Enrico Boninsegna

Pancreatic duct stenosis: Differential diagnosis between malignant and benign conditions at secretin-enhanced MRCP

PURPOSE To define imaging criteria of benign and malignant nature in patients with main pancreatic duct (MPD) stenosis. MATERIALS-METHODS S-MRCPs of 35 patients with pancreatitis and 14 with adenocarcinoma were evaluated. RESULTS Adenocarcinoma caused higher prevalence of complete stenosis (14/14-100% vs 17/35-49%), dilated side-branches (14/14-100% vs 18/35-51%) and lower prevalence of duct-penetrating sign (0/14-0% vs 31/35-89%). The number of stenoses was higher in benign conditions (mean 1.4 Vs 1). Upstream MPD diameter was higher in cancer-induced stenoses (4.5 vs 2.9mm). CONCLUSIONS Single complete stenosis with dilated side branches, increased MPD caliber and absent duct-penetrating sign are suggestive of malignancy.

Primary sphenoid lymphoma: Focus on imaging

Primary lymphoma of the sphenoid is an extremely rare pathology, therefore it is difficult to hypothesize and the imaging characteristics are not well-known. Here we report the imaging features in computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) scan of a 44-year-old patient who presented with severe headache. CT and MRI showed a sphenoid sinus mass that suggested rhinopharyngeal lesion or a chordoma. However, biopsy from the mass histologically proved it to be Diffuse large B-cell lymphoma and PET examinations revealed increased fluorodeoxyglucose uptake around the sphenoid bone and multiple spinal lesions.

Surgery after FOLFIRINOX treatment for locally advanced and borderline resectable pancreatic cancer: increase in tumour attenuation on CT correlates with R0 resection

ObjectivesTo assess factors associated with radical resection (R0) of pancreatic ductal adenocarcinoma (PDAC) after induction treatment with FOLFIRINOX.MethodsPatients with either locally advanced (LA) and borderline resectable (BR) PDAC undergoing surgical exploration after FOLFIRINOX were retrospectively enrolled. Two pancreatic radiologists reviewed the CT blinded to the final outcome and assessed chemotherapy response and resectability. Patients were then divided into R0 resected (group A) and not resected/R1 resected (group B), which were compared.ResultsOf 59 patients included, 19 were defined as unresectable (32%), 33 borderline resectable (56%) and 7 resectable (12%) during the blind radiological evaluation after FOLFIRINOX. Once in a surgical setting, 27% were non-resectable, whereas 73% received surgical resection with a 70% R0 rate. Consequent sensitivity and specificity were 86% and 29%. At imaging review, significant decreases in longest tumour dimension were observed in both groups: from 32 mm (95% CI 15–55) to 21 (10–44) in group A and from 34 (18–70) to 26 (7–60) in group B, p < 0.05. However, a significant increase in tumour attenuation in all phases was only observed for R0 resected, from 52 HU (26–75) to 65 (35–92) in arterial phase (p < 0.001) and from 62 (36–96) to 78 (40–120) in the venous (p = 0.001).ConclusionAfter neoadjuvant FOLFIRINOX, CT predicted resectability with acceptable sensitivity but low specificity. The observation of increased tumour attenuation at CT scan after FOLFIRINOX treatment might represent a reliable predictor of R0 resection.Key Points• CT drives the assessment of PDAC resectability after FOLFIRINOX• CT predicts resectability with acceptable sensitivity but low specificity• Significant increase in tumour attenuation was only observed for R0 resected PDAC• Tumour attenuation after FOLFIRINOX represents a reliable predictor of R0 resection

Paraduodenal pancreatitis as a mimicker of pancreatic adenocarcinoma: MRI evaluation

PURPOSE To evaluate the MRI features of paraduodenal pancreatitis (PDP) and to define useful signs to differentiate PDP from pancreatic ductal adenocarcinoma (PDAC). MATERIAL AND METHODS We reviewed the MRI scans of 56 patients, 28 affected by PDP and 28 by PDAC, all pathologically proven. The following parameters were evaluated: signal intensity of the lesion on T1-, T2-WI, DWI (b800) and after contrast medium administration; presence of cysts; dilation of common hepatic duct and main pancreatic duct; focal thickening of the second portion of the duodenum; maximum diameter and volume of the lesion. RESULTS Both PDPs and PDACs were more frequently hypointense on T1-WI, iso-hyperintense on T2-WI, hypointense in the pancreatic phase and iso-hypointense in the venous phase (p>0.05); in the delayed phase most PDP were hyperintense (p=0.0031); on DWI 71.4% PDPs were isointense and all PDACs were hyperintense (p=0.0041). Cystic components were present in 85.7% PDPs (p=0.0011); double duct sign was present in 50% PDACs (p=0.0048); focal thickening of the duodenum was depicted in 89.3 PDPs (p=0.0012). PDPs were larger than PDACs (p=0.0003). CONCLUSION The most suggestive signs of PDP are: signal hyperintensity in the delayed phase, isointensity on DWI, presence of cysts, focal thickening of the duodenum and large size of the lesion.

MR in Cystic Tumors of the Pancreas

Cystic neoplasms of the pancreas are rare pancreatic tumors; nowadays they are diagnosed more frequently due to the spread of accurate imaging techniques.

Type 1 and type 2 autoimmune pancreatitis: is there any difference in MRI?

Purpose: The justification and optimisation of medical imaging employing ionizing radiation have been intensely discussed in recent years, particularly for computed tomography (CT). A key point in this discussion is the estimation of patient dose, which commonly employs radiation output metrics developed for quality assurance and no patient specific information. Such patient dose estimates are of limited value, and more refined methods needs to be promoted and provided to the community. Methods and Materials: AAPM Task Group 246 was formed in 2013, and in a joint venture with EFOMP charged with summarizing present methodology and DICOM information available for estimating patient dose with computed tomography.Results: The Joint Report of AAPM Task Group 246 and EFOMP is a comprehensive resource for the clinical medical physicist. The possibilities of patient specific dosimetry from the Computed Tomography Dose Index (CTDIvol), to the Size-Specific Dose Estimates (SSDE) and advanced Monte Carlo methods are discussed together with available DICOM information, as well as practical examples on how patient dose estimates can be achieved. The report also summarizes important factors contributing to the uncertainty in patient dose estimates and gives examples of achievable confidence intervals.Conclusion: The SSDE and Monte Carlo methods can together with detailed scanner, examination and patient specific DICOM information offer refined estimates of patient dose for justification and optimisation of CT examinations. Given the present robustness of available methods AAPM Task Group 246 and EFOMP recommend that all reports of patient dose should be accompanied by estimates of the associated uncertainty.