Differential Diagnosis Of Pancreatic Masses Research Articles

Contrast-Enhanced Harmonic Endoscopic Ultrasonography in Pancreatic Diseases

Endoscopic ultrasonography (EUS) is the most sensitive imaging method for diagnosis of pancreatic tumors. However, it still has limits in the differentiation between pancreatic cancers and inflammatory tumor-like masses. A novel technology, contrast-enhanced harmonic EUS (CH-EUS), has been developed recently. It can visualize both parenchymal perfusion and microvasculature in pancreas without Doppler-related artifacts. Therefore, it is superior to EUS and CT in detecting small pancreatic masses and differential diagnosis of pancreatic masses. CH-EUS could be used for adequate sampling of pancreatic tumors and may predict the pathological features of the pancreatic solid lesions but still cannot replace EUS-FNA now.

Image enhancement by endoscopic ultrasonography-elastography

Elastography has been shown to increase the accuracy of endoscopic ultrasonography for the differential diagnosis of pancreatic masses. Recent data have led to questions about the validity of its use in a routine clinical setting, outside controlled studies. Further improvements of the technique are needed to increase the reproducibility of its results and make it a useful clinical tool.

Contrast-enhanced EUS in differential diagnosis of benign and malignant pancreatic masses: a meta-analysis

Objective To assess the accuracy of contrast-enhanced EUS in differential diagnosis of benign and malignant pancreatic masses. Methods We systematically searched the Medline, PubMed, Web of Science, Embase, Cochrane Central Trials, CNKI and VIP databases for relevant studies published. Study selection, quality assessment and data extraction were performed by two reviewers independently. Meta-Disc （version 1.4） software was used to perform this meta-analysis for sensitivity, specificity, positive likelihood ratio （LR）, and negative LR. Pooling results were derived by using the fixed-effect model when significant heterogeneity was not present. The random-effect model was applied otherwise. A summary receiver-operating characteristic （SROC） curve was constructed. Furthermore, to explore the potential sources of heterogeneity, we used meta-regression to estimate the effect of the following characteristics of the studies on the diagnostic accuracy of contrast-enhanced EUS. In addition, the outliers were identified with the method described by Deville and a subgroup analysis was performed by excluding the outliers. We used Stata statistical software （version 10. 0） to assess the publication bias with the Begg-Mazumdar indictor and HarbordEgger indictor. Results Twelve studies involving 1139 patients were included. The pooled sensitivity ofcontrast-enhanced EUS for the differential diagnosis of pancreatic masses was 94% （95% CI, O. 91 ～0. 95）, the specificity was 89% （95% CI, O. 85 ～0. 92）, the positive LR was 8.09 （95% CI, 4. 47 ～ 14. 64）, and the negative LR was 0, 08 （95% CI, O. 06 ～ 0. 10）. The area under the curve （AUC） under SROC was 0. 9732 （ SE = 0.02）. The subgroup analysis by excluding two outliers provided a sensitivity of 93 % （95% C1, O. 91～0. 95） and a specificity of 93% （95% C1, O. 89～0. 95）. Additionally, the subgroup analysis showed that the heterogeneities were eliminated in pooled estimates when the outliers were excluded and the AUC under SROC was 0. 9745 （SE = 0. 02）. Moreover, no significant publication bias was found with the Begg-Mazumdar indictor （ P = 0.244） or the Harbord-Egger indictor （ P = 0.442 ）. Conclusion Contrastenhanced EUS is a valuable method in the differential diagnosis of pancreatic masses. Key words: Endoscopic ultrasonography ; Image enhancement ; Pancreatic neoplasms ; Meta-analysis

Microcystic Serous Cystadenoma of the Pancreas With Subtotal Cystic Degeneration

Pancreatic serous cystadenomas are benign cystic neoplasms. Extensive degeneration mimicking a pancreatic pseudocyst has been described in several types of pancreatic neoplasms but has not been documented in serous cystadenomas. We report subtotal cystic degeneration of microcystic serous cystadenomas (MSCA) that produces radiographic, gross, and microscopic overlap with pancreatic pseudocyst. Resected MSCA with degenerative change were identified from the pathology archives of Memorial Sloan-Kettering Cancer Center and Johns Hopkins Hospital. The clinical, radiographic, gross, and microscopic findings were reviewed. Eight MSCAs with subtotal cystic degeneration were retrieved from among 397 resected serous cystadenomas (2.0%). There were 2 men and 6 women (mean age, 52 y). Available radiographic studies showed classic features of MSCA in 2 of 4 cases. Four cysts were unilocular, and 4 were multilocular. Gross features of MSCA were noted focally in the multilocular cases but were not evident in the unilocular examples. The predominant histologic features were those of pancreatic pseudocyst, including a fibrotic cyst wall lacking epithelium and instead composed of myofibroblastic proliferation, hemorrhage, and inflammation. Residual foci of MSCA were embedded in fibrosis, comprising 5% to 60% of the tumor volume. Most pancreatic serous cystadenomas display characteristic morphology, including a glycogen-rich epithelial lining and prominent subepithelial capillaries; however, extensive degenerative macrocystic change can obscure these classic features. This phenomenon is to be distinguished from macrocystic serous cystadenoma, in which thin-walled macrocystic spaces are epithelium lined. Thus, serous cystadenoma should be included in the differential diagnosis of pancreatic masses with extensive degenerative cystic change.

VH7 Contrast Enhanced EUS for the Differential Diagnosis of Pancreatic Mass

The differential diagnosis of pancreatic mass is frequently challenging even after all imaging modalities. Recently, contrast-enhanced endoscopic ultrasound (CE-EUS) was introduced into clinical medicine and it is possible to evaluate the dynamic enhancement of various lesions using this modality. However, the typical enhancement pattern of solid pancreatic mass is not well described. The aim of this study is to characterize the typical dynamic microvascular enhancement patterns of pancreatic mass according to histology.

Langerhans Cell Histiocytosis with Pancreatic Involvement: Imaging Findings Including Diffusion-Weighted Imaging

Langerhans cell histiocytosis (LCH) can affect many different organs. However, LCH with pancreatic involvement is very rare with a few reports about imaging findings. We present a case of multisystemic LCH with pancreatic involvement in a five-week-old infant. Pancreas lesion showed hypoechoic on ultrasonography, low density with poor enhancement on CT, and restricted diffusion on diffusion-weighted imaging. Although LCH with pancreatic involvement is rare, LCH should be considered in the differential diagnosis of pancreatic mass in children.

Adult Pancreatic Neuroblastoma, an Unusual Site and Fatal Outcome

In this report, we describe a classic case of stroma rich neuroblastoma, nodular type in a 22year old female presented with a pancreatic mass. This rare and unusual presentation elicits several differential diagnostic categories including solid pseudopapillary tumor, pancreatic endocrine tumor, pancreatoblastoma and PNET. In this report, we tried to differentiate between them depending on the histopathological features and using panel of epithelial and neuroendocrine markers. Although of the rarity of pancreatic neuroblastoma as a primary site of origin, however it should be considered in the differential diagnosis of pancreatic masses in children and young adult. Neuropil and ganglionic differentiation are helpful features to recognize neuroblastoma and differentiate them from other small blue cell tumors. The fatal outcome of adult neuroblastoma confirming the independence of age as a prognostic factor in this neoplasm regardless of stage and histology.

Pseudopapillary tumor in pediatric age: clinical and surgical management

Solid pseudopapillary tumors of the pancreas are rare exocrine pancreatic tumors. Through a review of pediatric cases in a single Institution, we present the clinical and surgical management of this neoplasm. We retrospectively reviewed the clinical charts of patients treated at our unit between 1995 and 2009 for SPT. Clinical and surgical management were analyzed and reported. During the study period 11 patients underwent surgery for pseudopapillary tumor. Five patients were treated with duodenum-preserving pancreatic head resection and six patients with splenopancreasectomy with a Roux-en-Y pancreatic jejunostomy. Patients did not show recurrence and are currently disease free. Blood tests, Ultrasound, Computed tomography and Magnetic Resonance Imaging were not useful to preoperatively identify the nature of the pancreatic masses. Solid pseudopapillary tumor is a rare condition that should be taken into account for the differential diagnosis of pancreatic masses in pediatric age. Due to its favourable prognosis, surgical removal should be planned and done following the intraoperative findings.

Pancreatic tuberculosis with splenic tuberculosis mimicking advanced pancreatic cancer with splenic metastasizes: a case report

A 60-year-old woman presented with vague abdominal pain for one week was referred to pancreatic tail carcinoma accompanied with splenic metastasizes. She came to our hospital for further treatment. Ultrasonography and abdominal computed tomography (CT) revealed a pancreatic tail tumor with splenic metastasizes. There was no history of tuberculosis. Laparotomy was performed because pancreatic tail carcinoma with splenic metastasizes was highly suspected. Indurated mass in the pancreatic tail and sporadic metastasizes in the spleen had been found during the surgery. The pancreatic tail and the spleen were removed and proved to be tuberculosis on histological examination of a frozen section. The patient was given antituberculosis therapy and is now getting well. Tuberculosis should be considered in the differential diagnosis of pancreatic masses. The response to antituberculosis treatment is very favorable.

Enhancing Accuracy of Endoscopic Ultrasonography (EUS) with SonoVue and a Dedicated Contrast Harmonic Echo (CHE): A Preliminary Experience

Background and Aim: EUS has good accuracy for the detection and staging of pancreatic masses. However, tissue confirmation is usually required for definitive differential diagnosis. Additionally, there are limiting factors including previous ERCP with stent placement, suboptimal interobserver agreement, long learning curve. The intravenous contrast agent SonoVue (Bracco International B.V., Amsterdam, NL) has been used to enhance EUS accuracy simply by evaluating color Doppler changes pre- and post-contrast infusion. However, only recently a dedicated CHE has become available with Olympus echoendoscopes allowing more accurate analysis of SonoVue uptake and washout. Our aim was to evaluate the feasibility of CHE-EUS for the detection and differential diagnosis of pancreatic masses. Materials and methods: We prospectively enrolled patients referred for suspicion of pancreatic solid lesions. Radial (GFUE160, Olympus Japan) and linear (XGFUCT180, prototype; Olympus, Japan) echoendoscopes were used in conjunction with the Aloka alfa 10 ultrasound unit (Aloka, Japan). After targeting the pancreatic region of interest, the full vial of Sonovue (5 ml) was injected i.v. followed by a 5 ml bolus of saline. The subsequent phases of SonoVue uptake and washout were evaluated for at least 3 minutes. Mechanical index was = 0.4. The results were analyzed in comparison with surgical pathology or EUS-FNA. Results. 24 patients were enrolled in this preliminary experience (13 M, 11 F, mean age 64 yrs, range 40-81 yrs). CHE-EUS was feasible in all cases; no complications occurred. We detected three major patterns of Sonovue uptake: no enhancement at all (A); network pattern (B); diffuse pattern (C). Pattern A (n = 3) corresponded to adenocarcinoma in all cases. Pattern B corresponded either to focal pancreatitis (n = 4) or to adenocarcinoma (n = 9). Pattern C corresponded to neuroendocrine tumor (n = 2). In 6 cases no lesions were detected and normal parenchymal enhancement was obtained. In 2 cases SonoVue was deemed to enhance the detection of the pancreatic lesion which would have been otherwise difficult to detect due to previous stenting of the bile duct. Conclusion: CHE-EUS using SonoVue is feasible and safe. SonoVue appeared to enhance diagnostic accuracy in difficult cases. In terms of differential diagnosis, while all cases of adenocarcinoma appeared markedly hypovascularized, there was no adequate discrimination between focal pancreatitis and adenocarcinoma. These results are still very preliminary and more cases are needed to standardize the technique.

Differential diagnosis of benign and malign pancreatic masses with 18F-fluordeoxyglucose-positron emission tomography recorded with a dual-head coincidence gamma camera

Metabolic imaging using 18F-fluordeoxyglucose and a ring-positron emission tomography camera is an established method in the differential diagnosis of pancreatic masses. Ring-positron emission tomography cameras, however, are expensive and available in only few specialized centres. The aim of this study was to investigate how far 18F-fluordeoxyglucose scan with a conventional dual-head gamma-camera could differentiate between benign and malign pancreatic masses. Forty-one patients (male/female: 25/16; mean age: 64.0 years; range: 41-86 years) with a pancreatic mass detected by ultrasound, computed tomography or MRI were included. In all patients 18F-fluordeoxyglucose scan was performed after overnight fasting and injection of 4 mCi 18F-fluordeoxyglucose using an ADAC Vertex MCD dual head gamma-camera (ADAC; Milpitas, California, USA), equipped with a 5/8-inch NaI-crystal. Images were acquired through a 180 degrees grade rotation in the three dimensional mode. The chosen matrix was 128 x 128 x 16, a Butterworthfilter (ADAC) was used and data were transferred into visible sinograms via Fourier-Rebinning. Coronar, sagittal and transversal slices of 3.9 mm thickness each were acquired. Focal tracer enhancement was suspicious for a malignoma and therefore regarded as positive, diffuse or no tracer uptake was suspicious for a benign process and was regarded as negative for cancer. DEFINITION OF GOLD STANDARDS: A diagnosis of cancer had to be confirmed histologically by specimens obtained by 18G-needle biopsy, surgical resection or at autopsy. A diagnosis of an inflammatory mass was considered proven, if no carcinoma could be found histologically in the surgically resected mass or at autopsy, or if there was no progression of the disease during a follow-up of at least 12 months. In 22 patients carcinoma was diagnosed (pancreatic cancer: n=17; endocrine tumour: n=3; carcinoma of the common bile duct: n=2). 18F-fluordeoxyglucose scan showed a focal tracer enhancement in 19 of these 22 patients (sensitivity: 86.4%). False negative results were acquired in two patients with cancer of the common bile duct and in one patient with poorly controlled insulin-dependent diabetes mellitus. In 19 patients the final diagnosis was an inflammatory pancreatic mass. 18F-fluordeoxyglucose scan showed a diffuse tracer enhancement in 15 of these 19 patients (specificity: 78.9%). False positive results were acquired in three patients whose blood tests showed signs of an acute episode of chronic pancreatitis. Positive and negative predictive values of 18F-fluordeoxyglucose scan were 82.6% and 83.3%, respectively. 18F-fluordeoxyglucose scan with a conventional dual-head gamma-camera is a highly sensitive and specific method in the differential diagnosis of benign and malign pancreatic masses.

Endoscopic retrograde cholangiopancreatography and endoscopic ultrasound for diagnosis of chronic pancreatitis

The diagnosis of chronic pancreatitis is based on altered pancreatic morphology and function. A spectrum of disease exists, and milder forms of disease may be missed by CT but demonstrated by endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic ultrasound (EUS). The accuracy of ERCP and EUS for diagnosis of "minimal change" or "early" chronic pancreatitis is controversial, particularly when the results from these imaging procedures are discordant with each other or with tests of pancreatic function; in some cases ERCP and EUS should be considered indeterminate for diagnosis. This review discusses recent data concerning the accuracy of ERCP and EUS for diagnosis of chronic pancreatitis, the use of EUS fine-needle aspiration for differential diagnosis of pancreatic masses, and the use of EUS and EUS-guided TruCut biopsy for diagnosis of autoimmune pancreatitis.

Pancreatic Tumors in Children: Radiologic-Pathologic Correlation

Pancreatic neoplasms are rare in children and have a different histologic spectrum and prognosis than those in adults. In general, these tumors are well demarcated with expansile rather than infiltrating growth patterns. They may be quite large at diagnosis, and central cystic necrosis is common. They infrequently cause biliary duct obstruction. The imaging appearance of each neoplasm reflects its pathologic features. Pancreatoblastoma is the most common pancreatic neoplasm in young children. At imaging, pancreatoblastomas are heterogeneous and often multilocular with hyperechoic and enhancing septa. Solid-pseudopapillary tumor occurs in adolescent girls. It is heterogeneous in internal architecture, with a mixture of solid and cystic hemorrhagic and necrotic elements. This tumor is distinguished by its fibrous capsule and hemorrhagic nature, which are best shown at magnetic resonance imaging as a dark rim on T1- or T2-weighted images and hyper-intense foci on T1-weighted images, respectively. Islet cell tumors in children are insulinomas or gastrinomas. These tumors manifest early due to hormonal syndromes and are distinguished by their small size, homogeneous appearance, and intense enhancement with intravenous contrast material. All pancreatic neoplasms in children are capable of producing metastases, usually to the liver and lymph nodes; however, on the whole, these tumors have a better clinical outcome than most pancreatic tumors in adults. Knowledge of the differential diagnosis of pancreatic masses in children and their relatively good prognosis may promote correct preoperative diagnosis and appropriate treatment.

Power Doppler Endoscopic Ultrasonography for the Differential Diagnosis Between Pancreatic Cancer and Pseudotumoral Chronic Pancreatitis

The accuracy of endoscopic ultrasonography (EUS) and EUS-guided fine-needle aspiration for the differential diagnosis of pancreatic masses is variable in the literature, being as low as 75% in some studies. The aim of the study was to assess the accuracy of power Doppler EUS for the differential diagnosis between pancreatic cancer and pseudotumoral chronic pancreatitis. We included 42 consecutive patients with pancreatic tumor masses (27 men and 15 women) examined by EUS between January 2002 and August 2004. Endoscopic ultrasonographic procedures included power Doppler EUS as well as EUS-guided fine-needle aspiration in all patients. Final diagnosis of pancreatic cancer was confirmed in 29 patients on the basis of a combination of information provided by imaging tests, follow-up of at least 6 months, and laparotomy in 18 patients for diagnostic or palliative reasons. Sensitivity and specificity of the absence of power Doppler signals inside the suggestive pancreatic mass were 93% and 77%, respectively, with accuracy of 88%. Moreover, the addition of the information provided by the presence of peripancreatic collaterals improved the sensitivity and specificity to 97% and 92%, with accuracy of 95%. Power Doppler EUS provides useful information for the differential diagnosis of pancreatic masses. The results were in concordance with previous studies that showed a hypovascular pattern of pancreatic carcinoma, as well as the formation of collaterals in advanced cases due to the invasion of the splenic or portal veins. Further studies of dynamic EUS with contrast agents are necessary to better characterize pancreatic masses.

Huge primitive neuroectodermal tumor of the pancreas: Report of a case and review of the literature

Primitive neuroectodermal tumor (PNET) of the pancreas is an extremely rare tumor that usually occurs in children or young adults. We report a case of a 33-year-old male patient with an 18 cm multiply 18 cm multiply 16 cm mass arising from the pancreatic body and tail with a one-day history of abdominal pain. Initial CT scan showed no signs of metastatic tumor spread. The tumor caused intrabdominal bleeding and the patient underwent primary tumor resection including partial gastrectomy, left pancreatic resection and splenectomy. Diagnosis of PNET was confirmed by histology, immunohistochemistry and FISH analysis. All neoplastic cells were stained positive for MIC2-protein (CD99). Approximately one month after surgery, several liver metastases were observed and the patient underwent chemotherapy according to the Euro-Ewing protocol. Subsequent relaparotomy excluded any residual hepatic or extrahepatic abdominal metastases. Although PNET in the pancreas is an extremely rare entity, it should be considered in the differential diagnosis of pancreatic masses, especially in young patients. This alarming case particularly illustrates that PNET in the pancreas although in an advanced stage can present with only a short history of mild symptoms.

UTILITY OF POWER DOPPLER ENDOSCOPIC ULTRASOUND FOR THE DIFFERENTIAL DIAGNOSIS BETWEEN PANCREATIC CANCER AND PSEUDOTUMORAL CHRONIC PANCREATITIS

Purpose: Endoscopic ultrasound (EUS) coupled with fine needle aspiration biopsy (EUS-FNA) are very useful for the detection of pancreatic tumors, for the differential diagnosis between benign and malignant tumors, as well as for staging and resecability. However, the accuracy of EUS and EUS-FNA for the differential diagnosis of pancreatic masses are variable in the literature, being as low as 75% in some studies.

F-18 fluorodeoxyglucose PET in vivo evaluation of pancreatic glucose metabolism for detection of pancreatic cancer.

To evaluate positron emission tomography (PET) with fluorine-18-labeled fluorodeoxyglucose (FDG) for detection of pancreatic cancer compared with computed tomography (CT) and ultrasonography (US). Forty patients with suspected pancreatic cancer underwent static PET after intravenous injection of 150-300 MBq FDG. Focal FDG accumulation was regarded as a sign of malignancy and was quantitated by calculating differential uptake ratios (DURs) and tumor-liver ratios (TLRs). Malignancy was histologically proved in 27 patients. PET helped correctly classify 25 of 27 malignant conditions and 11 of 13 benign disorders. DUR and TLR were statistically significantly higher in malignant compared with benign disease (P < .01). False-negative findings were obtained in patients with insulin-dependent diabetes. False-positive findings were noted in a patient with retroperitoneal fibrosis and in one with pancreas divisum with chronic pancreatitis. PET was superior to CT and US in detection of lymph node metastases (13 of 17 vs three of 17 or one of 15, respectively. FDG PET has the potential to improve the detection of lymphadenopathy and the differential diagnosis of pancreatic masses.