patients receiving modern ALL therapy, most cases
(69/88, 78%) of AP were diagnosed without imaging, using only char-
acteristic abdominal pain and elevated pancreatic enzymes. In our
cohort, 91% of patients could be diagnosed without imaging, includ-
ing 86% on the day of presentation and 5% within the subsequent
24 h.
In our cohort of ALL patients with documented AP, US had a lower
sensitivity than CT (47% vs 98%, P < .001). These findings under-
score the limited value of US in the diagnosis of asparaginase-related
AP.
Because the differential diagnosis of abdominal pain in pediatric
ALL patients is broad, a specific algorithm for workup of AP is chal-
lenging. In patients with abdominal pain potentially consistent with
AP, we suggest to first obtain serum amylase and lipase levels. For
most patients, this will be sufficient for diagnosis (Figure S3). In
patients with enzyme levels less than three times the upper limit of
normal, abdominal US to evaluate the pancreas and other potential
causes of abdominal pain (eg, colitis, cholecystitis, appendicitis) can
be obtained. Further evaluation should be directed by the history and
clinical circumstances. If pancreatic enzymes remain less than three
times the upper limit of normal after 48 h and pancreatitis remains
a consideration, a contrast-enhanced CT or MRI of the abdomen
should be obtained. If at any point in the acute setting, urgent imag-
ing is necessary for management, a contrast-enhanced CT or MRI
of the abdomen should be performed, as necrotizing pancreatitis
with or without superimposed infection is not well differentiated
RICHARDSON ET AL. 7 of 8

TA B L E 1 Demographics by patient and episode from interstitial edematous pancreatitis with US.7 Additionally,
contrast-enhanced abdominal MRI or CT will identify complica-
Characteristics Results
tions of AP such as pseudocyst formation, development of walled
Patients, episodes nP (%), nE (%)
off necrosis, splenic vein thrombosis, and arterial pseudoaneurysm
Male 44 (64%), 58 (66%)
formation.
Female 25 (36%), 30 (34%)
Limitations of our study include ascertainment bias due to the use of
Race/ethnicity an adverse events database to identify patients with known episodes
Caucasian 53 (77%), 69 (78%) of pancreatitis. The lack of availability of US and CT on all patients
African American 12 (18%), 14 (16%) reduces the precision of sensitivity estimates and the ability to com-
Asian 3 (4%), 4 (5%) pare these two methods; however, this reflects clinical practice at both

Other 1 (1%), 1 (1%) our own and external institutions. While some cases of AP may not have
been detected, these cases never presented to clinical attention and
Age at episode
therefore were likely to be mild.
Mean, years (SD) 10.1 (4.8)
This study is also limited in part by our institutional clinical prac-
≤ 5 years 18 (20%)
tices. Currently, US is used to rule out numerous complications of
>5 years, ≤ 10 years 28 (32%) oncologic treatment, including colitis, as well as common sources of
>10 years, ≤ 15 years 31 (35%) pediatric abdominal pain, including appendicitis, cholecystitis, and gall-
>15 years 11 (13%) stones. This reliance on US lends itself to a tendency to use US
CTCAE v3 of episode as a method to rule out any abdominal pathology rather than CT.
Grade 1 3 (4%) Furthermore, MRI is rarely used to assess for pancreatitis at our
institution (only 1/88 episodes included comparison MRI), so the sen-
Grade 2 43 (49%)
sitivity of MRI could not be assessed in comparison with the other
Grade 3 35 (40%)
modalities.
Grade 4 6 (7%)
Pancreatic enzyme levels Mean, median (range) in units/L
Amylase (normal < 91 units/L) 5 CONCLUSION
Diagnosis 343, 269 (60-1334)
First ultrasound 306, 232 (21-1334) Our study demonstrates the limited sensitivity of US in patients
Second ultrasound 232, 160 (19-809) with ALL being evaluated for potential pancreatitis. In children being

CT 300, 217 (16-1334) treated for ALL, US cannot be relied on to diagnose AP. In our pop-
ulation, most cases were diagnosed with clinical history and serum
Lipase (normal < 60 units/L)
enzymes. Alternative imaging should be considered in clinically equiv-
Diagnosis 1176, 820 (36-7345)
ocal cases in which there is a strong suspicion for AP, and the diagnosis
First ultrasound 773, 461 (30-7345)
cannot be made by history and serum enzymes alone.
Second ultrasound 465, 207 (27-2492)
CT 844, 457 (9-7345) ACKNOWLEDGMENTS
Note. nE , number of episodes; nP , number of patients; SD, standard deviation. Research was supported by American Lebanese Syrian Associated
Charities and K08CA250418.
TA B L E 2 Average CTSI score, percentage of CTs obtained that
demonstrate NPs, and US sensitivity for each CTCAE grade CONFLICT OF INTEREST
The authors declare that there is no conflict of interest.
Average CT with NP n US sensitivity
CTCAE v3 grade CTSI (%) (%)
DATA AVAILABILITY STATEMENT
Grade 1 (nCT = 2) 2.5 0 (0%) 0
The data that support the findings of this study are available on request
Grade 2 (nCT = 17) 4.3 4 (24%) 44
from the corresponding author. The data are not publicly available due
Grade 3 (nCT = 20) 4.8 7 (35%) 47
to privacy or ethical restrictions.
Grade 4 (nCT = 5) 7.6 3 (60%) 86

Note. nCT : Total number of CTs obtained per grade. n (%): Total number of ORCID
CTs that demonstrate necrotizing pancreatitis per grade and corresponding Cara E. Morin https://orcid.org/0000-0003-1953-4486
percentage of all CTs obtained in that grade that demonstrate necrotizing
Hiroto Inaba https://orcid.org/0000-0003-0605-7342
pancreatitis (NP).
Abbreviations: CT, computed tomography; CTSI, computed tomography Ching-Hon Pui https://orcid.org/0000-0003-0303-5658
severity index; US, ultrasound. Seth E. Karol https://orcid.org/0000-0001-8113-8180
8 of 8 RICHARDSON ET AL.

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