Jean Closset

Tumoral and Nontumoral Pancreas: Correlation between Quantitative Dynamic Contrast-enhanced MR Imaging and Histopathologic Parameters

PURPOSEnTo prospectively determine whether dynamic contrast material-enhanced (DCE) magnetic resonance (MR) quantitative parameters correlate with fibrosis and microvascular density (MVD) in malignant and benign solid pancreatic focal lesions and nontumoral pancreatic tissue.nnnMATERIALS AND METHODSnThe institutional review board approved the study; written informed consent was obtained. DCE MR was performed in 28 patients with surgically resectable focal pancreatic lesions. DCE MR quantitative parameters derived from one-compartment (OC) (transfer rate constant [K(trans)] and distribution fraction [ƒ]) and two-compartment (TC) (K(trans), tissue volume fraction occupied by extravascular extracellular space [v(i)], and tissue volume fraction occupied by vascular space [v(p)]) pharmacokinetic models were correlated with fibrosis content and MVD counts in focal lesions and nontumoral tissue (Spearman correlation coefficient [SCC]). Pharmacokinetic parameters were compared (Mann-Whitney test) between tumoral and nontumoral tissue. Diagnostic performance of DCE MR fibrosis detection was assessed (receiver operator characteristic curve analysis).nnnRESULTSnK(trans) OC and K(trans) TC were significantly lower in primary malignant tumors compared with benign lesions (P = .023) and nontumoral pancreatic tissue downstream (P < .001) and upstream (P = .006); ƒ and v(i) were significantly higher in primary malignant tumors compared with nontumoral pancreatic tissue downstream (P = .012 and .018, respectively). Fibrosis was correlated negatively with K(trans) OC (SCC, -0.600) and K(trans) TC (SCC, -0.564) and positively with ƒ (SCC, 0.514) and v(i) (SCC, 0.464), with P < .001 (all comparisons). MVD was positively correlated with ƒ (SCC, 0.355; P = .019) and v(i) (SCC, 0.297; P = .038) but not with K(trans) OC (SCC, -0.140; P = .33) and K(trans) TC (SCC, -0.194; P = .181). Sensitivity and specificity for fibrosis detection were 65% (24 of 37) and 83% (10 of 12) for K(trans) OC (cutoff value, 0.35 min(-1)) and 76% (28 of 37) and 83% (10 of 12) for K(trans) TC (cutoff value, 0.29 min(-1)), respectively.nnnCONCLUSIONnQuantitative DCE MR parameters, derived from pharmacokinetic models in malignant and benign pancreatic solid lesions and nontumoral pancreatic tissue, were significantly correlated with fibrosis and MVD.nnnSUPPLEMENTAL MATERIALnhttp://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.11103515/-/DC1.

Endotherapy for paraduodenal pancreatitis: A large retrospective case series

BACKGROUND AND STUDY AIMSnParaduodenal pancreatitis is histologically well defined but its epidemiology, natural history, and connection with chronic pancreatitis are not completely understood. The aim of this study was to review the endoscopic and medical management of paraduodenal pancreatitis.nnnPATIENTS AND METHODSnMedical records of all patients with paraduodenal pancreatitis diagnosed by magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasonography (EUS) between 1995 and 2010 were retrospectively reviewed. Clinical features, imaging procedures, and treatments were investigated. The primary end point was the rate of clinical success, and the secondary end points were the radiological or endoscopic improvement, complication rate, and overall survival rate.nnnRESULTSnA total of 51 patients were included in the study (88.2u200a% alcohol abuse; median age 49 years [range 37u200a-u200a70]; 50 men). The most frequent symptoms at presentation were pain (nu200a=u200a50; 98.0u200a%) and weight loss (nu200a=u200a36; 70.6u200a%). Chronic pancreatitis was present in 36 patients (70.6u200a%), and 45 patients (88.2u200a%) had cysts. Other findings included stricture of the pancreatic duct (nu200a=u200a37; 72.5u200a%), common bile duct (nu200a=u200a29; 56.9u200a%), and duodenum (nu200a=u200a24; 47.1u200a%). A total of 39 patients underwent initial endoscopic treatment: cystenterostomy (nu200a=u200a20), pancreatic and/or biliary duct drainage (nu200a=u200a19), and/or duodenal dilation (nu200a=u200a6). For the patients with available follow-up (nu200a=u200a41), 24 patients required repeat endoscopy and 9 patients required surgery after the initial endoscopic management. After a median follow-up of 54 months (range 6u200a-u200a156 months), complete clinical success was achieved in 70.7u200a% of patients, and the overall survival rate was 94.1u200a%.nnnCONCLUSIONSnThis is the largest series concerning the management of paraduodenal pancreatitis using endotherapy as the first-line intervention. Although repeat endoscopic procedures were required in half of the patients, no severe complication was observed and surgical treatment was ultimately needed in less than 25u200a% of the patients.

Endoscopic therapy for main pancreatic-duct rupture after Silastic-ring vertical gastroplasty.

BACKGROUNDnAcute pancreatitis with pancreatic-duct rupture and fluid collections is a rare complication after Silastic ring vertical gastroplasty. It can be attributed to pancreatic trauma occurring during surgery.nnnMETHODSnEndoscopic therapy with transmural drainage of collections was performed in 4 patients who had undergone Silastic ring vertical gastroplasty and who had presented with acute pancreatitis with main pancreatic-duct rupture at the body of the pancreas.nnnOBSERVATIONSnAll patients had successful transmural drainage with cystogastrostomy, followed by stent insertion. Only one patient had a late recurrence because of stent migration. The major difficulty was related to positioning of the endoscope and the possible need of pneumatic dilation of the outlet channel to reach the puncture site.nnnCONCLUSIONSnEndoscopic therapy is useful in acute pancreatitis with pancreatic-duct rupture after Silastic-ring vertical gastroplasty and, although technically difficult, could be considered as a first-line approach in the management of these patients.

Metastatic carcinoma of the gallbladder after a renal cell carcinoma

Abstract The gallbladder is rarely the site of distant metastases and in most cases malignant melanoma is the primary tumor. We report a case of a 64-year-old man with a gallbladder metastasis secondary to a renal cell carcinoma. Renal cell carcinoma has a tendency toward metastatic disease, the most notable features of this tumor being its unusual pattern of metastatic disease. Pre-operative imaging studies are often futile in the differentiation between primary and secondary tumors of the gallbladder. Since primary tumors of the gallbladder often coexist with gallstones, a polypoid lesion in an acalculous gallbladder is more consistent with metastasis than a primary tumour. If feasible, surgical resection of the gallbladder is mandatory because it could guarantee better chances of survival for patients with metastatic renal carcinoma.

TTF-1 positive small cell cancers: Don't think they're always primary pulmonary!

Thyroid transcription factor 1 (TTF-1) plays a key role in morphogenesis of the lungs and is expressed in up to 90% of pulmonary small cell carcinomas. This explains why this marker is frequently used in the search for the primary origin of metastatic endocrine tumours. Here we report on a TTF-1 expressing mixed endocrine-exocrine carcinoma of the common bile duct in a patient with pulmonary nodules that did not appear to be neoplastic. TTF-1 positivity in pulmonary and extrapulmonary neuroendocrine tumours is reviewed, and we conclude that TTF-1 expression in neuroendocrine tumours of the small-cell type are not uncommon at extrapulmonary locations. Therefore, immunohistochemistry for TTF-1 in such tumours should be interpreted with caution.

A rare case of a pancreatic mass due to accessory spleen; when EUS-FNA is not enough

asymptomatic elevation of pancreatic hydrolase levels. Magnetic resonance imaging (MRI) delineated a pancreatic lesion with a low T1 and high T2 signal (● Fig. 1). Endoscopic ultrasound (EUS) found an oval, well-defined, isoechogenic, homogeneous mass in the pancreatic parenchyma, without any vascular invasion and no locoregional lymph nodes (● Fig. 2). Fine-needle aspiration (FNA) showed small epithelioid cells. Immunostaining was positive for antichromogranin, antisynaptophysin, and anti-KI-67 (5%), and a few cells were positive for anti-CD56. This was consistent with a neuroendocrine tumor (NET). Octreotide positron emission tomography combined with computed tomography (PET-CT) showed a focal uptake into the pancreas without any other nonphysiological uptake (● Fig. 3). CA19–9 and chromogranin levels were normal. Caudal pancreatectomy with spleen preservation was performed. Histological examination found no proof of NET but did reveal an intrapancreatic accessory spleen (IPAS) (● Fig. 4). The postoperative period and follow-up were satisfactory. Accessory spleens may be found in 15% of the population but are rarely located in the pancreatic tail (17%) [1]. Most IPASs have a homogeneous contrast-enhanced appearance on CT and MRI, sharing features with hypervascular lesions (such as NETs) [1]. Octreotide scans have a high sensitivity for detection of gastrointestinal NET (70%– 95%). The somatostatin receptors on the surface of splenic lymphocytes may lead to false diagnosis ofNET [2]. Nuclear scintigraphic investigations such as those with 99mTc sulfur colloid can help in identifying IPAS [3]. EUS findings include regular margins and homogeneous echogenicity, ranging from hypoechoic to hyperechoic [4]. FNA reveals small lymphocytes and a mixed inflammatory infiltrate with the appearance of white pulp. Sampling of islet cell clusters from the adjacent pancreatic parenchyma can lead tomisdiagnosis. CD8 immunostaining of splenic sinus endothelial cells can help in confirming the diagnosis, as done retrospectively on FNA material in our patient [5]. Ultrasound endoscopists should be aware of this entity (IPAS) in order to avoid unnecessary surgery, even when FNA shows cells with NET characteristics.