Atif Zaheer

The revised Atlanta classification for acute pancreatitis: updates in imaging terminology and guidelines

Imaging of acute pancreatitis requires not only an understanding of the disease subtypes and the myriad of associated complications but also familiarity with the appropriate radiologic nomenclature as defined by the Atlanta symposium in 1992 and, more recently, by the Acute Pancreatitis Classification Working Group in 2008. The accurate description of the radiological findings plays a critical role in the evaluation and management of patients with acute pancreatitis, particularly those with severe disease. There have been increasing efforts to develop uniformity in the use of terminology used to define the radiologic findings in acute pancreatitis, in particular, the terminology for fluid collections, a common area of inconsistency and confusion. Terms such as “acute peripancreatic fluid collections,” “acute post- necrotic fluid collections,” “pseudocyst,” and “walled-off pancreatic necrosis” are now recommended as they describe the evolution of fluid collections in patients with both interstitial and necrotizing pancreatitis and nonspecific terms such as “pancreatic abscess” and “phlegmon” are being abandoned. In this review we illustrate, with case examples, the standardized terminology used in the radiological and clinical description of acute pancreatitis, its severity, and complications with an emphasis on the role of ultrasound, computed tomography and magnetic resonance imaging. Different management options of the associated complications are also discussed. The use of standardized terminology will hopefully improve the communication between radiologists, gastroenterologists, and surgeons to facilitate treatment planning and will lead to enhanced outcomes for patients with acute pancreatitis as well as create uniformity for enrollment into research studies.

A comparative evaluation of outcomes of endoscopic versus percutaneous drainage for symptomatic pancreatic pseudocysts

BACKGROUND Endoscopic drainage (ED) and percutaneous drainage (PD) have largely replaced surgical drainage as the initial approach for symptomatic pseudocysts. However, there are few studies comparing ED and PD. OBJECTIVE To compare the outcomes of ED and PD for symptomatic pseudocysts. DESIGN Retrospective cohort study. SETTING Academic center. PATIENTS Adult patients with symptomatic pseudocysts within ≤ 1 cm of the gastric or duodenal wall who underwent ED or PD between 1993 and 2011. Patients with walled-off pancreatic necrosis were excluded. INTERVENTION ED or PD. MAIN OUTCOME MEASUREMENTS Rates of technical success, procedural adverse events, clinical success, reinterventions, and failure. Other outcomes included the length of hospital stay and number of follow-up abdominal imaging studies. RESULTS There were 81 patients, 41 who underwent ED and 40 who underwent PD, with no differences in age, sex, and comorbidity between the 2 groups. There were no differences in the rates of technical success (90.2% vs 97.5%; P = .36), adverse events (14.6% vs 15%; P = .96), and clinical success (70.7% vs 72.5%; P = .86) between ED and PD, respectively. Patients who underwent PD had higher rates of reintervention (42.5% vs 9.8%; P = .001), longer length of hospital stay (14.8 ± 14.4 vs 6.5 ± 6.7 days; P = .001), and median number [quartiles] of follow-up abdominal imaging studies (6 [3.25, 10] vs 4 [2.5, 6]; P = .02) compared with patients who underwent ED. LIMITATIONS Single center, retrospective study. CONCLUSION ED and PD have similar clinical success rates for symptomatic pseudocysts. However, PD is associated with significantly higher rates of reintervention, longer length of hospital stay, and increased number of follow-up abdominal imaging studies.

Incidentally detected cystic lesions of the pancreas on CT: review of literature and management suggestions

PurposeTo facilitate a better understanding of incidentally noted cystic pancreatic lesions, since these lesions often pose a challenge regarding appropriate management.MethodsThis article reviews pathophysiology, prevalence, significance, and recommendations for management of the various pancreatic cystic lesions. Illustrative cases are demonstrated.ResultsDiagnostic benign lesions can be left alone. Cross-sectional imaging can be used to follow-up benign appearing lesions and to stage more aggressive ones. Endoscopic ultrasound with fine needle aspiration and cyst fluid analysis can be performed on certain indeterminate lesions. Lesions with high malignant potential should undergo resection.ConclusionsA better understanding of the variety of incidentally detected pancreatic cystic lesions can help direct appropriate management.

New Agents and Techniques for Imaging Prostate Cancer

The successful management of prostate cancer requires early detection, appropriate risk assessment, and optimum treatment. An unmet goal of prostate cancer imaging is to differentiate indolent from aggressive tumors, as treatment may vary for different grades of the disease. Different modalities have been tested to diagnose, stage, and monitor prostate cancer during therapy. This review briefly describes the key clinical issues in prostate cancer imaging and therapy and summarizes the various new imaging modalities and agents in use and on the horizon.

Hepatocellular adenomas: Current update on genetics, taxonomy, and management

Hepatocellular adenomas (HCAs) are uncommon, benign hepatocellular neoplasms that commonly occur in young women. Recent advances in pathology and cytogenetics have thrown fresh light on the pathogenesis of HCAs leading to classification of HCAs into 3 distinct subtypes, each with a characteristic epidemiology, histopathology, oncogenesis, and imaging findings. The aim of the article was to provide a comprehensive review of contemporary taxonomy of HCAs, with an emphasis on cross-sectional imaging findings and management.

Resolution of walled-off pancreatic necrosis by EUS-guided drainage when using a fully covered through-the-scope self-expandable metal stent in a single procedure (with video)

BACKGROUND Walled-off pancreatic necrosis (WOPN) is effectively managed with percutaneous and endoscopic techniques such as direct endoscopic necrosectomy. However, they require repeat interventions and lengthy hospital stays. OBJECTIVE To evaluate a new platform to manage WOPNs by using a large-bore, through-the-scope, fully covered, self-expandable metal stent (FCSEMS) to overcome the need for repeat interventions and extended hospital stays. DESIGN Retrospective, single-center study. SETTING Academic tertiary care center. PATIENTS Five consecutive patients with symptomatic WOPN underwent EUS-guided drainage of WOPN by using a large-bore FCSEMSs. INTERVENTIONS EUS-guided transgastric drainage of WOPN by using a large-bore FCSEMS. Cross-sectional imaging was repeated at 6- to 8-week intervals. The FCSEMS was removed after WOPN resolution. MAIN OUTCOME MEASUREMENTS Clinical success, number of repeat interventions, and length of hospital stay. RESULTS Five patients (mean age 60 years) with WOPN (mean diameter, 12.3 cm; range 9.8-14.3 cm) underwent drainage with the described technique. Technical and clinical success was achieved in 100% of patients. Direct endoscopic necrosectomy was not required in any patient. The median number of endoscopic procedures was 1. The median length of hospital stay was 1 day. There were no adverse events. LIMITATIONS Small, retrospective study. CONCLUSIONS The described novel platform facilitates resolution of WOPN with a single procedure, avoiding the need for repeat interventions and lengthy hospital stays.

Role of a Multidisciplinary Clinic in the Management of Patients with Pancreatic Cysts: A Single-Center Cohort Study

BackgroundIncidental pancreatic cysts are common, a small number of which are premalignant or malignant. Multidisciplinary care has been shown to alter management and improve outcomes in many types of cancers, but its role has not been examined in patients with pancreatic cysts. We assessed the effect of a multidisciplinary pancreatic cyst clinic (MPCC) on the diagnosis and management of patients with pancreatic cysts.MethodsThe referring institution and MPCC diagnosis and management plan were recorded. Patient were placed into one of five categories—no, low, intermediate, or high risk of malignancy within the cyst, and malignant cyst—on the basis of their diagnosis. Patients were assigned one of four management options: surveillance, surgical resection, further evaluation, or discharge with no further follow-up required. The MPCC was deemed to have altered patient care if the patient was assigned a different risk or management category after the MPCC review.ResultsReferring institution records were available for 262 patients (198 women; mean age 62.7 years), with data on risk category available in 138 patients and management category in 225. The most common diagnosis was branch duct intraductal papillary mucinous neoplasm. MPCC review altered the risk category in 11 (8.0%) of 138 patients. The management category was altered in 68 (30.2%) of 225 patients. Management was increased in 52 patients, including 22 patients who were recommended surgical resection. Management was decreased in 16 patients, including 10 who had their recommendation changed from surgery to surveillance.ConclusionsMPCC is helpful and alters the management over 30% of patients.

Dual-phase CT findings of groove pancreatitis.

PURPOSE Groove pancreatitis is a rare focal form of chronic pancreatitis that occurs in the pancreaticoduodenal groove between the major and minor papillae, duodenum and pancreatic head. Radiologic appearance and clinical presentation can result in suspicion of malignancy rendering pancreaticoduodenectomy inevitable. This study reports dual phase CT findings in a series of 12 patients with pathology proven groove pancreatitis. MATERIALS AND METHODS Retrospective review of preoperative CT findings in 12 patients with histologically proven groove pancreatitis after pancreaticoduodenectomy. Size, location, attenuation, presence of mass or cystic components in the pancreas, groove and duodenum, calcifications, duodenal stenosis and ductal changes were recorded. Clinical data, laboratory values, endoscopic ultrasonographic and histopathological findings were collected. RESULTS Soft tissue thickening in the groove was seen in all patients. Pancreatic head, groove and duodenum were all involved in 75% patients. A discrete lesion in the pancreatic head was seen in half of the patients, most of which appeared hypodense on both arterial and venous phases. Cystic changes in pancreatic head were seen in 75% patients. Duodenal involvement was seen in 92% patients including wall thickening and cyst formation. The main pancreatic duct was dilated in 7 patients, with an abrupt cut off in 3 and a smooth tapering stricture in 4. Five patients had evidence of chronic pancreatitis with parenchymal calcifications. CONCLUSION Presence of mass or soft tissue thickening in the groove with cystic duodenal thickening is highly suggestive of groove pancreatitis. Recognizing common radiological features may help in diagnosis and reduce suspicion of malignancy.

18F-FDG PET/CT and Lung Cancer: Value of Fourth and Subsequent Posttherapy Follow-up Scans for Patient Management

The Centers for Medicare and Medicaid Services recently ruled that only 3 posttherapy follow-up 18F-FDG PET/CT scans are funded for a tumor type per patient and any additional follow-up PET/CT scans will be funded at the discretion of the local Medicare administrator. The purpose of this study was to evaluate the added value of 4 or more follow-up PET/CT scans to clinical assessment and impact on patient management. Methods: This was an institutional review board–approved, retrospective study. A total of 1,171 patients with biopsy-proven lung cancer who had undergone 18F-FDG PET/CT at a single tertiary center from 2001 to 2013 were identified. Among these, 85 patients (7.3%) had undergone 4 or more follow-up PET/CT scans, for a total of 285 fourth and subsequent follow-up PET/CT scans. Median follow-up from the fourth follow-up PET/CT scan was 31.4 mo (range, 0–155.2 mo). The follow-up PET/CT scan results were correlated with clinical assessment and treatment changes. Results: Of the 285 fourth and subsequent follow-up PET/CT scans, 149 (52.28%) were interpreted as positive and 136 (47.7%) as negative for recurrence or metastasis. A total of 47 patients (55.3%) died during the study period. PET/CT identified recurrence or metastasis in 44.3% of scans performed without prior clinical suspicion and ruled out recurrence or metastasis in 24.2% of scans performed with prior clinical suspicion. The PET/CT scan resulted in a treatment change in 28.1% (80/285) of the patients. New treatment was initiated for 20.4% (58/285) of the scans, treatment was changed in 5.6% (16/285), and ongoing treatment was stopped in 2.1% (6/285). Conclusion: The fourth and subsequent 18F-FDG PET/CT scans performed during follow-up after completion of primary treatment added value to clinical assessment and changed management 28.1% of the time.

Liver transplant patients have a risk of progression similar to that of sporadic patients with branch duct intraductal papillary mucinous neoplasms

Intraductal papillary mucinous neoplasms (IPMNs) have malignant potential and can progress from low‐ to high‐grade dysplasia to invasive adenocarcinoma. The management of patients with IPMNs is dependent on their risk of malignant progression, with surgical resection recommended for patients with branch‐duct IPMN (BD‐IPMN) who develop high‐risk features. There is increasing evidence that liver transplant (LT) patients are at increased risk of extrahepatic malignancy. However, there are few data regarding the risk of progression of BD‐IPMNs in LT recipients. The aim of this study was to determine whether LT recipients with BD‐IPMNs are at higher risk of developing high‐risk features than patients with BD‐IPMNs who did not receive a transplant. Consecutive patients who underwent an LT with BD‐IPMNs were included. Patients with BD‐IPMNs with no history of immunosuppression were used as controls. Progression of the BD‐IPMNs was defined as development of a high‐risk feature (jaundice, dilated main pancreatic duct, mural nodule, cytology suspicious or diagnostic for malignancy, cyst diameter ≥3 cm). Twenty‐three LT patients with BD‐IPMN were compared with 274 control patients. The median length of follow‐up was 53.7 and 24.0 months in LT and control groups, respectively. Four (17.4%) LT patients and 45 (16.4%) controls developed high‐risk features (P = 0.99). In multivariate analysis, progression of BD‐IPMNs was associated with age at diagnosis but not with LT. There was no statistically significant difference in the risk of developing high‐risk features between the LT and the control groups. Liver Transpl 20:1462‐1467, 2014.