Distal Pancreatic Atrophy Research Articles

CT findings and clinical effects of high grade pancreatic intraepithelial neoplasia in patients with intraductal papillary mucinous neoplasms.

To investigate the common CT findings of high-grade (HG) PanIN and clinical effects in the remnant pancreas in patients with intraductal papillary mucinous neoplasm (IPMN) of the pancreas. Two hundred fifty-one patients with surgically confirmed IPMNs (118 malignant [invasive carcinoma/high-grade dysplasia] and 133 benign [low-grade dysplasia]) were retrospectively enrolled. The grade of PanIN (233 absent/low-grade and 18 high-grade) was recorded, and all patients underwent serial CT follow-up before and after surgery. Two radiologists analyzed CT findings of high-risk stigmata or worrisome features according to 2017 international consensus guidelines. They also analyzed tumor recurrence on serial follow-up CT after surgery. Statistical analyses were performed to identify significant predictors and clinical impact on postoperative outcomes of HG PanIN. PanIN grade showed a significant association with IPMN grade (p = 0.012). Enhancing mural nodules ≥5 mm, abrupt main pancreatic duct (MPD) changes with distal pancreatic atrophy, increased mural nodule size and MPD diameter were common findings in HG PanIN (P<0.05). In multivariate analysis, abrupt MPD change with distal pancreatic atrophy (odds ratio (OR) 6.59, 95% CI: 2.32-18.72, <0.001) and mural nodule size (OR, 1.05; 95% CI, 1.02-1.08, 0.004) were important predictors for HG PanIN. During postoperative follow-up, HG PanIN (OR, 4.98; 95% CI, 1.22-20.33, 0.025) was significantly associated with cancer recurrence in the remnant pancreas. CT can be useful for predicting HG PanIN using common features, such as abrupt MPD changes and mural nodules. In HG PanIN, extra caution is needed to monitor postoperative recurrence during follow-up.

Pancreatic Cancer and Its Mimics.

Pancreatic ductal adenocarcinoma (PDAC) is the most common primary pancreatic malignancy, ranking fourth in cancer-related mortality in the United States. Typically, PDAC appears on images as a hypovascular mass with upstream pancreatic duct dilatation and abrupt duct cutoff, distal pancreatic atrophy, and vascular encasement, with metastatic involvement including lymphadenopathy. However, atypical manifestations that may limit detection of the underlying PDAC may also occur. Atypical PDAC features include findings related to associated conditions such as acute or chronic pancreatitis, a mass that is isointense to the parenchyma, multiplicity, diffuse tumor infiltration, associated calcifications, and cystic components. Several neoplastic and inflammatory conditions can mimic PDAC, such as paraduodenal "groove" pancreatitis, autoimmune pancreatitis, focal acute and chronic pancreatitis, neuroendocrine tumors, solid pseudopapillary neoplasms, metastases, and lymphoma. Differentiation of these conditions from PDAC can be challenging due to overlapping CT and MRI features; however, certain findings can help in differentiation. Diffusion-weighted MRI can be helpful but also can be nonspecific. Accurate diagnosis is pivotal for guiding therapeutic planning and potential outcomes in PDAC and avoiding biopsy or surgical treatment of some of these mimics. Biopsy may still be required for diagnosis in some cases. The authors describe the typical and atypical imaging findings of PDAC and features that may help to differentiate PDAC from its mimics. ©RSNA, 2023 Online supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center. See the invited commentary by Zins in this issue.

Utility of Contrast-Enhanced Computed Tomography for Differentiating Pancreatic Ductal Adenocarcinoma from Inflammatory Mass in Chronic Calcific Pancreatitis

Abstract Objective The aim of this study was to identify the most useful contrast-enhanced computed tomography (CECT) features for differentiating pancreatic ductal adenocarcinoma (PDAC) from mass-forming chronic pancreatitis (MFCP) in chronic calcific pancreatitis (CCP). Methods In total, 101 patients with CCP and focal pancreatic mass formed the study group. Sixteen qualitative and four quantitative parameters were analyzed. Qualitative parameters included size, site, margin, intralesional hypodensity, collateral duct sign, abrupt pancreatic duct (PD) cutoff, upstream PD dilatation, distal pancreatic atrophy, double duct sign, enhancement pattern, contrast attenuation, peripancreatic inflammation, vascular involvement, regional nodes, and metastasis. Quantitative parameters included duct-to-body ratio, common bile duct (CBD) diameter, main pancreatic duct (MPD) diameter, and carcinoembryonic antigen 19-9 (CA19-9). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated for prediction of PDAC. A receiver operating characteristic (ROC) curve analysis was performed and the area under ROC curve (AUROC) was calculated to determine diagnostic accuracy to assess the optimal cutoff. Results PDAC was confirmed in 48 patients and MFCP in 53 patients. A duct-to-body ratio greater than 0.48 had 95.5% sensitivity, 83.3% specificity, 80.8% PPV, 96.2% NPV, and 88.5% accuracy for predicting PDAC. A CBD diameter cutoff ≥9.5 mm had an accuracy of 75% (p &lt; 0.019) and an MPD cutoff ≥6.25 mm had an accuracy of 67.8% (p = 0.008) for predicting PDAC. On binary logistic regression, the duct-to-body ratio was found to be the significant independent factor associated with malignancy. Conclusion A duct-to-body ratio greater than 0.48, intralesional hypodensity, and abrupt duct cutoff are the most helpful computed tomography (CT) features for distinguishing PDAC from MFCP in CCP. On binary logistic regression, the duct-to-body ratio was found to be a significant independent factor. Interspersed normal parenchyma was observed as a very specific sign of MFCP. Intraparenchymal hypodensity has high specificity, but further validation is needed.

Preoperative Predictive Features of Invasive Carcinoma Among Intraductal Papillary Mucinous Neoplasm of the Pancreas.

Noninvasive intraductal papillary mucinous neoplasms (IPMNs) theoretically do not metastasize. The purpose of this study is to preoperatively distinguish invasive carcinomas associated with IPMN from noninvasive IPMN. A total of 131 patients who underwent surgical resection for IPMN were retrospectively analyzed to identify the predictors of invasive carcinoma, based on the International Association of Pancreatology Consensus Guidelines. Of the 131 patients, 29 (22%) had invasive carcinomas and 102 (78%) had noninvasive IPMN. An enhancing mural nodule (MN) greater than or equal to 5 mm, obstructive jaundice, an abrupt change in the caliber of the pancreatic duct (PD) with distal pancreatic atrophy, and lymphadenopathy were the significant predictors of invasive carcinoma in univariate analysis. The optimal cutoff value for the size of the enhancing MN to differentiate invasive carcinoma was 13 mm. In multivariate analysis, enhancing MN greater than or equal to 13 mm, obstructive jaundice, and an abrupt change in the PD caliber were the independent predictors. When all these factors were absent, only 17% were invasive carcinomas. Enhancing MN greater than or equal to 13 mm, obstructive jaundice, and an abrupt change in the PD caliber were predictive factors for invasive carcinoma. Systematic lymph node dissection may be omitted when a high-risk patient has none of these factors.

MRI-Based Pancreatic Atrophy Is Associated With Malignancy or Invasive Carcinoma in Intraductal Papillary Mucinous Neoplasm.

BackgroundAbrupt change in the caliber of the main pancreatic duct (MPD) with distal pancreatic atrophy (PA) was considered as one of worrisome features in the International Association of Pancreatology guideline and American College of Gastroenterology guideline for the management of intraductal papillary mucinous neoplasms (IPMNs). However, this feature was not included in other guidelines. Moreover, the association between PA alone and malignancy in IPMNs has not been fully evaluated. In the present study, we investigated the role of image-based PA in identifying malignant IPMNs or invasive carcinoma.MethodsA total of 186 patients with IPMNs were included for analysis. The tumor size, location, MPD diameter, presence of a mural nodule (MN), and PA were evaluated using magnetic resonance imaging. Demographic information and serum carbohydrate antigen 19-9 and carcinoembryonic antigen (CEA) levels were also collected. IPMNs with high-grade dysplasia and associated invasive carcinoma were regarded as malignant IPMNs.ResultsPA was observed in 34 cases (18.3%). The occurrence of malignant IPMNs or invasive carcinoma in patients with PA were significantly higher than in those without PA (52.9% vs. 22.3%; 44.1% vs. 8.9%, all P < 0.01). Multivariate logistic regression analysis showed that PA was an independently associated factor for malignant IPMNs [odds ratio (OR) = 2.69, 95% confidence interval (CI): 1.07-6.78] or invasive carcinoma (OR = 7.78, 95%CI: 2.62-23.10) after modified with confounders. Subgroup analysis in MPD-involved IPMNs also indicated that PA was an independently associated factor for invasive carcinoma (OR = 9.72, 95%CI: 2.43-38.88). PA had a similar performance with MPD plus MN [the area under the curve (AUC) was both 0.71] in identifying malignancy. PA had a higher performance in identifying invasive carcinoma in MPD-involved IPMNs than MN (AUC = 0.71 vs. 0.65, P = 0.02).ConclusionOur data showed that imaging-based PA was associated with malignancy or invasive carcinoma regardless of abrupt change in the caliber of MPD in IPMNs. PA had an acceptable performance in identifying malignant IPMNs.

Predicting Factors for Pancreatic Malignancy with Computed Tomography and Endoscopic Ultrasonography in Chronic Pancreatitis.

Diagnosing pancreatic malignancy is challenging, especially in patients with chronic pancreatitis (CP). Endoscopic ultrasonography (EUS) is a promising diagnostic procedure for discriminating between malignancy and CP. We aimed to investigate the predictive factors and reliability of computed tomography (CT) and EUS for differentiating pancreatic mass lesions and the diagnostic accuracy of EUS-FNA or FNB in patients with CP. Forty patients with CP, receiving CT and EUS-FNA or FNB for pancreatic mass lesion evaluation, were enrolled in the study. Patients’ data, CT and EUS characteristics, image-based diagnosis, cytopathology, and final diagnosis were recorded. EUS was superior to CT in terms of diagnostic accuracy (92.5% vs. 82.5%, p = 0.02). Both CT and EUS showed significant predictive factors (all p < 0.05) with the tumor image hypoattenuation pattern or vessel invasion on CT and pancreatic duct dilatation, or distal pancreatic atrophy on EUS. EUS imaging is a reliable modality for evaluating pancreatic lesions, even with a CP background. The EUS image has a higher diagnostic accuracy than CT. Predicting factors, including hypoechoic pattern, pancreatic duct dilatation, and distal pancreas atrophy, may help to differentiate benign or malignant in patients with CP.

Application of MSCT characteristic nomogram model in predicting invasion of pancreatic solid pseudopapillary neoplasms

ObjectiveTo evaluate the value of multi-slice computed tomography (MSCT) characteristic nomogram model in predicting invasion of pancreatic solid pseudopapillary neoplasms (pSPN). MethodsFrom January 2016 to January 2021, the clinical characteristics, pathology and imaging data of 114 patients with pSPN were retrospectively analyzed. 42 cases were classified in invasive group while 72 cases in non-invasive group. The tumor location, shape, growth pattern, growth angle, margin calcification, floating cloud sign, annular enhancement, pancreatic and bile duct dilation, distal pancreatic atrophy, capsule, cystic degeneration and cystic to solid ratio between the two groups were analyzed. The maximum diameter and the CT value of the solid parts in the lesion were measured. ResultsThere were significant differences in tumor shape, growth pattern, margin, annular enhancement, capsule, CT value in arterial phase and venous phase (P < 0.05). There was no significant difference in tumor location, growth angle, calcification, floating cloud sign, pancreatic and bile duct dilation, distal pancreatic atrophy, cystic degeneration, cystic-solid ratio and CT value of lesion in plain scan (P > 0.05). The independent predictors of pSPN invasion included growth pattern, annular enhancement, capsule, and CT value of lesion in arterial phase. A nomogram model was successfully established to predict the invasion of pSPN. The area under the receiver operating characteristic curve was 0.888, and the calibration prediction curve was in good agreement with the standard curve. ConclusionThe nomogram model based on MSCT features has high application value in preoperative prediction of tumor invasion of pancreatic solid pseudopapillary neoplasms.

Computed tomography nomogram to predict a high-risk intraductal papillary mucinous neoplasm of the pancreas.

The intraductal papillary mucinous neoplasm (IPMN) of the pancreas is regarded as a precursor to pancreatic cancer; this study aimed to develop and validate a model based on CT characteristics for the non-invasive prediction of the high-risk IPMN of the pancreas. In this retrospective study, all patients underwent multidetector CT and surgical resection. A prediction model was developed based on a training set consisting of 136 patients with low-risk IPMN and 85 patients with high-risk IPMN between October 2012 and April 2019, and a multivariable logistic regression model was adopted to establish a nomogram. The nomogram performance was determined by its discrimination, calibration, and clinical usefulness. The model was validated in 80 consecutive patients between May 2019 and April 2020, of which 47 and 33 patients had low-risk and high-risk IPMNs, respectively. The multivariable logistic regression model of CT characteristics included the enhancing mural nodule size, the main pancreatic duct (MPD) diameter, the abrupt change in caliber of the MPD with distal pancreatic atrophy, cyst size, thickened enhancing cyst wall, and the presence of lymphadenopathy. The individualized prediction nomogram using these predictors of the high-risk IPMN achieved an area under the curve (AUC) of 0.92 (95% CI 0.88-0.95) in the training set and 0.87 (95% CI 0.79-0.95) in the validation set. The decision curve analysis demonstrated that the nomogram was clinically useful. The CT nomogram, which is a non-invasive predictive tool, can preoperatively predict the risk of malignant IPMN and help identify patients who require a surgical procedure.

S0891 The Natural Course of Pancreatic Cysts in Inflammatory Bowel Disease Patients: Long-Term Follow-Up From a Pancreatic Cyst Cohort

INTRODUCTION: Pancreatic cysts (PC) are detected incidentally in inflammatory bowel disease (IBD) due to frequent abdominal imaging. However, the natural history and outcomes of PC in IBD are unknown. We aim to describe the natural history of PC in IBD and evaluate the rate of growth, high-risk and malignant transformation, and surgical intervention of PC in IBD patients. METHODS: A retrospective study from a tertiary care center of patients with abdominal MRI findings of PC from 2008-2018 was conducted. Outcomes were measured at 1, 3, 5, and 10 years. These included increased growth (change in size or number of PC), surgical intervention, high-risk transformation (new communication with pancreatic duct (PD) or new dilation, change in size of previous dilation, extension of cyst location, cyst >=3 cm, new thickened enhanced cyst wall, new non-enhanced mural nodule, new distal pancreatic atrophy, new abrupt change in main PD size, new lymphadenopathy) and malignant transformation (dysplasia or malignant cells). Kaplan-Meier estimates and Cox proportional hazards models were used for time to high-risk transformation and surgery. Mixed effect logistic regression models were used to evaluate increased growth over time. RESULTS: Of the 1,789 patients evaluated, 1,690 had PC without IBD and 79 had IBD and PC. IPMN constituted 82.1% of PC in IBD. Patients with IBD and PC were more likely to have a lower BMI [P = 0.014]. They were also more likely to be White [P = 0.049] and be diagnosed with PC at a younger age [P < 0.001]. In multivariable analysis, IBD patients with PC were more likely to have a faster rate of growth at 3 [OR: 1.55; 95% CI: 1.55–2.23] and 5 years [OR: 1.66; 95% CI: 1.05–2.63] and they were more likely to undergo surgery at a younger age [OR: 0.97; 95% CI: 0.96–98]. There were no statistically significant differences in the rates of high-risk transformation [OR: 1.31; 95% CI: 0.46–3.68], malignant transformation [OR: 1.42; 95% CI: 0.61–3.30], or overall need for surgery [OR: 0.86; 95% CI: 0.35–2.12]. CONCLUSION: This is the first long-term study to date to describe the natural history of PC in IBD patients. Patients with IBD were more likely to have PCs detected at a younger age with increased rate of growth. This is likely due to increased imaging rates at a younger age. Despite the early presentation and increased rate of growth, there was not an increase in high-risk and malignant transformation.

Assessment of Malignancy Potential in Intraductal Papillary Mucinous Neoplasms of the Pancreas on MDCT

To assess the malignancy potential of intraduct papillary mucinous neoplasms (IPMNs) on multidetector-row computerized tomography according to the 2012 International Consensus Guidelines (ICG). This study retrospectively collected IPMNs confirmed by surgery from 2016 to 2019. The imaging findings of IPMNs were analyzed. IPMNs were classified as malignancy in the presence of high-grade dysplasia or invasive carcinoma and began in the presence of low- and intermediate-grade dysplasia. A total of 207 patients (mean age: 63.7 ± 7.9 years) were included, and the prevalence of malignancy was 28.0% (58 of 207). According to the 2012 ICG, the imaging findings of IPMNs were divided into worrisome features (WFs) and high-risk stigmata (HRS). The malignancy of IPMN with only one WF was relatively low (1.4%, 3 of 207). In multivariate regression analyses, the independent factors of IPMNs were enhanced mural nodule ≥5 mm (odds ratio [OR] = 19.5, 95% confidence interval [CI] 6.8-55.4), abrupt change in the main pancreatic duct caliber with distal pancreatic atrophy (OR = 4.6, 95%CI 1.67-12.71), and thickened enhanced cyst walls (OR = 2.9, 95%CI 1.1-8.2). When the presence of more than two WFs or HRS (score ≥ 3) was regarded as indicating the malignancy potential of IPMNs on multidetector-row computerized tomography, the sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) were 89.7%, 75.8%, 79.7%, 59.1%, and 95.0%, respectively. According to the ICG in 2012, patients with IPMNs with only one WF have a low risk for malignancy, and the presence of at least two WFs or any HRS (score ≥3) suggests malignant IPMNs.

2936 Use of Endoscopic Ultrasound for Pancreatic Cyst Surveillance

INTRODUCTION: Endoscopic ultrasound (EUS) is recommended by several society's guidelines for evaluation of asymptomatic pancreatic cysts. Though relatively low-risk, the procedure is costly and EUS-guided FNA has a low sensitivity for detecting malignant cytology. We evaluated a cohort of patients with pancreatic cysts who underwent EUS to determine if 1) EUS was warranted and 2) where EUS changed management. METHODS: We evaluated patients who underwent EUS for pancreatic cysts at our medical center. Cysts were evaluated for size, worrisome features and high risk stigmata. The primary outcomes, based on the Fukuoka guidelines, were whether the initial EUS was recommended and if the EUS procedure resulted in a change in clinical management (shortened surveillance interval, lengthened surveillance interval, or surgical intervention). RESULTS: 204 patients were included in the study and the baseline characteristics are listed in Table 1. We found that EUS was warranted in only 30.9% of patients, all of whom had acute pancreatitis or worrisome features* seen on prior imaging. Though its use led to a change in management for 130 patients, it lengthened the surveillance interval in 70% of these cases (see Figure 1). In patients in whom shortened intervals were recommended, this was mostly due to worrisome features seen in 43.3% (see Figure 2). Additionally, benign cytology was found in 47.7% of cases, and was read as hypocellular or insufficient in 16.7% of cases (N = 174) (see Table 2). *Worrisome features are defined by the 2012 Fukuoka guidelines as: pancreatitis, cyst ≥3 cm, enhancing mural nodule &lt;5 mm, thickened/enhancing cyst walls, main duct size 5-9 mm, abrupt change in caliber of pancreatic duct with distal pancreatic atrophy, lymphadenopathy, increased serum level of CA 19-9, or cyst growth rate ≥5 mm/2 years. CONCLUSION: Our findings demonstrate the overutilization of endoscopic ultrasound in the management of pancreatic cysts, suggesting that if worrisome features are not present, follow up can be determined by cyst size alone.

Evaluating the malignant potential of intraductal papillary mucinous neoplasms of the pancreas: added value of non-enhanced endoscopic ultrasound to supplement non-enhanced magnetic resonance imaging.

PurposeTo evaluate the diagnostic performance of combining non-enhanced magnetic resonance imaging (MRI) and non-enhanced endoscopic ultrasonography (EUS) for assessing the malignant potential of lesions in patients with intraductal papillary mucinous neoplasms of the pancreas (IPMNs).Material and methodsData from 38 patients histopathologically diagnosed with IPMN adenomas or IPMN adenocarcinomas were retrospectively analysed. Preliminary univariate and multivariate analyses were conducted to identify statistically significant associations. Three blinded radiologists evaluated the image sets to assess the diagnostic performance of combined use of non-enhanced MRI and EUS as opposed to non-enhanced MRI alone in distinguishing malignant from benign lesions. Observer performance and interobserver variability were determined using receiver-operating-characteristic curve analysis and weighted κ statistics.ResultsMultivariate analyses identified a significant difference between the abrupt change in the main pancreatic duct (MPD) calibre with distal pancreatic atrophy and the signal intensity of lesion-to-spinal cord ratio on MRI; a significant difference was observed in MPD size on EUS. Diagnostic performance assessments of the image sets did not differ significantly between the blinded radiologists.ConclusionsThe clinical utility of non-enhanced EUS may be attributive in evaluating IPMN that has already been evaluated by non-enhanced MRI.

Clinicopathological Features of Intraductal Pancreatic Neuroendocrine Tumors.

Objective To evaluate the clinical and pathologic characteristics of intraductal pancreatic neuroendocrine tumors (PanNETs). Methods Four cases of intraductal PanNETs were studied by light microscopy and immunohistochemistry with the analysis of morphologic features and review of relevant literatures. Results Two female patients and two male patients aged 41- 58 years were enrolled in this study. The chief complaint was abdominal pain in two patients,vomiting in one patient,and jaundice in the last patient. Imaging examination showed intraductal neoplasm with diagnosis as intraductal papillary mucinous neoplasm (IPMN) in case 1; space-occupying lesions were found in the head of pancreas in the other three cases with pancreatic ductal ectasia and distal pancreatic atrophy. Grossly the masses were located in pancreatic main duct and invaded into surrounding pancreatic parachyma. Microscopically the tumors arranged with solid pattern,with some trabecular structures in the last two cases. Small duct and ductules were seen in intraductal PanNETs. The immunohistochemical expression showed that SYN and CgA were positive in neoplastic cells and negative in small duct and ductules.Conclusions Intraductal PanNETs are rare conditions. The clinical symptoms and imaging findings are similar to IPMN or pancreatic carcinoma. The tumors are located within pancreatic duct partly and can invade the pancreatic parenchyma. Microscopically the neuroendocrine tumors mix with small duct and forms ductulo-insular structure,which should be differentiated with mixed ductal endocrine carcinoma. The grade and prognosis are similar to those of classical neuroendocrine tumors.

Sendai criteria is safe for follow up of patients with branch duct IPMN

Introduction: Branch duct intraductal papillary mucinous neoplasm (BD-IPMN) of the pancreas can exhibit various degrees of dysplasia, and pancreatic cancer may develop in up to 20%. The Sendai Criteria recommend that patients with ‘high-risk stigmata' (jaundice, enhanced solid component, and main pancreatic duct size ≥10 mm) should undergo resection. Patients with ‘worrisome features' (cyst size ≥3 cm, thickened enhanced cyst walls, non-enhanced mural nodules, main pancreatic duct size 5–9 mm, abrupt change in main pancreatic duct caliber with distal pancreatic atrophy, lymphadenopathy, and clinical acute pancreatitis) should be evaluated by endoscopic ultrasonography. The objective of this study is to analyze our population of patients with BD-IPMN. Methods: We perform a retrospective analysis of a prospective database including population of with type II IPMNs. Patients were selected for follow up according to 2006 Sendai criteria. All the patients completed the follow up at our institution exclusively. Results: 118 BD-IPMN were diagnosed. Mean age of 66 (31–91). Most were incidentally diagnosed. Only 10% required surgery. The reason to indicate surgery were: pain (8), the presence of mural nodules (1) and increase in size (3). No patient presented invasive cancer on pathology examination. Coexistence of oncological disease was found in 15% of these patients. Conclusion: The management of small BD-IPMNs remains controversial. The 2012 guidelines should be considered to indicate surgery and patients who do not undergo resection should undergo careful surveillance. Sendai criteria is a safe strategy for follow up of patients with type II IPMN.

Prevalence and Outcomes of Cystic Neoplasm of the Pancreas in Immunosuppressed Patients With Solid Organ Transplantation

Introduction: To determine the prevalence of incidental pancreatic cystic neoplasms (PCNs) in solid organ transplant (SOT) recipients and describe the clinical course of these lesions in patients on chronic immunosuppressive therapy after transplantation. Methods: Using organ transplant databases at Mayo Clinic Florida, we retrospectively reviewed medical records of all patients who received a SOT between 2000 and 2013. Records of cross-sectional abdominal imaging were searched for the diagnosis of pancreatic cyst(s). We also reviewed radiographic imaging to confirm the presence of PCNs. The “worrisome features” were defined as: main pancreatic duct (MPD) involvement (dilation >6 mm), mural nodule, abrupt change in the MPD caliber with distal pancreatic atrophy. The characteristics of the PCN at the initial and follow-up imaging were compared. Cyst size was considered to have changed if there was a difference of ≥5 mm. Results: Of 3,188 patients, 11.4% (n=356) had at least 1 incidental PCN detected on imaging. The prevalence of PCN increased with age; was more common in females (14.7%) than in males (9.7%); and more common in liver transplant recipients (14.9%) as compared to kidney (5%), lung (3%), and heart (6%) transplant patients. The median diameter of the largest pancreatic cyst was 7.0 mm (range: 1-31) and in 6.8% of patients, the cysts were ≥2 cm. Two patients (0.5%) had worrisome features at the time of pancreatic cyst diagnosis. One patient who had a mural nodule at the time of cyst diagnosis had no evidence of malignant transformation after 71 months of follow-up. One patient with branch duct intraductal papillary mucinous neoplasms (IPMN) and MPD involvement died of a non-pancreatic related cause 2 months after the cyst diagnosis. In a cohort of 155 patients with follow-up examination (median follow-up of 39 months), only 2 patients (1.3%) developed worrisome features on follow-up imaging. One case with a newly developed mural nodule underwent pancreatic surgery, with a pathologic diagnosis of high-grade dysplasia. One case with progressive MPD dilatation noted during the follow-up did not undergo surgical resection due to multiple comorbidities. The majority (83%) of pancreatic cysts evaluated at follow-up were either unchanged or smaller in size. Although 16% of patients had increased cyst size during follow-up, none of them developed malignancy or had pancreatic-related morbidity. Conclusion: PCNs are common in SOT recipients. In PCN without high-risk features, the development of features worrisome for cancer is a rare event. Therefore, PCNs can be managed conservatively and their presence should not affect patients’ eligibility for transplant.

Extended distal pancreatectomy for advanced pancreatic neck cancer.

Backgrounds/AimsWe investigated the clinical application of extended distal pancreatectomy in patients with pancreatic neck cancer accompanied by distal pancreatic atrophy. In this study, we have emphasized on the technical aspects of using the linear stapling device for a bulky target organ.MethodsFrom March 2010 to September 2013, 46 patients with pancreatic adenocarcinoma, who underwent pancreatic resection with radical intent at our institute, were reviewed retrospectively. Among them, three patients (6.5%) underwent extended distal pancreatectomy. A linear stapling device and vise-grip locking pliers were used for en bloc resection of the distal pancreas, first duodenal portion, and distal common bile duct. The results were compared with those after standard pancreatectomy.ResultsAll three patients presented with jaundice, and the ratio of pancreatic duct to parenchymal thickness of the pancreatic body was greater than 0.5. Grade A pancreatic fistula developed in all of the cases, but none of these fistulae were lethal. Pathological staging was T3N1M0 in all of the patients. The postoperative daily serum glucose fluctuations and insulin requirements were comparable to those in patients who received pancreaticoduodenectomy or distal pancreatectomy. At the last follow-up, two patients were alive with liver metastasis at 4 and 10 months postoperatively, respectively, and one patient died of liver metastasis at 5 months postoperatively.ConclusionsWhile the prognosis of advanced pancreatic neck adenocarcinoma is still dismal, extended distal pancreatectomy is a valid treatment option, especially when there is atrophy of the distal pancreas. Also, the procedure is technically feasible, and further refinement is necessary to improve patient survival.

Clinical Predictors of Pancreatic Carcinoma Causing Acute Pancreatitis

Acute pancreatitis may be the first presentation of pancreatic carcinoma (PaCa). The present study was designed to identify clinical findings suggestive of PaCa in patients with nonalcoholic nongallstone-related (NANG) acute pancreatitis and evaluate accuracy of endoscopic ultrasound for diagnosing PaCa in this setting. This is a retrospective analysis of 332 consecutive patients who underwent endoscopic ultrasound-fine-needle aspiration after acute pancreatitis. Patients with gallstones or common bile duct stones, who were heavy or binge alcohol drinkers, or who had post-endoscopic retrograde cholangiopancreatography pancreatitis were excluded. Among 218 patients with NANG acute pancreatitis, 38 patients had PaCa. Age more than 50 years (P = 0.008), history of smoking (P < 0.001), weight loss of 10 lb or greater (P = 0.003), serum bilirubin levels of higher than 2 mg/dL (P = 0.035) or serum alkaline phosphatase level of higher than 165 U/mL (in patients with normal serum bilirubin levels) (P = 0.003), and radiological findings of an identifiable pancreatic mass (P = 0.001) or distal pancreatic atrophy (P = 0.006) had significant association with an underlying PaCa on multivariate analysis. Of the 38 patients with PaCa in this cohort, 37 had 2 or more of these findings. Endoscopic ultrasound-fine-needle aspiration had 99.5% accuracy (98.6, 100%) for diagnosing carcinoma in this clinical setting. The clinical criteria defined previously potentially can help select patients with NANG acute pancreatitis with a higher likelihood of an underlying pancreatic neoplasm for further imaging.

Mass‐forming autoimmune pancreatitis and pancreatic carcinoma: Differential diagnosis on the basis of computed tomography and magnetic resonance cholangiopancreatography, and diffusion‐weighted imaging findings

To differentiate mass-forming autoimmune pancreatitis (AIP) from pancreatic carcinoma by means of analysis of both computed tomography (CT) and magnetic resonance imaging (MRI) findings. Ten patients with mass-forming AIP diagnosed by revised clinical criteria of Japan Pancreas Society and 70 patients with pathologically proven pancreatic carcinoma were enrolled in this retrospective study. Two radiologists independently evaluated the CT and MR imaging findings. The sensitivity, specificity, and odds ratio of significant imaging findings and combinations of findings were calculated. Seven findings were more frequently observed in AIP patients: (i) early homogeneous good enhancement, (ii) delayed homogeneous good enhancement, (iii) hypoattenuating capsule-like rim, (iv) absence of distal pancreatic atrophy, (v5) duct penetrating sign, (vi) main pancreatic duct (MPD) upstream dilatation ≤ 4 mm, and (vii) an apparent diffusion coefficient (ADC) ≤ 0.88 × 10(-3) mm(2) /s. When the findings of delayed homogeneous enhancement and ADC ≤ 0.88 × 10(-3) mm(2) /s were both used in diagnosis of mass-forming AIP, a sensitivity of 100% and a specificity of 100% were achieved. When 4 of any of the 7 findings were used in the diagnosis of AIP, a sensitivity of 100% and a specificity of 98% were achieved. Analysis of a combination of CT and MR imaging findings allows for highly accurate differentiation between mass-forming AIP and pancreatic carcinoma.

Pancreatic ductal adenocarcinoma with intratumoral cystic lesions on MRI: correlation with histopathological findings

The purpose of this study was to evaluate intratumoral cystic lesions of pancreatic ductal adenocarcinoma (PDAC) depicted on MRI, and to correlate these cystic lesions with their histopathological findings. This study included 12 patients (7 males and 5 females; mean age, 59 years) with intratumoral cystic lesions of PDAC detected on a retrospective MRI review. We reviewed the histopathological findings of the cystic lesions within PDACs and analysed the MRI findings, focusing on the appearance of the intratumoral cystic lesions, i.e. the size, number, margin and intratumoral location, and on the ancillary findings of PDAC, i.e. peripancreatic infiltration, upstream pancreatic duct dilatation and distal parenchymal atrophy. Intratumoral cystic lesions were classified as neoplastic mucin cysts (n = 7, 58%) or cystic necrosis (n = 5, 42%) according to the histopathological findings; they ranged in greatest dimension from 0.5 cm to 3.4 cm (mean, 1.7 cm). Seven patients had only one cystic lesion each, while the remaining five had multiple cystic lesions. Most of the neoplastic mucin cysts had smooth margins (n = 6, 86%) and eccentric locations (n = 6), whereas most cystic necroses had irregular margins (n = 4, 80%) and centric locations (n = 4). The most common ancillary findings of PDAC were peripancreatic infiltration, distal pancreatic atrophy and upstream pancreatic duct dilatation (92%, 75% and 58%, respectively). The intratumoral cystic lesions of PDACs on MRI were classified as either neoplastic mucin cysts with smooth margins and eccentric locations or cystic necroses with irregular margins and centric locations.