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Lee JE, Lee S, Park HJ, Hwang JA, Choi SY, Lee J. Imaging classification of pancreatic ductal adenocarcinoma with histological large duct pattern. Eur Radiol 2024:10.1007/s00330-024-10810-8. [PMID: 38806802 DOI: 10.1007/s00330-024-10810-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 03/24/2024] [Accepted: 04/08/2024] [Indexed: 05/30/2024]
Abstract
OBJECTIVES To investigate the imaging features of pancreatic ductal adenocarcinoma (PDAC) with histological large duct pattern. METHODS Our study included 37 patients (mean age, 66.5 years; 22 women) with surgically proven PDAC with histological large duct pattern, whose imaging features were classified into four types: Type I, solid mass; Type II, predominantly cystic mass with intracystic solid components; Type III, predominantly solid mass with intratumoral cysts; and Type IV, solid mass with peritumoral retention cysts or pseudocysts. Two radiologists independently analyzed both CT and MRI images for the morphological type, presence of abrupt main pancreatic duct (MPD) cutoff, adjacent vascular invasion, diffusion restriction, and reached consensus. RESULTS On CT, 26 patients (70.3%) had Type I tumors, five (13.5%) had Type II, three (8.1%) had Type III, and three (8.1%) had Type IV. Among the 26 patients with Type I tumors on CT, 16 had tumors with multiple intratumoral cysts within the solid mass on MRI and were subsequently classified as Type III. Accordingly, 10 patients (27.0%) were classified as Type I, five (13.5%) as Type II, 19 (51.7%) as Type III, and three (8.1%) as Type IV on MRI. Of the 37 patients, 27 (73.0%) had an abrupt MPD cutoff, 15 (40.5%) had adjacent vascular invasion, and 25 (67.6%) had diffusion restriction on MRI. CONCLUSIONS Predominantly solid pancreatic masses with small intratumoral cysts visualized on MRI may be a characteristic imaging finding of PDAC with histological large duct pattern, and differentiate it from conventional PDAC or other cystic pancreatic tumors. CLINICAL RELEVANCE STATEMENT Radiologists should be familiar with the various imaging features of PDAC with histological large duct pattern and should be aware that it may mimic other solid or cystic tumors of the pancreas. KEY POINTS Imaging features of pancreatic ductal adenocarcinoma with histological large duct pattern can be classified into four types. This pathology more frequently appears as a predominantly solid mass with intratumoral cysts on MRI than on CT. Adding MRI to CT may help identify pancreatic ductal adenocarcinoma with histological large duct pattern.
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Affiliation(s)
- Ji Eun Lee
- Department of Radiology, Soonchunhyang University College of Medicine, Bucheon Hospital, Gyeonggi-do, Republic of Korea
| | - Sunyoung Lee
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Hee Jun Park
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jeong Ah Hwang
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Republic of Korea
| | - Seo-Youn Choi
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Republic of Korea
| | - Jisun Lee
- Department of Radiology, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
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Choi SJ, Kim SJ, Kim DW, Lee SS, Hong SM, Kim KW, Kim JH, Kim HJ, Byun JH. Large Duct Pancreatic Ductal Adenocarcinoma: A Morphological Variant of Pancreatic Ductal Adenocarcinoma With Distinct CT and MRI Characteristics. Korean J Radiol 2023; 24:1232-1240. [PMID: 38016682 DOI: 10.3348/kjr.2023.0521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/31/2023] [Accepted: 09/19/2023] [Indexed: 11/30/2023] Open
Abstract
OBJECTIVE To investigate the imaging characteristics of large duct pancreatic ductal adenocarcinoma (LD-PDAC) on computed tomography (CT) and magnetic resonance imaging (MRI). MATERIALS AND METHODS Thirty-five patients with LD-PDAC (63.2 ± 9.7 years) were retrospectively evaluated. Tumor morphology on CT and MRI (predominantly solid mass vs. solid mass with prominent cysts vs. predominantly cystic mass) was evaluated. Additionally, the visibility, quantity, shape (oval vs. branching vs. irregular), and MRI signal intensity of neoplastic cysts within the LD-PDAC were investigated. The radiological diagnoses rendered for LD-PDAC in radiology reports were reviewed. RESULTS LD-PDAC was more commonly observed as a solid mass with prominent cysts (45.7% [16/35] on CT and 37.1% [13/35] on MRI) or a predominantly cystic mass (20.0% [7/35] on CT and 40.0% [14/35] on MRI) and less commonly as a predominantly solid mass on CT (34.3% [12/35]) and MRI (22.9% [8/35]). The tumor morphology on imaging was significantly associated with the size of the cancer gland on histopathological examination (P = 0.020 [CT] and 0.013 [MRI]). Neoplastic cysts were visible in 88.6% (31/35) and 91.4% (32/35) of the LD-PDAC cases on CT and MRI, respectively. The cysts appeared as branching (51.6% [16/35] on CT and 59.4% [19/35] on MRI) or oval shapes (45.2% [14/35] on CT and 31.2% [10/35] on MRI) with fluid-like MRI signal intensity. In the radiology reports, 10 LD-PDAC cases (28.6%) were misinterpreted as diseases other than typical PDAC, particularly intraductal papillary mucinous neoplasms. CONCLUSION LD-PDAC frequently appears as a solid mass with prominent cysts or as a predominantly cystic mass on CT and MRI. Radiologists should be familiar with the imaging features of LD-PDAC to avoid misdiagnosis.
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Affiliation(s)
- Se Jin Choi
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung Joo Kim
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dong Wook Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - Seung Soo Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seung-Mo Hong
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kyung Won Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jin Hee Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyoung Jung Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae Ho Byun
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Abstract
The basic pancreatic lesions include location, size, shape, number, capsule, calcification/calculi, hemorrhage, cystic degeneration, fibrosis, pancreatic duct alterations, and microvessel. One or more basic lesions form a kind of pancreatic disease. As recognizing the characteristic imaging features of pancreatic basic lesions and their relationships with pathology aids in differentiating the variety of pancreatic diseases. The purpose of this study is to review the pathological and imaging features of the basic pancreatic lesions.
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Cystic pancreatic lesions: MR imaging findings and management. Insights Imaging 2021; 12:115. [PMID: 34374885 PMCID: PMC8355307 DOI: 10.1186/s13244-021-01060-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 07/17/2021] [Indexed: 12/14/2022] Open
Abstract
Cystic pancreatic lesions (CPLs) are frequently casual findings in radiological examinations performed for other reasons in patients with unrelated symptoms. As they require different management according to their histological nature, differential diagnosis is essential. Radiologist plays a key role in the diagnosis and management of these lesions as imaging is able to correctly characterize most of them and thus address to a correct management. The first step for a correct characterization is to look for a communication between the CPLs and the main pancreatic duct, and then, it is essential to evaluate the morphology of the lesions. Age, sex and a history of previous pancreatic pathologies are important information to be used in the differential diagnosis. As some CPLs with different pathologic backgrounds can show the same morphological findings, differential diagnosis can be difficult, and thus, the final diagnosis can require other techniques, such as endoscopic ultrasound, endoscopic ultrasound-fine needle aspiration and endoscopic ultrasound-through the needle biopsy, and multidisciplinary management is important for a correct management.
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Li Q, Staiculescu D, Zhou Y, Chen J. Pancreatic Leiomyosarcoma With Schistosomiasis Hematobia: A Case Report and Literature Review. Front Oncol 2021; 11:638905. [PMID: 33869026 PMCID: PMC8045707 DOI: 10.3389/fonc.2021.638905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/26/2021] [Indexed: 11/17/2022] Open
Abstract
Pancreatic leiomyosarcoma (PL) is a very rare, malignant neoplasm with a very poor prognosis. Here, we examine a novel case of PL with schistosomiasis hematobia. The patient had been initially misdiagnosed by the first magnetic resonance imaging (MRI). The second imaging examination demonstrated an enlarged heterogeneous tumor mass in the body-tail of pancreas. Following image analysis, the patient underwent a pancreatectomy, splenectomy and lymph node dissections. Sixteen months after the tumor resection, follow-up computed tomography (CT) and MRI revealed tumor metastasis in the liver and lung. PL has non-specific clinical manifestations and imaging characteristics, making early diagnosis very challenging. When it is difficult to distinguish between benign and malignant pancreatic lesions, short-term imaging follow-up is preferred. In this case report, we discuss the relationship between PL and schistosomiasis hematobia.
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Affiliation(s)
- Qiang Li
- Department of Radiology, The Affiliated People's Hospital of Ningbo University, Ningbo, China
| | - Daniel Staiculescu
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Yurong Zhou
- Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jiang Chen
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.,Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, China
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Min JH, Kim YK, Kim H, Cha DL, Ahn S. Prognosis of resected intraductal papillary mucinous neoplasm of the pancreas: using revised 2017 international consensus guidelines. Abdom Radiol (NY) 2020; 45:4290-4301. [PMID: 32583137 DOI: 10.1007/s00261-020-02627-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 06/10/2020] [Accepted: 06/13/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE Although there has been considerable effort to define pre-operative features to predict the malignant potential of intraductal papillary mucinous neoplasms (IPMNs), the prognostic value of pre-operative clinical and MRI features has not been assessed. The aim of this study was to determine pre-operative clinical and MRI features that are predictive of disease-specific death or recurrence in patients undergoing pancreatic resection for IPMNs. METHODS We performed a retrospective analysis of 167 patients (mean age, 65 years; 114 men and 53 women) who underwent pre-operative MRI and surgical resection of IPMN of pancreas between 2009 and 2019. We evaluated disease-specific survival (DSS) and recurrence-free survival (RFS). Prognostic factor analysis was performed using clinical and MRI features according to the 2017 international consensus guidelines. RESULTS Of 167 patients, 86 (51.5%) had benign IPMNs and 81 (48.5%) had malignant IPMNs (48 [28.7%] invasive carcinoma and 33 [19.8%] high grade). On multivariable analysis, mural nodule size (hazard ratio [HR], 1.11; 95% confidence interval [CI], 1.04-1.18 and HR 1.07; 95% CI 1.03-1.12) and obstructive jaundice (HR 5.01; 95% CI 1.44-17.46 and HR 5.60; 95% CI 2.42-12.99) were the significant variables that were associated with DSS and RFS. The presence of lymphadenopathy (HR 50.7; 95% CI 4.0-643.0; P = 0.002) was the significant factor for DSS. IPMNs with mural nodule showed a significantly lower 5-year DSS (83.7% vs. 100%, P value < 0.01) and RFS (73.1% vs. 95.0%, P value < 0.01) compared with IPMNs with no mural nodule. CONCLUSIONS Mural nodule size on MRI and obstructive jaundice were prognostic markers in the pre-operative evaluation of patients with IPMN of pancreas.
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Mahalingam S, Langdon J, Muniraj T, Do A, Guo Y, Spektor M, Mathur M. Endoscopic Retrograde Cholangiopancreatography: Deciphering the Black and White. Curr Probl Diagn Radiol 2020; 50:74-84. [PMID: 32063296 DOI: 10.1067/j.cpradiol.2020.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 01/01/2020] [Accepted: 01/06/2020] [Indexed: 12/12/2022]
Abstract
Endoscopic Retrograde Cholangiopancreatography (ERCP) remains the conventional method of imaging the pancreatic and biliary tree and is performed by direct injection of iodinated contrast material via the major papilla. This diagnostic procedure gained popularity in the 1970s and subsequently paved way for ERCP guided interventions such as sphincterotomy, stone retrieval and stent placement. Currently, therapeutic ERCP is more widespread than diagnostic ERCP primarily due to the availability of noninvasive imaging. Nevertheless, more than half a million ERCPs are performed annually in the United States and radiologists need to be comfortable interpreting them. The following review will familiarize the reader with the imaging appearances of biliary and pancreatic disorders on conventional ERCP, and elaborate on therapeutic ERCP with illustrative examples.
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Affiliation(s)
- Sowmya Mahalingam
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT.
| | - Jonathan Langdon
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT
| | | | - Albert Do
- Yale University School of Medicine, Section of Digestive Diseases, New Haven, CT
| | - Yang Guo
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT; Brigham and Women's Hospital, Brookline, MA
| | - Michael Spektor
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT
| | - Mahan Mathur
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT
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Affiliation(s)
- Jelena Djokić Kovač
- Center for Radiology and Magnetic Resonance Imaging, Clinical Center of Serbia, Pasterova 2, 11000, Belgrade, Serbia.
- School of Medicine, University of Belgrade, Belgrade, Serbia.
| | - Aleksandra Janković
- Center for Radiology and Magnetic Resonance Imaging, Clinical Center of Serbia, Pasterova 2, 11000, Belgrade, Serbia
| | - Dragan Mašulović
- Center for Radiology and Magnetic Resonance Imaging, Clinical Center of Serbia, Pasterova 2, 11000, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
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Lee JE, Choi SY, Min JH, Yi BH, Lee MH, Kim SS, Hwang JA, Kim JH. Determining Malignant Potential of Intraductal Papillary Mucinous Neoplasm of the Pancreas: CT versus MRI by Using Revised 2017 International Consensus Guidelines. Radiology 2019; 293:134-143. [PMID: 31478800 DOI: 10.1148/radiol.2019190144] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background Several changes have been made to the revised 2017 international consensus guidelines for management of pancreatic intraductal papillary mucinous neoplasms (IPMNs). However, the diagnostic performance is yet to be verified. Purpose To evaluate the revised guidelines for predicting malignant potential of pancreatic IPMNs and to compare diagnostic performance and intermodality agreement between contrast material-enhanced CT and MRI. Materials and Methods In this retrospective study, two radiologists analyzed the preoperative contrast-enhanced CT and MRI of patients with surgically resected pancreatic IPMNs from January 2007 to December 2017. The diagnostic performance of CT and MRI were analyzed by using receiver operating curve analysis. Intermodality agreement was assessed by using weighted κ and intraclass correlation coefficient values. Results A total of 86 patients (mean age, 67.6 years ± 8.9 [standard deviation]; 47 men and 39 women) with pancreatic IPMNs (benign, 58; malignant, 28) were included. At both CT and MRI, enhancing mural nodule (P < .001), abrupt main pancreatic duct caliber change (P < .001), lymphadenopathy (P = .006), larger main pancreatic duct size (P = .003), and faster cyst growth rate (P = .04) were more common in malignant than benign IPMNs. Irrespective of the modality, enhancing mural nodule of 5 mm or greater had the highest odds ratio (25 at CT vs 29 at MRI). The diagnostic performance of CT (area under the receiver operating characteristic curve, 0.83 [95% confidence interval: 0.75, 0.92]) and MRI (area under the receiver operating characteristic curve, 0.86 [95% confidence interval: 0.77, 0.95]) for predicting malignant IPMNs were comparable (P = .43), with good intermodality agreement (κ = 0.70). Conclusion Among revised features, enhancing mural nodule of 5 mm or greater had the strongest association with malignant intraductal papillary mucinous neoplasm (IPMN), and diagnostic performance for prediction of malignant IPMNs were comparable between contrast-enhanced CT and MRI with good intermodality agreement. © RSNA, 2019 Online supplemental material is available for this article.
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Affiliation(s)
- Ji Eun Lee
- From the Department of Radiology, Soonchunhyang University College of Medicine, Bucheon Hospital, 170 Jomaru-ro, Bucheon-Si, Gyeonggi-do 14584, Republic of Korea (J.E.L., S.Y.C., B.H.Y., M.H.L.); Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (J.H.M.); Department of Radiology, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan-si, Republic of Korea (S.S.K., J.A.H.); and Department of Radiology and Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea (J.H.K.)
| | - Seo-Youn Choi
- From the Department of Radiology, Soonchunhyang University College of Medicine, Bucheon Hospital, 170 Jomaru-ro, Bucheon-Si, Gyeonggi-do 14584, Republic of Korea (J.E.L., S.Y.C., B.H.Y., M.H.L.); Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (J.H.M.); Department of Radiology, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan-si, Republic of Korea (S.S.K., J.A.H.); and Department of Radiology and Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea (J.H.K.)
| | - Ji Hye Min
- From the Department of Radiology, Soonchunhyang University College of Medicine, Bucheon Hospital, 170 Jomaru-ro, Bucheon-Si, Gyeonggi-do 14584, Republic of Korea (J.E.L., S.Y.C., B.H.Y., M.H.L.); Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (J.H.M.); Department of Radiology, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan-si, Republic of Korea (S.S.K., J.A.H.); and Department of Radiology and Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea (J.H.K.)
| | - Boem Ha Yi
- From the Department of Radiology, Soonchunhyang University College of Medicine, Bucheon Hospital, 170 Jomaru-ro, Bucheon-Si, Gyeonggi-do 14584, Republic of Korea (J.E.L., S.Y.C., B.H.Y., M.H.L.); Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (J.H.M.); Department of Radiology, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan-si, Republic of Korea (S.S.K., J.A.H.); and Department of Radiology and Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea (J.H.K.)
| | - Min Hee Lee
- From the Department of Radiology, Soonchunhyang University College of Medicine, Bucheon Hospital, 170 Jomaru-ro, Bucheon-Si, Gyeonggi-do 14584, Republic of Korea (J.E.L., S.Y.C., B.H.Y., M.H.L.); Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (J.H.M.); Department of Radiology, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan-si, Republic of Korea (S.S.K., J.A.H.); and Department of Radiology and Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea (J.H.K.)
| | - Seung Soo Kim
- From the Department of Radiology, Soonchunhyang University College of Medicine, Bucheon Hospital, 170 Jomaru-ro, Bucheon-Si, Gyeonggi-do 14584, Republic of Korea (J.E.L., S.Y.C., B.H.Y., M.H.L.); Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (J.H.M.); Department of Radiology, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan-si, Republic of Korea (S.S.K., J.A.H.); and Department of Radiology and Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea (J.H.K.)
| | - Jeong Ah Hwang
- From the Department of Radiology, Soonchunhyang University College of Medicine, Bucheon Hospital, 170 Jomaru-ro, Bucheon-Si, Gyeonggi-do 14584, Republic of Korea (J.E.L., S.Y.C., B.H.Y., M.H.L.); Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (J.H.M.); Department of Radiology, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan-si, Republic of Korea (S.S.K., J.A.H.); and Department of Radiology and Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea (J.H.K.)
| | - Jung Hoon Kim
- From the Department of Radiology, Soonchunhyang University College of Medicine, Bucheon Hospital, 170 Jomaru-ro, Bucheon-Si, Gyeonggi-do 14584, Republic of Korea (J.E.L., S.Y.C., B.H.Y., M.H.L.); Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (J.H.M.); Department of Radiology, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan-si, Republic of Korea (S.S.K., J.A.H.); and Department of Radiology and Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea (J.H.K.)
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Zhang TT, Sadler TJ, Whitley S, Brais R, Godfrey E. The CT fish mouth ampulla sign: a highly specific finding in main duct and mixed intraductal papillary mucinous neoplasms. Br J Radiol 2019; 92:20190461. [PMID: 31430199 DOI: 10.1259/bjr.20190461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE Main duct and mixed intraductal papillary mucinous neoplasms (IPMN) are pre-malignant cystic pancreatic neoplasms associated with pancreatic duct dilatation. Distinguishing these from benign causes of pancreatic duct dilatation is important in order to allow appropriate surveillance or surgery. A patulous duodenal papilla with extrusion of mucus at endoscopic evaluation, the endoscopic fish mouth ampulla (E-FMA) sign, is reported in main duct and mixed IPMN. We aimed to establish whether a CT correlate (CT-FMA) of this sign exists and whether this was associated with the presence of invasion or high-grade dysplasia. We defined the CT-FMA sign as an uninterrupted column of water attenuation material running from the pancreatic duct to the duodenal lumen. METHODS A retrospective, blinded review of 44 patients with histologically confirmed IPMN and 87 age-matched controls with pancreatic duct dilatation on CT was undertaken. A case-control series matched for the degree of pancreatic duct dilatation was used to compare the rates of invasion or high-grade dysplasia between main duct and mixed IPMN patients, with and without a CT-FMA sign. RESULTS The CT-FMA sign could be identified in 18.5% patients with main duct/mixed IPMN with specificity 100%, positive predictive value 100% and negative predictive value 79.8%. A significant association was found between CT-FMA in main duct/mixed IPMN compared to controls, but not with the presence of high-grade dysplasia or invasion. CONCLUSIONS The CT-FMA sign is a newly reported, highly specific sign of MD and mixed IPMN. ADVANCES IN KNOWLEDGE If a fish mouth ampulla is identified at CT, a diagnosis of main duct or mixed IPMN is highly likely.
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Affiliation(s)
- Ting Ting Zhang
- Department of Radiology, Brighton and Sussex University Hospitals, Brighton, United Kingdom
| | - Timothy J Sadler
- Department of Radiology, Royal Papworth Hospital, Cambridge, United Kingdom
| | - Siobhan Whitley
- Department of Radiology, West Suffolk Hospital, Bury St Edmunds, United Kingdom
| | - Rebecca Brais
- Department of Pathology, Cambridge University Hospitals, Cambridge, United Kingdom
| | - Edmund Godfrey
- Department of Radiology, Cambridge University Hospitals, Cambridge, United Kingdom
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Xu W, Liu X, Zhang J, Yang L. Intraductal Papillary Mucinous Neoplasms of the Pancreas: Correlation of Helical Computed Tomography (CT) Features With Pathologic Findings. Acad Radiol 2017; 24:609-614. [PMID: 28153575 DOI: 10.1016/j.acra.2016.12.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 12/09/2016] [Accepted: 12/14/2016] [Indexed: 01/06/2023]
Abstract
RATIONALE AND OBJECTIVES Intraductal papillary mucinous neoplasms (IPMNs) are precancerous lesions of the pancreas. Computed tomography (CT) has been recommended to screen the malignant potential of IPMNs. However, data evaluating the use of CT to differentiate categories of IPMN based on disease progression are limited. This study aimed to explore the correlation between CT characteristics and pathology in IPMN associated with invasive carcinoma. MATERIALS AND METHODS A total of 31 patients with intraductal papillary mucinous carcinoma (IPMC) treated at one local regional hospital in Shanghai, China, were enrolled in this study. Patients were divided into two groups based on invasion component and characterized as follows: group A, an invasive component of less than 50% (IPMC-I); and group B, with invasion of 50% or greater and defined as pancreatic ductal adenocarcinoma associated with IPMN (PDAC-IPMN). First, we analyzed the imaging information of the 31 patients retrospectively. Then, we compared the imaging differences between the two groups. RESULTS Fifteen patients with IPMC-1 and 16 patients with PDAC-IPMN were identified. There was no statistically significant difference in sex, age, lesion location, radiologic type, tumor size, mural nodule size, and lymphatic metastasis between the two groups. However, the arterial increased CT values were significantly different between the two groups (P < .01), with values of 29.2 ± 12.4 HU for group A and 14.2 ± 8.8 HU for group B. The venous increased CT values were 44.6 ± 12.0 HU for group A and 28.4 ± 12.3 HU for group B, and these were significantly different between the two groups (P < .01). In group A, 13 cases (86.7%) were classified as T1 or T2 stage, and in group B, eight cases (50.0%) were classified as T1 and T2 stage. There was a statistically significant difference in tumor classification between group A and group B patients (P < .05). CONCLUSIONS IPMC-I and PDAC-IPMN have different characteristics in CT imaging, and we demonstrated that CT scans based on blood supply and lymphatic metastasis could be used to evaluate and potentially screen for variation in IPMC disease outcomes.
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Affiliation(s)
- Wanbo Xu
- Department of Radiology, Dezhou People's Hospital, Dezhou, China
| | - Xiaojin Liu
- Department of Pharmacy, Dezhou People's Hospital, Dezhou, China
| | - Jiawen Zhang
- Department of Radiology, Huashan Hospital of Fudan University, 12 WuLuMuQi Rd, Shanghai, China.
| | - Li Yang
- Department of Medical Imaging and Nuclear Medicine, Fudan University, Shanghai, China
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Hoffman DH, Ream JM, Hajdu CH, Rosenkrantz AB. Utility of whole-lesion ADC histogram metrics for assessing the malignant potential of pancreatic intraductal papillary mucinous neoplasms (IPMNs). Abdom Radiol (NY) 2017; 42:1222-1228. [PMID: 27900458 DOI: 10.1007/s00261-016-1001-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE To evaluate whole-lesion ADC histogram metrics for assessing the malignant potential of pancreatic intraductal papillary mucinous neoplasms (IPMNs), including in comparison with conventional MRI features. METHODS Eighteen branch-duct IPMNs underwent MRI with DWI prior to resection (n = 16) or FNA (n = 2). A blinded radiologist placed 3D volumes-of-interest on the entire IPMN on the ADC map, from which whole-lesion histogram metrics were generated. The reader also assessed IPMN size, mural nodularity, and adjacent main-duct dilation. Benign (low-to-intermediate grade dysplasia; n = 10) and malignant (high-grade dysplasia or invasive adenocarcinoma; n = 8) IPMNs were compared. RESULTS Whole-lesion ADC histogram metrics demonstrating significant differences between benign and malignant IPMNs were: entropy (5.1 ± 0.2 vs. 5.4 ± 0.2; p = 0.01, AUC = 86%); mean of the bottom 10th percentile (2.2 ± 0.4 vs. 1.6 ± 0.7; p = 0.03; AUC = 81%); and mean of the 10-25th percentile (2.8 ± 0.4 vs. 2.3 ± 0.6; p = 0.04; AUC = 79%). The overall mean ADC, skewness, and kurtosis were not significantly different between groups (p ≥ 0.06; AUC = 50-78%). For entropy (highest performing histogram metric), an optimal threshold of >5.3 achieved a sensitivity of 100%, a specificity of 70%, and an accuracy of 83% for predicting malignancy. No significant difference (p = 0.18-0.64) was observed between benign and malignant IPMNs for cyst size ≥3 cm, adjacent main-duct dilatation, or mural nodule. At multivariable analysis of entropy in combination with all other ADC histogram and conventional MRI features, entropy was the only significant independent predictor of malignancy (p = 0.004). CONCLUSION Although requiring larger studies, ADC entropy obtained from 3D whole-lesion histogram analysis may serve as a biomarker for identifying the malignant potential of IPMNs, independent of conventional MRI features.
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You L, Xiao J, Cao Z, Zhang W, Liao Q, Dai M, Zhang T, Zhao Y. Analysis of clinical characteristics and treatment of pancreatic cystic tumors. Chin J Cancer Res 2016; 28:519-527. [PMID: 27877011 PMCID: PMC5101226 DOI: 10.21147/j.issn.1000-9604.2016.05.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objective To summarize experience in the diagnosis and treatment of pancreatic cystic neoplasms. Methods This is a retrospective study of 207 patients who were diagnosed with pancreatic cystic tumors at Peking Union Medical College Hospital between Jan 2009 and Mar 2014. Clinical data, such as clinical manifestations, radiological and pathological images and surgical recordings, were collected. Results Of the 207 included patients, females accounted for 76.81%, and the mean patient age was 52.04 years. Malignancy was more common in older patients who presented with marasmus and jaundice. Other risk factors included solid components in the tumor, a large tumor size, and elevated levels of tumor markers. Surgical treatment was required when a malignant tumor was suspected. The operation approach was selected based on the location, size and characteristics of the tumor. The position of the tumor relative to the pancreatic duct also played a significant role. Conclusions No specific symptoms were observed for the patients with pancreatic cystic tumors. Imaging played an important role in making a differential diagnosis. Furthermore, surgical treatment should be proposed for patients with significant symptoms and potentially malignant tumors. The tumor resection rate is high, suggestive of good prognosis.
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Affiliation(s)
- Lei You
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Jianchun Xiao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Zhe Cao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Wanying Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Quan Liao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Menghua Dai
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Taiping Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Yupei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
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Abstract
In this article, we aimed to review the literature on the clinics and management of intraductal papillary mucinous neoplasm (IPMN). Intraductal papillary mucinous neoplasm of the pancreas is a mucin-producing cystic mass originating from the pancreatic ductal system. Approximately 25% of the pancreatic neoplasms resected surgically and 50% of pancreatic cysts detected incidentally are IPMNs. They can be benign or malignant in character, while malignant transformation of benign forms can be encountered. It is important to determine IPMNs in the early stages, implementation of appropriate treatment approaches, and follow-up to provide better prognosis. We reviewed the studies published in the English medical literature through PubMed and summarized the clinical features and current approaches to the treatment and follow-up of the IPMN. Due to the recent advances and widespread implementation of radiological imaging techniques, the incidental detection rate of IPMNs has increased significantly. The effective treatment of the disease is possible via the detailed diagnosis of the disease, determination of the prognostic factors, and a multidisciplinary approach. Recent literature also emphasized the molecular profile determination approaches for assessment of prognosis of patients with IPMN. Current knowledge on IPMN, a clinically important epidemiologic problem, shows that the treatment should be personalized considering the prognostic features and life expectancy of the patient.
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Strauss A, Birdsey M, Fritz S, Schwarz-Bundy BD, Bergmann F, Hackert T, Kauczor HU, Grenacher L, Klauss M. Intraductal papillary mucinous neoplasms of the pancreas: radiological predictors of malignant transformation and the introduction of bile duct dilation to current guidelines. Br J Radiol 2016; 89:20150853. [PMID: 26959611 DOI: 10.1259/bjr.20150853] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To evaluate the current guidelines as a model to predict malignancy and to determine further radiological predictors of malignancy in intraductal papillary mucinous neoplasms (IPMNs). METHODS 384 patients who had undergone a pancreatic operation with the pathological diagnosis of IPMN as well as applicable pre-operative imaging (CT/MRI) were included in the study. Images were evaluated retrospectively in consensus by two radiologists, using a standardized checklist. Descriptive statistics, binary logistic regression and receiver operator curve analysis were performed to assess the International Consensus Guidelines and other radiological predictors of clinical malignancy (defined as carcinoma in situ and invasive carcinoma). RESULTS The best independent predictors of malignancy (n = 191) were solid components [odds ratio (OR) 3.98], parenchymal atrophy with main pancreatic duct dilation 5-9 mm (OR: 5.1) and common bile duct (CBD) dilation (OR: 31.26). >96% of all cases with CBD dilation were malignant IPMNs (positive-predictive value 96.4%; negative-predictive value 63.1%). Analysis of the current guidelines showed a diagnostic improvement with the addition of CBD dilation on determining the malignancy of IPMNs (sensitivity 82.2%/86.9%; specificity 72.7%/74.6%). Subanalysis of branch duct intraductal papillary mucinous neoplasms (BD-IPMNs; n = 168) also resulted in a diagnostic improvement with the addition of CBD dilation (sensitivity 28.6%/45.2%; specificity 92.9%/92.1%). The best independent predictors of malignancy for BD-IPMNs were parenchymal atrophy (OR: 4.00) and CBD dilation (OR: 29.3). Frequency analysis revealed that even small BD-IPMNs had already undergone malignant transformation (≤1 cm: 15%; 1-2 cm: 26%; 2-3 cm: 20%) with about 10% of those having a dilated bile duct. CONCLUSION CBD dilation was a significant positive predictor of malignancy in IPMNs regardless of their size. ADVANCES IN KNOWLEDGE Introduction of CBD dilation as a radiological predictor for malignancy might increase the diagnostic accuracy of current imaging-based guidelines.
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Affiliation(s)
- Albert Strauss
- 1 Radiology Department, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthew Birdsey
- 1 Radiology Department, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefan Fritz
- 2 Surgery Department, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Frank Bergmann
- 3 Institute of Pathology Heidelberg, University Hospital of Heidelberg, Heidelberg, Germany
| | - Thilo Hackert
- 2 Surgery Department, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Lars Grenacher
- 4 Diagnostic Imaging Center, Diagnostik Muenchen, München, Germany
| | - Miriam Klauss
- 1 Radiology Department, University Hospital Heidelberg, Heidelberg, Germany
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Value of diffusion-weighted MRI for differentiating malignant from benign intraductal papillary mucinous neoplasms of the pancreas. AJR Am J Roentgenol 2015; 203:992-1000. [PMID: 25341136 DOI: 10.2214/ajr.13.11980] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The purpose of this study was to evaluate whether the use of diffusion-weighted MRI (DWI) increases diagnostic accuracy in the differentiation of malignant from benign intraductal papillary mucinous neoplasms (IPMNs) of the pancreas over the accuracy of contrast-enhanced MRI with MRCP. MATERIALS AND METHODS A total of 61 patients with surgically resected IPMNs (19 malignant, 42 benign) who underwent gadoxetic acid-enhanced MRI, DWI, and MRCP were included. Two blinded observers evaluated two image sets, that is, conventional MRI with MRCP images versus combined conventional MRI with MRCP and DW images, and scored their confidence for malignancy of IPMNs. Qualitative analyses of the IPMNs were also conducted. Diagnostic performance (ROC curve analysis), accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were evaluated. The Fisher exact test was used to compare groups. RESULTS The diagnostic performance (area under the ROC curve [Az]) with respect to predicting malignancy of IPMNs improved significantly for both observers after additional review of DW images (p < 0.05). The diagnostic accuracy, sensitivity, specificity, PPV, and NPV of combined conventional and DW images were higher than those of conventional MR images alone. Diffusion restriction was more often present in malignant IPMNs (78.9%) than in benign IPMNs (16.7%) (p < 0.001) with excellent interobserver agreement (ĸ = 0.965). CONCLUSION Compared with conventional MRI alone, adding DWI to conventional MRI improves diagnostic accuracy with increased specificity for differentiating malignant from benign IPMNs of the pancreas.
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Kim SH, Lee JM, Lee ES, Baek JH, Kim JH, Han JK, Choi BI. Intraductal papillary mucinous neoplasms of the pancreas: evaluation of malignant potential and surgical resectability by using MR imaging with MR cholangiography. Radiology 2014; 274:723-33. [PMID: 25302831 DOI: 10.1148/radiol.14132960] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE To evaluate the diagnostic performance of magnetic resonance (MR) imaging with MR cholangiopancreatography (MRCP) in determining the malignant potential and surgical resectability of pancreas intraductal papillary mucinous neoplasms (IPMNs). MATERIALS AND METHODS Institutional review board approval was obtained, and the requirement for informed consent was waived. Ninety-eight patients with pathologically proved pancreas IPMNs who underwent MR imaging with MRCP comprised the study population. MR images were analyzed for findings suggestive of high-risk stigmata or worrisome features, as proposed by the international consensus guidelines 2012. Interobserver agreement between two experienced observers (observers 1 and 2) and one inexperienced observer (observer 3) was assessed. Diagnostic performance of MR imaging in the evaluation of the malignant potential and surgical resectability of IPMNs was analyzed in these three observers by using receiver operating curve analysis. RESULTS MR imaging with MRCP showed sensitivity of 83% (35/42), 79% (33/42), and 90% (38/42); specificity of 80% (41/51), 51% (26/51), and 24% (12/51); and accuracy of 82% (76/93), 63% (59/93), and 54% (50/93) for observers 1, 2, and 3, respectively, in the evaluation of the malignant potential of pancreas IPMNs when at least one worrisome feature was present. Interobserver agreement in the detection of intramural nodules (κ = 0.349-0.574), enhanced solid components (κ = 0.318-0.574), and measurement of main pancreatic duct diameter (intraclass correlation coefficient = 0.9477) was fair to high. The respective sensitivity, specificity, and accuracy in determination of surgical resectability were 95% (81/85), 99% (84/85), and 88% (75/85); 69% (9/13), 69% (9/13), and 54% (7/13); and 92% (90/98), 95% (93/98), and 84% (82/98) for observers 1, 2, and 3. CONCLUSION MR imaging with MRCP is a useful modality in the evaluation of the malignant potential and resectability of IPMNs, with high sensitivity and moderate specificity in the experienced radiologists but relatively low specificity in the inexperienced radiology trainee.
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Affiliation(s)
- Seong Ho Kim
- From the Department of Radiology (S.H.K., J.M.L., J.H.B., J.H.K., J.K.H., B.I.C.) and Institute of Radiation Medicine (J.M.L., J.H.K., J.K.H., B.I.C.), Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Republic of Korea; and Department of Radiology, Research Institute and Hospital of National Cancer Center, Goyang, Republic of Korea (E.S.L.)
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Does secretin stimulation add to magnetic resonance cholangiopancreatography in characterising pancreatic cystic lesions as side-branch intraductal papillary mucinous neoplasm? Eur Radiol 2014; 24:3134-41. [DOI: 10.1007/s00330-014-3355-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2013] [Revised: 07/13/2014] [Accepted: 07/16/2014] [Indexed: 12/21/2022]
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Yoon WJ, Brugge WR. Endoscopic ultrasound and pancreatic cystic lesions-diagnostic and therapeutic applications. Endosc Ultrasound 2014; 1:75-9. [PMID: 24949341 PMCID: PMC4062214 DOI: 10.7178/eus.02.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Accepted: 04/26/2012] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Won Jae Yoon
- Gastrointestinal Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - William R Brugge
- Harvard Medical School; Gastrointestinal Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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20
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Iatrogenic pancreatitis in patients with IPMN after ERCP: incidence and predictive signs. ACTA ACUST UNITED AC 2014; 39:949-54. [DOI: 10.1007/s00261-014-0122-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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21
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Three-dimensional contrast-enhanced ultrasonography of intraductal papillary mucinous neoplasms of the pancreas: a comparison with magnetic resonance imaging. Pancreas 2013; 42:1164-8. [PMID: 23770711 DOI: 10.1097/mpa.0b013e318291fbe5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES The objective of this study was to prospectively compare the diagnostic accuracy of 3-dimensional contrast-enhanced ultrasonography (3D-CEUS) with that of magnetic resonance imaging (MRI) in the study of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas. METHODS Thirty consecutive patients with IPMN were studied. RESULTS Three patients (10.0%) did not undergo diagnostic 3D-CEUS because of technical problems. Three dimensional CEUS identified 12 (44.4%) main-duct IPMNs versus no cases by MRI (P < 0.001). Intraductal papillary mucinous neoplasm localization showed poor agreement between 3D-CEUS and MRI (κ = 0.058), whereas good agreement was found in detecting the pancreatic calcifications (κ = 1.000). Significant differences between 3D-CEUS and MRI were found regarding the number of lesions detected (1.4 ± 0.8 vs 3.8 ± 3.6; P < 0.001), the detection of mucinous plugs (3.7% vs 50.0%; P < 0.001), chronic pancreatitis (7.4% vs 26.7%; P = 0.031), pancreatic atrophy (0% vs 50.0%; P < 0.001), thick septa (22.2% vs 53.3%; P = 0.004), and mural nodules (25.9% vs 3.3%; P = 0.016). Three dimensional CEUS showed similar results as compared with MRI in evaluating IPMNs smaller than 1 cm of diameter or greater than 2 cm. CONCLUSIONS Even if MRI remains the criterion standard technique for the diagnosis of IPMNs, 3D-CEUS can be safely used to follow patients with IPMNs of less than 1 cm.
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Bai XL, Zhang Q, Masood N, Masood W, Zhang Y, Liang TB. Pancreatic cystic neoplasms: a review of preoperative diagnosis and management. J Zhejiang Univ Sci B 2013; 14:185-94. [PMID: 23463761 DOI: 10.1631/jzus.b1200283] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Pancreatic cystic neoplasms (PCNs) are a diverse group of neoplasms in the pancreas, and are more increasingly encountered with widespread abdominal screening and improved imaging techniques. The most common types of PCNs are serous cystic neoplasms (SCNs), mucinous cystic neoplasms (MCNs), and intraductal papillary mucinous neoplasms (IPMNs). Clinicians frequently feel bewildered in the differential diagnosis and subsequent management among the various types of lesions in the pancreas, which may lead to overtreatment or delayed treatment. The current review provides recent developments in the understanding of the three most common types of PCNs, the latest modalities used in preoperative diagnosis and differential diagnosis, as well as the most up to date management. Suggestions for diagnosis and differential diagnosis of SCNs, MCNs, and IPMNs are also provided for young surgeons. Better understanding of these neoplasms is essential for clinicians to make accurate diagnosis and to provide the best management for patients.
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Affiliation(s)
- Xue-li Bai
- Department of Hepatobiliary-Pancreatic Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Castelli F, Bosetti D, Negrelli R, Di Paola V, Zantedeschi L, Ventriglia A, Manfredi R, Mucelli RP. Multifocal branch-duct intraductal papillary mucinous neoplasms (IPMNs) of the pancreas: magnetic resonance (MR) imaging pattern and evolution over time. Radiol Med 2013; 118:917-29. [PMID: 23801393 DOI: 10.1007/s11547-013-0945-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Accepted: 08/14/2012] [Indexed: 12/18/2022]
Abstract
PURPOSE The aim of our study was to follow the evolution over time of multifocal intraductal papillary mucinous neoplasms (IPMN) of the pancreatic duct side branches by means of magnetic resonance imaging (MRI). MATERIALS AND METHODS A total of 155 patients with multifocal IPMN of the side branches were examined with MRI and MR cholangiopancreatography (MRI/MRCP). Inclusion criteria were patients with ≥2 dilated side branches involving any site of the parenchyma; presence of communication with the main pancreatic duct and previous investigations by MRI/MRCP within at least six months. Median follow-up was 25.8 months (range, 12-217). Patients with a follow-up period shorter than 12 months (n=33) and those with a diagnosis of multifocal IPMN of the side branches without any follow-up (n=14) were excluded from the study. The final study population thus comprised 108 patients. A double, quantitative and qualitative, analysis was carried out. The quantitative image analysis included: number of dilated side branches in the head-uncinate process and body-tail; maximum diameter of lesions in the head-uncinate process; maximum diameter in the body-tail; maximum diameter of the main pancreatic duct in the head and body-tail. The qualitative image analysis included: presence of malformations or anatomical variants of the pancreatic ductal system; site of the lesions (head-uncinate process, body-tail, ubiquitous, bridge morphology); presence of gravity-dependent intraluminal filling defects; presence of enhancing mural nodules. RESULTS At diagnosis, the mean number of cystic lesions of the side branches was 7.09. The mean diameter of the cystic lesions was 13.7 mm. The mean diameter of the main pancreatic duct was 3.6 mm. At follow-up, the mean number of cystic lesions was 7.76. The mean diameter of the cystic lesions was 13.9 mm. The mean diameter of the main pancreatic duct was 3.7 mm. Intraluminal filling defects in the side branches were seen in 18/108 patients (16.6%); enhancing mural nodules were seen in 3/108 patients (2.7%). CONCLUSIONS Multifocal IPMN of the branch ducts shows a very slow growth and evolution over time. In our study, only 3/108 patients showed mural nodules which, however, did not require any surgical procedure, indicating that careful nonoperative management may be safe and effective in asymptomatic patients.
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Affiliation(s)
- Federica Castelli
- Istituto di Radiologia, Azienda Ospedaliero Universitaria Integrata - Policlinico "G.B. Rossi", P.le L.A. Scuro 10, 37134, Verona, Italy
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SHERIDAN MB, MANOHARAN P. Neoplasms of the pancreas. IMAGING 2013. [DOI: 10.1259/imaging/20369618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Falkowski AL, Graber J, Haack HG, Tarr PE, Rasch H. Isolated pancreatic tuberculosis: a case report and radiological comparison with cystic pancreatic lesions. J Radiol Case Rep 2013; 7:1-11. [PMID: 23372869 DOI: 10.3941/jrcr.v7i1.1292] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Pancreatic tuberculosis is rare and can occur in the absence of evidence of tuberculosis elsewhere in the body. Here we review the radiological appearance of pancreatic tuberculosis and compare it with other cystic pancreatic lesions, including common lesions (pseudocysts, serous or mucinous cystadenomas, intraductal papillary mucinous neoplasm) and rare lesions such as solid pseudopapillary tumors, etc. Their typical localizations within the pancreas and their malignant potential are presented. Knowledge of these can assist radiologists and clinicians in selecting the best approach towards making the correct diagnosis.
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Affiliation(s)
- Anna L Falkowski
- Department of Radiology and Nuclear Medicine, Kantonsspital Baselland, Bruderholz, Switzerland.
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26
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Solución del caso 43. Tumor mucinoso papilar intraductal de páncreas. RADIOLOGIA 2012; 54:473-5. [DOI: 10.1016/j.rx.2011.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Accepted: 02/04/2011] [Indexed: 11/22/2022]
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Abstract
OBJECTIVES Chronic asymptomatic pancreatic hyperenzymemia (CAPH) has been described since 1996 as a benign disease. Recent studies described pathological findings at magnetic resonance cholangiopancreatography with secretin stimulation (s-MRCP) in more than half of the CAPH subjects. The aim of this study was to investigate the frequency and clinical relevance of s-MRCP findings in patients with CAPH. METHODS Subjects prospectively enrolled from January 2005 to December 2010 underwent s-MRCP and biochemical tests routinely performed. RESULTS Data relative to 160 subjects (94 males, 66 females, age 49.6±13.6 years) were analyzed. In all, 51 (32%) subjects had hyperamylasemia, 9 (6%) hyperlipasemia, and 100 (62%) an increase in both enzyme levels. The time between the first increased dosage of serum pancreatic enzymes and our observation was 3.3±3.9 years (range: 1-15). Familial pancreatic hyperenzymemia was observed in 26 out of 133 subjects (19.5%). Anatomic abnormalities of the pancreatic duct system at s-MRCP were found in 24 out of 160 subjects (15%). Pathological MRCP findings were present in 44 subjects (27.5%) before and in 80 subjects (50%) after secretin administration (P<0.0001). Five subjects (3.1%) underwent surgery, 3 for pancreatic endocrine tumor, 1 for pancreatic adenocarcinoma, and 1 for intraductal papillary-mucinous neoplasia (IPMN) involving the main pancreatic duct, and 18 patients (11.3%) needed a follow-up (17 for IPMN and 1 for endocrine tumor). CONCLUSIONS Alterations of the pancreatic duct system at s-MRCP in subjects with CAPH can be observed in 50% of the subjects and are clinically relevant in 14.4% of cases.
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Bae SY, Lee KT, Lee JH, Lee JK, Lee KH, Rhee JC. Proper management and follow-up strategy of branch duct intraductal papillary mucinous neoplasms of the pancreas. Dig Liver Dis 2012; 44:257-60. [PMID: 22030480 DOI: 10.1016/j.dld.2011.09.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 08/26/2011] [Accepted: 09/18/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM It has been reported that main duct intraductal papillary mucinous neoplasms are more invasive and have a worse prognosis than branch duct intraductal papillary mucinous neoplasms. Therefore, an aggressive surgical approach has mainly been recommended for all MD-IPMNs. However, the surgical management of BD-IPMNs has been controversial and the consensus guidelines are not specific for an indicator of malignancy in BD-IPMNs. The objective of this study was to determine the proper management and follow-up strategy of BD-IPMNs. METHODS We monitored and analysed patients with presumed BD-IPMNs between March 1995 and March 2010. RESULT The mean value of the initial cyst size in all patients with BD-IPMNs was 2.19 cm. Amongst 194 patients with BD-IPMNs, 34 underwent immediate surgical resection, 152 were followed conservatively. Amongst the 152 conservatively managed patients, 18 (11.8%) underwent surgical resection after a median follow-up of 12.7 months (range, 3-48 months). In 132 patients who were managed conservatively without surgery, the mean incremental rate of cyst size growth was 0.0038 cm/month during a median of 30.7 months of follow-up and there were no IPMN-related deaths. CONCLUSION Amongst patients with BD-IPMNs, about 10% have surgery within approximately 1 year from the time of diagnosis because of the occurrence of new malignant stigmata. Therefore, a conservative approach without surgery and careful follow-up every 3 months or 6 months during the first year after diagnosis can be safely advocated in patients with BD-IPMNs larger than 10mm in size who have no risk factors for malignant IPMNs.
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Affiliation(s)
- Sun Youn Bae
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, South Korea
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Yoon WJ, Brugge WR. Pancreatic cystic neoplasms: diagnosis and management. Gastroenterol Clin North Am 2012; 41:103-18. [PMID: 22341252 DOI: 10.1016/j.gtc.2011.12.016] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PCNs are composed of a wide range of lesions from benign cysts to malignancies . Although a cross-sectional imaging provides a sensitive screening test, EUS with FNA and cyst fluid analysis greatly increase the diagnostic certainty. Cyst fluid CEA offers the greatest accuracy in the differentiation between mucinous and nonmucinous PCNs. In the future, endoscopic ablation therapy might offer an alternative to the traditional surgical approach.
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Affiliation(s)
- Won Jae Yoon
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA 02114, USA
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Lee NK, Kim S, Kim HS, Jeon TY, Kim GH, Kim DU, Park DY, Kim TU, Kang DH. Spectrum of mucin-producing neoplastic conditions of the abdomen and pelvis: Cross-sectional imaging evaluation. World J Gastroenterol 2011; 17:4757-71. [PMID: 22147976 PMCID: PMC3229624 DOI: 10.3748/wjg.v17.i43.4757] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Revised: 03/29/2011] [Accepted: 04/05/2011] [Indexed: 02/06/2023] Open
Abstract
Various mucin-producing neoplasms originate in different abdominal and pelvic organs. Mucinous neoplasms differ from non-mucinous neoplasms because of the differences in clinical outcome and imaging appearance. Mucinous carcinoma, in which at least 50% of the tumor is composed of large pools of extracellular mucin and columns of malignant cells, is associated with a worse prognosis. Signet ring cell carcinoma is characterized by large intracytoplasmic mucin vacuoles that expand in the malignant cells with the nucleus displaced to the periphery. Its prognosis is also generally poor. In contrast, intraductal papillary mucinous neoplasm of the bile duct and pancreas, which is characterized by proliferation of ductal epithelium and variable mucin production, has a better prognosis than other malignancies in the pancreaticobiliary tree. Imaging modalities play a critical role in differentiating mucinous from non-mucinous neoplasms. Due to high water content, mucin has a similar appearance to water on ultrasound (US), computed tomography (CT), and magnetic resonance imaging, except when thick and proteinaceous, and then it tends to be hypoechoic with fine internal echoes or have complex echogenicity on US, hyperdense on CT, and hyperintense on T1- and hypointense on T2-weighted images, compared to water. Therefore, knowledge of characteristic mucin imaging features is helpful to diagnose various mucin-producing neoplastic conditions and to facilitate appropriate treatment.
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Hernandez-Jover D, Pernas JC, Gonzalez-Ceballos S, Lupu I, Monill JM, Pérez C. Pancreatoduodenal junction: review of anatomy and pathologic conditions. J Gastrointest Surg 2011; 15:1269-81. [PMID: 21312068 DOI: 10.1007/s11605-011-1443-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Accepted: 01/27/2011] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The pancreatoduodenal junction is a small anatomic area where pathologic processes involving the distal bile duct, duodenum, pancreatic head, ampulla de Vater, and retroperitoneum converge. Differential diagnosis includes a spectrum of entities that ranges from anatomical variants to malignancies. PURPOSE The aim of this paper was to review the anatomy and different pathologic conditions, whether tumoral, inflammatory, or congenital in origin, in this specific area that involves the pancreatic head, duodenum, duodenal ampulla, distal pancreatobiliary tract junction, and retroperitoneum. METHODS Computed tomography (CT) and magnetic resonance (MR) help us to identify specific radiologic signs that allow to divide the pancreatic-duodenal junction abnormalities into three cathegories: (1) normal variants and congenital anomalies (pancreas divisum, santorinicele, annular pancreas,duodenal duplication cyst, choledocal cyst,...); (2) acquired non-tumoral: traumatic, iatrogenic, inflammatory (duodenal hematoma, duodenal iatrogenic perforation, groove pancreatitis, gastroduodenal artery pseudoaneurysm,...); (3) tumoral (pancreatic head adenocarcinoma, periampullary tumors, neuroendocrine pancreatic tumors, duodenal adenocarcinoma,...). The images illustrate morphologic aspects of these entities. RESULTS AND CONCLUSIONS CT and MR are the most appropiate imaging modalities to evaluate pancreatoduodenal junction. Knowing the imaging features is crucial to reach the right diagnosis and treatment of the different entities that involve this anatomic area.
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Affiliation(s)
- Diana Hernandez-Jover
- Radiology Department, Abdominal Section, Hospital de la Santa Creu i Sant Pau, C/Sant Quintí 90 08025, Barcelona, Spain.
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Galvin A, Sutherland T, Little AF. Part 1: CT characterisation of pancreatic neoplasms: a pictorial essay. Insights Imaging 2011; 2:379-388. [PMID: 22347959 PMCID: PMC3259323 DOI: 10.1007/s13244-011-0102-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Revised: 02/28/2011] [Accepted: 05/04/2011] [Indexed: 12/14/2022] Open
Abstract
The pancreas is a site of origin of a diverse range of benign and malignant tumours, and these are frequently detected, diagnosed and staged with computed tomography (CT). Knowledge of the typical appearance of these neoplasms as well as the features of locoregional invasion is fundamental for all general and abdominal radiologists. This pictorial essay aims to outline the characteristic CT appearances of the spectrum of pancreatic neoplasms, as well as important demographic and clinical information that aids diagnosis. The second article in this series addresses common mimics of pancreatic neoplasia.
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Affiliation(s)
- Angela Galvin
- Medical Imaging Department, St Vincent's Hospital, 41 Victoria Pde, 3065 Fitzroy, Australia
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Mason K, Higgs SM, Norton SA. Endoscopic ultrasound in the assessment of solid and cystic pancreatic lesions. Br J Hosp Med (Lond) 2011; 72:78-85. [PMID: 21378613 DOI: 10.12968/hmed.2011.72.2.78] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Pancreatic masses can be solid or cystic, benign or malignant. Rapid and accurate diagnosis is essential for optimal management. Clinical presentation and radiological appearance are often inadequate for a definitive diagnosis. Endoscopic ultrasound allows more detailed assessment of the pancreas than traditional imaging techniques.
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Affiliation(s)
- Karen Mason
- Department of Radiology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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Pedrosa I, Boparai D. Imaging considerations in intraductal papillary mucinous neoplasms of the pancreas. World J Gastrointest Surg 2010; 2:324-30. [PMID: 21160838 PMCID: PMC2999202 DOI: 10.4240/wjgs.v2.i10.324] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Revised: 09/21/2010] [Accepted: 09/28/2010] [Indexed: 02/06/2023] Open
Abstract
With the widespread use of cross-sectional imaging, particularly computed tomography (CT) and magnetic resonance imaging (MRI), and the continuous improvement in the image quality of these techniques, the diagnosis of incidental pancreatic cysts has increased dramatically in the last decades. While the vast majority of these cysts are not clinically relevant, a small percentage of them will evolve into an invasive malignant tumor making their management challenging. Mucinous cystic neoplasms and intraductal papillary mucinous neoplasms (IPMN) are the most common pancreatic cystic lesions with malignant potential. Imaging findings on CT and MRI correlate tightly with the presence of malignant degeneration in these neoplasms. IPMN can be classified based on their distribution as main duct, branch duct or mixed type lesions. MRI is superior to CT in demonstrating the communication of a branch duct IPMN with the main pancreatic duct (MPD). Most branch duct lesions are benign whereas tumors involving the MPD are frequently associated with malignancy. The presence of solid nodules, thick enhancing walls and/or septae, a wide (> 1 cm) connection of a side-branch lesion with the MPD and the size of the tumor > 3 cm are indicative of malignancy in a branch and mixed type IPMN. A main pancreatic duct > 6 mm, a mural nodule > 3 mm and an abnormal attenuating area in the adjacent pancreatic parenchyma on CT correlates with malignant disease in main duct and mixed type IPMN. An accurate characterization of these neoplasms by imaging is thus crucial for selecting the best management options. In this article, we review the imaging findings of IPMN including imaging predictors of malignancy and surgical resectability. We also discuss follow-up strategies for patients with surgically resected IPMN and patients with incidental pancreatic cysts.
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Affiliation(s)
- Ivan Pedrosa
- Ivan Pedrosa, Dennis Boparai, Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
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Pancreatic and extrapancreatic lesions in patients with intraductal papillary mucinous neoplasms of the pancreas: a single-centre experience. Radiol Med 2010; 115:442-52. [PMID: 20082228 DOI: 10.1007/s11547-010-0502-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Accepted: 07/19/2009] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was performed to describe the possible presence of extrapancreatic neoplasms in patients with intraductal papillary mucinous neoplasm (IPMN) and to evaluate whether the extrapancreatic tumours were synchronous or metachronous to IPMNs. MATERIALS AND METHODS One hundred and forty-two patients (56 men and 86 women; mean age 69.5 years, range 37-98) with IPMN diagnosed using the Sendai criteria were enrolled. Six patients (4.2%) had type I, 103 (72.5%) type II and 33 (23.2%) type III IPMN. All patients were studied using the following imaging techniques: ultrasonography (US), multidetector computed tomography (MDCT) and magnetic resonance cholangiopancreatography (MRCP). RESULTS Pancreatic IPMN was localised in the head in 43 patients (30.3%), in the body in 13 (9.2%), in the tail in ten (7.0%), in the head-body in 17 (12.0%), in the body-tail in 15 (10.6%) diffuse throughout the gland in 44 (31.0%). The mean size of the cystic lesions was [(mean+/-standard deviation (SD)] 1.9+/-1.9 cm (range 0.5-8.0 cm). Twenty patients (14.1%) had associated pancreatic or extrapancreatic diseases. In evaluating the distribution of pancreatic or extrapancreatic diseases according to IPMN type, we found that this was not significantly different among types I, II and III (p=0.776). CONCLUSIONS The majority of pancreatic and extrapancreatic cancers occur before the diagnosis of IPMNs is made and is not related to the type of IPMN.
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Lee NK, Kim S, Lee JW, Lee SH, Kang DH, Kim DU, Kim GH, Seo HI. MR appearance of normal and abnormal bile: correlation with imaging and endoscopic finding. Eur J Radiol 2009; 76:211-21. [PMID: 19545960 DOI: 10.1016/j.ejrad.2009.05.050] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2009] [Accepted: 05/28/2009] [Indexed: 01/13/2023]
Abstract
Identification of abnormal bile related to various pathological processes in the pancreaticobiliary tract can be important in the diagnosis of disease and the determination of appropriate treatment. Magnetic resonance (MR) imaging can allow comprehensive evaluation of abnormal bile because MR usually provides better tissue characterization than other imaging modalities. A high-intensity signal from bile is frequently encountered on T1-weighted images and can be seen in concentrated bile, sludge, stones, or hemobilia. Contrast-enhanced MR features, such as inhomogeneous hepatic enhancement in the arterial phase and papillitis or mild-to-moderate bile duct wall thickening with enhancement, along with clinical characteristics, may suggest clinically significant bile, such as sludge or purulent bile, rather than merely concentrated bile. A history of trauma and appropriate imaging findings in the hepatobiliary tract can support a diagnosis of hemobilia. MR imaging may assist in diagnosing intraductal papillary mucinous neoplasm of the bile duct via detection of an intraductal mass or several indirect signs, suggesting a large amount of mucin. Additionally, Gd-EOB-DTPA-enhanced MR may delineate mucin as a filling defect surrounding hyperintense bile. A floating filling defect on all MR sequences is helpful in discriminating pneumobilia from other intraluminal filling defects. Familiarity with the various different MR features of abnormal bile signals can therefore facilitate accurate diagnosis and treatment.
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Affiliation(s)
- Nam Kyung Lee
- Department of Radiology, Pusan National University Hospital, Pusan National University School of Medicine and Medical Research Institute, Pusan National University, Busan, Republic of Korea
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Stamatakos M, Sargedi C, Angelousi A, Kontzoglou K, Safioleas P, Petropoulou C, Safioleas M. Management of the rare entity of primary pancreatic cystic neoplasms. J Gastroenterol Hepatol 2009; 24:1203-10. [PMID: 19467142 DOI: 10.1111/j.1440-1746.2009.05855.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Primary cystic neoplasms of the pancreas constitute a rare entity and are composed of a variety of neoplasms with a wide range of malignant potential. Approximately 90% of these lesions are serous cystic neoplasms or mucin-producing neoplasms. In contrast to serous cystadenomas which are nearly always benign, the mucinous cystic neoplasms represent a more diverse, heterogeneous spectrum of related neoplasms. Intraductal papillary mucinous neoplasms manifest a much greater latent or overt malignant potential than other cystic neoplasms of the pancreas. The various subgroups of cystic neoplasms of the pancreas are evaluated and compared through a review of current literature. No symptoms or signs are pathognomonic for the cystic pancreatic neoplasms. While identification of a cystic tumor is relatively easy, the identification of the specific tumor type may be difficult. Most investigators agree that accurate differentiation of benign from malignant neoplasms can be made only at histopathologic examination of the entire resected segment of the pancreas. Because of the low mortality and low postoperative morbidity, surgical resection is indicated in all patients with cystic tumors.
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Affiliation(s)
- Michael Stamatakos
- 4th Department of Surgery, Medical School, University of Athens, Attikon Hospital, Athens, Greece.
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38
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Gaa J, Fingerle AA, Holzapfel K, Rummeny EJ. [MRI for malignant pancreatic tumors]. Radiologe 2009; 49:124-30. [PMID: 19107457 DOI: 10.1007/s00117-008-1757-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
In recent years continuous advancements in software and hardware technology of modern MRI systems have contributed to substantial progress in the field of pancreatic tumor imaging. Despite technical advances in abdominal MRI, multislice CT still remains the preferential diagnostic tool for pancreatic lesions. In the majority of cases the essential clinical questions can thereby be answered with a high degree of accuracy. However, in dilemma cases state-of-the-art MR imaging can provide relevant information for the diagnosis allowing an optimal therapeutic concept. This report gives an overview on possible applications for MRI in the diagnostic evaluation of malignant pancreatic tumors.
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Affiliation(s)
- J Gaa
- Institut für Röntgendiagnostik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland.
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Sahani DV, Lin DJ, Venkatesan AM, Sainani N, Mino-Kenudson M, Brugge WR, Fernandez-Del-Castillo C. Multidisciplinary approach to diagnosis and management of intraductal papillary mucinous neoplasms of the pancreas. Clin Gastroenterol Hepatol 2009; 7:259-69. [PMID: 19121413 DOI: 10.1016/j.cgh.2008.11.008] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2008] [Revised: 10/28/2008] [Accepted: 11/02/2008] [Indexed: 02/07/2023]
Abstract
Intraductal papillary mucinous neoplasms have gained recognition in recent years as premalignant precursors to pancreatic cancer that enable early detection and often are found incidentally at imaging. Accurate diagnosis and optimal, finely tuned management of these lesions are important and require collaboration across various disciplines, including radiology, endoscopy, surgery, and pathology. Several imaging modalities can visualize these lesions adequately, each with specific advantages and disadvantages. Multidetector computed tomography and magnetic resonance cholangiopancreatography are generally the first-line imaging modalities; endoscopic imaging such as endoscopic ultrasound and endoscopic retrograde cholangiopancreatography are beneficial when the former 2 modalities are equivocal. Surgical candidates generally include patients with main duct lesions or branch duct lesions greater than 3 cm or any possessing a solid component. A management algorithm indicating when surgery should be pursued is proposed. For nonsurgical and postsurgical patients, follow-up management is important to monitor growth and recurrence, and risks from repeated radiation exposure should be taken into account. Furthermore, issues of multifocality and increased predisposition of the pancreas to ductal adenocarcinoma must be addressed at follow-up evaluation. A follow-up management algorithm also is proposed in this review.
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Affiliation(s)
- Dushyant V Sahani
- Department of Radiology, Division of Abdominal Imaging and Intervention, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA.
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41
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42
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Pancreatitis del surco y su diagnóstico diferencial con el adenocarcinoma de páncreas. GASTROENTEROLOGIA Y HEPATOLOGIA 2009; 32:22-8. [DOI: 10.1016/j.gastrohep.2008.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2008] [Accepted: 09/01/2008] [Indexed: 01/07/2023]
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Guarise A, Faccioli N, Morana G, Megibow AJ. Chronic Pancreatitis vs Pancreatic Tumors. ACTA ACUST UNITED AC 2009. [DOI: 10.1007/978-3-540-68251-6_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Guarise A, Faccioli N, Ferrari M, Salvia R, Mucelli RP, Morana G, Megibow AJ. Evaluation of serial changes of pancreatic branch duct intraductal papillary mucinous neoplasms by follow-up with magnetic resonance imaging. Cancer Imaging 2008; 8:220-8. [PMID: 19042176 PMCID: PMC2590877 DOI: 10.1102/1470-7330.2008.0028] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The purpose of this study was to clarify the biological behaviour of branch duct type intraductal papillary mucinous neoplasm (IPMN) by evaluating serial changes at magnetic resonance cholangiopancreatography (MRCP). Fifty-two patients with a diagnosis of branch duct IPMN based on either endoscopic retrograde cholangiopancreatography (ERCP) (9/52) and/or MRCP examination (43/52), were followed up over a mean period of 31.2 months (range 12-108). All imaging data were retrospectively reviewed by two radiologists in order to evaluate serial changes in the maximum diameter of the cystic lesion, in the presence of main pancreatic duct dilatation (MPD), and filling defects within the lesion. Statistical analysis was performed using the Fisher exact probability test. Serial MRCP proved growth in seven cases. In two cases the size decreased; in the remaining 43 there was no change in size. Lesions greater than 3 cm at presentation and the presence of MPD dilatation or filling defects at imaging were most likely to grow. Only 2/37 cystic lesions less than 3 cm in diameter grew in size over the period of observation. No cystic lesion showed changes in morphology and structure. Branch duct IPMNs smaller than 3 cm, without associated filling defects, tend to be stable, making 'watch and wait' management possible.
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Peddu P, Quaglia A, Kane PA, Karani JB. Role of imaging in the management of pancreatic mass. Crit Rev Oncol Hematol 2008; 70:12-23. [PMID: 18951813 DOI: 10.1016/j.critrevonc.2008.09.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2007] [Revised: 08/15/2008] [Accepted: 09/10/2008] [Indexed: 11/26/2022] Open
Abstract
Pancreatic cancer is the second commonest malignant gastrointestinal neoplasm. Modern imaging techniques have greatly increased sensitivity in diagnosing and staging pancreatic cancers. Multidetector CT in particular, plays a critical role in local staging and determining the resectability of pancreatic tumours. MR and endoscopic ultrasound are valuable in those groups of patients in whom CT findings alone are inconclusive in tumour characterisation and local staging, particularly vascular involvement. In this article we review the current established concepts and the role of imaging in the multidisciplinary management of pancreatic tumours together with a comprehensive review of the literature.
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Affiliation(s)
- P Peddu
- Department of Radiology, Kings College Hospital, Denmark Hill, London SE5 9RS, United Kingdom.
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46
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Ferreira AM, Vaz A, Viana M, Gil-Agostinho P, Caseiro-Alves F. Case 136: intraductal papillary mucinous tumor (main duct type) of the pancreas. Radiology 2008; 248:695-7. [PMID: 18641258 DOI: 10.1148/radiol.2482031139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Ana M Ferreira
- Departments of Radiology, Hospital Infante D Pedro-Aveiro, Aveiro, Portugal.
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Manfredi R, Mehrabi S, Motton M, Graziani R, Ferrari M, Salvia R, Pozzi Mucelli R. MR imaging and MR cholangiopancreatography of multifocal intraductal papillary mucinous neoplasms of the side branches: MR pattern and its evolution. Radiol Med 2008; 113:414-28. [PMID: 18493777 DOI: 10.1007/s11547-008-0260-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2007] [Accepted: 07/04/2007] [Indexed: 12/29/2022]
Abstract
PURPOSE This paper describes the magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) pattern of multifocal intraductal papillary mucinous tumours (IPMT) of the pancreatic side branches and its evolution during followup. MATERIALS AND METHODS Twenty-six patients with multifocal IPMT of the side branches were included in this retrospective study. Inclusion criteria were > or =2 ectasic side branches, presence of communication with the main pancreatic duct, and > or =2 MRI/MRCP examinations after > or = 6-12 months. Exclusion criteria were IPMT involving both the main pancreatic duct and its branch ducts, previous surgery and lack of follow-up MRI examinations. Median follow-up was 27 (range 6-59) months. Images were assessed qualitatively and quantitatively. Qualitative assessment considered: the number of cystic lesions of the branch ducts, morphology of the communication between the cystic lesion and the main duct (direct or neck), presence of intraluminal filling defects within the cystic lesions, presence of mural nodules and mural enhancement of the cystic lesion. quantitative assessment considered mean maximal diameter of the cystic lesions and mean length of the communication neck. RESULTS At diagnosis, the mean number of cystic lesions of the side branches was 7.5. a communication neck was detected in 16/26 patients (60%). Intraluminal filling defects in the side branches were present in 6/26 patients (23%). Mural nodules were seen in 1/26 patients (4%). The mean diameter of the cystic lesions was 18.8 mm. The mean length of the communication neck was 6.9 mm. At follow-up, the mean number of cystic lesions of the side branches was 8.4. A communication neck was detected in 20/26 patients (77%). Intraluminal filling defects in the side branches were detected in 7/26 patients (27%); mural nodules were seen in 2/26 patients (8%). Mural enhancement of the branch duct was detected in 2/26 patients (8%). The mean diameter of the cystic lesions increased to 22.3 mm (p < 0.05), and the mean length of the communication neck was 8.6 mm. CONCLUSIONS MultifocaL IPMT of the side branches shows a constant but very slow progression over time. In our series, only 2/26 patients showed mural nodules.
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Affiliation(s)
- R Manfredi
- Istituto di Radiologia, Università di Verona, Policlinico G.B. Rossi, Piazzale L.A. Scuro 10, Verona, Italy.
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Katz DS, Friedel DM, Kho D, Georgiou N, Hines JJ. Relative Accuracy of CT and MRI for Characterization of Cystic Pancreatic Masses. AJR Am J Roentgenol 2007; 189:657-61. [PMID: 17715114 DOI: 10.2214/ajr.07.2772] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Douglas S Katz
- Department of Radiology, Winthrop-University Hospital, Mineola, NY 11501, USA
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49
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García Figueiras R, Villalba Martín C, García Figueiras A, Otero Echart M, Requejo Isidro I, Pazos González G, Rosario A. The Spectrum of Cystic Masses of the Pancreas: Imaging Features and Diagnostic Difficulties. Curr Probl Diagn Radiol 2007; 36:199-212. [PMID: 17765799 DOI: 10.1067/j.cpradiol.2007.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Cystic masses of the pancreas comprise a diverse group of pathologic entities ranging from pseudocysts to cystic tumors. Although their presentations may be similar, the appropriate treatment and patient management can differ greatly. There is an overlap in radiologic features, but the clinical context and some imaging findings are useful in differentiating among these entities; the differential diagnosis could be considerably reduced and it is generally possible to reach the correct diagnosis. In this article, we review imaging characteristics and radiologic patterns of both common and uncommon cystic masses of the pancreas. An algorithmic approach for the management of cystic pancreatic lesions is proposed.
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Affiliation(s)
- Roberto García Figueiras
- Department of Radiology, Complexo Hospitalario Universitario de Santiago (CHUS), Santiago de Compostela 15706, Spain.
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Kim S, Lee NK, Lee JW, Kim CW, Lee SH, Kim GH, Kang DH. CT evaluation of the bulging papilla with endoscopic correlation. Radiographics 2007; 27:1023-38. [PMID: 17620465 DOI: 10.1148/rg.274065047] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A variety of pathologic conditions can cause abnormalities of the ampulla of Vater. A bulging papilla is frequently encountered at computed tomography (CT) and can be seen in healthy individuals as well as in patients with various pathologic conditions such as papillitis, ampullary cancer, and intraductal papillary mucinous tumor. Mural thickening and certain attenuation patterns seen at contrast material-enhanced CT can help differentiate pathologic papilla from normal papilla. Increased targetlike enhancement of the papilla is likely to represent a benign condition such as papillitis, whereas an enhancing polypoid mass or focal asymmetric or irregular thickening with prolonged enhancement in the ampulla of Vater indicates a malignant condition such as ampullary or periampullary carcinoma. Although CT often does not clarify the exact cause of bulging, adequate duodenal distention may allow detection of an abnormal papilla, thereby providing additional information about other abnormalities in the pancreaticobiliary system. Thus, CT findings may prove useful for subsequent imaging studies such as magnetic resonance (MR) cholangiography or endoscopy. MR cholangiography may be equivalent to CT for identifying a bulging papilla and superior for distinguishing the underlying cause. However, endoscopy with or without biopsy is the best method for making a definitive diagnosis in patients with a bulging papilla. Familiarity with the normal imaging anatomy of the periampullary region and with the imaging features of the various pathologic causes of a bulging papilla may be useful in making the diagnosis.
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Affiliation(s)
- Suk Kim
- Department of Diagnostic Radiology, Pusan National University Hospital, Pusan National University School of Medicine, 1-10 Ami-Dong, Seo-gu, Busan 602-739, Republic of Korea
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