Emilio Barbi

Feasibility and safety of radiofrequency ablation for locally advanced pancreatic cancer.

Radiofrequency ablation (RFA) may be a valuable treatment option for locally advanced pancreatic cancer. The present study examined its feasibility and safety.

Pancreatic multicenter ultrasound study (PAMUS)

AIM To describe the typical CEUS pattern of pancreatic lesions and to evaluate the diagnostic accuracy of Contrast-enhanced ultrasound (CEUS) in their characterization. MATERIALS AND METHODS All US and CEUS examinations of focal pancreatic masses performed in six centers during a period of five years were reviewed. Inclusion criteria were: focal pancreatic mass pathologically proved, visible at ultrasound (US) and studied with CEUS. All lesions were then evaluated for size, aspect and enhancement pattern. Sensitivity, specificity, positive and negative predictive values with 95% CIs were calculated to define diagnostic accuracy of CEUS in respect to pathology. Diagnostic confidence of US and CEUS, discerning between benign and malignant lesions, were represented by using ROC (receiver operating characteristics) curves. Agreement was evaluated by means of k statistics. RESULTS 1439 pancreatic lesions were included. At CEUS the lesions were divided into solid (89%) and cystic (12%) masses and classified into six and eight categories, respectively. Among the solid lesions, adenocarcinomas were characterized with an accuracy of 87.8%. Among the cystic lesions, cystic tumors were diagnosed with an accuracy of 97.1%. ROC curve area increased from 0.637 for US to 0.877 for CEUS (p<0.0001). Inter-observer agreement was slightly higher for solid (k=0.78) than cystic (k=0.62) lesions. In none of the centers side effects were reported. CONCLUSION CEUS is accurate in the characterization of pancreatic lesions. CEUS should be considered as a complementary imaging method for pancreatic lesions characterization.

Intrahepatic peripheral cholangiocarcinoma (IPCC): comparison between perfusion ultrasound and CT imaging

PurposeThis study was done to compare the perfusion patterns of intrahepatic peripheral cholangiocarcinoma (IPCC) on contrast-enhanced ultrasound (CEUS) and dynamic computed tomography (CT).Materials and methodsWe retrospectively reviewed 23 histologically proven cases of IPCC. All lesions were studied by CEUS with sulfur hexafluoride-filled microbubbles coated with a phospholipid capsule, and by dynamic CT. Contrast-enhancement patterns were evaluated in the arterial phase (CEUS 10–20 s after the injection; CT 25–30 s after the injection) and in the delayed phase (CEUS 120 s after the injection; CT>2–3 min after the injection).ResultsLesions were single in 18/23 cases (78%), single with nearby satellite lesions in 1/23 (4%) cases and multifocal with distant secondary lesions in 4/23 (17%) cases. Lesion diameter was 2–5 cm in 7/23 cases (30%), 5–7 cm in 13/23 cases (57%) and >7 cm in 3/23 (13%) cases. On CEUS, lesions were hypervascular in 16/23 cases (70%). On delayed-phase CEUS, 22/23 lesions (96%) were markedly hypoechoic. CT showed that the lesions were hypovascular in the arterial phase in 15/23 cases (66%) and hypervascular in 7/23 (30%) cases; one lesion (1/23; 4%) was isovascular. On delayed-phase CT, lesions were hyperdense in 17/23 cases (74%), hypodense in 5/23 (22%) cases and isodense in 1/23 (43%) cases.ConclusionsEnhancement discrepancy between delayed-phase CEUS (hypoechogenicity) and CT (hyperdensity) is common semiological findings in the study of IPCC.RiassuntoObiettivoConfrontare le caratteristiche perfusionali del colangiocarcinoma intra-epatico periferico (IPCC) in ecografia con mdc (CEUS) e TC dinamica.Materiali e metodiAnalisi retrospettiva di 23 casi di colangiocarcinoma periferico istologicamente accertati. Tutte le lesioni sono state studiate con CEUS utilizzando microbolle a base di esaflururo di zolfo ricoperte da una capsula di fosfolipidi quale mezzo di contrasto e con TC dinamica. Sono state valutate le caratteristiche della impregnazione lesionale nelle fasi arteriosa (CEUS: 10–20 s dopo l’iniezione; TC: 25–30 s dopo l’iniezione) e tardiva (CEUS: 120 s dopo l’iniezione; TC>2–3 min dopo l’iniezione).RisultatiIn 18/23 (78%) la lesione era singola, in 1/23 (4%) singola con lesioni satelliti a ridosso della lesione principale e in 4/23 (17%) multifocale con lesioni a distanza rispetto alla lesione prinicipale. Le dimensioni delle lesioni erano comprese tra 2 e 5 cm di diametro in 7/23 (30%), tra 5 e 7 cm in 13/23 (57%) e superiori a 7 cm in 3/23 (13%). La CEUS ha evidenziato ipervascolarizzazione delle lesioni in 16/23 (70%). Ventidue su 23 lesioni (96%) in fase tardiva CEUS, sono risultate marcatamente ipoecogene. La TC ha evidenziato ipovascolarizzazione delle lesioni in fase arteriosa in 15/23 (66%) ed ipervascolarizzazione in 7/23 (30%); una lesione (1/23; 4%) era isovascolarizzata. In fase tardiva TC la lesione era iperdensa in 17/23 (74%) casi, ipodensa in 5/23 (22%) e isodensa in 1/23 (43%) casi.ConclusioniIl riscontro di una discordanza di enhancement in fase tardiva tra CEUS (ipoecogenicità) e TC (iperdensità) rappresenta frequente rilievo semeiologico nello studio del colangiocarcinoma intraepatico periferico.

Variation of tumoral marker after radiofrequency ablation of pancreatic adenocarcinoma

BACKGROUND To evaluate the correlation between variations of CA 19.9 blood levels and the entity of necrosis at CT after radiofrequency ablation (RFA) of unresectable pancreatic adenocarcinoma. METHODS In this study, from June 2010 to February 2014, patients with diagnosis of unresectable and not metastatic pancreatic ductal adenocarcinoma, expressing tumor marker CA 19.9, treated with RFA procedure were included. All these patients underwent RFA. CT study was performed 1 week after RFA. The dosage of CA 19.9 levels was performed 1 month after RFA. Features of necrosis at CT, as mean entity, density and necrosis percentages compared to the original lesion, were evaluated and compared by using t-test with CA 19.9 blood levels variations after RFA procedure. RESULTS In this study were included 51 patients with diagnosis of unresectable and not metastatic pancreatic ductal adenocarcinoma, expressing tumor marker CA 19.9, treated with RFA procedure and with CT study and CA 19.9 available for analysis. After the procedure, CA 19.9 blood levels reduced in 24/51 (47%), remained stable in 10/51 (20%) and increased in 17/51 (33%). In patients with CA 19.9 levels reduced, the tumor marker were reduced less than 20% in 4/24 (17%) and more than 20% in 20/24 (83%); instead the tumor marker were reduced less than 30% in 8/24 (33%) and more than 30% in 16/24 (67%). At CT scan necrotic area density difference was not statistically significant. Also there was no statistically significant difference among the mean area, the mean volume and the mean ablation volume in percentage related to the treated tumor among the three different groups of patients divided depending on the CA 19.9 blood levels. But a tendency to a statistically significant difference was found in comparing the mean percentage of ablation volume between two subgroups of patients with a decrease of CA 19.9 levels with less or more than 20% reduction of tumor markers and between two subgroups with less or more than 30% reduction of CA 19.9 levels. CONCLUSIONS RFA of unresectable pancreatic adenocarcinoma induces reduction of CA 19.9 blood levels in about half of the cases.

Uncommon presentations of common pancreatic neoplasms: a pictorial essay.

AbstractPancreatic neoplasms are a wide group of solid and cystic lesions with different and often characteristic imaging features, clinical presentations, and management. Among solid tumors, ductal adenocarcinoma is the most common: it arises from exocrine pancreas, comprises about 90% of all pancreatic neoplasms, and generally has a bad prognosis; its therapeutic management must be multidisciplinary, involving surgeons, oncologists, gastroenterologists, radiologists, and radiotherapists. The second most common solid pancreatic neoplasms are neuroendocrine tumors: they can be divided into functioning or non-functioning and present different degrees of malignancy. Cystic pancreatic neoplasms comprise serous neoplasms, which are almost always benign, mucinous cystic neoplasms and intraductal papillary mucinous neoplasms, which can vary from benign to frankly malignant lesions, and solid pseudopapillary tumors. Other pancreatic neoplasms, such as lymphoma, metastases, or pancreatoblastoma, are rarely seen in clinical practice and have different and sometimes controversial managements. Rare clinical presentations and imaging appearance of the most common pancreatic neoplasms, both solid and cystic, are more frequently seen and clinically relevant than rare pancreatic tumors; their pathologic and radiologic appearances must be known to improve their management. The purpose of this paper is to present some rare or uncommon clinical and radiological presentations of common pancreatic neoplasms providing examples of multi-modality imaging approach with pathologic correlations, thus describing the histopathological bases that can explain the peculiar imaging features, in order to avoid relevant misdiagnosis and to improve lesion management.

Percutaneous ablation of pancreatic cancer

Pancreatic ductal adenocarcinoma is a highly aggressive tumor with an overall 5-year survival rate of less than 5%. Prognosis and treatment depend on whether the tumor is resectable or not, which mostly depends on how quickly the diagnosis is made. Chemotherapy and radiotherapy can be both used in cases of non-resectable pancreatic cancer. In cases of pancreatic neoplasm that is locally advanced, non-resectable, but non-metastatic, it is possible to apply percutaneous treatments that are able to induce tumor cytoreduction. The aim of this article will be to describe the multiple currently available treatment techniques (radiofrequency ablation, microwave ablation, cryoablation, and irreversible electroporation), their results, and their possible complications, with the aid of a literature review.

Contrast-enhanced ultrasound of pancreatic tumours

Indication/purpose: To review contrast‐enhanced ultrasound features of the most common pancreatic tumours.

Intraoperative ultrasonography of the pancreas

Intraoperative ultrasonography (IOUS) still remains a useful and occasionally a problem-solving technique in pancreatic diseases, even though its role has recently been downsized owing to preoperative imaging advances [1]. Since its introduction in the 1980s, progressive technical developments have led to an increase in the diagnostic accuracy of IOUS. The availability of scanners that provide the depiction of fine anatomic details and the detection of small lesions in real-time with excellent spatial and contrast resolution allow the widespread application of this imaging method [1, 2]. Moreover, IOUS is able to clearly show lesions not detectable with other preoperative imaging modalities, and to accurately define the extension of the tumor and its relationship with vessels, sometimes determining significant changes in the therapeutic management of patients [3]–[5]. In addition, its ability in guiding interventional procedures (i.e. biopsy, duct cannulation and drainage of abscesses or cysts) has been widely reported [2, 6]. Lastly, its impact has significantly increased since both the development of mini-invasive laparoscopic approaches, due to the impossibility for the surgeon to visually and manually inspect the affected organ and the retroperitoneum, and the recent introduction of alternative palliative treatments under IOUS-guidance [7, 8].

Pancreatic Anatomy, Variants and Pseudolesions of the Pancreas

For many years the pancreas was left unexplored by radiologic research except indirectly and for more important diseases, such as calcifications in chronic pancreatitis on plain film radiography, gastric and duodenal imprint of largest masses on the barium meal study or the neoplastic involvement of peri-pancreatic vessels on the angiographic study.