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Molero X, Ayuso JR, Balsells J, Boadas J, Busquets J, Casteràs A, Concepción M, Cuatrecasas M, Fernàndez Esparrach G, Fort E, Garcia Borobia F, Ginès À, Ilzarbe L, Loras C, Masachs M, Merino X, Olsina JJ, Puig-Diví V, Salord S, Serrano T, Vaquero EC. Chronic pancreatitis for the clinician: complications and special forms of the disease. Interdisciplinary position paper of the Catalan Society of Digestology (SCD) and the Catalan Pancreatic Society (SCPanc). Minerva Gastroenterol (Torino) 2024; 70:208-224. [PMID: 35262306 DOI: 10.23736/s2724-5985.22.03127-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Chronic pancreatitis tends to develop a number of complications that may constitute the form of presentation of the disease. Some societies have issued guidelines for diagnosis and treatment of chronic pancreatitis complications, but the level of evidence for any topic is usually low and recommendations tend to be weak. We aimed to provide defined position statements for the clinician based on updated review of published literature and on multidisciplinary expert agreement. The goal was to propose defined terminology and rational diagnostic/therapeutic circuits based on current knowledge. To this end 14 sections related to complications and special forms of chronic pancreatitis (early chronic, groove and autoimmune pancreatitis) were reviewed by 21 specialists from 6 different fields to generate 32 statements. Featured statements assert common bile duct stenosis does not require invasive treatment (endoscopic or surgical) unless cholestasis, cholangitis, lithiasis or other symptoms develop. Pancreatic duct strictures and calculi should be approached (after ruling out malignancy) if causing pain, pancreatitis, pseudocysts or other complications. Treatment of symptomatic pseudocysts must be individualized, considering associated main duct stenosis, vascular and pericystic complications. Higher risk conditions for pancreatic cancer are advance age, smoking, genetic background, recent diagnosis of chronic pancreatitis or diabetes, and appearance of new symptoms. Groove pancreatitis can initially be treated with conservative measures. Both prednisolone or rituximab can induce remission and maintenance of autoimmune pancreatitis. Internal fistula, vascular complications, bacterial overgrowth, osteoporosis and renal lithiasis require specific therapeutic approaches.
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Affiliation(s)
- Xavier Molero
- Unit of Exocrine Pancreas Research, Department of Gastroenterology, VHIR, CIBERehd, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain -
| | - Juan R Ayuso
- Department of Radiology, CDI, IDIBAPS, Hospital Clínic Barcelona, Barcelona, Spain
| | - Joaquim Balsells
- Department of Hepato-Pancreato-Biliary and Transplantation Surgery, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Jaume Boadas
- Department of Gastroenterology, Consorci Sanitari de Terrassa, Terrassa, Spain
| | - Juli Busquets
- Department of Hepatobiliary and Pancreatic Surgery, IDIBELL, Bellvitge University Hospital, University of Barcelona, L'Hospitalet de Llobregat, Spain
| | - Anna Casteràs
- Unit of Diabetes and Metabolism Research, VHIR, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - Mar Concepción
- Department of Gastroenterology, Santa Creu i Sant Pau Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - Míriam Cuatrecasas
- Department of Pathology, CIBEREHD, IDIBAPS, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain
| | - Gloria Fernàndez Esparrach
- Unit of Endoscopy, Department of Gastroenterology, CIBEREHD IDIBAPS, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain
| | - Esther Fort
- Department of Gastroenterology, Doctor Josep Trueta University Hospital, Girona, Spain
| | | | - Àngels Ginès
- Unit of Endoscopy, Department of Gastroenterology, CIBEREHD IDIBAPS, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain
| | - Lucas Ilzarbe
- Department of Gastroenterology, Hospital del Mar Parc Salut Mar, Barcelona, Spain
| | - Carme Loras
- Department of Gastroenterology, CIBERehd, University of Barcelona, Terrassa, Spain
| | - Miquel Masachs
- Department of Endocopy, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Terrassa, Spain
| | - Xavier Merino
- Department of Radiodiagnostic, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Jorge J Olsina
- Department of General Surgery, Institute for Research in Biomedicine of Lleida (IRBLleida), University Hospital Arnau de Vilanova, Lleida, Spain
| | - Valentí Puig-Diví
- Department of Gastroenterology, Parc Taulí Research and Innovation Institute I3PT, Parc Taulí University Hospital, Sabadell, Spain
| | - Sílvia Salord
- Unit of Hepato-Bilio-Pancreatic, Department of Digestive Diseases, IDIBELL, Bellvitge University Hospital, University of Barcelona, L'Hospitalet de Llobregat, Spain
| | - Teresa Serrano
- Department of Pathology, IDIBELL, CIBERehd, Bellvitge University Hospital, L'Hospitalet de Llobregat, Spain
| | - Eva C Vaquero
- Department of Gastroenterology, CIBEREHD IDIBAPS, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain
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Inayat F, Afzal A, Anwar MS, Saeed A, Chaudhry A, Haider M, Zulfiqar L, Afzal MS, Arslan HM, Saif MW. Acute pancreatitis associated with pembrolizumab-induced hypertriglyceridemia. J Oncol Pharm Pract 2024:10781552241245332. [PMID: 38576329 DOI: 10.1177/10781552241245332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
INTRODUCTION Acute pancreatitis (AP) following drug-induced hypertriglyceridemia is a rare clinical phenomenon. Immune checkpoint inhibitors have revolutionized treatment for a variety of solid organ and hematological malignancies. Pembrolizumab is a programmed cell death receptor-1 (PD-1) inhibitor that has shown promising responses in many advanced cancers. However, a constellation of immune-related adverse events has also been described. There are reports of pembrolizumab-induced hypertriglyceridemia, but AP as a result of this side effect remains an exceedingly rare clinical sequela. CASE REPORT We delineate a case of a patient with stage IVB non-small-cell lung cancer who developed progressive abdominal pain and nausea following administration of pembrolizumab for four months. Laboratory studies revealed increased serum lipase and triglyceride levels at 12,562 IU/L and 16,901 mg/dL, respectively. The diagnosis of AP was made based on the revised Atlanta classification criteria. After ruling out alternative causes, pembrolizumab-induced hypertriglyceridemia was considered the likely etiology of AP. MANAGEMENT AND OUTCOME The patient was transferred to the medical intensive care unit for close monitoring. Treatment was initiated with intravenous fluids, pain medications, and an insulin infusion. However, her hypertriglyceridemia levels remained persistently elevated, necessitating therapeutic apheresis. She recovered well with no complications after triglyceride apheresis. DISCUSSION AP following pembrolizumab-associated hypertriglyceridemia remains a rare clinicopathologic entity. Given the widespread clinical use of immune checkpoint inhibitors, knowledge of such rare adverse events is crucial. Evaluation of serum triglyceride levels before and after initiating pembrolizumab therapy may be mandated, especially in patients with metabolic comorbidities.
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Affiliation(s)
- Faisal Inayat
- Allama Iqbal Medical College, Lahore, Punjab, Pakistan
| | - Arslan Afzal
- Allama Iqbal Medical College, Lahore, Punjab, Pakistan
| | | | | | | | | | | | | | | | - Muhammad Wasif Saif
- St. Dominic's Hospital, Jackson, MS, USA
- Karmanos Cancer Center, Wayne State University, Detroit, MI, USA
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Gallo C, Dispinzieri G, Zucchini N, Invernizzi P, Massironi S. Autoimmune pancreatitis: Cornerstones and future perspectives. World J Gastroenterol 2024; 30:817-832. [PMID: 38516247 PMCID: PMC10950636 DOI: 10.3748/wjg.v30.i8.817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/18/2023] [Accepted: 01/25/2024] [Indexed: 02/26/2024] Open
Abstract
Autoimmune pancreatitis (AIP) is an autoimmune subtype of chronic pancreatitis resulting from the aberrant immune response against the pancreas, leading to inflammation and fibrosis. Although AIP is rare, its incidence is increasing and is often misdiagnosed as other pancreatic diseases. AIP is commonly classified into two types. Type 1 AIP (AIP-1) is typically associated with elevated serum immunoglobulin G4 (IgG4) levels and systemic manifestations, while type 2 AIP is typically a more localized form of the disease, and may coexist with other autoimmune disorders, especially inflammatory bowel diseases. Additionally, there is emerging recognition of a third type (type 3 AIP), which refers to immunotherapy-triggered AIP, although this classification is still gaining acceptance in medical literature. The clinical manifestations of AIP mainly include painless jaundice and weight loss. Elevated serum IgG4 levels are particularly characteristic of AIP-1. Diagnosis relies on a combination of clinical, laboratory, radiological, and histological findings, given the similarity of AIP symptoms to other pancreatic disorders. The mainstay of treatment for AIP is steroid therapy, which is effective in most cases. Severe cases might require additional imm-unosuppressive agents. This review aims to summarize the current knowledge of AIP, encompassing its epidemiology, etiology, clinical presentation, diagnosis, and treatment options. We also address the challenges and controversies in diagnosing and treating AIP, such as distinguishing it from pancreatic cancer and managing long-term treatment, highlighting the need for increased awareness and knowledge of this complex disease.
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Affiliation(s)
- Camilla Gallo
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, Fondazione IRCCS San Gerardo dei Tintori; University of Milano-Bicocca, Monza 20900, Italy
| | - Giulia Dispinzieri
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, Fondazione IRCCS San Gerardo dei Tintori; University of Milano-Bicocca, Monza 20900, Italy
| | - Nicola Zucchini
- Department of Pathology, Fondazione IRCCS San Gerardo dei Tintori, Monza 20900, Italy
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, Fondazione IRCCS San Gerardo dei Tintori; University of Milano-Bicocca, Monza 20900, Italy
| | - Sara Massironi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, Fondazione IRCCS San Gerardo dei Tintori; University of Milano-Bicocca, Monza 20900, Italy
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Ciesielka J, Jakimów K, Tekiela N, Peisert L, Kwaśniewska A, Kata D, Chudek J. Significantly Elevated CA 19-9 after COVID-19 Vaccination and Literature Review of Non-Cancerous Cases with CA 19-9 > 1000 U/mL. J Clin Med 2024; 13:1263. [PMID: 38592088 PMCID: PMC10932348 DOI: 10.3390/jcm13051263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 02/15/2024] [Accepted: 02/19/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND CA 19-9 is a commonly assessed tumor marker, considered characteristic of pancreatic ductal adenocarcinoma (PDAC) and biliary tract cancers; however, the positive predictive value of CA 19.9 is too low, and the usage of CA 19.9 as a screening tool in the healthy population remains controversial. METHODS The presented case illustrates a reversed diagnosis of highly elevated serum CA 19-9 levels in a 54-year-old female complaining of pain in the epigastric region, shortly after COVID-19 vaccination. Laboratory tests showed a significantly elevated level of the CA 19-9 marker (>12,000 U/mL, reference value: <37 U/mL) with normal pancreatic enzyme activity. The patient underwent imaging examination, which showed no abnormalities, except for increased pancreatic dimension and areas of fluid signal in the pancreas in magnetic resonance imaging (MRI), which may correspond to autoimmune pancreatitis (AIP). The patient remains asymptomatic with a recommendation for a follow-up MRI in 12 months. RESULTS A literature review conducted revealed multi-causal CA 19-9 increases above 1000 U/mL, including non-cancerous diseases of the lung, pancreas, liver, ovary, kidney, and others. The median concentration of CA 19-9 regardless of the cause of disease was 2810 U/mL (IQR ± 6895). The median CA 19-9 values in men and women were 3500 (IQR ± 10,050) and 2455 (IQR ± 3927), respectively, and differ significantly between the compared groups (p < 0.05). There was no difference between CA 19-9 values and the categorized cause of the increase. CONCLUSIONS Conducting differential diagnosis, it should not be forgotten that most international guidelines recommend the use of CA 19-9 only in conjunction with pathology of pancreas in radiological imaging; however, even such a combination can point the diagnostic pathway in the wrong direction. A highly elevated CA 19-9 level, typically associated with PDAC, may be the result of benign disease including AIP related to COVID-19 vaccination.
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Affiliation(s)
- Jakub Ciesielka
- Student’s Research Group, Department of Internal Medicine and Oncological Chemotherapy, Medical University of Silesia in Katowice, 40-055 Katowice, Poland; (K.J.); (N.T.); (L.P.)
| | - Krzysztof Jakimów
- Student’s Research Group, Department of Internal Medicine and Oncological Chemotherapy, Medical University of Silesia in Katowice, 40-055 Katowice, Poland; (K.J.); (N.T.); (L.P.)
| | - Natalia Tekiela
- Student’s Research Group, Department of Internal Medicine and Oncological Chemotherapy, Medical University of Silesia in Katowice, 40-055 Katowice, Poland; (K.J.); (N.T.); (L.P.)
| | - Laura Peisert
- Student’s Research Group, Department of Internal Medicine and Oncological Chemotherapy, Medical University of Silesia in Katowice, 40-055 Katowice, Poland; (K.J.); (N.T.); (L.P.)
| | - Anna Kwaśniewska
- Department of Radiology, The Mielecki Hospital, Medical University of Silesia in Katowice, 40-055 Katowice, Poland
| | - Dariusz Kata
- Department of Hematology and Bone Marrow Transplantation, Medical University of Silesia in Katowice, 40-055 Katowice, Poland;
| | - Jerzy Chudek
- Department of Internal Medicine and Oncological Chemotherapy, Medical University of Silesia in Katowice, 40-055 Katowice, Poland
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Wei W, Jia G, Wu Z, Wang T, Wang H, Wei K, Cheng C, Liu Z, Zuo C. A multidomain fusion model of radiomics and deep learning to discriminate between PDAC and AIP based on 18F-FDG PET/CT images. Jpn J Radiol 2022; 41:417-427. [PMID: 36409398 PMCID: PMC9676903 DOI: 10.1007/s11604-022-01363-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 11/09/2022] [Indexed: 11/22/2022]
Abstract
PURPOSE To explore a multidomain fusion model of radiomics and deep learning features based on 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) images to distinguish pancreatic ductal adenocarcinoma (PDAC) and autoimmune pancreatitis (AIP), which could effectively improve the accuracy of diseases diagnosis. MATERIALS AND METHODS This retrospective study included 48 patients with AIP (mean age, 65 ± 12.0 years; range, 37-90 years) and 64 patients with PDAC patients (mean age, 66 ± 11.3 years; range, 32-88 years). Three different methods were discussed to identify PDAC and AIP based on 18F-FDG PET/CT images, including the radiomics model (RAD_model), the deep learning model (DL_model), and the multidomain fusion model (MF_model). We also compared the classification results of PET/CT, PET, and CT images in these three models. In addition, we explored the attributes of deep learning abstract features by analyzing the correlation between radiomics and deep learning features. Five-fold cross-validation was used to calculate receiver operating characteristic (ROC), area under the roc curve (AUC), accuracy (Acc), sensitivity (Sen), and specificity (Spe) to quantitatively evaluate the performance of different classification models. RESULTS The experimental results showed that the multidomain fusion model had the best comprehensive performance compared with radiomics and deep learning models, and the AUC, accuracy, sensitivity, specificity were 96.4% (95% CI 95.4-97.3%), 90.1% (95% CI 88.7-91.5%), 87.5% (95% CI 84.3-90.6%), and 93.0% (95% CI 90.3-95.6%), respectively. And our study proved that the multimodal features of PET/CT were superior to using either PET or CT features alone. First-order features of radiomics provided valuable complementary information for the deep learning model. CONCLUSION The preliminary results of this paper demonstrated that our proposed multidomain fusion model fully exploits the value of radiomics and deep learning features based on 18F-FDG PET/CT images, which provided competitive accuracy for the discrimination of PDAC and AIP.
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Affiliation(s)
- Wenting Wei
- School of Electronic and Information Engineering, Changchun University of Science and Technology, Changchun, 130022 China ,Department of Medical Imaging, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, 88 Keling Road, Suzhou, 215163 China
| | - Guorong Jia
- Department of Nuclear Medicine, The First Affiliated Hospital of Naval Medical University (Changhai Hospital), 168 Changhai Road, Shanghai, 200433 China
| | - Zhongyi Wu
- Department of Medical Imaging, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, 88 Keling Road, Suzhou, 215163 China
| | - Tao Wang
- Department of Nuclear Medicine, The First Affiliated Hospital of Naval Medical University (Changhai Hospital), 168 Changhai Road, Shanghai, 200433 China
| | - Heng Wang
- School of Electronic and Information Engineering, Changchun University of Science and Technology, Changchun, 130022 China ,Department of Medical Imaging, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, 88 Keling Road, Suzhou, 215163 China
| | - Kezhen Wei
- School of Electronic and Information Engineering, Changchun University of Science and Technology, Changchun, 130022 China ,Department of Medical Imaging, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, 88 Keling Road, Suzhou, 215163 China
| | - Chao Cheng
- Department of Nuclear Medicine, The First Affiliated Hospital of Naval Medical University (Changhai Hospital), 168 Changhai Road, Shanghai, 200433 China
| | - Zhaobang Liu
- Department of Medical Imaging, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, 88 Keling Road, Suzhou, 215163 China
| | - Changjing Zuo
- Department of Nuclear Medicine, The First Affiliated Hospital of Naval Medical University (Changhai Hospital), 168 Changhai Road, Shanghai, 200433 China
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American College of Rheumatology and the European League Against Rheumatism classification criteria for IgG4-related disease: an update for radiologists. Jpn J Radiol 2022; 40:876-893. [PMID: 35474439 DOI: 10.1007/s11604-022-01282-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/09/2022] [Indexed: 10/18/2022]
Abstract
IgG4-related disease (IgG4-RD) is an immune-mediated, multiorgan, chronic inflammatory disease. The three-step classification criteria proposed in 2019 by the American College of Rheumatology and the European League Against Rheumatism (ACR/EULAR) encompass a wide range of clinical, radiological, serological, and histopathological findings. The ACR/EULAR proposed a three-step classification process, i.e., entry step, exclusion step, and scoring system. Radiologists need to know that the radiological findings observed in the five domains of the lacrimal and salivary glands, chest, pancreas and biliary ducts, kidney, and retroperitoneum are independently weighted with different points in the scoring system. A total score < 20 points indicates that the patient should not be classified as having IgG4-RD; conversely, a total score ≥ 20 points indicates that the patient should be classified as having IgG4-RD. In this review, the 2019 ACR/EULAR classification criteria are discussed, focusing on the interpretation of each radiological item, with the aim of applying them to the diagnosis of IgG4-RD in clinical practice.
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Ohno E, Hirooka Y. Encyclopedia of autoimmune pancreatitis: this is all we need. J Med Ultrason (2001) 2021; 48:523-524. [PMID: 34755227 DOI: 10.1007/s10396-021-01150-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 09/25/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Yoshiki Hirooka
- Department of Gastroenterology and Hepatology, Fujita Health University, Toyoake, Japan
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