Cystic pancreatic neoplasms evaluation by CT and magnetic resonance cholangiopancreatography

Comparison of utility of deep learning reconstruction on 3D MRCPs obtained with three different k-space data acquisitions in patients with IPMN

OBJECTIVE

To compare the utility of deep learning reconstruction (DLR) for improving acquisition time, image quality, and intraductal papillary mucinous neoplasm (IPMN) evaluation for 3D MRCP obtained with parallel imaging (PI), multiple k-space data acquisition for each repetition time (TR) technique (Fast 3D mode multiple: Fast 3Dm) and compressed sensing (CS) with PI.

MATERIALS AND METHODS

A total of 32 IPMN patients who had undergone 3D MRCPs obtained with PI, Fast 3Dm, and CS with PI and reconstructed with and without DLR were retrospectively included in this study. Acquisition time, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) obtained with all protocols were compared using Tukey's HSD test. Results of endoscopic ultrasound, ERCP, surgery, or pathological examination were determined as standard reference, and distribution classifications were compared among all 3D MRCP protocols by McNemar's test.

RESULTS

Acquisition times of Fast 3Dm and CS with PI with and without DLR were significantly shorter than those of PI with and without DLR (p < 0.05). Each MRCP sequence with DLR showed significantly higher SNRs and CNRs than those without DLR (p < 0.05). IPMN distribution accuracy of PI with and without DLR and Fast 3Dm with DLR was significantly higher than that of Fast 3Dm without DLR and CS with PI without DLR (p < 0.05).

CONCLUSION

DLR is useful for improving image quality and IPMN evaluation capability on 3D MRCP obtained with PI, Fast 3Dm, or CS with PI. Moreover, Fast 3Dm and CS with PI may play as substitution to PI for MRCP in patients with IPMN.

KEY POINTS

• Mean examination times of multiple k-space data acquisitions for each TR and compressed sensing with parallel imaging were significantly shorter than that of parallel imaging (p < 0.0001). • When comparing image quality of 3D MRCPs with and without deep learning reconstruction, deep learning reconstruction significantly improved signal-to-noise ratio and contrast-to-noise ratio (p < 0.05). • IPMN distribution accuracies of parallel imaging with and without deep learning reconstruction (with vs. without: 88.0% vs. 88.0%) and multiple k-space data acquisitions for each TR with deep learning reconstruction (86.0%) were significantly higher than those of others (p < 0.05).

Invasive Intraductal Papillary Mucinous Neoplasms: CT Features of Colloid Carcinoma Versus Tubular Adenocarcinoma of the Pancreas

OBJECTIVE. The purpose of this study is to compare the CT features of colloid carcinoma and tubular adenocarcinoma of the pancreas arising in association with intraductal papillary mucinous neoplasms (IPMNs). MATERIALS AND METHODS. The preoperative CT images of 85 patients with histopathologically proven IPMNs and associated invasive adenocarcinoma located next to each other were retrospectively reviewed. Twenty-nine patients (34.1%; 19 men and 10 women; mean [± SD] age, 68.0 ± 9.5 years) had invasive colloid carcinoma, and 56 patients (65.9%; 31 men and 25 women; mean age, 70.8 ± 10.6 years) had invasive tubular adenocarcinoma. We compared the following CT features between the two groups: IPMN type, main pancreatic duct (MPD) and common bile duct diameters, diameter and characteristics of the largest cystic lesion for branch duct and mixed-type IPMNs, presence of an extracystic or extraductal solid mass next to the cystic lesion or MPD, morphologic features of the upstream MPD in relation to the cystic lesion or solid mass, and presence of a fistula to the adjacent organs. RESULTS. An MPD size of 9.5 mm or greater, a largest cystic lesion diameter of 28 mm or greater, location in the head or neck, septation, calcification, presence of a mural nodule(s) within a cystic lesion or MPD, and presence of a fistula were all more commonly associated with colloid carcinoma. In contrast, presence of an extracystic or extraductal solid mass and an abrupt change in the caliber of the dilated MPD were associated with tubular adenocarcinoma. The best CT feature for differentiating between the two groups was the morphologic features of the upstream MPD in relation to the cystic lesion or solid mass (sensitivity, 81.3%; specificity, 92.3%). CONCLUSION. Preoperative CT is helpful in differentiating two types of invasive carcinoma arising in association with IPMNs. These findings are clinically important because prognosis is better for colloid carcinoma than for tubular adenocarcinoma.

MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP) VERSUS ENDOSONOGRAPHY-GUIDED FINE NEEDLE ASPIRATION (EUS-FNA) FOR DIAGNOSIS AND FOLLOW-UP OF PANCREATIC INTRADUCTAL PAPILLARY MUCINOUS NEOPLASMS

BACKGROUND

Intraductal papillary mucinous tumor (IPMN) are being diagnosed with increasing frequency. Computerized tomography scanning is commonly used as the primary imaging modality before surgery nonetheless magnetic resonance cholangiopancreatography (MRCP) provides better characterization. Endosonography-guided fine needle aspiration (EUS-FNA) has emerged as a way to reach pathological diagnose.

AIM

To compare results of both methods with surgical pathology findings for classification of IPMN.

METHODS

Thirty-six patients submitted to surgical resection with preoperative suspect of IPMN were submitted preoperatively to MRCP and EUS-FNA. Images obtained were analyzed according to a classification determined for each method. ROC curve was used for statistical analysis, that compared the images tests with the purpose of finding the best method for diagnosis and classification of IPMN.

RESULTS

Sixteen patients underwent pancreatoduodenectomy, 16 to subtotal pancreatectomy and only four laparotomy. Pathological diagnosis was IPMN (n=33) and pancreatic intraepithelial neoplasia type 2 (n=3). Twenty-nine revealed non-invasive neoplasia and invasive form in four patients. MRCP and EUS-FNA have correctly diagnosed and classified (type of IPMN), in 62.5% and 83.3% (p=0.811), the affected segment location in 69% and 92% (p=0.638) and identification of nodules and/or vegetation presence in 45% and 90% (p=0.5). Regarding to histopathological diagnosis by EUS-FNA the sensitivity was 83.3%; specificity was 100%; positive predictive value was 100%; negative predictive value was 33.3% and accuracy was 91.7%.

CONCLUSIONS

There was no significant difference in the diagnosis of IPMN. However, EUS-FNA showed better absolute results than MRCP to identify nodule and/or vegetation.

Preoperative contrast-enhanced computed tomographic characterisation of pancreatic cystic lesions: A prospective study

Background

Characterisation of pancreatic cystic lesions has a direct role in their management and computed tomography is the mainstay of investigation for diagnosing and characterising them.

Objectives

The aim of this study was to prospectively assess the diagnostic accuracy of contrast-enhanced computed tomography (CECT) in preoperative characterisation of pancreatic cystic lesions with histopathology as the reference standard.

Method

A total of 38 patients with cystic pancreatic lesions diagnosed after clinical, laboratory and sonographic evaluation, irrespective of age, were preoperatively evaluated with CECT. Images were reviewed for the general characteristics of the lesions on pre-contrast and portal venous phase images and overall diagnostic accuracy calculated. Imaging findings were compared with histopathology, or cytology and/or intra-operative findings.

Results

Serous cystadenoma (SCA) was the most common cystic pancreatic lesion found in 31.6% of patients followed by mucinous cystadenoma (MCA) (26.3%), solid pseudo-papillary tumour (SPT) (21.1%) and intra-ductal papillary mucinous neoplasm (IPMN) (10.5%). Three patients (7.9%) had simple cysts and one patient (2.6%) had a lymphangioma. The diagnostic accuracy of CECT for pancreatic cystic lesions was found to be 72.5.

Conclusion

The diagnostic accuracy of computed tomography (CT) was high for SCA, IPMN and pancreatic cysts, and low for MCA and SPT. Combination of a multiloculated cystic lesion with locule size of less than 20 mm, septal enhancement with relative lack of wall enhancement, central scar and lobulated outline are highly specific for SCA. Unilocular or macro-cystic pattern with locule size of more than 20 mm, female gender and wall enhancement with smooth external contour are pointers towards MCA. Solid cystic pancreatic head lesions in young females may be suggestive of SPT. A dilated main pancreatic duct in a cystic lesion with internal septations may point towards IPMN. Fluid attenuation lesions with imperceptible non-enhancing wall indicate pancreatic cysts. Lastly, pseudocysts and neuroendocrine tumours with cystic components are great mimickers of pancreatic cystic lesions, and a history of pancreatitis and hormonal profile of patients should always be sought.

Prospective study on the incidence, prevalence and 5-year pancreatic-related mortality of pancreatic cysts in a population-based study

OBJECTIVE

To analyse the prevalence, incidence and clinical relevance of pancreatic cysts detected as incidental finding in a population-based longitudinal study.

DESIGN

A total of 1077 participants (521 men, mean age 55.8±12.8 years) of 2333 participants from the population-based Study of Health in Pomerania (SHIP) underwent magnetic resonance cholangiopancreaticography (MRCP) at baseline (2008-2012). MRCP was analysed for pancreatic cysts with a diameter ≥2 mm. 676/1077 subjects received a 5-year follow-up (2014-2016). The prevalence and incidence of pancreatic cysts (weighted for study participation) were assessed in association to age, gender and suspected epidemiological risk factors. Mortality follow-up was performed in 2015 for all SHIP participants (mean follow-up period 5.9 years, range 3.2-7.5 years).

RESULTS

At baseline pancreatic cysts had a weighted prevalence of 49.1%, with an average number of 3.9 (95% CI 3.2 to 4.5) cysts per subject in the subgroup harbouring cysts. Cyst size ranged from 2 to 29 mm. Prevalence (p<0.001), number (p=0.001) and maximum size (p<0.001) increased significantly with age. The 5-year follow-up revealed a weighted incidence of 12.9% newly detected pancreatic cysts. 57.1% of the subjects initially harbouring pancreatic cysts showed an increase in number and/or maximum cyst size. Of all subjects undergoing MRCP, no participant died of pancreatic diseases within mortality follow-up.

CONCLUSION

The prevalence of pancreatic cysts in the general population is unexpectedly high, and their number and size increase with age. Overall, no pancreatic cancer was observed in this collective during a 5-year follow-up. Nevertheless, prospective follow-up imaging showed minimal progress in more than 50%. Only about 6% of cysts and 2.5% of the study group initially presented with cysts of more than 1 cm and thus might be clinically meaningful.

The utilization of imaging features in the management of intraductal papillary mucinous neoplasms

Intraductal papillary mucinous neoplasms (IPMNs) represent a group of cystic pancreatic neoplasms with large range of clinical behaviours, ranging from low-grade dysplasia or borderline lesions to invasive carcinomas. They can be grouped into lesions originating from the main pancreatic duct, main duct IPMNs (MD-IPMNs), and lesions which arise from secondary branches of parenchyma, denominated branch-duct IPMNs (BD-IPMNs). Management of these cystic lesions is essentially based on clinical and radiological features. The latter have been very well described in the last fifteen years, with many studies published in literature showing the main radiological features of IPMNs. Currently, the goal of imaging modalities is to identify "high-risk stigmata" or "worrisome feature" in the evaluation of pancreatic cysts. Marked dilatation of the main duct (>1 cm), large size (3-5 cm), and intramural nodules have been associated with increased risk of degeneration. BD-IPMNs could be observed as microcystic or macrocystic in appearance, with or without communication with main duct. Their imaging features are frequently overlapped with cystic neoplasms. The risk of progression for secondary IPMNs is lower, and subsequently an imaging based follow-up is very often proposed for these lesions.

Misdiagnosis of pancreatic papillary mucinous cystadenocarcinoma: A case report

The morbidity of papillary cystadenocarcinoma of the pancreas is extremely low and the condition is rarely first found as spinal metastases, thus it is often misdiagnosed prior to surgery. The present study reports a case of papillary cystadenocarcinoma with thoracolumbar metastases in a 56-year-old male. The first symptom to occur was backache, however, computed tomography revealed no positive findings. The pain became exacerbated and the patient underwent lumbar and thoracic vertebrae magnetic resonance imaging, which identified abnormal signals. Imaging and pathological examinations were used for the final diagnosis. Due to multiple bone metastases, the patient the administration of induction chemotherapy was suggested, however, the patient refused. The patient succumbed to the disease in June 2013.

Endoscopic ultrasound and pancreatic cystic lesions-diagnostic and therapeutic applications

Pancreatic cystic lesions are being detected with an increasing frequency. Endoscopic ultrasound (EUS) provides both diagnostic and therapeutic means for pancreatic cystic lesions. Detailed imaging and EUS-guided fine-needle aspiration provide additional information on pancreatic cystic lesions. EUS-guided pseudocyst drainage has advantages over conventional drainage modalities. EUS-guided cyst ablation is a promising therapeutic modality.

Incidental pancreatic cysts: natural history and diagnostic accuracy of a limited serial pancreatic cyst MRI protocol

OBJECTIVES

To examine the natural history of incidentally detected pancreatic cysts and whether a simplified MRI protocol without gadolinium is adequate for lesion follow-up.

METHODS

Over a 10-year period, 301-patients with asymptomatic pancreatic cysts underwent follow-up (45 months ± 30). The magnetic resonance imaging (MRI) protocol included axial, coronal T2-weighted images, MR cholangiopancreatographic and fat suppressed T1-weighted sequences before and after gadolinium. Three radiologists independently reviewed the initial MRI, the follow-up studies using first only unenhanced images, then secondly gadolinium-enhanced-sequences. Lesion changes during follow-up were recorded and the added value of gadolinium-enhanced sequences was determined by classifying the lesions into risk categories.

RESULTS

Three hundred and one patients (1,174 cysts) constituted the study population. Only 35/301 patients (12 %) showed significant lesion change on follow-up. Using multivariate analysis the only independent factor of lesion growth (OR = 2.4; 95 % CI, 1.7-3.3; P < 0.001) and mural nodule development (OR = 1.9; 95 % CI, 1.1-3.4, P = 0.03) during follow-up was initial lesion size. No patient with a lesion initial size less than 2 cm developed cancer during follow-up. Intra-observer agreement with and without gadolinium enhancement ranged from 0.86 to 0.97. After consensus review of discordant cases, gadolinium-enhanced sequences demonstrated no added value.

CONCLUSION

Most incidental pancreatic cystic lesions did not demonstrate change during follow-up. The addition of gadolinium-enhanced-sequences had no added-value for risk assignment on serial follow-up.

KEY POINTS

Significant growth of pancreatic cysts occurred in a minority of patients only. No lesion <2 cm demonstrated any change during the first year of follow-up. Intra-observer agreement between MR pancreatic protocols with and without gadolinium was excellent. Gadolinium application had limited value for follow-up of asymptomatic pancreatic cystic lesions.

Rate of growth of pancreatic serous cystadenoma as an indication for resection

BACKGROUND

The purpose of this study was to examine the natural history and growth rate of pancreatic serous cystadenomas (SCAs) to determine which factors lead to resection for these benign neoplasms.

METHODS

We reviewed retrospectively a prospectively maintained database, identifying patients diagnosed with SCAs of the pancreas. The diagnosis was made via a combination of classic imaging features with or without cyst aspiration results consistent with SCA. To determine growth rates, gamma regression models were used and the average was modeled using the log function.

RESULTS

A prospectively maintained database of 1,241 pancreatic cystic neoplasms was queried from 1998 to 2010. A total of 219 patients (18%) were diagnosed with SCA, 194 in the surveillance group and 25 in the resection group. Twenty patients underwent resection after initial imaging principally for presence of symptoms and indeterminate diagnosis, and 5 underwent resection after surveillance for development of symptoms and/or rapid rate of growth. Rate of growth increased at a steady state over time, with an estimated doubling time of 12 years (95% confidence interval, 7.8-21.5).

CONCLUSION

This study shows that growth patterns are similar for SCAs of the pancreas regardless of initial size. When doubling time is faster than 12 years, resection should be considered.

Should we do EUS/FNA on patients with pancreatic cysts? The incremental diagnostic yield of EUS over CT/MRI for prediction of cystic neoplasms

OBJECTIVES

To evaluate the performance characteristics of endoscopic ultrasonography (EUS) compared with computed tomography (CT) and magnetic resonance imaging (MRI) and determine the incremental diagnostic yield and accuracy of EUS with or without fine needle aspiration (FNA) over CT and MRI for prediction of neoplastic pancreatic cysts.

METHODS

The EUS database was queried for procedures performed for pancreatic cysts between March 2006 and January 2010. Cystic pancreatic ductal adenocarcinoma, cystic pancreatic neuroendocrine tumor, mucinous cystic neoplasm, intraductal papillary neoplasm, and solid pseudopapillary neoplasm were categorized as neoplastic; pseudocysts and serous cysts were designated as nonneoplastic/low risk.

RESULTS

Final diagnoses were established by surgery in 154 patients (mucinous cystic neoplasm/intraductal papillary neoplasm [69.4%], pancreatic neuroendocrine tumor [10%], pancreatic ductal adenocarcinoma [6.4%], solid pseudopapillary neoplasm [0.6%], nonneoplastic/low risk [13.6%]). Endoscopic ultrasonography with or without FNA was superior to CT and MRI in accurately classifying a cyst as neoplastic (P < 0.0001). After CT and MRI, EUS increased the rate of correctly predicting neoplastic cysts in 43 (36%) and 27 (54%) additional cases, respectively.

CONCLUSIONS

The incremental increase in diagnostic yield of EUS and fluid analysis over CT and MRI for prediction of a neoplastic cyst is 36% and 54%, respectively. The addition of EUS-FNA to abdominal imaging significantly increases overall accuracy for diagnosis of neoplastic pancreatic cysts.

Incidentally discovered benign pancreatic cystic neoplasms not communicating with the ductal system: MR/MRCP imaging appearance and evolution

PURPOSE

The authors sought to determine magnetic resonance/magnetic resonance cholangiopancreatography (MR/MRCP) imaging features of incidentally discovered benign, noncommunicating cystic neoplasms (BNCNs) of the pancreas to assess their evolution over time and identify MR/MRCP imaging features predictive of tumour growth.

MATERIAL AND METHODS

This was a retrospective study, so informed consent was waived. Sixty-two patients with a diagnosis of BNCN were assessed. Inclusion criteria were incidentally discovered cystic neoplasm of the pancreas with nonmeasurable walls, no mural nodules and no communication with the pancreatic ductal system and who underwent ≥ 1 MR/MRCP examination. Image analysis, performed at diagnosis and during follow-up, included macroscopic pattern (microcystic/macrocystic/mixed), number of cysts (unicystic/oligocystic/multicystic), BNCN maximum diameter and tumour growth rates.

RESULTS

A total of 64 BNCNs was detected. Macroscopic pattern was mixed in 31/64 (48%), microcystic in 28/64 (44%) and macrocystic in 5/64 (8%). BNCNs appeared multicystic in 38/64 (59%) cases, oligocystic in 22/64 (35%) and unicystic in 4/64(6%). All qualitative parameters remained unchanged during follow-up. At diagnosis, the median maximum BNCN diameter was 35.0 mm and 38.0 mm at the final examination (p<0.001). BNCNs showed a tumour growth rate of 2 mm/year.

CONCLUSIONS

Mixed and microcystic patterns were the most common, accounting for 48% and 44% of cases, respectively, and showed no change over time. MR/MRCP features predictive of lesion enlargement were a mixed/ macrocystic pattern, and lesion size was >3 cm (both p<0.001).

Serous cyst adenoma of the pancreas: appraisal of active surgical strategy before it causes problems

BACKGROUND

Patients who are diagnosed with symptomatic or ambiguous serous cyst adenoma (SCA) need surgery. The purpose of this study is to suggest a potential management plan based on analysis of surgically treated SCAs.

METHODS

Between August 1995 and December 2010, 38 patients with SCA were surgically treated. Data were analyzed retrospectively.

RESULTS

Among 38 patients, 28 were female and ten were male. Mean age was 49.6 ± 14.1 years, and five patients (13.2%) were older than 65 years. Among the five patients, two were more than 70 years old. Seventeen patients (44.7%) were symptomatic, and the rest (21, 55.3%) were incidentally found to have SCA. Twenty-seven patients underwent open pancreatectomy, and 11 patients received laparoscopic distal pancreatectomy. Mean tumor size was 4.4 ± 2.8 cm. Most asymptomatic patients of SCA had a left-sided pancreatic tumor and distal pancreatectomy with or without splenectomy were frequently performed with short operative time and less blood transfusion (P < 0.05). Minimally invasive surgery was mostly applied to left-sided tumors less than 5 cm in size (11/19 vs. 0/6, P = 0.029). Combined resection of the right colon was performed in two patients (5.3%) due to severe adhesion associated with large tumors. Significant association was noted between age and tumor size in asymptomatic patients (correlation coefficient = 0.541, R (2) = 0.293, P = 0.014). Postoperative pancreatic fistula was observed in five patients (13.2%, grade B) but could be managed conservatively. No mortality was found.

CONCLUSION

Before SCA causes symptoms or grows larger than 5 cm, an active surgical approach, such as minimally invasive surgery, needs to be considered.

Precursor Lesions of Pancreatic Cancer: A Current Appraisal on Diagnosis

 The dramatic increase in the number of patients diagnosed with incidental pancreatic cysts through imaging methods provides a unique opportunity to detect and treat these precursor lesions of ductal adenocarcinoma before their manifestation. However, without any reliable biomarkers, the cost-effectiveness and the limited accuracy of high-resolution imaging techniques for diagnose and staging seems troublesome. Small pancreatic cysts can be easily detected, but many are clinically irrelevant and are not harmful to the patient. Furthermore, patients with clinically benign lesions are at high risk of overtreatment and morbidity and mortality from unnecessary surgical intervention. It is believed that cyst fluid analysis may provide important information for a possible diagnosis, allowing stratification and treatment of these patients. Anyway, only the logical reasoning based on all available information (medical history, imaging, and laboratory analysis of the aspirated cyst fluid) can adequately stratify patients. It has been considered that there are three precursor lesions of the pancreatic cancer (PC): mucinous cystadenoma (MCA), intraductal papillary mucinous tumor (IPMT) and pancreatic intraepithelial neoplasia (PanIN). MCA and IPMT can be diagnosed by imaging methods, but PanIN are difficult to be identified. They must be detected and treated as soon as possible, as this is the only way to increase survival and reduce mortality of pancreatic ductal adenocarcinoma. The aim of this work is to establish diagnosis, staging, and the pathological findings and to compare the effectiveness and accuracy of the other imaging methods versus endoscopic ultrasound guided fine-needle aspiration (EUS-FNA) for diagnosis of malignancy in the precursor lesions of pancreatic cancer.

MDCT evaluation of the growth kinetics of serous and benign mucinous cystic neoplasms of the pancreas

We assessed the growth kinetics of pathologically proven benign neoplastic cystic lesions of the pancreas. The volume and longest axial diameter (LAD) of 20 pathologically proven pancreatic cystic lesions (12 mucinous cystic neoplasms (MCN) and 8 serous cystadenomas (SCN)) on 2 multidetector computed tomography scans, obtained before resection, were measured. Reciprocal of doubling time, doubling time and growth rate based on volume and LAD were calculated. A P value <0.05 was considered significant. For all cysts, growth kinetics based on volume were: reciprocal of doubling time (mean = 3.03, median=1.0), doubling time (mean = 644, median = 388 days) and growth rate (mean = 74.7, median = 5.7 ml/year). Results based on LAD were: reciprocal of doubling time (mean = 3.09, median = 1.3), doubling time (mean = 752, median = 273 days) and growth rate (mean = 24.5, median = 5.6 mm/year). These variables were not statistically different between MCNs and SCNs (P > 0.05 in all instances). Reciprocal of doubling time based on volume and LAD were comparable (P > 0.05). We concluded that the mean reciprocal of doubling time was 3.03 and 3.09 using volume and LAD, respectively. This may aid in designing follow-up guidelines for pancreatic cysts.

Tumor size and location correlate with behavior of pancreatic serous cystic neoplasms

OBJECTIVES

The majority of pancreatic serous cystic neoplasms (SCNs) are benign. However, these neoplasms can cause symptoms and rarely can be aggressive. Identification of factors associated with symptomatic or aggressive SCNs may aid management decisions. The aim of this study was to identify variables that predict aggressive SCNs.

METHODS

Prospective pathology database was queried for SCNs that were surgically resected at Johns Hopkins Hospital. Tumors were considered aggressive if they invaded surrounding structures and/or vessels or if they metastasized to lymph nodes or distant organs. The associations of gender, tumor size, and tumor location, with the presence or absence of symptoms and tumor behavior were examined using Fisher's exact test, logistic regression, and multivariate analyses.

RESULTS

A total of 257 patients with SCNs underwent surgical resection. Mean tumor diameter was 4.9 cm. Tumor location in the head of pancreas (HOP) was associated with symptoms (odds ratio (OR) 1.87, 95% confidence interval (CI) 1.1-3.3). Computed tomography (CT) predicted the diagnosis of SCN in approximately a quarter of patients. Thirteen tumors (mean 10.5 cm) were considered aggressive. Multivariate analysis showed that tumor diameter (OR 1.53, 95% CI 1.24-1.89) and location of tumor in pancreatic head (OR 10.44, 95% CI 1.73-63.04) were independently associated with aggressive behavior.

CONCLUSIONS

We describe the largest case series of patients with pathologically proven SCNs. CT performed poorly in preoperative diagnosis of SCNs. Large tumor size and head location predicted aggressive behavior. These factors should be considered in the management of patients with SCN.

Serous Cystic Neoplasm: Do We Have to Wait Till It Causes Trouble?

Serous cystic neoplasm (SCN) of the pancreas is considered a benign tumor with almost no malignant potential. Most surgeons agree that asymptomatic SCN requires only regular observation. However, several complexities and interference with organ preservation during the operation, may develop when a huge symptomatic tumor is treated with surgery. So, the purpose of this study is to develop a potential management plan based on a literature review and by describing three recent cases of SCN of the pancreas. We suggest that SCNs be responded to with a timely and appropriate surgical intervention - before they require clinical attention.

Primary pancreatic cystic neoplasms revisited: part II. Mucinous cystic neoplasms

Mucinous cystic neoplasms (MCNs) of the pancreas represent one of the most common primary pancreatic cystic neoplasms, accounting for approximately half of these cases. MCNs are observed almost exclusively in women, and most commonly are located in the body/tail of the pancreas. In contrast to SCNs, MCNs have malignant potential. Proliferative changes (hyperplasia with or without atypia, borderline changes, non-invasive or carcinomas in-situ, and invasive carcinomas) can often be observed within the same neoplasm. Several risk factors for the presence of underlying malignancy within an MCN have recently been recognized. Cross-sectional imaging is of key importance for the diagnostic evaluation of patients with a cystic pancreatic lesion. Cyst fluid examination (cytology, biochemical/genetic analysis) is possible by using fine needle aspiration of the MCN, usually under endoscopic guidance, and may provide useful information for the differential diagnosis. Since MCNs have malignant potential, surgical resection is the treatment of choice.

Primary pancreatic cystic neoplasms revisited. Part I: serous cystic neoplasms

Primary pancreatic cystic neoplasms have been recognized increasingly during the two recent decades and include mainly serous cystic neoplasms, mucinous cystic neoplasms, and intraductal papillary mucinous neoplasms. Serous cystic neoplasms represent about 30% of all cystic neoplasms of the pancreas and are characterized by their microcystic appearance (on imaging, macroscopically, and microscopically) and their benign biologic behavior. Modern diagnostic methodology allows the preoperative diagnosis with an acceptable accuracy. Currently, indications for resection of serous cystic neoplasms of the pancreas include the presence of symptoms, size > 4 cm (because these 'large' neoplasms have a more rapid growth rate and probably will soon become symptomatic), and any uncertainty about the diagnosis of a serous versus a mucinous cystic neoplasm. Resection should also be considered for lesions in the body/tail of the pancreas. Conservative treatment is a reasonable option in selected patients (for example in the presence of small, asymptomatic lesions in the pancreatic head, especially in the frail or elderly patient).

Relative accuracy of CT and MRI in the differentiation of benign from malignant pancreatic cystic lesions

AIMS

To assess the diagnostic accuracies of multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) for differentiating benign from malignant lesions and suggesting the specific diagnoses for pancreatic cystic lesions, and to assess whether review of both MDCT and MRI is beneficial.

MATERIALS AND METHODS

Patients with various neoplastic and non-neoplastic pancreatic cystic lesions that were identifiable by biopsy or surgery, who underwent both MRI and MDCT (n=63), were retrospectively reviewed by three reviewers. The likelihood of malignancy was recorded on a five-point scale, and a specific diagnosis was given. ROC analysis was performed and the sensitivity, specificity for the characterization of malignancy, and the accuracy of specific diagnoses were calculated.

RESULTS

MDCT and MRI yielded comparable results for the characterization of malignancy (Az: 0.639, 0.735, 0.806 for MDCT and 0.732, 0.753, 0.792 for MRI, for each reviewer). The accuracies of specific diagnosis based on MDCT or MRI were 61.9 versus 55.6% for reviewer 1; 76.2 versus 76.2% for reviewer 2; and 65.1 versus 61.9% for reviewer 3. There was a trend toward better prediction of malignancy (Az: 0.787, 0.745, 0.849 for each reviewer), and better accuracy in suggesting a specific diagnosis (77.8, 73, and 73% for each reviewer) for MDCT+MRI over MDCT or MRI alone, although it was statistically significant for one reviewer in the comparison of MDCT versus MDCT+MRI for the prediction of malignancy, and MRI versus MDCT for suggesting a specific diagnosis.

CONCLUSIONS

MDCT and MRI have equivalent accuracy for characterizing pancreatic cystic lesions as benign or malignant, and suggesting a specific diagnosis. Combined review of MDCT and MRI was not significantly better but may have the potential to improve diagnostic accuracy in equivocal cases.

Pleomorphic giant cell carcinoma of the pancreas with hepatic metastases--initially presenting as a benign serous cystadenoma: a case report and review of the literature

INTRODUCTION

Pleomorphic giant cell pancreatic cancer is a very rare and aggressive pancreatic neoplasm. A case of pleomorphic giant cell pancreatic cancer presenting as a cystic lesion and in association with a serous cystadenoma presents a unique case which has not been described before.

CASE PRESENTATION

A 44-year-old alcoholic man presented with abdominal pain, vomiting, and weight loss. Initially, imaging suspected a pancreatic pseudocyst measuring 4.2 cm. Endoscopic ultrasound- (EUS-) guided fine-needle aspiration revealed a serous cystadenoma. With conservative intervention only (fluid resuscitation, analgesia, and antiemetics) the patient improved and was discharged under close observation. Follow-up scan at four months revealed minimal change. Three months later, he was admitted acutely. Repeat scans demonstrated mild cyst enlargement with new liver lesions. Laparoscopic biopsy revealed pleomorphic giant cell carcinoma with the organ of origin the pancreas.

CONCLUSION

This unusual case highlights the challenges in managing pancreatic cystic lesions and emphasizes the importance of considering less common forms of pancreatic cystic masses when the findings are atypical for the presentation. Surgical excision in these cases over conservative steps may be the most appropriate management.

Management of mucinous cystic neoplasms of the pancreas

The purpose of this study was to investigate the actual management of mucinous cystic neoplasm (MCN) of the pancreas. A systematic review was performed in December 2009 by consulting PubMed MEDLINE for publications and matching the key words “pancreatic mucinous cystic neoplasm”, “pancreatic mucinous cystic tumour”, “pancreatic mucinous cystic mass”, “pancreatic cyst”, and “pancreatic cystic neoplasm” to identify English language articles describing the diagnosis and treatment of the mucinous cystic neoplasm of the pancreas. In total, 16 322 references ranging from January 1969 to December 2009 were analysed and 77 articles were identified. No articles published before 1996 were selected because MCNs were not previously considered to be a completely autonomous disease. Definition, epidemiology, anatomopathological findings, clinical presentation, preoperative evaluation, treatment and prognosis were reviewed. MCNs are pancreatic mucin-producing cysts with a distinctive ovarian-type stroma localized in the body-tail of the gland and occurring in middle-aged females. The majority of MCNs are slow growing and asymptomatic. The prevalence of invasive carcinoma varies between 6% and 55%. Preoperative diagnosis depends on a combination of clinical features, tumor markers, computed tomography (CT), magnetic resonance imaging, endoscopic ultrasound with cyst fluid analysis, and positron emission tomography-CT. Surgery is indicated for all MCNs.

Management of pancreatic serous cystadenomas

With more widespread use of imaging, cystic neoplasms of the pancreas are being diagnosed with increased frequency. Serous cystadenomas are the most common type of cystic neoplasm of the pancreas and have a natural history and malignant potential different than that of other cystic neoplasms. Although characteristic findings on imaging may be supportive, definitive diagnosis of these lesions often cannot be made by imaging alone. Endoscopic ultrasound with fine needle aspiration and cyst aspiration may facilitate the diagnosis, and after definitive diagnosis, patients with lesions that are small and asymptomatic may be followed with serial imaging. If definitive diagnosis cannot be made or if the patient is symptomatic, resection is warranted. In addition, large (> 4 cm) serous cystadenomas should be resected in appropriate surgical candidates given their propensity for growth and developing symptoms.

Cystic neoplasms of the pancreas: A diagnostic challenge

Cystic neoplasms of the pancreas are increasingly recognized due to the expanding use and improved sensitivity of cross-sectional abdominal imaging. Major advances in the last decade have led to an improved understanding of the various types of cystic lesions and their biologic behavior. Despite significant improvements in imaging technology and the advent of endoscopic-ultrasound (EUS)-guided fine-needle aspiration, the diagnosis and management of pancreatic cystic lesions remains a significant clinical challenge. The first diagnostic step is to differentiate between pancreatic pseudocyst and cystic neoplasm. If a pseudocyst has been effectively excluded, the cornerstone issue is then to determine the malignant potential of the pancreatic cystic neoplasm. In the majority of cases, the correct diagnosis and successful management is based not on a single test but on incorporating data from various sources including patient history, radiologic studies, endoscopic evaluation, and cyst fluid analysis. This review will focus on describing the various types of cystic neoplasms of the pancreas, their malignant potential, and will provide the clinician with a comprehensive diagnostic approach.

[Importance of endoscopy and endosonography for chronic pancreatitis and benign pancreas tumors]

Endoscopic retrograde pancreatography (ERP) and endoscopic ultrasound (EUS) are superior to cross-sectional imaging procedures for detection of low-grade pancreatitis, but detection of duct alterations is more reliable by middle and high-grade chronic pancreatitis than by low-grade. In addition to assessment of alterations in the pancreatic duct, EUS also allows detection of parenchymatous alterations. Because of the risk of post-ERP pancreatitis, ERP has been mostly eliminated from diagnostic procedures. In contrast, endoscopic retrograde cholangiopancreatography (ERCP) allows an unrivalled access to interventional treatment of inflammatory alterations of the biliopancreatic duct system, by retrograde, non-penetrable papillae even in the rendezvous procedure with EUS-assisted probing of the Ductus Wirsungianus. Despite the technical success of endoscopic procedures, surgical duct decompression has proven to be superior for relief from pancreatitic pain. Biliary drainage is also more likely to be successful on a permanent basis using surgical procedures than by repeat multi-stenting, at least by calcifying pancreatitis. Peroral transgastral transmural therapy of postpancreatitic necroses opens up further options over surgical removal of necroses.

Correlation between CT patterns and pathological classification of intraductal papillary mucinous neoplasm

OBJECTIVE

To examine CT patterns of intraductal papillary mucinous neoplasm (IPMN), analyze their correlation with pathologic classification, and discuss the value of CT in the diagnosis and differential diagnosis of IPMN.

METHODS

CT patterns of 39 IPMN patients, whose clinical data were complete and whose diagnosis was confirmed by surgery and pathology, were classified into three types: (1) simple main pancreatic duct (MPD) dilation type, (2) MPD dilation with pancreatic cystic lesion type, and (3) simple pancreatic cystic lesion type. Correlations between the three CT types and Takada pathologic classification (MPD type, furcation type and mixture type) were analyzed. The 39 IPMN cases were pathologically classified as the benign group and the malignant/borderline group. CT characteristics including the presence or absence of mural nodules, intrafocal partitions, focal size and the degree of MPD and common bile duct (CBD) dilation were analyzed statistically.

RESULTS

A correlation was found between the CT simple MPD dilation type and the pathological MPD type, between the MPD dilation with pancreatic cystic lesion type and the furcation and mixture types, and between the simple cystic lesion type and the furcation type (p<0.001). The benign rate was 92% in patients without intrafocal mural nodules, and 42% in patients with intrafocal mural nodules. The difference between the two groups was statistically significant (p=0.003). The presence or absence of intrafocal partitions was not correlated with benignancy or malignancy (p=0.793). The maximum diameter of malignant/borderline lesions was bigger than that of benign ones (p=0.016). There was no significant difference in MPD and CBD diameters between the benign and malignant/borderline groups. Regardless of pathological classification, the MPD diameter was larger than the CBD diameter in all cases (p=0.02).

CONCLUSION

The three CT types of IPMN well correlated with the pathologic classification, which is helpful for analyzing CT manifestations and improving the accuracy of diagnosis. MPD dilation is usually larger than CBD dilation in IPMN patients, which is also helpful in the diagnosis and differential diagnosis of IPMN in the context of other related findings.

Update in imaging of cystic pancreatic masses for gastroenterologists

Cystic pancreatic masses are increasingly recognized as a direct consequence of widespread imaging. Once detected, there is controversy as to further management. This review briefly describes the radiologic appearance of these lesions on computed tomography or magnetic resonance imaging. Recommendations for management based on the imaging findings are discussed.

Advances in pancreatitic intraductal papillary mucinous neoplasms

Intraductal papillary mucinous neoplasms (IPMNs) are a well-characterized group of intraductal mucin-producing cystic neoplasms of pancreas with clear malignant potential. It has a favorable prognosis and distinct molecular or clicinopathologic features compared with other types of pancreatic tumors. In addition, IPMNs can be divided into several subtypes in accordance with the papillary structure and mucin expression profile. Importantly, as IPMNs are acknowledged as key stages during pancreatic carcinogenesis, it can better reveal the mechanism and biological characteristics of IPMNs through further investigation of the pathologic features and the molecular aberrations harbored in different subtypes of IPMNs. This paper reviewed relevant literatures and elucidated its progression in terms of the molecular and clicinopathologic characteristics, diagnosis, treatment and prognosis of IPMNs.

Endoscopic diagnosis and treatment of pancreatic cysts

Pancreatic cystic neoplasms have emerged as an important new opportunity for many disciplines to participate in the diagnosis and management of early pancreatic neoplasia. With an increase in an understanding of these lesions and their potential for malignant transformation, there has been a dramatic increase in the frequency of diagnosis. We critically examined the literature on diagnostic methods for pancreatic cystic lesions over the past 5 years. The methods of endoscopic pancreatic pseudocyst drainage and clinical outcomes are also discussed. Morphologic studies of cystic lesions using cross-sectional imaging or endoscopic ultrasound have a low diagnostic rate. Cyst fluid analysis with the use of tumor markers (eg, carcinoembryonic antigen) increases the accuracy of diagnosis. The management of cystic lesions is heavily dependent on the type of cyst, the neoplastic potential, and the risk of surgery. The traditional therapy is pancreatic resection and not cyst enucleation. In contrast to cystic neoplasms, pseudocysts are localized collections of inflammatory fluid that mimic cystic neoplasms. The fluid collections arise from chronic pancreatitis and ductal leaks. Because pseudocysts have no neoplastic potential, they can be drained rather than resected. Drainage can be safely accomplished with external catheters or endoscopically with internal catheters. As we learn more about the pathophysiology of the various cystic lesions, treatment will be tailored to the specific cyst lesion. Endoscopic ultrasound has an important role in the characterization of pancreatic cystic lesions and helps in selection of the optimal treatment modality.

Management of serous cystadenoma of the pancreas

Serous cystadenoma of the pancreas is a diagnosis being entertained with increasing frequency. The histopathologic findings, diagnostic strategy, differential diagnosis, and treatment strategy of these generally benign but sometimes symptomatic lesions are discussed. Based on the available case series, surgical resection should be considered in good-risk patients with symptomatic tumors, with tumors at least 4 cm in maximum diameter, or in whom a more worrisome diagnosis cannot be excluded.

Asymptomatic pancreatic cysts: a decision analysis approach to observation versus resection

OBJECTIVES

Pancreatic cysts are being found with increasing frequency. Although symptomatic cysts should be resected, what to do about asymptomatic cysts is less clear. The purpose of this study was to determine threshold values to choose resection over observation for a patient with an asymptomatic pancreatic cyst.

METHODS

Decision analysis assesses the consequences of a decision based on occurrence probabilities. This decision analysis assessed 1 decision, to resect or observe a patient with an asymptomatic pancreatic cyst. The consequences for resection are operative mortality/no operative mortality, short-term morbidity of patients surviving the operation, benign/malignant cyst, and life expectancy after resection of malignant lesions. The probabilities are based on the extant literature. The age-specific life expectancy for benign cysts was considered the same as for the general age-specific population from the 2002 United States Life Table. Because the operative mortality, distribution of benign versus malignant cysts, and life expectancy after resection or observation for malignant cysts vary, sensitivity analysis was done to assess the threshold values of these factors when resection becomes favored over observation.

RESULTS

The baseline decision analysis is based on the following assumptions: 30% of lesions are malignant, operative mortality rate is 3%, and the 5-year survival rate of resected malignant cysts is 50%. Varying on age, the risk of the cystic lesion being malignant to favor resection is greater than 11.6% to 15.5%, the operative mortality rate has to be less than 7.4% to 13.8%, and the life expectancy gain by resecting, rather than observing a malignant lesion, has to be greater than 3.49 to 5.38 years.

CONCLUSIONS

The decision to resect must be based on the surgeon's operative mortality rate, the predicted operative mortality for the individual patient, the probability that the lesion is malignant, and the survival difference between resecting and observing malignant cystic lesions. Overall, for resection to be recommended, the physician must believe that the risk that the lesion is malignant is approximately 15% or greater, that the life expectancy gained from resection be approximately 5 years or greater, and that the surgeons' operative mortality rate be approximately 8% or less.

Technology insight: applications of MRI for the evaluation of benign disease of the pancreas

This article reviews the role of MRI in the evaluation of benign pancreatic disease. Although MRI and magnetic resonance cholangiopancreatography (MRCP) are most often used to evaluate the liver and bile duct, technical advances such as the use of secretin stimulation also allow for high-quality imaging of the pancreas and pancreatic ductal system. Secretin-stimulated MRCP (S-MRCP) can aid the diagnosis of acute and chronic pancreatitis, and delineate ductal pathology such as benign strictures and duct leaks. There seems to be a role for S-MRCP in the assessment of pancreatic function and (possibly) sphincter of Oddi dysfunction. When endoscopic or surgical therapy is planned, S-MRCP can help to establish a diagnosis as well as offer a 'road map' to guide therapy. S-MRCP is noninvasive and almost entirely without risk to the patient, which gives it a distinct advantage over traditional endoscopic methods of diagnosis for conditions such as pancreas divisum and other ductal pathology. The information provided by S-MRCP, obtained before endoscopic or surgical therapy is attempted, can assist the patient and physician in making a fully informed decision with regard to the risks and probable benefits of any planned intervention.

Cystic pancreatic lesions: a simple imaging-based classification system for guiding management

Cystic lesions of the pancreas are increasingly being recognized due to the widespread use of cross-sectional imaging. The initial evaluation of a pancreatic cyst should be directed toward exclusion of a pseudocyst. Patients with pseudocysts generally have a history of acute or chronic pancreatitis, whereas those with cystic tumors most often lack such a history. Several types of cystic lesions are encountered in the pancreas. Because of morphologic overlap at imaging, accurate characterization of these lesions can be difficult. Computed tomography and magnetic resonance imaging are excellent modalities for both initial detection and characterization of cystic pancreatic lesions. An imaging classification system for these lesions has been proposed that is based on the morphologic features of the lesion. This system can be helpful in characterizing lesions, narrowing the differential diagnosis, and making decisions regarding the treatment of affected patients. Endoscopic ultrasonography-guided aspiration and biopsy is useful in cases that are indeterminate at cross-sectional imaging or that require observation.

Intraductal papillary mucinous neoplasms of the pancreas: A surgical perspective

Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas represent a relatively "new", but increasingly recognized entity. The emergence of this entity is due primarily to the widespread use of modern imaging methods, but also to a heightened awareness of physicians regarding this cystic neoplasm of the pancreas. No signs or symptoms are pathognomonic of IPMNs, but frequently, patients have a pancreatitis-like abdominal pain. Fully one-third of patients with IPMN are asymptomatic at the time of diagnosis. Cross-sectional imaging (ultrasonography, computed tomography, magnetic resonance cholangiopancreatography), endoscopic retrograde cholangiopancreatography, and endoscopic ultrasonography are the diagnostic and staging methods of choice in the evaluation of patients with IPMNs. IPMNs show a wide spectrum of histologic changes, ranging from adenoma to invasive neoplasm, even within the same neoplasm, suggesting a "field defect" predisposing major segments or even the entire ductal epithelium to the development of IPMN. Fine-needle aspiration/cytology and/or analysis of the cystic fluid may be useful diagnostic tools; however, these examinations are associated with high false-negative rates. Complete surgical resection is the therapeutic method of choice. The extent and type of pancreatectomy remain somewhat controversial but should be based on morphologic changes of the pancreas. Even the role of adjuvant therapy remains unclear; however, being "duct-derived" neoplasms of potential malignant character, some form of adjuvant chemo- or ratio-therapy seems indicated in the presence of invasive disease, despite a "curative" resection. In the absence of invasive disease, prognosis after R0 resection is highly favorable with recurrences of 5-10%. However, invasive IPMNs behave quite similar to ductal adenocarcinoma of the pancreas when analyzed stage-by-stage, with a slightly better prognosis; however, even after an R0 resection, recurrence is common.

Cystic neoplasms of the pancreas; What a clinician should know

Primary cystic neoplasms of the pancreas (serous cystic neoplasms, mucinous serous neoplasms, and intraductal papillary mucinous neoplasms) are lesions of emerging importance. With the wide availability of modern imaging methods, these neoplasms are being recognized with increasing frequency. Due to the improvement of these sophisticated imaging techniques, it is often possible to differentiate preoperatively these primary pancreatic cystic neoplasms not only from other cystic pancreatic disorders (such as pancreatic pseudocysts) but also from one another. This differentiation is very important for the clinician, since these neoplasms have radically different biologic behavior. Serous cystic neoplasms are uniformly benign and usually do not mandate resection unless the lesion is symptomatic. In contrast, mucinous cystic neoplasms and intraductal papillary mucinous neoplasms have a premalignant or overtly malignant tendency, and therefore should be managed aggressively by pancreatic resection. In these mucinous cystic neoplasms, recognition of an underlying malignancy is often not possible without a detailed histopathologic examination of the entire resected specimen. In the absence of invasive disease, prognosis is excellent after appropriate surgery. The presence of invasive malignancy signifies a poor prognosis.

Serous cystadenoma of the pancreas: tumor growth rates and recommendations for treatment

OBJECTIVE

To define the natural history and optimal management of serous cystadenoma of the pancreas.

SUMMARY BACKGROUND DATA

Serous cystadenoma of the pancreas is the most common benign pancreatic neoplasm. Diagnostic criteria, potential for growth or malignancy, and outcomes are not well defined. As a result, management for patients with serous cystadenomas varies widely in current practice.

METHODS

A total of 106 patients presenting with serous cystadenoma of the pancreas from 1976-2004 were identified. Hospital records were evaluated for patient and tumor characteristics, diagnostic workup, treatment, and outcome. Twenty-four patients with serial radiographic imaging were identified, and tumor growth curves calculated.

RESULTS

Mean age at presentation was 61.5 years and 75% of patients were female. The most common symptoms were abdominal pain (25%), fullness/mass (10%), and jaundice (7%); 47% were asymptomatic. Mean tumor diameter was 4.9 +/- 3.1 cm, which did not vary by location. Tumors <4 cm were less likely to be symptomatic than were tumors > or =4 cm (22% vs. 72%, P < 0.001). The median growth rate in the patients who had serial radiography was 0.60 cm/y. For tumors <4 cm at presentation (n = 15), the rate was 0.12 cm/y, whereas for tumors > or =4 cm (n = 9), the rate was 1.98 cm/y (P = 0.0002). Overall, 86 patients underwent surgery, with one perioperative death.

CONCLUSIONS

Large (>4 cm) serous cystadenomas are more likely to be symptomatic. Although the median growth rate for this neoplasm is only 0.6 cm/y, it is significantly greater in large tumors. Whereas expectant management is reasonable in small asymptomatic tumors, we recommend resection for large serous cystadenomas regardless of the presence or absence of symptoms.

Approach to cystic pancreatic lesions

Cystic neoplasms of the pancreas represent the best example of a malignant precursor in the pancreas. There are many parallels between pancreatic cystic neoplasms and the colon polyp-cancer sequence. In the past, cystic neoplasms of the pancreas were thought to be relatively rare, composing less than 10% of cancers of the pancreas. With the greater use of cross-sectional imaging, an increasing number of these neoplasms are being seen.

State-of-the-art computed tomographic and magnetic resonance imaging of the gastrointestinal system

Among the major innovations in radiology of the gastrointestinal (GI) system are the replacement of classic invasive diagnostic methods with noninvasive ones and the improvement in lesion characterization and staging of pancreatobiliary malignancies. Developments in imaging technology have led to many improvements in the field of diagnostic GI radiology. With its fast and thin-section scanning abilities, multidetector-row CT (MDCT) strengthens the place of CT as the most efficient tool to diagnose, characterize, and preoperatively stage pancreatic neoplasms. MR cholangiopancreatography has widely replaced endoscopic retrograde cholangiopancreatography in the diagnosis and staging of pancreatobiliary malignancies. MR imaging, using phased-array or endorectal coils, demonstrates local tumor invasion accurately in rectal cancers and thus allows an improved surgical planning. Virtual colonoscopy with MDCTs is an efficient screening method for colon cancer, and MDCT enterography is becoming the standard imaging technique for many small bowel disorders. The continuing developments in CT and MR technology will most probably further improve the accuracy of these and other imaging applications in the near future.

Imaging and Cancer: Research Strategy of the American College of Radiology Imaging Network

The American College of Radiology Imaging Network (ACRIN) is a cooperative group funded by the National Cancer Institute and dedicated to developing and conducting clinical trials of diagnostic imaging and image-guided treatment technologies. ACRIN's six disease site committees are responsible for developing scientific strategies and resultant trials within the framework of ACRIN's five key hypotheses: (a) Screening and early detection with imaging can reduce cancer-specific mortality. (b) Less invasive image-guided therapeutic methods can reduce the mortality and morbidity associated with treating cancer. (c) Molecular-based physiologic and functional imaging can improve the diagnosis and staging of cancer, thus improving treatment. (d) Functional imaging can portray the effectiveness of treatment earlier and more accurately, thus reducing mortality and improving the likelihood of a cure. (e) Informatics and other "smart systems" can improve the evaluation of patients with cancer, thus leading to better and more effective treatments. This article details ACRIN's research strategy according to disease site through the year 2007.