Rossella Graziani

Autoimmune Pancreatitis: Differences Between the Focal and Diffuse Forms in 87 Patients

OBJECTIVES:Autoimmune pancreatitis (AIP) is a particular type of chronic pancreatitis that can be classified into diffuse and focal forms. The aim of this study was to analyze clinical and instrumental features of patients suffering from the diffuse and focal forms of AIP.METHODS:AIP patients diagnosed between 1995–2008 were studied.RESULTS:A total of 87 AIP patients (54 male and 33 female patients, mean age 43.4±15.3 years) were studied. Focal-type AIP was diagnosed in 63% and diffuse-type in 37%. Association with autoimmune diseases was observed in 53% of cases, the most common being ulcerative colitis (30%). Serum levels of IgG4 exceeded the upper normal limits (135 mg/dl) in 66% of focal AIP and in 27% of diffuse AIP (P=0.006). All patients responded to steroids. At recurrence non-steroid immunosuppressive drugs were successfully used in six patients. Recurrences were observed in 25% of cases, and were more frequent in focal AIP (33%) than in diffuse AIP (12%) (P=0.043), in smokers than in non-smokers (41% vs. 15%; P=0.011), and in patients with pathological serum levels of IgG4 compared to those with normal serum levels (50% vs. 12%; P=0.009). In all, 23% of the patients underwent pancreatic resections. Among patients with focal AIP, recurrences were observed in 30% of operated and in 34% of not operated patients.CONCLUSIONS:Focal-type and diffuse-type AIP differ as regards clinical symptoms and signs. Recurrences occur more frequently in focal AIP than in diffuse AIP. The use of non-steroid immunosuppressants may be a therapeutic option in relapsing AIP.

Serous cystadenoma of the pancreas : Report of 30 cases with emphasis on the imaging findings

PURPOSE Our goal was to evaluate retrospectively 30 cases of serous cystadenoma (SCA) to determine its main imaging features as well as to discuss the differential diagnosis problems versus the other cystic lesions of the pancreas. METHOD Thirty SCAs were analyzed; they were all benign lesions, proven at surgery. Twenty-three tumors were evaluated with US, 26 with CT, and 5 with MRI. RESULTS Three different morphostructural patterns were identified: microlacunar (n = 19), mixed (n = 6), and macrolacunar (n = 5). The diagnosis of SCA, possible in either the microlacunar or the mixed patterns, was achieved in 74% of cases with US (17/23) and in 61.5% with CT (16/26). Among the 19 patients evaluated with both modalities, the joint information allowed a correct diagnosis in 16 cases (84%). The five macrolacunar tumors were undistinguishable from other cystic masses of the pancreas. CONCLUSION The diagnosis of SCA can be considered certain in the microlacunar, likely in the mixed, and not possible in the macrolacunar type.

Italian consensus guidelines for chronic pancreatitis

This paper gives practical guidelines for diagnosis and treatment of chronic pancreatitis. Statements have been elaborated by working teams of experts, by searching for and analysing the literature, and submitted to a consensus process by using a Delphi modified procedure. The statements report recommendations on clinical and nutritional approach, assessment of pancreatic function, treatment of exocrine pancreatic failure and of secondary diabetes, treatment of pain and prevention of painful relapses. Moreover, the role of endoscopy in approaching pancreatic pain, pancreatic stones, duct narrowing and dilation, and complications was considered. Recommendations for most appropriate use of various imaging techniques and of ultrasound endoscopy are reported. Finally, a group of recommendations are addressed to the surgical treatment, with definition of right indications, timing, most appropriate procedures and techniques in different clinical conditions and targets, and clinical and functional outcomes following surgery.

Autoimmune Pancreatitis: CT Patterns and Their Changes after Steroid Treatment

PURPOSE To retrospectively evaluate the computed tomographic (CT) patterns of autoimmune pancreatitis (AIP) and their changes after steroid therapy. MATERIALS AND METHODS Investigational review board approval was obtained, and the informed consent requirement was waived. The medical and imaging data of 21 patients (13 men, eight women; mean age, 47.5 years; age range, 25-79 years) with histopathologically proved AIP who underwent contrast material-enhanced CT at diagnosis and after steroid treatment were included in this study. Image analysis included assessment of the (a) presence or absence and type (focal or diffuse) of pancreatic parenchyma enlargement, (b) contrast enhancement of pancreatic parenchyma, (c) size of the main pancreatic duct (MPD) within the lesion and upstream, and (d) pancreatic parenchyma thickness in the head, body, and tail of the pancreas. The same criteria were applied to follow-up CT examinations, the follow-up data were compared with pretreatment data, and a paired sample t test was applied. RESULTS Pancreatic parenchyma showed focal enlargement in 14 (67%) patients and diffuse enlargement in seven (33%). Pancreatic parenchyma affected by AIP appeared hypoattenuating in 19 (90%) patients and isoattenuating in two (10%). During the portal venous phase, pancreatic parenchyma showed contrast material retention in 18 (86%) patients and contrast material washout in three (14%). The MPD was never visible within the lesion. After treatment, there was a reduction in the size of pancreatic parenchyma segments affected by AIP (P < .05). Fifteen (71%) of the 21 patients had a normal enhancement pattern in the pancreatic parenchyma, whereas the enhancement pattern remained hypovascular in six (29%). The MPD returned to its normal size within the lesion in all patients at follow-up CT. In one of the eight patients with focal forms of AIP, the upstream MPD remained dilated. CONCLUSION AIP appeared as pancreatic parenchyma enlargement, with MPD stenosis within the lesion and upstream dilatation in focal forms of AIP. After steroid treatment, there was normalization of these findings.

Main pancreatic duct intraductal papillary mucinous neoplasms: accuracy of MR imaging in differentiation between benign and malignant tumors compared with histopathologic analysis.

PURPOSE To retrospectively determine the accuracy of magnetic resonance (MR) imaging combined with MR cholangiopancreatography (CP) in differentiating benign from malignant intraductal papillary mucinous neoplasms (IPMNs) involving the main pancreatic duct (MPD), with histopathologic analysis as the reference standard. MATERIALS AND METHODS The informed consent requirement was waived for this institutional review board-approved study. A total of 51 patients with histopathologically proved IPMNs (MPD IPMN, n = 29; mixed type IPMN, n = 22), underwent MR imaging, MR CP, and surgery, with a mean interval of 2.6 months between MR examination and surgery. Qualitative image analysis included assessment of the site of MPD dilatation (head of the pancreas, body and/or tail of the pancreas, or diffuse), presence or absence of duct wall nodules, and contrast enhancement of the MPD walls. Quantitative image analysis included measurement of the maximum diameter of the MPD. A comparison of adenomas and borderline IPMNs with cancerous IPMNs was performed with the Student t test or the Mann-Whitney U test for continuous variables. RESULTS At histopathologic analysis, 27 IPMNs were classified as carcinomas; 13, as borderline tumors; and 11, as adenomas. MPD wall nodules were observed in 16 carcinomas involving the MPD and one adenoma or borderline neoplasm (P < .00001). Duct wall enhancement was observed in 20 MPD or mixed type carcinomas and five adenomas or borderline neoplasms (P = .0001). The median maximal diameter of the MPD was 18 mm in malignant MPD or mixed type IPMNs and 11 mm in benign borderline IPMNs (P = .038). No significant difference in the overall 5-year survival rate of patients with MPD IPMNs and those with mixed type IPMNs was observed (P = .813). CONCLUSION Duct wall nodules and enhancement of the MPD walls are signs of malignant MPD or mixed type IPMNs. SUPPLEMENTAL MATERIAL http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.2531080604/-/DC1.

Italian consensus guidelines for the diagnostic work-up and follow-up of cystic pancreatic neoplasms.

This report contains clinically oriented guidelines for the diagnostic work-up and follow-up of cystic pancreatic neoplasms in patients fit for treatment. The statements were elaborated by working groups of experts by searching and analysing the literature, and then underwent a consensus process using a modified Delphi procedure. The statements report recommendations regarding the most appropriate use and timing of various imaging techniques and of endoscopic ultrasound, the role of circulating and intracystic markers and the pathologic evaluation for the diagnosis and follow-up of cystic pancreatic neoplasms.

Autoimmune Pancreatitis: Pancreatic and Extrapancreatic MR Imaging―MR Cholangiopancreatography Findings at Diagnosis, after Steroid Therapy, and at Recurrence

PURPOSE To determine and describe the magnetic resonance (MR) imaging-MR cholangiopancreatographic pancreatic and extrapancreatic findings of autoimmune pancreatitis (AIP) and the probability, site, and MR features of recurrent AIP after steroid therapy. MATERIALS AND METHODS This retrospective study was approved by the institutional review board, and the requirement for informed patient consent was waived. The data of 27 patients with AIP were included in the study. All patients had undergone MR imaging with MR cholangiopancreatography before and after steroid treatment and during follow-up (median follow-up period, 45 months). Image analysis included assessment of pancreatic parenchyma enlargement, signal intensity on T1- and T2-weighted MR images, contrast enhancement, and presence of bile duct and/or renal involvement. The probability of AIP recurrence was assessed by using Kaplan-Meier curves and the unadjusted Cox model. RESULTS At the time of diagnosis, the AIP-affected pancreatic parenchyma showed diffuse enlargement in 14 (52%) of the 27 patients and segmental enlargement in 13 (48%). The pancreatic parenchyma appeared hypointense on T1-weighted images in all 27 (100%) patients, hyperintense on T2-weighted images in 25 (93%), and isointense in two (7%). During the pancreatic phase of the dynamic contrast material-enhanced study, the affected pancreatic parenchyma appeared hypointense in 25 (93%) patients and isointense in two (7%). During the portal venous and delayed phases, the images of 19 (70%) patients showed delayed enhancement. Bile duct involvement was observed in 10 (37%) patients, and renal involvement was observed in two (7%). After steroid treatment, six (22%) patients had recurrent AIP, with a median disease-free interval of 20.6 months. The sites of recurrence were the pancreas and the kidneys in three of the six patients, solely the pancreas in two patients, and the biliary ducts in one patient. CONCLUSION MR imaging with MR cholangiopancreatography enables the diagnosis of pancreatic and extrapancreatic AIP and the assessment of changes after steroid therapy.

Surgical Treatment of Pancreatic Metastases from Renal Cell Carcinomas

Pancreatic metastases from a renal cell carcinoma are rare and may occur long after manifestation of the primary disease. Resection of the metastases should be regarded as the best treatment. In our center, owing to the slow evolution of these secondaries, we perform resections capable of limiting the destruction of the pancreatic parenchyma as far as possible. The use of ‘atypical’ resections of the pancreas is characterized by a higher incidence of postoperative complications, particularly fistulas. Despite this, we believe that adjusted resection is to be advocated because of the possibility of additional remote secondaries, the shorter duration of surgery, the preservation of the glandular parenchyma and intact adjacent organs, such as duodenum, stomach, and spleen, and the fact that there have been no reports on local recurrences.

Papillary cystic neoplasm of the pancreas: radiological findings.

We report a series of 10 papillary cystic neoplasms of the pancreas evaluated in our institution. The lesions are analyzed in retrospect to define the existence of eventual specific imaging patterns as well as to point out the existing problems of differential diagnosis versus other pancreatic tumors.We report a series of 10 papillary cystic neoplasms of the pancreas evaluated in our institution. The lesions are analyzed in retrospect to define the existence of eventual specific imaging patterns as well as to point out the existing problems of differential diagnosis versus other pancreatic tumors.

MR imaging and MR cholangiopancreatography of multifocal intraductal papillary mucinous neoplasms of the side branches: MR pattern and its evolution

Purpose . This paper describes the magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) pattern of multifocal intraductal papillary mucinous tumours (IPMT) of the pancreatic side branches and its evolution during followupMaterials and methods . Twenty-six patients with multifocal IPMT of the side branches were included in this retrospective study. Inclusion criteria were ≥2 ectasic side branches, presence of communication with the main pancreatic duct, and ≥2 MRI/MRCP examinations after ≥6-12 months. Exclusion criteria were IPMT involving both the main pancreatic duct and its branch ducts, previous surgery and lack of follow-up MRI examinations. Median follow-up was 27 (range 6–59) months. Images were assessed qualitatively and quantitatively. Qualitative assessment considered: the number of cystic lesions of the branch ducts, morphology of the communication between the cystic lesion and the main duct (direct or neck), presence of intraluminal filling defects within the cystic lesions, presence of mural nodules and mural enhancement of the cystic lesion. Quantitative assessment considered mean maximal diameter of the cystic lesions and mean length of the communication neckResults . At diagnosis, the mean number of cystic lesions of the side branches was 7.5. A communication neck was detected in 16/26 patients (60%). Intraluminal filling defects in the side branches were present in 6/26 patients (23%). Mural nodules were seen in 1/26 patients (4%). The mean diameter of the cystic lesions was 18.8 mm. The mean length of the communication neck was 6.9 mm. At follow-up, the mean number of cystic lesions of the side branches was 8.4. A communication neck was detected in 20/26 patients (77%). Intraluminal filling defects in the side branches were detected in 7/26 patients (27%); mural nodules were seen in 2/26 patients (8%). Mural enhancement of the branch duct was detected in 2/26 patients (8%). The mean diameter of the cystic lesions increased to 22.3 mm ( p < 0.05), and the mean length of the communication neck was 8.6 mmConclusions . Multifocal IPMT of the side branches shows a constant but very slow progression over time. In our series, only 2/26 patients showed mural nodulesRiassuntoObiettivo . Descrivere le caratteristiche RM/CPRM dei tumori intraduttali papillari mucino-secernenti (TIPM), multifocali dei dotti pancreatici secondari (dotti II) e loro evoluzioneMateriali e metodi . Ventisei pazienti (Pz) con TIPM multifocali dei dotti II sono stati inclusi in questo studio retrospettivo. Criteri di inclusione: ≥2 dotti II ectasici, presenza di comunicazione con il dotto pancreatico principale (DPP), ≥2 RM/CPRM a distanza ≥6-12 mesi. Criteri di esclusione: TIPM coinvolgenti sia il DPP che i dotti II, pregressa chirurgia, assenza di controllo RM. Mediana del monitoraggio: 27 mesi (range 6–59 mesi). Analisi qualitativa: numero delle dilatazioni cistiche dei dotti II, morfologia della comunicazione tra ectasie dei dotti II e DPP (diretta/colletto), presenza di difetti di riempimento endoluminali delle dilatazioni dei dotti II, presenza di noduli parietali, impregnazione di contrasto parietale delle dilatazioni cistiche dei dotti II. Analisi quantitativa: diametro medio delle dilatazioni cistiche dotti II; lunghezza media del colletto di comunicazione tra dotti II e DPPRisultati . Diagnosi. Numero medio ectasie dei dotti II: 7,5. Un colletto di comunicazione era presente in 16/26 Pz (60%). Difetti endoluminali erano presenti in 6/26 Pz (23%). Noduli parietali erano presenti in 1/26 Pz (4%). Il diametro medio delle dilatazioni cistiche dei dotti II era di 18,8 mm. La lunghezza media dei colletti di comunicazione era 6,9 mm. Controllo. Numero medio ectasie dei dotti II: 8,4. Il colletto di comunicazione era presente in 20/26 Pz (77%). Difetti endoluminali erano presenti in 7/26 Pz (27%); noduli parietali in 2/26 Pz (8%); ed in 2/26 (8%) era presente impregnazione di contrasto parietale. Diametro medio delle ectasie dei dotti II: 22,3 mm (p<0,05). La lunghezza media dei colletti rilevati era 8,6 mmConclusioni . I TIPM multifocali dei dotti II presentano un’evoluzione molto lenta. Solo 2/26 Pz (8%) hanno dimostrato noduli parietali