A solid pancreatic mass: tumour or inflammation?

Acute pancreatitis as an early sign of pancreatic cancer; a retrospective, matched cohort study

BACKGROUND AND AIMS

Pancreatic ductal adenocarcinoma (PDAC) often presents as acute pancreatitis (AP). However, data on the clinical outcomes of PDAC initially presenting as AP are limited. We aimed to assess the clinical features of PDAC that manifest as AP.

METHODS

We reviewed the PDAC database at the Asan Medical Center between 2010-2016. Our study included 77 patients with PDAC who presented with AP (PDAC-AP group) and 154 age-gender-matched PDAC patients as controls (PDAC-other group). Patients' demographics, disease characteristics, and outcomes were compared between both groups.

RESULTS

Acute pancreatitis was an initial symptom in 1.12% of the patients with PDAC (77 of 6,821). Approximately 81.8% of the patients had clinically mild pancreatitis, and 91% were diagnosed with PDAC within two months of presentation with AP. Main tumor size was significantly smaller in the PDAC-AP group than in the PDAC-other group (PDAC-AP: 2.59 ± 1.21 cm vs. PDAC-other: 3.73 ± 1.78 cm, p < 0.01). The PDAC-AP group patients were diagnosed earlier than those in the PDAC-other group (PDAC-AP: stage 1-2, 80.6% vs. PDAC-other: 46.7%, p < 0.01). The proportion of resectable PDAC was significantly higher in the PDAC-AP group (PDAC-AP: 64.9% vs. PDAC-other: 50%, p < 0.01). Overall survival was significantly longer in the PDAC-AP group than in the PDAC-other group (30.2 months vs. 19.9 months, p = 0.03).

CONCLUSIONS

In patients who presented with clinical AP, PDAC was identified at an earlier stage, and these patients showed better survival rates. These results suggest that AP may be an early sign of PDAC.

Hidden in plain sight: commonly missed early signs of pancreatic cancer on CT

Pancreatic ductal adenocarcinoma (PDAC) has poor prognosis mostly due to the advanced stage at which disease is diagnosed. Early detection of disease at a resectable stage is, therefore, critical for improving outcomes of patients. Prior studies have demonstrated that pancreatic abnormalities may be detected on CT in up to 38% of CT studies 5 years before clinical diagnosis of PDAC. In this review, we highlight commonly missed signs of early PDAC on CT. Broadly, these commonly missed signs consist of small isoattenuating PDAC without contour deformity, isolated pancreatic duct dilatation and cutoff, focal pancreatic enhancement and focal parenchymal atrophy, pancreatitis with underlying PDAC, and vascular encasement. Through providing commentary on demonstrative examples of these signs, we demonstrate how to reduce the risk of missing or misinterpreting radiological features of early PDAC.

Early detection of pancreatic cancer in the era of precision medicine

Pancreatic ductal adenocarcinoma (PDAC) is the third leading cause of cancer-related mortality and it is often diagnosed at advanced stages due to non-specific clinical presentation. Disease detection at localized disease stage followed by surgical resection remains the only potentially curative treatment. In this era of precision medicine, a multifaceted approach to early detection of PDAC includes targeted screening in high-risk populations, serum biomarkers and "liquid biopsies", and artificial intelligence augmented tumor detection from radiologic examinations. In this review, we will review these emerging techniques in the early detection of PDAC.

Comparison between pancreatoblastoma (PB) and solid pseudopapillary neoplasm (SPN) in pediatric patients with enhanced CT

RATIONALE AND OBJECTIVES

To investigate whether computed tomography features can differentiate pancreatoblastoma (PB) from solid pseudopapillary tumor (SPN) in children.

MATERIALS AND METHODS

Clinical and imaging data of 18 cases of PB and 61 cases of SPN confirmed by surgery or biopsy were retrospectively analyzed. All enrolled patients underwent 3 phases (non-contrast, arterial, and portal venous phases) of CT scanning. Qualitative CT analysis (location, margin, solid/cystic component proportion, calcification, hemorrhage, peritumoral vascularity, bile duct dilatation, pancreatic duct dilatation, pancreatic atrophy, vascular invasion, peripancreatic invasion, and distant metastases) and quantitative analysis (maximum tumor diameter, interface between tumor and parenchyma [delta], arterial enhancement ratio [AER], and portal enhancement ratio [PER]) were performed. The general CT morphologic features, age and tumor markers were compared also compared between the groups. Univariate analysis and the F test were conducted to identify features of PB. Then logistic Regression classifier was trained using the top five features with the highest F-value. Moreover, we used 5-fold cross-validation techniques for the validation of our model.

RESULTS

PB exhibited a significantly higher frequency of location in the body/tail, larger tumor size, poorly defined margins, calcification, peritumoral vascularity, pancreatic atrophy, and less hemorrhage. In addition, PB had higher AER, PER and lower delta relative to SPN (p < 0.05). PB presented a younger age and higher levels of AFP. Results of the F test indicated that AFP, AER, Age, calcification and pancreatic atrophy were the top five features included in the model that could differentiate pediatric PB from SPN. The combined model of CT and clinical features performed well in differentiating PB from SPN, with an AUC of 0.981 in the training cohort and 0.953 in the validation cohort.

CONCLUSIONS

AFP, AER, age, calcification and pancreatic atrophy are robust CT and clinical features for differentiating pediatric PB from SPN. A combination of qualitative and quantitative CT features may provide good diagnostic accuracy in differentiating PB from SPN in children.

Inflammatory myofibroblastic tumor of the pancreatic neck misdiagnosed as neuroendocrine tumor: A case report

BACKGROUND

Inflammatory myofibroblastic tumor (IMT) is a relatively rare tumor. The global incidence of IMT is less than 1%. There is no specific clinical manifestation. It usually occurs in the lungs, but the pancreas is not the predilection site.

CASE SUMMARY

We present a case of a male patient, 51 years old, who was diagnosed with a pancreatic neck small mass on ultrasound one year ago during a physical examination. As he had no clinical symptoms and the mass was relatively small, he did not undergo treatment. However, the mass was found to be larger on review, and he was referred to our hospital. Since the primal clinical diagnosis was pancreatic neuroendocrine tumor, the patient underwent surgical treatment. However, the case was confirmed as pancreatic IMT by postoperative pathology.

CONCLUSION

Pancreatic IMT is relatively rare and easily misdiagnosed. We can better under-stand and correctly diagnose this disease by this case report.

Multitasking dynamic contrast enhanced magnetic resonance imaging can accurately differentiate chronic pancreatitis from pancreatic ductal adenocarcinoma

Background and aims

Accurate differentiation of chronic pancreatitis (CP) and pancreatic ductal adenocarcinoma (PDAC) is an area of unmet clinical need. In this study, a novel Multitasking dynamic contrast enhanced (DCE) magnetic resonance imaging (MRI) technique was used to quantitatively evaluate the microcirculation properties of pancreas in CP and PDAC and differentiate between them.

Methods

The Multitasking DCE technique was able to acquire one 3D image per second during the passage of MRI contrast agent, allowing the quantitative estimation of microcirculation properties of tissue, including blood flow F_p, plasma volume fraction v_p, transfer constant K^trans, and extravascular extracellular volume fraction v_e. Receiver operating characteristic (ROC) analysis was performed to differentiate the CP pancreas, PDAC pancreas, normal control pancreas, PDAC tumor, PDAC upstream, and PDAC downstream. ROCs from quantitative analysis and conventional analysis were compared.

Results

Fourteen PDAC patients, 8 CP patients and 20 healthy subjects were prospectively recruited. The combination of F_p, v_p, K^trans, and v_e can differentiate CP versus PDAC pancreas with good AUC (AUC [95% CI] = 0.821 [0.654 - 0.988]), CP versus normal pancreas with excellent AUC (1.000 [1.000 - 1.000]), PDAC pancreas versus normal pancreas with excellent AUC (1.000 [1.000 - 1.000]), CP versus PDAC tumor with excellent AUC (1.000 [1.000 - 1.000]), CP versus PDAC downstream with excellent AUC (0.917 [0.795 - 1.000]), and CP versus PDAC upstream with fair AUC (0.722 [0.465 - 0.980]). This quantitative analysis outperformed conventional analysis in differentiation of each pair.

Conclusion

Multitasking DCE MRI is a promising clinical tool that is capable of unbiased quantitative differentiation between CP from PDAC.

Pancreatic Neoplasms: CT Evaluation of the Uncommon Presentations of Common Lesions and Common Presentations of the Uncommon Lesions!

Pancreatic masses are commonly encountered entities in radiology practice. Pancreatic ductal adenocarcinomas (PDAC) are the commonest pancreatic malignancies that typically present as infiltrative hypodense focal masses in the pancreatic head, which are hypoattenuating to the pancreatic parenchyma on pancreatic parenchymal and venous phases. However, there are various atypical imaging features of PDACs that create a diagnostic dilemma like tumor in body or tail, diffuse glandular involvement, isoattenuating tumors, cystic changes, or calcifications. Also, few relatively uncommon pancreatic malignancies like pancreatic neuroendocrine tumors, cystic pancreatic tumors, pancreatic lymphoma, and pancreatic metastases present with overlapping features. Accurate radiological characterization of pancreatic masses is important for optimal management and prognostication. Thus, it is imperative for radiologists to be aware of all the uncommon presentations of common pancreatic lesions and common presentations of uncommon pancreatic lesions to avoid erroneous interpretations and establishing the correct diagnosis.

Endoscopic ultrasound with combined fine needle aspiration plus biopsy improves diagnostic yield in solid pancreatic masses

GOALS

Our aim was to compare the diagnostic yield of endoscopic ultrasound guided fine needle aspiration (EUS-FNA) versus combined fine needle aspiration and fine needle biopsy (EUS-FNA + FNB) in the evaluation of solid pancreatic masses (SPMs).

BACKGROUND

EUS-FNA and EUS-FNB are established methods to diagnose SPMs. No studies have evaluated the efficacy of combination of both (EUS-FNA + FNB). Our senior author (MRS) hypothesized that combining the two techniques by using a single FNB needle improves diagnostic yield and started combination technique in October 2016.

STUDY

Patients who underwent EUS for SPMs by MRS during January 2014-September 2019 were included. They were divided into the EUS-FNA group and EUS-FNA + FNB group. EUS-FNA was performed using a 22 or 25 gauge Expect Slimline needle (Boston Scientific, Marlborough, MA) and EUS-FNA + FNB was performed using a single 22 or 25 gauge Shark-core needle (Medtronics, Minneapolis, MN, USA). Our primary outcome was to compare the diagnostic yield in the two groups.

RESULTS

Among 105 patients included, 58 were in the EUS-FNA group and 47 were in the EUS-FNA + FNB group. EUS-FNA + FNB group had significantly higher diagnostic yield and required fewer needle passes compared to EUS-FNA group, 95.7% vs. 77.6%, p = .01: and 4 vs. 5, p = .002; respectively. Procedural duration was similar in both groups but the combined technique required less number of needles per procedure. There was no difference in adverse events in the two groups.

CONCLUSION

Our study showed that combined EUS-FNA + FNB had higher diagnostic yield compared to EUS-FNA in SPMs along with less number of needle passes and needles required. Further prospective studies are needed to validate these findings and cost-effectiveness of this strategy.

Evaluating Pancreatic and Biliary Neoplasms with Small Biopsy-Based Next Generation Sequencing (NGS): Doing More with Less

Simple Summary

Pancreatic cancer and cholangiocarcinoma are aggressive diseases mostly diagnosed at an advanced and inoperable stage. This review presents the value of next-generation sequencing (NGS) when performed on small biopsies—including fine-needle aspiration/biopsy samples, brushings, pancreatic juice and bile, and also blood—in the field of pancreatobiliary neoplasia. NGS could guide physicians while evaluating pancreatic solid and cystic lesions or suspicious biliary strictures, performing surveillance in high-risk individuals, or monitoring the disease and assessing prognosis in already diagnosed cancer patients. Evidence suggests that NGS performed on small biopsies is a robust tool for the diagnosis and pre-operative risk stratification of pancreatic and biliary lesions, whereas it also carries significant prognostic and therapeutic value. However, effective standardization of the pre-analytical and analytical assay parameters used for each clinical scenario is needed to fully implement NGS into routine practice and provide more personalized management in patients with suspected or established pancreatobiliary neoplasia.

Abstract

Pancreatic cancer and cholangiocarcinoma are lethal diseases mainly diagnosed at an inoperable stage. As pancreatobiliary surgical specimens are often unavailable for further molecular testing, this review aimed to highlight the diagnostic, prognostic, and therapeutic impact of next-generation sequencing (NGS) performed on distinct small biopsies, including endoscopic ultrasound fine-needle aspirations and biopsies of pancreatic solid and cystic lesions, biliary duct brushings, and also “liquid biopsies” such as the pancreatic juice, bile, and blood. NGS could clarify indeterminate pancreatic lesions or biliary strictures, for instance by identifying TP53 or SMAD4 mutations indicating high-grade dysplasia or cancer. It could also stratify pancreatic cystic lesions, by distinguishing mucinous from non-mucinous cysts and identifying high-risk cysts that should be excised in surgically fit patients, whereas the combination of cytology, elevated cystic CEA levels and NGS could improve the overall diagnostic accuracy. When NGS is performed on the pancreatic juice, it could stratify high-risk patients under surveillance. On the plasma, it could dynamically monitor the disease course and response to therapy. Notably, the circulating tumor DNA (ctDNA) levels have been associated with staging, grading, and survival. Lastly, NGS has shown potential in identifying potentially actionable molecular alterations. In conclusion, NGS applied on small biopsies could carry significant diagnostic, prognostic, and therapeutic value.

A narrative review of a type of pancreatitis worthy of attention: acute pancreatitis associated with pancreatic tumors-current problems and future thinking

OBJECTIVE

Our purpose is to explain the onset, diagnosis, and treatment of pancreatic tumor-associated pancreatitis (PTP), and inform clinicians about the management of PTP. It is hoped that clinicians can gain some experience and inspiration from this review, so that patients can obtain better treatment results.

BACKGROUND

Acute pancreatitis (AP) is an inflammatory disease, and pancreatic tumors are one of the causes of pancreatitis. When pancreatic tumors and pancreatitis exist at the same time, and there is a "connection" between them, this type of pancreatitis is referred to as PTP. The manifestations of PTP can be as follows: (I) AP is the first symptom of pancreatic tumors; (II) pancreatitis is found in patients after pancreatic tumor diagnosis or during pancreatic tumor surgery. Because pancreatic tumors are not one of the most common causes of pancreatitis, PTP has not attracted the attention of researchers and clinicians, and there is no consistent and clear understanding of the diagnosis and treatment of PTP.

METHODS

From the online database PubMed (https://pubmed.ncbi.nlm.nih.gov/) and Web of Science (https://webofknowledge.com/), we use specific retrieval strategies to retrieve relevant articles, and we review and discuss them.

CONCLUSIONS

What we need to realize is that PTP is different from ordinary AP. It has its own characteristics in terms of diagnosis and treatment, which requires the attention of clinicians. More importantly, future research should design the best diagnosis and treatment algorithms for PTP.

Clinical characteristics and outcome of tumor-associated acute pancreatitis: a single-center cohort study

Background

What features should alert clinicians to suspect underlying tumors in patients with acute pancreatitis (AP) was largely unknown. This study aimed to assess the clinical characteristics and outcome in patients with tumor-associated AP.

Methods

Patients who presented with AP and were diagnosed with tumor after admission were included according to the inclusion and exclusion criteria and followed up by hospital notes, telephone, WeChat and/or e-mail. The clinical characteristics and outcome were analyzed with multivariable logistic regression and were compared with AP patients without tumor.

Results

Out of a cohort of 1,792 AP patients we identified 103 who had a neoplastic etiology. The 103 patients had a median age of 57 (range, 13-81) and 65 were males. AP was mild in 92 patients, moderately severe in 7 and severe in 4. The three most common tumors included pancreatic cancer (PC) (40), periampullary carcinoma (PAC) (25), and neoplastic pancreatic cysts (NPC) (22). The following ranked features were predictive of a tumor etiology: dilation of main pancreatic duct (MPD) (OR 417.83, 95% CI: 80.40-2,171.42), vascular invasion (OR 82.04, 95% CI: 6.05-1,113.14), mild AP (8.29, 95% CI: 1.98-34.73), and anemia (OR 5.73, 95% CI: 2.02-16.26). The median survival period of AP patients with PC, PAC, and NPC was 10.0 (7.0-23.5), 21.0 (5.0-37.0), and 35.0 (30.0-96.0) months, respectively.

Conclusions

Mild AP patients with dilation of MPD, vascular invasion, and anemia were more frequently suggested a tumor etiology. Thus, clinical vigilance is needed for timely detection of tumor-associated pancreatitis with these characteristics.

Radiomics Model Based on MR Images to Discriminate Pancreatic Ductal Adenocarcinoma and Mass-Forming Chronic Pancreatitis Lesions

Background

It is difficult to identify pancreatic ductal adenocarcinoma (PDAC) and mass-forming chronic pancreatitis (MFCP) lesions through conventional CT or MR examination. As an innovative image analysis method, radiomics may possess potential clinical value in identifying PDAC and MFCP. To develop and validate radiomics models derived from multiparametric MRI to distinguish pancreatic ductal adenocarcinoma (PDAC) and mass-forming chronic pancreatitis (MFCP) lesions.

Methods

This retrospective study included 119 patients from two independent institutions. Patients from one institution were used as the training cohort (51 patients with PDAC and 13 patients with MFCP), and patients from the other institution were used as the testing cohort (45 patients with PDAC and 10 patients with MFCP). All the patients had pathologically confirmed results, and preoperative MRI was performed. Four feature sets were extracted from T1-weighted imaging (T1WI), T2-weighted imaging (T2WI), and the artery (A) and portal (P) phases of dynamic contrast-enhanced MRI, and the corresponding radiomics models were established. Several clinical characteristics were used to discriminate PDAC and MFCP lesions, and clinical model was established. The results of radiologists’ evaluation were compared with pathology and radiomics models. Univariate analysis and the least absolute shrinkage and selection operator algorithm were performed for feature selection, and a support vector machine was used for classification. The receiver operating characteristic (ROC) curve was applied to assess the model discrimination.

Results

The areas under the ROC curves (AUCs) for the T1WI, T2WI, A and, P and clinical models were 0.893, 0.911, 0.958, 0.997 and 0.516 in the primary cohort, and 0.882, 0.902, 0.920, 0.962 and 0.649 in the validation cohort, respectively. All radiomics models performed better than clinical model and radiologists’ evaluation both in the training and testing cohorts by comparing the AUC of various models, all P<0.050. Good calibration was achieved.

Conclusions

The radiomics models based on multiparametric MRI have the potential ability to classify PDAC and MFCP lesions.

Meta-analysis reveals an association between acute pancreatitis and the risk of pancreatic cancer

BACKGROUND

Chronic pancreatitis is associated with pancreatic cancer (PC), although the relationship between acute pancreatitis (AP) and the risk of PC remains unclear due to inconsistent and contradictory results.

AIM

To conduct a meta-analysis of retrospective and prospective studies to explore the association between AP and PC risk.

METHODS

We first searched original articles on the association of AP with PC using PubMed, Web of Science, Cochrane, and EMBASE databases. Then we calculated the combined overall effect estimates (EEs) between AP and PC risk at a 95% confidence interval (CI) deploying a random-effects model, and assessed heterogeneity using the I² test. The combined relative risk with 95%CI was performed to examine the relationship between AP and PC. Publication bias and subgroup analyses were also conducted. Furthermore, we performed sensitivity analysis to explain this heterogeneity.

RESULTS

Eleven studies were eligible for inclusion standards in this meta-analysis, resulting in pooled EEs of 2.07 (95%CI: 1.36-2.78) for AP and PC risk. Additionally, five prospective cohort studies reported 103961 patients in the AP group, relative to 1442158 subjects in the control group, with a pooled relative risk of 7.81 (95%CI: 5.00-12.19). We also performed subgroup analyses using different follow-up times and type of research methods (case-control or cohort). Results from analyses of different follow-up times revealed the following pooled effect values: 1-year lag period (EEs = 23.47, 95%CI: 3.26-43.68), 2-year lag period (EEs = 9.82, 95%CI: 3.01-16.64), 5-year lag period (EEs = 2.47, 95%CI: 1.93-3.02), 10-year lag period (EEs = 1.69, 95%CI: 1.26-2.11), and > 10-year lag period (EEs = 1.17, 95%CI: 0.78-1.57). With regards to the methods, the case-control studies recorded EEs = 3.03 (95%CI: -1.02 to 7.08), whereas cohort studies had EEs = 2.09 (95%CI: 1.22-2.97) pooled effect values.

CONCLUSION

Overall, our findings indicated an association between AP and PC risk. Based on subgroup analyses, AP is unlikely to be a causal factor for PC.

CT and MR features that can help to differentiate between focal chronic pancreatitis and pancreatic cancer

Diagnosis of a focal pancreatic mass in routine clinical practice can be a challenge because patients with chronic pancreatitis may present with symptoms and imaging findings that can be difficult to distinguish from pancreatic cancer. Markers, such as cancer antigen 19-9 and carcinoembryonic antigen, are helpful if abnormal, but normal values do not rule out pancreatic cancer. One of the strongest complicating factors is that chronic pancreatitis is a risk factor for pancreatic cancer. Transition of chronic pancreatitis to pancreatic cancer is relatively rare, but it normally has a poor prognosis because diagnosis is often delayed. From a radiologic diagnosis perspective, the classic so-called double-duct sign is helpful. This sign is considered a hallmark sign of pancreatic cancer on magnetic resonance cholangiopancreatography, but it can also be identified in patients with chronic pancreatitis or with other conditions. A number of additional imaging findings or signs are, therefore, necessary. The aim of this article was to describe the strong CT and MR imaging features or integrated imaging features that can help to differentiate between pancreatic cancer and focal chronic pancreatitis.

Acute pancreatitis as an early marker of pancreatic cancer and cancer stage, treatment, and prognosis

BACKGROUND

We aimed to examine the association between acute pancreatitis, a potential early symptom of pancreatic cancer, and pancreatic cancer stage, treatment, and prognosis.

METHODS

We conducted a cohort study of patients diagnosed with pancreatic cancer during 2004-2017 using population-based registry data from Denmark and Surveillance, Epidemiology, and End Results (SEER) data linked with Medicare claims from the United States (US), which include individuals aged 65 + . We ascertained information on acute pancreatitis diagnoses up to 90 days before pancreatic cancer and followed them for a maximum of five years. We assessed overall survival difference at 30 days, six months, and one, three and five years, comparing patients with and without coexistence of acute pancreatitis. Secondary outcomes were cancer stage and treatment.

RESULTS

We identified 12,522 Danish and 37,552 US patients with pancreatic cancer (median age 71 and 78 years, respectively). In the Danish cohort, 1.4 % had acute pancreatitis before pancreatic cancer vs. 5.9 % in the US cohort. After five years of follow-up, the survival difference was 6.1 % (95 % CI: [-0.4 %, 12.6 %]) in Danish and 1.7 % (95 % CI: [0.8 %, 2.7 %]) in US patients, comparing patients with and without acute pancreatitis. Patients with acute pancreatitis had lower prevalence of metastatic tumors at diagnosis (Denmark: 42.5 % vs. 48.7 %; US: 34.4 % vs. 45.9 %) and higher resection frequencies (Denmark: 20.1 % vs. 12.1 %; US: 16.1 % vs.11.3 %) than patients without acute pancreatitis.

CONCLUSIONS

Pancreatic cancer patients with acute pancreatitis diagnosed up to 90 days before cancer diagnosis had earlier stage at diagnosis and better survival than patients without acute pancreatitis.

Pancreatic Head Mass: A Rare Manifestation of Granulomatosis With Polyangiitis

Granulomatosis with polyangiitis may rarely present as an inflammatory pancreatic mass and mimic pancreatic cancer. We report a 73-year-old man who presented with fever and weight loss. Computed tomography imaging demonstrated a mass in the pancreatic head along with multiple cavitary pulmonary nodules. Our differential included metastatic pancreatic cancer vs an autoimmune process. Positive cytoplasmic antineutrophil cytoplasmic antibodies coupled with the lung biopsy findings established the diagnosis of granulomatosis with polyangiitis, a very rare cause of pancreatic masses. After completion of immunosuppressive therapy, magnetic resonance imaging demonstrated no evidence of a pancreatic mass. More studies are required to establish the management of these masses.

Chronic Pancreatitis or Pancreatic Tumor? A Problem-solving Approach

Certain inflammatory pancreatic abnormalities may mimic pancreatic ductal adenocarcinoma at imaging, which precludes accurate preoperative diagnosis and may lead to unnecessary surgery. Inflammatory conditions that may appear masslike include mass-forming chronic pancreatitis, focal autoimmune pancreatitis, and paraduodenal pancreatitis or "groove pancreatitis." In addition, obstructive chronic pancreatitis can mimic an obstructing ampullary mass or main duct intraductal papillary mucinous neoplasm. Secondary imaging features such as the duct-penetrating sign, biliary or main pancreatic duct skip strictures, a capsulelike rim, the pancreatic duct-to-parenchyma ratio, displaced calcifications in patients with chronic calcific pancreatitis, the "double duct" sign, and vessel encasement or displacement can help to suggest the possibility of an inflammatory mass or a neoplastic process. An awareness of the secondary signs that favor a diagnosis of malignant or inflammatory lesions in the pancreas can help the radiologist to perform the differential diagnosis and determine the degree of suspicion for malignancy. Repeat biopsy or surgical resection may be necessary to achieve an accurate diagnosis and prevent unnecessary surgery for inflammatory conditions. Online supplemental material and DICOM image stacks are available for this article. ^©RSNA, 2019.

Pancreatic Cancer Following Acute Pancreatitis: A Population-based Matched Cohort Study

BACKGROUND

Acute pancreatitis is linked to pancreatic cancer, but the direction of this association is not fully elaborated.

METHODS

This was a population-based cohort study including all Swedish residents diagnosed with a first-time episode of acute pancreatitis between 1997 and 2013 and corresponding matched pancreatitis-free individuals from the general population. Hazard ratios for the association between acute pancreatitis and pancreatic cancer were estimated using multivariable Cox regression models.

RESULTS

Overall, 49,749 individuals with acute pancreatitis and 138,750 matched individuals without acute pancreatitis were followed up for 1,192,134 person-years (median 5.3 years). A total of 769 individuals developed pancreatic cancer, of whom 536 (69.7%) had a history of acute pancreatitis. The risk of pancreatic cancer was substantially increased during the first few years after a diagnosis of acute pancreatitis but declined gradually over time, reaching a level comparable to the pancreatitis-free population after >10 years of follow-up. In those with non-gallstone-related acute pancreatitis, the risk of pancreatic cancer declined to a level comparable to the pancreatitis-free population only when follow-up time was censored for a second episode of acute pancreatitis or a diagnosis of chronic pancreatitis. Increasing number of recurrent episodes of acute pancreatitis was associated with increased risk of pancreatic cancer.

CONCLUSION

These findings imply a delay in the diagnosis of pre-existing pancreatic cancer, if clinically presented as acute pancreatitis. Any association between non-gallstone-related acute pancreatitis and pancreatic cancer in the long-term (>10 years) could be mediated through recurrent acute pancreatitis or chronic pancreatitis.

Hemosuccus pancreaticus from superior mesenteric artery pseudoaneurysm within perceived pancreatic mass

Bleeding from the pancreatic duct is a rare source of gastrointestinal hemorrhage and is referred to as hemosuccus pancreaticus. Often a result of pseudoaneurysm formation from chronic pancreatitis, hemosuccus pancreaticus is a difficult diagnosis due to its peculiar clinical presentation. This is a case of a 51-year-old male with a history of chronic pancreatitis, who initially presented with a pancreatic mass found on CT scan. The mass was found to be inconclusive for malignancy on endoscopic ultrasound-guided fine needle aspiration. The patient subsequently was lost to follow-up and returned with melena and evidence of a superior mesenteric pseudoaneurysm in the previous mass on CT angiography. The pseudoaneurysm was successfully treated with endovascular embolization. Diagnosis of hemosuccus pancreaticus can be challenging due to the intermittent nature of hemorrhage and the variable clinical presentation-which initially appeared as a pancreatic neoplasm in our patient. Repeat imaging and angiography are invaluable for both the diagnosis and treatment of gastrointestinal bleeding from an unknown source in the setting of chronic pancreatitis.

Growth differentiation factor (GDF-15) concentration combined with Ca125 levels in serum is superior to commonly used cancer biomarkers in differentiation of pancreatic mass

BACKGROUND

Pancreatic cancer (PDAC) will have been the second leading cancer-related death in the United States by 2020, according to current estimation. Its late manifestation and the lack of good early detection methods are the cause of extremely low survival rates. Therefore, there is an urgent need to develop highly sensitive and specific marker. GDF-15, a member of TGFbeta family, has recently emerged as a protein playing an important role in carcinogenesis of various neoplasms.

OBJECTIVE

Our aim was to assess the potential of GDF-15, IL-17, IL-23 serum concentration, and the panel of PDAC markers in differentiating pancreatic adenocarcinoma from chronic pancreatitis.

METHODS

Sixty-three consecutive patients operated on due to pancreatobiliary lesions were enrolled in this study. Levels of CEA, CA125 and Ca19-9 were assessed using standard laboratory protocols. A sample of serum was collected prior to the surgery via central line. Levels of GDF-15, Il-17, Il-23 were measured using a ELISA kit. After standard pathological examination of specimens obtained on surgery, patients were divided into 2 groups: 42 patients with pancreatic adenocarcinoma and 21 patients with focal chronic pancreatitis.

RESULTS

Mean GDF-15 concentration in patients with CP vs PDAC was 2247.95 (± 179.27) vs 7694.58 (± 1878.94) [pg/mL] respectively (p= 0.011). Mean concentration of Il-17, Il-23, Ca19-9, Ca125, Ca15-3, CEA in patients with CP and PDAC was 862.36 (± 30.84) vs 841.83 (± 33.94) p= 0.833; 127.85 (± 5.87) vs 127.51 (± 9.74) p= 0.175; 34.95 (± 23.34) vs 266.62 (± 49.7) p= 0.001; 13.4 (± 1.6) vs 39.27 (± 6.85) p= 0.005; 18.4 (± 1.48) vs 20.2 (± 1.38) p= 0.416; 1.96 (± 0.38) vs 5.93 (± 1.74) p= 0.004 respectively. In order to compare these markers with the routinely used ones, ROC curve was built. CA19-9 with clinically used cut-off point of ⩾ 36 IU/mL has specificity of 90.5% and sensitivity of 57.14%. At the same time GDF-15 with the optimal cut-off point of 2.7 ng/mL has specificity of 76.19% and sensitivity of 73.8%. Although in our research group CA19-9 has an excellent specificity, its usefulness is hampered by its low sensitivity. On the other hand, GDF-15 parameters are well-balanced making it a more useful biomarker of PDAC.

CONCLUSIONS

In conclusion, GDF-15 is more accurate than Ca19-9 in differentiating pancreatic mass due to chronic pancreatitis from pancreatic adenocarcinoma. Interleukin 17 and 23 cannot be considered as PDAC biomarkers. GDF-15 concentration in serum should be further investigated in order to assess their usefulness in pancreatic adenocarcinoma diagnosis.

Differentiation of benign and malignant solid pancreatic masses using magnetic resonance elastography with spin-echo echo planar imaging and three-dimensional inversion reconstruction: a prospective study

OBJECTIVES

To determine the diagnostic performance of MR elastography (MRE) and compare it with serum CA19-9 in differentiating malignant from benign pancreatic masses, with emphasis on differentiating between pancreatic ductal adenocarcinoma (PDAC) and mass-forming pancreatitis (MFP).

METHODS

We performed a prospective, consecutive, 24-month study in 85 patients with solid pancreatic masses confirmed by histopathologic examinations. The mass stiffness and stiffness ratio (calculated as the ratio of mass stiffness to the parenchymal stiffness) were assessed. The diagnostic accuracy was analysed by calculating the area under the ROC curve (AUROC).

RESULTS

The final diagnosis included 54 malignant tumours (43 patients with PDAC) and 31 benign masses (24 patients with MFP). The stiffness ratio showed better diagnostic performance than the mass stiffness and serum CA19-9 for the differentiation between malignant and benign masses (AUC: 0.912 vs. 0.845 vs. 0.702; P = 0.026, P < 0.001) and, specifically, between PDAC and MFP (AUC: 0.955 vs. 0.882 vs. 0.745; P = 0.026, P = 0.003). The sensitivity, specificity, and accuracy of stiffness ratio for the differentiation of PDAC and MFP were all higher than 0.9.

CONCLUSIONS

MRE presents an effective and quantitative strategy for non-invasive differentiation between PDAC and MFP based on their mechanical properties.

KEY POINTS

• 3D MRE is useful for calculating stiffness of solid pancreatic tumours. • Stiffness ratio outperformed stiffness and CA19-9 for differentiating PDAC from MFP. • Incorporation of 3D MRE into a standard MRI protocol is recommended.

Present status and perspectives of endosonography 2017 in gastroenterology

Endoscopic ultrasound has become an essential tool in modern gastroenterology and abdominal surgery. Compared with all other endoscopic methods, it has the most potential for innovation and its future looks bright. Thus, we compiled this summary of established and novel applications of endoscopic ultrasound methods to inform the reader about what is already possible and where future developments will lead in improving patient care further. This review is structured in four parts. The first section reports on developments in diagnostic endoscopic ultrasound, the second looks at semi-invasive endoscopic ultrasound, and the third discusses advances in therapeutic endoscopic ultrasound. An overview on the future prospects of endoscopic ultrasound methods concludes this article.

A case of multicentric pancreatic mixed acinar-ductal carcinoma diagnosed by a yogurt-like cell clump flowing from the papilla of Vater

BACKGROUND

Histological confirmation is needed when the pancreatic lesions is uncertain for neoplastic or nonneoplastic. Current case with multicentric pancreatic carcinomas showing indefinite clinical images was successfully diagnosed by a biopsy of a novel object expelled from the papilla.

CASE PRESENTATION

A 71-year-old male was referred because of elevated serum pancreatic enzymes. Computed tomography revealed an unclear low-density area in the pancreatic body without evidence of tumor and mild dilation of the upstream main pancreatic duct (MPD). Other images, including abdominal ultrasound, endoscopic ultrasound, and magnetic resonance imaging, did not demonstrate cancerous findings. Endoscopic retrograde cholangiopancreatography showed a crab-claw-like obstruction in the MPD. Surprisingly, the component constituting the obstruction was moved by contrast injection and spilled out of the papilla orifice as a yogurt-like white object. Biopsy of this object by histology revealed a cancer cell clump. Pancreatectomy was performed, and pathology of the resected pancreas showed multiple nodular tumors replacing the acini and extending into the MPD. These neoplasms histologically resembled mixed acinar-ductal carcinoma.

CONCLUSION

Current report presented a rare tumor with multicentric pancreatic lesions, preoperatively diagnosed by a biopsy of an uncommon substance.

Neutrophil Gelatinase-Associated Lipocalin (NGAL) concentration in urine is superior to CA19-9 and Ca 125 in differentiation of pancreatic mass: Preliminary report

BACKGROUND

Currently pancreatic cancer is the fourth leading cause of cancer-related death worldwide. Because of its late manifestation and consequent dismal prognosis, there is an urgent need to develop highly sensitive and specific marker. Neutrophil Gelatinase-Associated Lipocalin (NGAL) recently emerged as a protein playing an important role in carcinogenesis of various neoplasms.

OBJECTIVE

Our aim was to assess the potential of urine and bile concentration of NGAL in differentiating pancreatic adenocarcinoma from chronic pancreatitis.

METHODS

Forty-two patients operated on due to pancreatobiliary lesions were enrolled in this study. All enrolled patients had eGFR within reference range. Levels of CEA, CA 125 and Ca19-9 were assessed using standard laboratory protocols. A sample of urine was collected prior to the surgery. Intraoperatively a 5 ml sample of bile was collected directly from the common bile duct. Bile and urine levels of NGAL were measured using a ELISA kit. After standard pathological examination of specimens obtained during surgery, patients were divided into 2 groups: 21 patients with pancreatic adenocarcinoma and 15 patients with focal chronic pancreatitis.

RESULTS

NGAL concentration in bile in patients with PDAC vs CP was 75.72 ± 16.05 ng/mL vs 62.62 ± 18.6 ng/mL respectively (p= 0,011). NGAL concentration in urine was 43.26 ± 21.21 ng/mL vs 17.96 ± 14.58 ng/mL (p= 0.002) respectively. In order to compare these markers with routinely used ones, ROC curve was built for Ca125 to establish cutoff point and in case of CA19-9 clinically used cutoff (≥ 37U/mL) was applied. Sensitivity and specificity for NGALurine with cutoff value of 27 ng/mL was 80.95% and 80% respectively, while these values for NGALbile were 71.43% and 80% respectively. Ca19-9 measured in plasma with clinically used cutoff value had sensitivity of 71.43% and specificity of 73.33%. Sensitivity and specificity for Ca 125 measured in plasma with cutoff value of 13 U/mL were 85.71% and 66.67% respectively.

CONCLUSIONS

In conclusion, NGAL in urine and bile are remarkably accurate in differentiating pancreatic mass due to chronic pancreatitis from pancreatic adenocarcinoma. Therefore, NGAL concentrations in bile and urine should be further investigated in order to assess their usefulness in early pancreatic adenocarcinoma diagnosis.