Joe Ariyama

Imaging of Small Pancreatic Ductal Adenocarcinoma

Symptoms and laboratory studies provide only limited assistance in the diagnosis of small pancreatic carcinomas. Ultrasound and computed tomography are best suited for screening small pancreatic carcinomas because of their ease and accuracy. When findings of ultrasound and computed tomography suggest small pancreatic carcinomas, MR cholangiopancreatography and endoscopic ultrasound should be indicated. Both techniques can show very small tumors. Follow-up of 77 patients with pancreatic carcinoma in whom the tumor was resected showed a 100% 5-year survival rate of patients with tumor limited to the duct epithelium. The majority of these tumors were <1 cm. These tumors are considered early pancreatic carcinoma.

Endoscopic ultrasound and intraductal ultrasound in the diagnosis of small pancreatic tumors

AbstractBackground: The purpose of this study was to assess the diagnostic value of endoscopic ultrasound (EUS) and intraductal ultrasound (IDUS) in the detection of small pancreatic tumors. Methods: EUS was performed in 166 patients with verified pancreatic disease. IDUS was performed in 46 patients. A microprobe was introduced into the main pancreatic duct through the papilla of Vater using the duodenoscope. Results: EUS was valuable in the detection of small pancreatic tumors. Ductal adenocarcinomas smaller than 1 cm were demonstrated as a hypoechoic mass with a central irregular hyperechoic area. EUS and IDUS were useful in the characterization of intraductal paillary tumors (ductectatic mucinous tumors). EUS demonstrated nodular excrescences, and IDUS depicted papillary proliferation of the duct epithelium, which are characteristic of carcinomas and adenomas but not of hyperplasia. Internal architecture of cystic neoplasms was clearly depicted by EUS, and differentiation of serous and mucinous tumors was readily achieved. A tumor as small as a 5-mm islet cell was demonstrated on EUS because islet cell tumors are very hypoechoic. Conclusion: EUS and IDUS are relatively noninvasive procedures and are useful in the detection of small tumors and differentiation of pancreatic diseases.

The detection and prognosis of small pancreatic carcinoma

SummaryDuring a period of 16 years, 203 proven pancreatic ductal adenocarcinomas were studied. Tumor size was measured on either the resected or the autopsy specimen. Four tumors were smaller than 1 cm, and 17 tumors were between 1.1 and 2 cm. ERCP has been found to be the most accurate in the diagnosis of small pancreatic carcinoma. Followup of 44 patients in whom the tumor was resected showed that survival depended on tumor size. In four patients with tumors smaller than 1 cm without parenchymal invasion, the postoperative 5-yr cumulative survival rate was 100%. Pancreatic carcinoma smaller than 1 cm limited to duct epithelium is considered as early cancer. Various diagnostic imaging modalities are now available to evaluate patients in whom pancreatic carcinoma is clinically suspected. These include ultrasonography (US), computed tomography (CT), endoscopic retrograde cholangiopancreatography (ERCP), and angiography. More recently magnetic resonance imaging (MRI), endoscopic ultrasound (EUS), and peroral pancreatic ductal biopsy also have been used. This report compares diagnostic modalities for pancreatic carcinoma in order to provide a data base for their rational use in the diagnosis of small resectable pancreatic carcinomas.

Gastroduodenal erosions in Crohn's disease.

Gastroduodenal erosions were observed endoscopically and shown by double-contrast radiology in nine of 38 patients who had established Crohns disease elsewhere in the intestinal tract. One of the nine patients was known to have duodenal involvement by Crohns disease, but in the other eight there was no clinical suspicion of upper gastrointestinal disease. The possible significance of this finding is discussed.

Primary hepatic marginal zone B-cell lymphoma with mantle cell lymphoma phenotype

We report a rare case of primary hepatic lymphoma, Stage II disease, in a 48-year-old male who had a solitary hepatic tumour measuring 4×4.5×3 cm. The tumour showed a nodular growth pattern and lymphoepithelial lesions with bile ducts. Some neoplastic nodules had a non-neoplastic atrophic germinal centre and/or a thin mantle cell layer. Morphologically, the neoplastic cells were centrocyte-like cells or intermediate lymphocytes. They expressed L26(CD20)+/LN-1(CDw75)±/LN-2(CD74)+/cyclin D1− and had a monotypic immunoglobulin of cytoplasmic IgM (к) on paraffin sections. The neoplastic cells or neoplastic nodules expressed surface IgM+/surface IgD±/Leu-1(CD5)+/DRC-1+/alkaline phosphatase+/B1(CD20)+/B4(CD19)− on fresh frozen sections. We therefore diagnosed this case as primary hepatic marginal zone B-cell lymphoma with mantle cell lymphoma phenotype. We confirm that it is difficult to differentiate extranodal marginal zone B-cell lymphoma (low grade B-cell lymphoma of mucosa-associated lymphoid tissue type; MALT lymphoma) and mantle cell lymphoma.

Experience with percutaneous transhepatic cholangiography using the Japanese needle

Percutaneous transhepatic cholangiography using a very thin needle has been performed in 885 patients with a variety of underlying hepatic, biliary, and pancreatic disorders. The procedure was successful in 99% of the patients with dilated intrahepatic bile ducts and in 85% of those with non-dilated ducts. Complications which required surgical intervention occurred only in two cases (0.2%). In patients with obstructive jaundice, external bile drainage was performed immediately after visualization of the bile duct. Percutaneous transhepatic cholangiography is an extremely useful and safe method for investigating disorders of the biliary tract, for localizing the cause of obstructive jaundice, and for reducing the degree of jaundice and improving the general status of patients with obstructive jaundice.

The diagnosis of the small resectable pancreatic carcinoma

ERCP and angiography are essential for the accurate diagnosis of pancreatic carcinoma. ERCP is of value in detecting a pancreatic tumour and is the only examination which makes it possible to detect a small pancreatic carcinoma. Angiography is indispensable for the evaluation of the extent and size of the carcinoma, for prediction of resectability, and for differentiation between pancreatitis and carcinoma. Thirty-one out of 32 pancreatic carcinomas (96%) were correctly diagnosed pre-operatively by the use of a combination of the two examinations. Ten of them (31%) were resectable, and of these six measured less than 2 cm in diameter.

Intraductal oncocytic papillary carcinoma with invasion arising from the accessory pancreatic duct.

Mucin-producing tumors of the pancreas were first reported by Ohhashi and Takagi in 1980.1 Since then, many cases of intraductal papillarymucinous tumors (IMPTs) of the pancreas, which are similar to mucin-producing tumors of the pancreas, have been reported.2 IMPTs are generally regarded as tumors with a favorable prognosis. However, those with associated infiltration, noted in up to 25% of cases, are often mucinous and clinically indolent.3 Furthermore, some IMPTs exhibit ductal type infiltration and these are always associated with a poor prognosis.4 Intraductal oncocytic papillary neoplasms (IOPNs) of the pancreas have also been reported; these have the potential to develop into invasive carcinoma.5 Most IMPTs arise from the main pancreatic duct and IMPTs arising from the accessory pancreatic duct are relatively rare, there being only 6 reported cases.2,6-10 We present a case of invasive IPON arising from the accessory pancreatic duct.

Angiographic evaluation of the abnormal endoscopic pancreatogram.

Out of 1,269 pancreatograms, 122 were abnormal. Angiography was performed in these patients. Fifty-five were found to have pancreatic carcinoma. In the remaining 67 patients a false positive angiographic diagnosis of either chronic pancreatitis or pancreatic cancer was made in 11%. In one patient a hemangioma was diagnosed as a pancreatic cyst. The remaining 58 patients all had normal pancreatic angiograms in spite of gross ductal abnormality on endoscopic retrograde cholangiopancreatography (ERCP). All these patients were followed for an average of 19 months and showed no clinical evidence of pancreatic disease. It is suggested that angiography should be considered a complementary examination to ERCP and is particularly useful to exclude carcinoma when the pancreatogram is abnormal.

Early pancreatic ductal adenocarcinoma: Definition, diagnosis, and prognosis

Early pancreatic ductal adenocarcinomas may be defined as tumors limited to the duct epithelium without invasion to the parenchyma. The majority of these tumors are less than 1 cm in diameter. The patients symptoms and laboratory studies provide only limited assistance in the screening of small pancreatic carcinomas. Ultrasound (US), because of its ease of use and accuracy, is best suited as a screening procedure for small pancreatic carcinomas. Computed tomography (CT) is also valuable for such screening. When US and CT findings suggest the presence of small pancreatic carcinomas, endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) should be employed; these latter two modalities can show very small tumors. Our follow up of patients with pancreatic ductal adeno-carcinoma in whom the tumor was resected showed that survial depended on tumor size. The postoperative 5-year cumulative survival rate of patients with tumors less than 1 cm in diameter was 100%.