Giuseppe Corrias

Imaging features of malignant abdominal neuroendocrine tumors with rare presentation

BACKGROUNDnGastroenteropancreatic neuroendocrine tumors (NETs) are rare entities arising from neuroendocrine cells in the gastroenteric tract and pancreas. The purpose of this article is to present four cases of gastroenteropancreatic NETs that featured a challenging diagnosis.nnnCASE PRESENTATIONnWe report a case series of four NETs, each with different features. All NETs were suspected based on clinical and biochemical data. The workup of the abnormalities was performed with CT, PET or MRI.nnnCONCLUSIONnThe diagnosis of NETs is challenging and generally based on clinical manifestations, blood biochemical tests, imaging techniques, and pathology.

Does Second Reader Opinion Affect Patient Management in Pancreatic Ductal Adenocarcinoma

RATIONALE AND OBJECTIVESnTo determine the impact of second-opinion assessment on cancer staging and patient management in patients with pancreatic ductal adenocarcinoma.nnnMETHODS AND MATERIALSnThis retrospective study was approved by our institutional review board with a waiver of informed consent. Second-opinion reports between January 1, 2009 and December 31, 2013, alongside outside reports for 65 consecutive cases of biopsy-proven pancreatic adenocarcinomas, were presented in random order to two experienced abdominal surgeons who independently reviewed them blinded to the origin of the report, images of the examinations, and patient identifier. Each surgeon filled in a questionnaire for each report recommending cancer staging and patient management. Recommended patient management and staging were evaluated against reference standards (actual patient management at 6 months following second-opinion assessment, and pathology or other clinical and imaging reference standards at 6 months or longer, respectively) using Cohen kappa.nnnRESULTSnCancer staging differed in 13% (9 of 65) of cases for surgeon 1 and in 18.4% (12 of 65) for surgeon 2. Patient management changed in 38.4% (25 of 65) of cases for surgeon 1 and in 20% (13 of 65) for surgeon 2. When compared to the pathologic staging gold standard, second opinion was correct in 85.7% (six of seven) of the time for both surgeons. Recommended patient management from second-opinion reports showed good agreement with the reference standard (weighted ku2009=u20090.6467 [0.4014-0.892] and weighted ku2009=u20090.6262 [0.3954-0.857] for surgeon 2).nnnCONCLUSIONnSecond-opinion review by subspecialized oncologic radiologists can impact patient care, specifically in terms of management decision.

MRI liver fat quantification in an oncologic population: the added value of complex chemical shift-encoded MRI

INTRODUCTIONnChemotherapy prolongs the survival of patients with advanced and metastatic tumors. Since the liver plays an active role in the metabolism of chemotherapy agents, hepatic injury is a common adverse effect. The purpose of this study is to compare a novel quantitative chemical shift encoded magnetic resonance imaging (CSE-MRI) method with conventional T1-weighted In and Out of phase (T1 IOP) MR for evaluating the reproducibility of the methods in an oncologic population exposed to chemotherapy.nnnMATERIALS AND METHODSnThis retrospective study was approved by the institutional review board with a waiver for informed consent. The study included patients who underwent chemotherapy, no suspected liver iron overload, and underwent upper abdomen MRI. Two radiologists independently draw circular ROIsin the liver parenchyma. The fat fraction was calculated from IOP imaging and measured from IDEAL-IQ fat fraction maps. Two different equations were used to estimate fat with IOP sequences. Intra-class correlation coefficient and repeatability coefficient were estimated to evaluate agreement between two readers on iron level and fat fraction measurement.nnnRESULTSnCSE-MRI showed a higher reliability in fat quantification compared with both IOP methods, with a substantially higher inter-reader agreement (0.961 vs 0.372). This has important clinical implications.nnnCONCLUSIONnThe novel CSE-MRI method described here provides increased reproducibility and confidence in diagnosing hepatic steatosis in a oncologic clinical setting. IDEAL-IQ has been proved to be more reproducible than conventional IOP imaging.

Detection of recurrent pancreatic cancer: value of second-opinion interpretations of cross-sectional images by subspecialized radiologists

PurposeTo investigate the value of second-opinion interpretation of cross-sectional images by subspecialized radiologists to diagnose recurrent pancreatic cancer after surgery.MethodsThe IRB approved and issued a waiver of informed consent for this retrospective study. Initial and second-opinion interpretations of 69 consecutive submitted MRI or CT follow-up after pancreatic cancer resection between January 1, 2009 and December 31, 2013 were evaluated by one oncologic imaging radiologist, who was blinded to patient’s clinical details and histopathologic data. The reviewer was asked to classify each interpretation in reference of the diagnosis of PDAC recurrence. It was also recorded if the radiologic interpretation recommended additional imaging studies to confirm recurrence. The diagnosis of recurrence was determined by pathology when available, otherwise by imaging follow-up, clinical, or laboratory assessments. Cohen’s kappa statistic was used to assess agreement between initial and second-opinion interpretations. The differences between the initial and second-opinion interpretations were examined using McNemar test or Bowker’s test of symmetry.ResultsDisagreement on recurrence between the initial report and the second-opinion interpretation was observed in 32% of cases (22/69; ku2009=u20090.44). Second-opinion interpretations had a higher sensitivity and a higher specificity on recurrence compared to the initial interpretations (0.93 vs. 0.75 and 0.90 vs. 0.68, respectively), and the difference in specificity was significant (pu2009=u20090.016). Additional imaging studies were recommended more frequently in the initial interpretation (22% vs. 6%, pu2009=u20090.006).ConclusionsOur study shows the second-opinion interpretation by subspecialized radiologists improves the detection of pancreatic cancer recurrence after surgical resection.

Hepatic angiosarcomatous transformation of a mediastinal germinal cell tumor: A care case report

Rationale: Mediastinal nonseminomatous germ cell tumor (NSGCT) is an uncommon entity. Metastatic hepatic sarcomatous transformation is rare. Patient concerns: We report a 24-year-old man with no previous related medical history presented with chest pain and left arm numbness. Diagnoses: The x-ray showed an anterior mediastinal mass. The chest computed tomography (CT) confirmed the presence of a mildly enhancing mass in the same location, without invasion of any vascular structure. A CT-guided biopsy was performed, revealing a primary mediastinal nonseminomatous germ cell tumor (NSGCT), yolk sac histology, with areas of somatic transformation to malignant nerve sheath tumor. After surgery patient was followed-up with imaging. Two years later a CT scan showed a new hepatic hyper vascular lesion, confirmed by a subsequent magnetic resonance imaging (MRI) and positron emission tomography (PET) scan. A CT-guided biopsy revealed a hepatic metastatic transformation to angiosarcoma of the primitive NSGCT. Interventions: The patient went on to received palliative chemotherapy. Outcomes: The patient is being followed-up regularly at the outpatient department. Lessons: Because of the potential of metastatic sarcoma arising from germ cell tumors, these patients should undergo periodical follow-up, with periodical scans. PETCT scan might have a role in the follow-up of these patients.

Malignant transformation of glucagonoma with SPECT/CT In-111 OctreoScan features: A case report

Rationale: Glucagonoma is an uncommon disease but it has been associated with a pattern of symptoms defined as glucagonoma syndrome. These symptoms, if promptly recognized, could help to speed up the diagnosing process. Patient concerns: We report a case of a 68-year-old woman with a pancreatic glucagonoma. Her symptoms at the onset were typical of the glucagonoma syndrome. Diagnoses: After a significant weight loss, she underwent a computer tomography scan of the abdomen, which showed a hypervascular lesion of the tail of the pancreas and hypervascular lesions of the liver. An ultrasound guided biopsy was performed and pathology was consistent with glucagonoma. Her blood glucagon levels were elevated. Outcomes: She was treated with chemotherapy and somatostatin analogs. After 4 years, the disease had a malignant transformation, and metastases suddenly started to grow up. She stopped being responsive to treatment and eventually passed away. Lessons: Due to its rarity, clinical diagnosis is challenging and generally it comes after a long interval since the onset of symptoms. Awareness of physicians and dermatologists of the characteristic necrolytic migratory erythema, and of the other symptoms, often leads to early diagnosis.

Pancreatoblastoma with Metastatic Retroperitoneal Lymph Node and PET/CT

A previously healthy 4-year-old girl presented with petechial rash and low platelet count. There were no other symptoms. On abdominal ultrasound, a 4.7-cm heterogeneous mass was demonstrated anterior to the left kidney. An abdominal MRI subsequently performed demonstrated a heterogeneously enhancing mass at the same location extending to the pancreas and spleen. A surgical biopsy of the mass was obtained. Pathology reported a malignant epithelioid neoplasm consistent with pancreatoblastoma. The mass demonstrated intense FDG uptake on PET and an FDG avid retrocaval lymph node.