Mimics of pancreatic ductal adenocarcinoma

A rare case of concurrent intrahepatic splenosis and pancreatic adenocarcinoma following splenectomy

We present an extremely rare case of intrahepatic splenosis (IHS). On admission and examination, the patient was diagnosed with hepatocellular carcinoma and postoperative injury or inflammatory lesions of the pancreas, based on image analysis. Postoperative histopathology showed that the lesions of the liver and diaphragm were of splenic origin, and the pancreatic lesion was identified as a moderately differentiated adenocarcinoma. The lesson of this case is that if there is a history of splenic rupture or splenectomy, even in the presence of hepatitis or cirrhosis, doctors should be alert to the possibility of IHS. Furthermore, splenectomy may affect the blood supply to the tail of the pancreas, so patients with a pancreatic tail mass following splenectomy need follow-up and biopsy, if necessary.

Advancements in Pancreatic Cancer Detection: Integrating Biomarkers, Imaging Technologies, and Machine Learning for Early Diagnosis

Artificial intelligence (AI) has come to play a pivotal role in revolutionizing medical practices, particularly in the field of pancreatic cancer detection and management. As a leading cause of cancer-related deaths, pancreatic cancer warrants innovative approaches due to its typically advanced stage at diagnosis and dismal survival rates. Present detection methods, constrained by limitations in accuracy and efficiency, underscore the necessity for novel solutions. AI-driven methodologies present promising avenues for enhancing early detection and prognosis forecasting. Through the analysis of imaging data, biomarker profiles, and clinical information, AI algorithms excel in discerning subtle abnormalities indicative of pancreatic cancer with remarkable precision. Moreover, machine learning (ML) algorithms facilitate the amalgamation of diverse data sources to optimize patient care. However, despite its huge potential, the implementation of AI in pancreatic cancer detection faces various challenges. Issues such as the scarcity of comprehensive datasets, biases in algorithm development, and concerns regarding data privacy and security necessitate thorough scrutiny. While AI offers immense promise in transforming pancreatic cancer detection and management, ongoing research and collaborative efforts are indispensable in overcoming technical hurdles and ethical dilemmas. This review delves into the evolution of AI, its application in pancreatic cancer detection, and the challenges and ethical considerations inherent in its integration.

Complementary comments on diagnosis, severity and prognosis prediction of acute pancreatitis

The radiological differential diagnosis of acute pancreatitis includes diffuse pancreatic lymphoma, diffuse autoimmune pancreatitis and groove located mass lesions that may mimic groove pancreatitis. Dual energy computed tomography and diffusion weighted magnetic resonance imaging are useful in the early diagnosis of acute pancreatitis, and dual energy computed tomography is also useful in severity assessment and prognosis prediction. Walled off necrosis is an important complication in terms of prognosis, and it is important to know its radiological findings and distinguish it from pseudocyst.

Pancreatic Cancer and Its Mimics

Pancreatic ductal adenocarcinoma (PDAC) is the most common primary pancreatic malignancy, ranking fourth in cancer-related mortality in the United States. Typically, PDAC appears on images as a hypovascular mass with upstream pancreatic duct dilatation and abrupt duct cutoff, distal pancreatic atrophy, and vascular encasement, with metastatic involvement including lymphadenopathy. However, atypical manifestations that may limit detection of the underlying PDAC may also occur. Atypical PDAC features include findings related to associated conditions such as acute or chronic pancreatitis, a mass that is isointense to the parenchyma, multiplicity, diffuse tumor infiltration, associated calcifications, and cystic components. Several neoplastic and inflammatory conditions can mimic PDAC, such as paraduodenal "groove" pancreatitis, autoimmune pancreatitis, focal acute and chronic pancreatitis, neuroendocrine tumors, solid pseudopapillary neoplasms, metastases, and lymphoma. Differentiation of these conditions from PDAC can be challenging due to overlapping CT and MRI features; however, certain findings can help in differentiation. Diffusion-weighted MRI can be helpful but also can be nonspecific. Accurate diagnosis is pivotal for guiding therapeutic planning and potential outcomes in PDAC and avoiding biopsy or surgical treatment of some of these mimics. Biopsy may still be required for diagnosis in some cases. The authors describe the typical and atypical imaging findings of PDAC and features that may help to differentiate PDAC from its mimics. ©RSNA, 2023 Online supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center. See the invited commentary by Zins in this issue.

Identification and Interaction Analysis of Molecular Markers in Pancreatic Ductal Adenocarcinoma by Bioinformatics and Next-Generation Sequencing Data Analysis

Background

Pancreatic ductal adenocarcinoma (PDAC) is one of the most common cancers worldwide. Intense efforts have been made to elucidate the molecular pathogenesis, but the molecular mechanisms of PDAC are still not well understood. The purpose of this study is to further explore the molecular mechanism of PDAC through integrated bioinformatics analysis.

Methods

To identify the candidate genes in the carcinogenesis and progression of PDAC, next-generation sequencing (NGS) data set GSE133684 was downloaded from Gene Expression Omnibus (GEO) database. The differentially expressed genes (DEGs) were identified, and Gene Ontology (GO) and pathway enrichment analyses were performed. The protein-protein interaction network (PPI) was constructed and the module analysis was performed using Integrated Interactions Database (IID) interactome database and Cytoscape. Subsequently, miRNA-DEG regulatory network and TF-DEG regulatory network were constructed using miRNet database, NetworkAnalyst database, and Cytoscape software. The expression levels of hub genes were validated based on Kaplan-Meier analysis, expression analysis, stage analysis, mutation analysis, protein expression analysis, immune infiltration analysis, and receiver operating characteristic (ROC) curve analysis.

Results

A total of 463 DEGs were identified, consisting of 232 upregulated genes and 233 downregulated genes. The enriched GO terms and pathways of the DEGs include vesicle organization, secretory vesicle, protein dimerization activity, lymphocyte activation, cell surface, transferase activity, transferring phosphorus-containing groups, hemostasis, and adaptive immune system. Four hub genes (namely, cathepsin B [CCNB1], four-and-a-half LIM domains 2 (FHL2), major histocompatibility complex, class II, DP alpha 1 (HLA-DPA1) and tubulin beta 1 class VI (TUBB1)) were obtained via taking interaction of different analysis results.

Conclusions

On the whole, the findings of this investigation enhance our understanding of the potential molecular mechanisms of PDAC and provide potential targets for further investigation.

Pancreatic cancer, autoimmune or chronic pancreatitis, beyond tissue diagnosis: Collateral imaging and clinical characteristics may differentiate them

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal malignancies and is developing into the 2^nd leading cause of cancer-related death. Often, the clinical and radiological presentation of PDAC may be mirrored by other inflammatory pancreatic masses, such as autoimmune pancreatitis (AIP) and mass-forming chronic pancreatitis (MFCP), making its diagnosis challenging. Differentiating AIP and MFCP from PDAC is vital due to significant therapeutic and prognostic implications. Current diagnostic criteria and tools allow the precise differentiation of benign from malignant masses; however, the diagnostic accuracy is imperfect. Major pancreatic resections have been performed in AIP cases under initial suspicion of PDAC after a diagnostic approach failed to provide an accurate diagnosis. It is not unusual that after a thorough diagnostic evaluation, the clinician is confronted with a pancreatic mass with uncertain diagnosis. In those cases, a re-evaluation must be entertained, preferably by an experienced multispecialty team including radiologists, pathologists, gastroenterologists, and surgeons, looking for disease-specific clinical, imaging, and histological hallmarks or collateral evidence that could favor a specific diagnosis. Our aim is to describe current diagnostic limitations that hinder our ability to reach an accurate diagnosis among AIP, PDAC, and MFCP and to highlight those disease-specific clinical, radiological, serological, and histological characteristics that could support the presence of any of these three disorders when facing a pancreatic mass with uncertain diagnosis after an initial diagnostic approach has been unsuccessful.

Approach to Pancreatic Head Mass in the Background of Chronic Pancreatitis

Chronic pancreatitis (CP) is a known risk factor for pancreatic cancer. CP may present with an inflammatory mass, and differentiation from pancreatic cancer is often difficult. Clinical suspicion of malignancy dictates a need for further evaluation for underlying pancreatic cancer. Imaging modalities remain the mainstay of evaluation for a mass in background CP; however, they have their shortcomings. Endoscopic ultrasound (EUS) has become the go-to investigation. Adjunct modalities such as contrast-harmonic EUS and EUS elastography, as well as EUS-guided sampling using newer-generation needles are useful in differentiating inflammatory from malignant masses in the pancreas. Paraduodenal pancreatitis and autoimmune pancreatitis often masquerade as pancreatic cancer. In this narrative review, we discuss the various modalities used to differentiate inflammatory from malignant masses of the pancreas.

A CT based radiomics nomogram for differentiation between focal-type autoimmune pancreatitis and pancreatic ductal adenocarcinoma

Objectives

The purpose of this study was to develop and validate an CT-based radiomics nomogram for the preoperative differentiation of focal-type autoimmune pancreatitis from pancreatic ductal adenocarcinoma.

Methods

96 patients with focal-type autoimmune pancreatitis and pancreatic ductal adenocarcinoma have been enrolled in the study (32 and 64 cases respectively). All cases have been confirmed by imaging, clinical follow-up and/or pathology. The imaging data were considered as: 70% training cohort and 30% test cohort. Pancreatic lesions have been manually delineated by two radiologists and image segmentation was performed to extract radiomic features from the CT images. Independent-sample T tests and LASSO regression were used for feature selection. The training cohort was classified using a variety of machine learning-based classifiers, and 5-fold cross-validation has been performed. The classification performance was evaluated using the test cohort. Multivariate logistic regression analysis was then used to develop a radiomics nomogram model, containing the CT findings and Rad-Score. Calibration curves have been plotted showing the agreement between the predicted and actual probabilities of the radiomics nomogram model. Different patients have been selected to test and evaluate the model prediction process. Finally, receiver operating characteristic curves and decision curves were plotted, and the radiomics nomogram model was compared with a single model to visually assess its diagnostic ability.

Results

A total of 158 radiomics features were extracted from each image. 7 features were selected to construct the radiomics model, then a variety of classifiers were used for classification and multinomial logistic regression (MLR) was selected to be the optimal classifier. Combining CT findings with radiomics model, a prediction model based on CT findings and radiomics was finally obtained. The nomogram model showed a good sensitivity and specificity with AUCs of 0.87 and 0.83 in training and test cohorts, respectively. The areas under the curve and decision curve analysis showed that the radiomics nomogram model may provide better diagnostic performance than the single model and achieve greater clinical net benefits than the CT finding model and radiomics signature model individually.

Conclusions

The CT image-based radiomics nomogram model can accurately distinguish between focal-type autoimmune pancreatitis and pancreatic ductal adenocarcinoma patients and provide additional clinical benefits.

PINTology: A short history of the lncRNA LINC-PINT in different diseases

LINC-PINT is a p53-induced long intergenic noncoding transcript that plays a crucial role in many diseases, especially cancer. This long noncoding RNA (lncRNA) gene produces in total 102 (LNCipedia) alternatively spliced variants (LINC-PINT:1 to LINC-PINT:102). The functions of known variants include RNA transcripts, host transcripts for circular RNA (circRNA) generation and as sources for the translation of short peptides. In most human tumors, LINC-PINT is down-regulated where it serves as a tumor suppressor. However, the diversity of its functions in other maladies signifies its general clinical importance. Current LINC-PINT molecular functions include RNA-protein interactions, miRNA sponging and epigenetic modulation with these mechanisms operating in different cellular contexts to exert effects on biological processes ranging from DNA damage responses, cell cycle and growth arrest, senescence, cell migration and invasion, and apoptosis. Genetic polymorphisms in LINC-PINT have also been functionally associated with cancer and other pathologies including the autoimmune diseases pemphigus foliaceus and arthritis. Hence, LINC-PINT shows great potential as a clinical biomarker, especially for the diagnosis and prognosis of cancer. In this review, we explore the current knowledge highlighting the distinctive molecular functions of LINC-PINT in specific cancers and other disease states. This article is categorized under: RNA in Disease and Development > RNA in Disease.

Biological Characterization and Clinical Value of OAS Gene Family in Pancreatic Cancer

Background

OAS gene family plays an important role in antiviral process, but its role in pancreatic cancer has not yet been studied.

Methods

We analyzed the expression, prognostic value and biological function of the OAS gene family in human pancreatic cancer through comprehensive bioinformatic analysis and cellular level validation.

Results

OAS family was highly expressed in pancreatic cancer, and this high expression significantly affected the clinical stage and prognosis of the tumor. OAS gene family was closely related to the immune infiltration of pancreatic cancer, especially neutrophils and dendritic cells, and many immune-related factors and pathways are enriched in the tumor, such as type I interferon signaling pathway and NOD-like receptor signaling pathway.

Conclusion

Taken together, high expression of OAS family is closely related to poor prognosis of pancreatic cancer. OAS gene family may serve as the biomarker and even therapeutic target of pancreatic cancer.

Predicting Factors for Pancreatic Malignancy with Computed Tomography and Endoscopic Ultrasonography in Chronic Pancreatitis

Diagnosing pancreatic malignancy is challenging, especially in patients with chronic pancreatitis (CP). Endoscopic ultrasonography (EUS) is a promising diagnostic procedure for discriminating between malignancy and CP. We aimed to investigate the predictive factors and reliability of computed tomography (CT) and EUS for differentiating pancreatic mass lesions and the diagnostic accuracy of EUS-FNA or FNB in patients with CP. Forty patients with CP, receiving CT and EUS-FNA or FNB for pancreatic mass lesion evaluation, were enrolled in the study. Patients’ data, CT and EUS characteristics, image-based diagnosis, cytopathology, and final diagnosis were recorded. EUS was superior to CT in terms of diagnostic accuracy (92.5% vs. 82.5%, p = 0.02). Both CT and EUS showed significant predictive factors (all p < 0.05) with the tumor image hypoattenuation pattern or vessel invasion on CT and pancreatic duct dilatation, or distal pancreatic atrophy on EUS. EUS imaging is a reliable modality for evaluating pancreatic lesions, even with a CP background. The EUS image has a higher diagnostic accuracy than CT. Predicting factors, including hypoechoic pattern, pancreatic duct dilatation, and distal pancreas atrophy, may help to differentiate benign or malignant in patients with CP.

Multimodel magnetic resonance imaging of mass-forming autoimmune pancreatitis: differential diagnosis with pancreatic ductal adenocarcinoma

PURPOSE

To assess the value of the multimodel magnetic resonance imaging (MRI), including unenhanced images, dynamic contrast-enhanced MRI (DCE-MRI), MR-cholangiopancreatography (MRCP), and diffusion-weighted imaging (DWI), in differentiation of mass-forming autoimmune pancreatitis (AIP) from pancreatic ductal adenocarcinoma (PDAC).

METHODS

Twelve patients with mass-forming AIP and 30 with PDAC were included. All patients underwent unenhanced MRI, DCE-MRI, DWI, and MRCP. Relevant values including sensitivity and specificity of the imaging features and their diagnostic performance for predicting mass-forming AIP were analyzed.

RESULTS

Several statistically significant MR findings and quantitative indexes differentiating mass-forming AIP from PDAC, including multiplicity, irregularity or conformation, capsule-like rim enhancement, absence of internal cystic or necrotic portion, homogeneous enhancement during pancreatic, venous, and delayed phases, skipped stricture or stricture of MPD, absence of side branch dilation, maximum upstream MPD diameter < 2.4 mm, ContrastUP > 0.739, ContrastAP > 0.710, ContrastPP > 0.879, and ContrastVP or ContrastDP > 0.949, indicated mass-forming AIP (P < 0.05). The apparent diffusion coefficient (ADC) value was also significantly lower in mass-forming AIP compared to that in PDAC (P = 0.006). The cutoff value of ADC for distinguishing mass-forming AIP from PDAC was 1.099 × 10-3 mm2/s.

CONCLUSION

Multimodel MRI, including unenhanced MRI, DCE-MRI with DWI and MRCP can provide qualitative and quantitative information about mass-forming AIP characterization. Multimodel MRI are valuable for differentiating mass-forming AIP from PDAC.

Imaging Spectrum of Duodenal Emergencies

The duodenum, the first portion of the small bowel, is divided into four segments and extends to both retro- and intraperitoneal spaces. Some conditions arise primarily from the duodenum, but it can be secondarily affected by processes that involve neighboring structures. When duodenal emergencies are not identified and treated promptly, they may result in high morbidity and mortality. Imaging plays an important role in the diagnosis of duodenal conditions in the acute setting. However, the radiologic findings can be subtle, and awareness of relevant patient history and clinical presentation is important as it may increase the index of suspicion and one's ability to diagnose these conditions. Duodenal peptic disease is common and can be complicated by bleeding and perforation. The duodenum can be secondarily involved by pancreatitis and gallbladder pathologic conditions and may be affected by iatrogenic complications following endoscopic procedures. Traumatic injuries to the duodenum are generally uncommon, with penetrating traumatic injury being the most frequent mechanism of injury. Duodenal vascular pathologic conditions such as aortoduodenal fistula are uncommon but can be life threatening. The knowledge of which pathologic condition can involve which duodenal segment can help the radiologist establish a differential diagnosis and achieve a more targeted imaging approach. The online slide presentation from the RSNA Annual Meeting is available for this article. ^©RSNA, 2020.

Benign vs malignant pancreatic lesions: Molecular insights to an ongoing debate

Several benign conditions such as chronic pancreatitis, autoimmune pancreatitis, and paraduodenal pancreatitis can present as mass lesions and may mimic pancreatic ductal adenocarcinoma (PDAC) clinically and radiologically. Thorough histologic examination with attention to certain morphologic features can assist in deciphering neoplastic from reactive, however small biopsies often remain a challenge. Variable histologic patterns in conventional PDAC may also confound the diagnosis of PDAC. Uncommon subtypes of pancreatic carcinoma such as adenosquamous and squamous cell carcinoma, colloid carcinoma, medullary carcinoma, hepatoid carcinoma and signet ring cell carcinoma necessitate excluding metastasis from other sites prior to rendering the diagnosis of pancreatic carcinoma. The use of immunohistochemical staining and molecular markers can aid in separating benign from malignant and PDAC from metastasis. PDAC expresses a few non-specific epithelial and mucin immunomarkers such as CK7, CK19, MUC1, MUC4 and MUC5AC. However, the only immunohistochemical marker that is specific for PDAC in the right clinical context is SMAD4. Loss of SMAD4 within atypical glands and ducts supports the diagnosis of PDAC in a limited sample. Unfortunately, this finding is seen only in 50% of PDAC cases. The identification of certain mutations can help support a diagnosis of PDAC when benign conditions are in the differential. At the molecular level, KRAS oncogene mutations are seen in approximately 93% of PDACs. Subsequent neoplastic progression is driven by additional mutations of tumor suppressor genes, such as CDKN2A, TP53, and SMAD4. Molecular markers can also provide an insight to the prognosis. For instance, the loss of SMAD4 is associated with a poor outcome whereas mutations in MLL, MLL2, MLL3, and ARID1A are associated with improved survival.

Differentiation of focal autoimmune pancreatitis from pancreatic ductal adenocarcinoma

Autoimmune pancreatitis (AIP) is an inflammatory process of the pancreas that occurs most commonly in elderly males and clinically can mimic pancreatic adenocarcinoma and present with jaundice, weight loss, and abdominal pain. Mass-forming lesions in the pancreas are seen in the focal form of AIP and both clinical and imaging findings can overlap those of pancreatic cancer. The accurate distinction of AIP from pancreatic cancer is of utmost importance as it means avoiding unnecessary surgery in AIP cases or inaccurate steroid treatment in patients with pancreatic cancer. Imaging concomitantly with serological examinations (IgG4 and Ca 19-9) plays an important role in the distinction between these entities. Characteristic extra-pancreatic manifestations as well as favorable good response to treatment with steroids are characteristic of AIP. This paper will review current diagnostic parameters useful in differentiating between focal AIP and pancreatic adenocarcinoma.

EUS-FNB with or without on-site evaluation for the diagnosis of solid pancreatic lesions (FROSENOR): Protocol for a multicenter randomized non-inferiority trial

BACKGROUND

Rapid on-site evaluation (ROSE) of cytological specimensacquired with EUS-guided fine needle aspiration (EUS-FNA) represents the most accurate available technique to reach a definitive diagnosis in patients with pancreatic solid masses. Recently, needles with high histological yield have been developed for EUS-guided fine needle biopsy (EUS-FNB), with which the need for ROSE can be potentially overcome.

AIMS

The primary aim is to compare the diagnostic accuracy of EUS-FNB with or without ROSE. The main endpoint will be measured against the gold standard diagnosis (surgical pathology whenever available or diagnostic work-up in agreement with a clinical course of at least six months). Secondary endpoints include: (a) safety; (b) presence of tissue core; (c) quality of specimens; (d) time of the sampling procedure. Reliability of macroscopic on-site evaluation (MOSE) by endosonographers will be also assessed.

METHODS

FROSENOR is an international randomized non-inferiority ongoing study at sixteen centers in four continents. Eight hundred patients will be randomized in two arms (EUS-FNB + ROSE vs. EUS-FNB alone) and outcomes compared. Sample size has been calculated in order to demonstrate the non-inferiority of FNB alone. Randomization and data collection will be performed online.

DISCUSSION

This study will ascertain if ROSE is still needed when performing EUS-FNB of solid pancreatic lesions.

Touch imprint cytology on endoscopic ultrasound fine-needle biopsy provides comparable sample quality and diagnostic yield to standard endoscopic ultrasound fine-needle aspiration specimens in the evaluation of solid pancreatic lesions

OBJECTIVES

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is the gold standard for the diagnosis of solid pancreatic lesions (SPLs). Cytological samples can also be obtained using touch imprint cytology (TIC) on EUS fine-needle biopsy (FNB) specimens. We aimed to compare sample quality and diagnostic yield of EUS-FNA-standard cytology (EUS-FNA-SC) to that of EUS-FNB-TIC in a series of patients with SPLs.

METHODS

Thirty-two consecutive patients referred for EUS-tissue acquisition of SPLs who underwent rapid on-site evaluation of both EUS-FNA-SC and paired EUS-FNB-TIC during the same endoscopic session were retrospectively identified. Sample quality (evaluated in terms of blood contamination, presence of clots, tissue casts, cellularity, and necrosis) and diagnostic yield were compared between the techniques.

RESULTS

The mean number of passes to reach diagnosis at rapid on-site evaluation was similar between EUS-FNA-SC and EUS-FNB-TIC (1.09 ± 0.3 vs 1.13 ± 0.34, P = .711). EUS-FNA-SC scores of sample quality were comparable to those of EUS-FNB-TIC (blood contamination, 2.47 ± 1.11 vs 2.25 ± 1.14, P = .109; clots, 1.25 ± 0.76 vs 1.19 ± 0.69, P = .624; tissue casts, 3.56 ± 0.88 vs 3.59 ± 1.09, P = .872; cellularity, 2.84 ± 1.11 vs 3.09 ± 1.09, P = .244; necrosis, 2.25 ± 1.08 vs 2.53 ± 1.02 P = .059; total score, 12.38 ± 2.88 vs 17.66 ± 2.38, P = .536). Adequacy, sensitivity and diagnostic accuracy of the two sampling techniques were equal (93.7%, 90.6% and 90.6%, respectively).

CONCLUSIONS

EUS-FNB-TIC provides comparable samples to those of EUS-FNA-SC and combines the benefits of cytology and histology for the evaluation of SPLs by employing a single needle during the same endoscopic procedure.

Discriminating chronic pancreatitis from pancreatic cancer: Contrast-enhanced EUS and multidetector computed tomography in direct comparison

BACKGROUND AND OBJECTIVES

To compare the ability of multidetector computed tomography (MDCT) and contrast-enhanced EUS to discriminate chronic pancreatitis (CP) from pancreatic ductal adenocarcinoma (PDAC).

SUBJECTS AND METHODS

A total of 215 patients (age: 62 ± 15 years, sex: f/m 80/135) were included in this retrospective study. All patients were examined by conventional endoscopic B-mode and contrast-enhanced high mechanical index EUS (CEHMI-EUS). CELMI-EUS was performed in 159 patients and endoscopic sonoelastography (ESE) in 210 patients. MDCT was carried out in 131 patients as part of their clinical work-up. Radiological reports were retrospectively analyzed. Final diagnosis was achieved by biopsy and evaluation of cytological specimens collected was performed by EUS-FNA, surgery, or follow-up of 12 months or more in patients with benign findings. In a subgroup of 100 patients, all diagnostic five methods were performed, and head-to-head analysis was performed.

RESULTS

Sensitivity and specificity for MDCT were 89% and 70% and for CEHMI-EUS were 96% and 91%, respectively. Sensitivities and specificities for EUS were 92% and 63% for B-Mode EUS, 96% and 38% for ESE, and 82% and 76% for CELMI-EUS, respectively. In the head-to-head analysis, each modality had shown lower numbers for specificity than shown in the overall group analysis because of high drop-out rate. EUS-FNA for PDAC had a sensitivity of 96% and a specificity of 100%.

CONCLUSIONS

Contrast-enhanced EUS is a reliable tool in discriminating PDAC from CP.

The Levels of Tumor Markers in Pancreatic Neuroendocrine Carcinoma and Their Values in Differentiation Between Pancreatic Neuroendocrine Carcinoma and Pancreatic Ductal Adenocarcinoma

OBJECTIVES

The levels of tumor markers in pancreatic neuroendocrine carcinoma (PNEC) are unknown, and imaging findings of PNEC and pancreatic ductal adenocarcinoma (PDAC) have overlaps. In this study, we show the tumor markers in PNEC and evaluate their values for distinguishing PNEC from PDAC.

METHODS

Thirty-three cases of PDAC and 21 cases of PNEC were retrospectively evaluated. The demographic information and clinical data were reviewed.

RESULTS

Pancreatic neuroendocrine carcinoma was usually misdiagnosed (57.1%) as PDAC based on imaging findings. Abnormal carbohydrate antigen (CA) 19-9, carcinoembryonic antigen (CEA), and α-fetoprotein (AFP) were observed in 19.0% to 28.6% of PNECs. Abnormal CA 19-9 and CA 125 levels were more common in PDAC than in PNEC (P < 0.05). Higher level of AFP was more common in PNEC than in PDAC (33.3% vs 3.0%, P < 0.05). The cutoff value of CA 19-9 for detecting PNEC was calculated as 38.5 U/mL or less with 0.788 sensitivity and 0.800 specificity. Carbohydrate antigen 19-9 (odds ratio [OR], 22.9; 95% confidence interval [CI], 2.94-179.3), AFP (OR, 0.08; 95% CI, 0.012-0.564), and CA 125 (OR, 17.4; 95% CI, 1.13-267.3) were predictors in differentiating PDAC from PNEC.

CONCLUSIONS

Carbohydrate antigen 19-9, AFP, and CA 125 have potential for distinguishing hypovascularized PNEC from PDAC.

Histologic retrieval rate of a newly designed side-bevelled 20G needle for EUS-guided tissue acquisition of solid pancreatic lesions

Background

Innovative approaches to improve diagnostic yield of endoscopic ultrasound-guided tissue acquisition (EUS-TA) have focused on needle design with development of fine-needle biopsy (FNB) needles with microcore-acquisition technology. Recently, a 20-gauge (20G) antegrade-cutting-side-bevelled biopsy needle (ProCore®) was developed for EUS-TA, but data about its diagnostic performance and histological capability are scant.

Objectives

We assessed the diagnostic performance and histologic retrieval rate of a new 20G antegrade-cutting-side-bevelled biopsy needle compared with a 22G reverse-side-bevelled needle for EUS sampling of solid pancreatic lesions.

Patients and methods

A retrospective analysis of 238 consecutively collected patients who underwent EUS-TA using a 20G or a 22G ProCore® needle, without rapid on-site evaluation (ROSE), was conducted at two centres.Sensitivity, specificity, positive predictive value and negative predictive value were calculated. Histologic tissue retrieval was evaluated applying a scoring system for each case.

Results

Sensitivity and specificity were estimated as 98.4-100% in the 20G-, and 94.9-100% in the 22G-needle groups, respectively (p > 0.99). The 20G procured more histologic-grade tissues (92.6% vs 49.5%, p < 0.0001) achieved by a lower number of passes (2.64 vs 3.44, p < 0.0001) compared to the 22G.

Conclusions

Both side-bevelled FNB needles achieved a high diagnostic sensitivity. The 20G-side-bevelled needle obtained a significantly higher microcore retrieval rate.

Benign Tumors and Tumorlike Lesions of the Pancreas

The pancreas is a complex organ that may give rise to large number of neoplasms and non-neoplastic lesions. This article focuses on benign neoplasms, such as serous neoplasms, and tumorlike (pseudotumoral) lesions that may be mistaken for neoplasm not only by clinicians and radiologists, but also by pathologists. The family of pancreatic pseudotumors, by a loosely defined conception of that term, includes a variety of lesions including heterotopia, hamartoma, and lipomatous pseudohypertrophy. Autoimmune pancreatitis and paraduodenal ("groove") pancreatitis may also lead to pseudotumor formation. Knowledge of these entities will help in making an accurate diagnosis.

Imaging mimics of pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma is the most common primary malignancy of the pancreas. The classic imaging features are a hypovascular mass with proximal ductal dilatation. Different pancreatic pathologies can mimic the imaging appearance of carcinoma including other tumors involving the pancreas (pancreatic neuroendocrine tumors, lymphoma, metastasis, and rare tumors like pancreatic acinar cell carcinoma and solid pseudopapillary tumors), inflammatory processes (chronic pancreatitis and autoimmune pancreatitis), and anatomic variants (annular pancreas). Differentiation between these entities can sometimes be challenging due to overlap of imaging features. The purpose of this article is to describe the common entities that can mimic pancreatic cancer on imaging with illustrative examples and to suggest features that can help in differentiation of these entities.

Imaging of non-neoplastic duodenal diseases. A pictorial review with emphasis on MDCT

Abstract

A wide spectrum of abnormalities can affect the duodenum, ranging from congenital anomalies to traumatic and inflammatory entities. The location of the duodenum and its close relationship with other organs make it easy to miss or misinterpret duodenal abnormalities on cross-sectional imaging. Endoscopy has largely supplanted fluoroscopy for the assessment of the duodenal lumen. Cross-sectional imaging modalities, especially multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI), enable comprehensive assessment of the duodenum and surrounding viscera. Although overlapping imaging findings can make it difficult to differentiate between some lesions, characteristic features may suggest a specific diagnosis in some cases. Familiarity with pathologic conditions that can affect the duodenum and with the optimal MDCT and MRI techniques for studying them can help ensure diagnostic accuracy in duodenal diseases. The goal of this pictorial review is to illustrate the most common non-malignant duodenal processes. Special emphasis is placed on MDCT features and their endoscopic correlation as well as on avoiding the most common pitfalls in the evaluation of the duodenum.

Teaching points

• Cross-sectional imaging modalities enable comprehensive assessment of duodenum diseases.

• Causes of duodenal obstruction include intraluminal masses, inflammation and hematomas.

• Distinguishing between tumour and groove pancreatitis can be challenging by cross-sectional imaging.

• Infectious diseases of the duodenum are difficult to diagnose, as the findings are not specific.

• The most common cause of nonvariceal upper gastrointestinal bleeding is peptic ulcer disease.

Rare Tumors and Lesions of the Pancreas

There are a few entities that account for most solid and cystic masses of the pancreas. The pancreas harbors a wide array of diseases, including adenocarcinoma, and its variants, such as anaplastic and adenosquamous carcinoma. Other neoplasms include acinar cell carcinoma, solid pseudopapillary tumor, and sarcomas. Benign lesions include hamartomas, hemangiomas, lymphangioma, and plasmacytoma. Isolated metastases include renal cell carcinoma, melanoma, and other carcinomas. Benign inflammatory conditions, such as autoimmune pancreatitis and groove pancreatitis can also mimic solid neoplasms of the pancreas.

Nonhypervascular Pancreatic Neuroendocrine Tumors: Differential Diagnosis from Pancreatic Ductal Adenocarcinomas at MR Imaging-Retrospective Cross-sectional Study

Purpose To determine useful magnetic resonance (MR) imaging features to differentiate nonhypervascular pancreatic neuroendocrine tumors (PNETs) from pancreatic ductal adenocarcinomas (PDACs). Materials and Methods The institutional review board approved this retrospective study and waived the informed consent requirement. Seventy-four patients with surgically confirmed PNETs and 82 patients with PDACs who underwent gadobutrol-enhanced MR imaging were included. Two radiologists independently evaluated the morphologic characteristics and temporal enhancement patterns of each tumor. Quantitative analysis, including measurement of tumor size, maximal upstream parenchymal thickness (MUPT), contrast-to-noise ratio, and apparent diffusion coefficient values, was performed. Uni- and multivariate logistic regression analyses were performed to identify relevant features to differentiate between PNETs and PDACs. Results On the basis of arterial enhancement, 38 PNETs (51%, 38 of 74) were hypervascular and 36 PNETs (49%, 36 of 74) were nonhypervascular. At MR imaging, nonhypervascular PNETs showed significantly higher frequencies of a well-defined margin, portal hyper- or isoenhancement, and MUPT of 10 mm or greater but lower frequencies of ductal dilatation, vascular invasion, and peripancreatic infiltration when compared with PDACs (P < .05 for all). At multivariate analysis, a well-defined margin and portal hyper- or isoenhancement were independent significant differentiators of PNETs from PDACs (odds ratio, 20.3 and 16.1, respectively). When applying the criteria of a well-defined margin and portal hyper- or isoenhancement, 64% of sensitivity and 99% of specificity were observed for the differential diagnosis of PNETs from PDACs. Conclusion A well-defined margin and hyper- or isoenhancement in the portal venous phase are useful MR imaging features that are more common in nonhypervascular PNETs and may help discriminate nonhypervascular PNETs from PDACs. ^© RSNA, 2017 Online supplemental material is available for this article.

Challenging the limits in pancreatic surgery: A case report

INTRODUCTION

Today, pancreatic surgery can be performed with low mortality and tolerable morbidity in specialized centers. Nevertheless, due to its anatomical localization and proximity to important vascular structures, surgical resection of the pancreas remains challenging in many cases.

PRESENTATION OF CASE

Here, we present the case of a young woman who presented in our department with abdominal pain and a tumor mass located at the pancreatic head. She had undergone explorative laparotomy elsewhere before, in which the pancreatic tumor mass was reported to be unresectable due to infiltration of the mesenteric root. However, biopsies obtained had not revealed malignancy. Moreover, postoperatively a stenting of the portal vein had been performed due to portal vein thrombosis and varices. Upon admission in our clinic, computed tomography revealed a tumor of the pancreatic head, occlusion of the portal vein stent and, more importantly, extravascular dislocation of the stent with perforation into the stomach. Upon explorative laparotomy we initially performed a mesenterico-caval shunt to release portal hypertension. Secondly, the dislocated stent was successfully removed upon gastrotomy, and finally, a partial pancreaticoduodencectomy was performed. Interestingly, the histopathological analysis revealed granulocytic epithelial lesions (GELs) confirming a type-2 autoimmune pancreatitis without evidence for malignancy. The postoperative course was uneventful and the patients was dismissed without any remaining symptoms.

DISCUSSION & CONCLUSION

This interesting and unique case underlines the complexity in diagnosis of pancreatic tumors with unsolved dignity and differential diagnosis of pancreatitis and pancreatic cancer. Furthermore, it demonstrated the challenges in pancreatic surgery for exceptional and uncommon conditions demanding complex surgical approaches.

Imaging Characteristics and Prevalence of Pancreatic Carcinoma in Kosovo During 2011-2015 - Diagnostic Method as Choice

INTRODUCTION

Pancreatic cancer is the 10(th)most common malignancy and the 4(th)largest cancer killer in adults.

AIM

The purpose of this paper is to evaluate the number of cases presented with pancreatic carcinoma during the years 2011-2015, our experience of the imaging characteristics of pancreatic carcinoma. We evaluated prevalence of the pancreatic cancers, distant metastases and other local infiltration signs among the total cases of the pancreatic cancers diagnosed in the University Clinical Center of Kosovo, with the aim to compare these research findings to similar studies made in the developed countries. This is a retrospective research study done during the period of 2011-2015.

MATERIALS AND METHODOLOGY

This retrospective research study includes 362 patients recently diagnosed with pancreatic cancer, examined in the period of 2011-2015 at the University Clinical Center of Kosovo. The imaging diagnostics are performed with MSCT Sensation 64 Siemens, MSCT Emotion 6 Siemens, and 1.5T MRI Symphony Siemens, biopsy guide with MSCT Sensation 64 Siemens in the Radiologic Clinic of UCCK; while the histopathology diagnostics has been performed in Clinic of Pathology at UCCK and prevalence is taken from the number of cases Reported at the Institute of Oncology Institute of Statistics and NIPH (National Institute of Public Health of Kosovo).

RESULTS

Out of a total of the 362 patients diagnosed with pancreas cancer, results is female 39.5% (n=143) and male 61.5% (n=219), report M: F (1: 1.6), 286 cases resulted in head and neck 79 % (n=286), 76 cases resulted in body and tail cancers (21%), distant metastases in first imaging modality were found in(n=155) patients 43 %, local infiltration was found in patients: gastric infiltration 15 % (n=54), duodenal and papilla infiltration 26% (n=94), local infiltration spleen 16% (n=57), local infiltration mesentery 43 % (n= 155), dilated biliary tree 34 % (n=123), regional lymph node infiltration 83 % (n= 300). Out of a total of the 362 patients diagnosed with pancreas cancer, 346 cases resulted > 2 cm and 16 cases resulted < 2 cm and with component cystic was 41.2 % (n = 149), solid with component cystic - necrotic 33% (n= 119), solid 25.7% (n= 93). The prevalence is 19.9: 100,000 inhabitants.

CONCLUSIONS

Prevalence of carcinoma of the pancreas for 5 years in Kosovo has proved to be prevalence is 19.9: 100,000 inhabitants. Seventy-four percent (74 %, n= 268) of all cancers are found in Stage III and IV. From an imaging point of view, these cancers were presented in an advanced stage, mainly due to their late clinical symptoms and limited access to imaging methods in our country.

[Ductal adenocarcinoma and unusual differential diagnosis]

Ductal pancreatic adenocarcinoma is by far the most common solid tumor of the pancreas. It has a very poor prognosis, especially in the more advanced stages which are no longer locally confined. Due to mostly unspecific symptoms, imaging is key in the diagnostic process. Because of the widespread use of imaging techniques, incidental findings are to a greater extent discovered in the pancreas, which subsequently entail further work-up. Ductal pancreatic adenocarcinoma can be mimicked by a large number of different lesions, such as anatomical variants, peripancreatic structures and tumors, rarer primary solid pancreatic tumors, cystic tumors, metastases or different variants of pancreatitis. Additionally, a number of precursor lesions can be differentiated. The correct classification is thus important as an early diagnosis of ductal pancreatic adenocarcinoma is relevant for the prognosis and because the possibly avoidable treatment is very invasive. All major imaging techniques are principally suitable for pancreatic imaging. In addition to sonography of the abdomen, usually the baseline diagnostic tool, computed tomography (CT) with its superior spatial resolution, magnetic resonance imaging (MRI) with its good soft tissue differentiation capabilities, possibly in combination with MR cholangiopancreatography (MRCP), endosonography with its extraordinary spatial resolution, conceivably with additional endoscopic retrograde CP or the option of direct biopsy and finally positron emission tomography CT (PET-CT) as a molecular imaging tool are all particularly useful modalities. The various techniques all have its advantages and disadvantages; depending on the individual situation they may need to be combined.

Common and uncommon pitfalls in pancreatic imaging: it is not always cancer

Despite advances in multimodality imaging of pancreas, there is still overlap between imaging findings of several pancreatic/peripancreatic disease processes. Pancreatic and peripancreatic non-neoplastic entities may mimic primary pancreatic neoplasms on ultrasound, CT, and MRI. On the other hand, primary pancreatic cancer may be overlooked on imaging because of technical and inherent factors. The purpose of this pictorial review is to describe and illustrate pancreatic imaging pitfalls and highlight the basic radiological features for proper differential diagnosis.

99mTc-HYNIC-TOC imaging in the evaluation of pancreatic masses which are potential neuroendocrine tumors

PURPOSE

The aim of this investigation was to determine the accuracy of the findings and the diagnoses of Tc-hydrazinonicotinyl-Tyr3-octreotide scan (Tc-HYNIC-TOC imaging) in patients with pancreatic masses which were potential neuroendocrine tumors.

METHODS

Records of total 20 patients with pancreatic masses were retrospectively reviewed. All of the patients had been revealed by abdominal contrast CT and possibility of neuroendocrine tumors could not be excluded by CT imaging before Tc-HYNIC-TOC imaging. Tc-HYNIC-TOC imaging was performed at 1 and 4 hours post-tracer injection, and SPECT/CT images of the abdomen were also acquired. The image findings were compared to final diagnoses which were made from pathological examination.

RESULTS

Among all 20 pancreatic masses evaluated, there were 16 malignant lesions which included 1 ductal adenocarcinoma and 15 neuroendocrine tumors. Tc-HYNIC-TOC imaging identified 14 of 15 pancreatic neuroendocrine tumors and excluded 4 of 5 lesions which were not neuroendocrine tumors. The overall sensitivity, specificity, and accuracy was therefore 93.3% (14 of 15), 80% (4 of 5), and 90.0% (18 of 20), respectively, in our patient population.

CONCLUSION

Tc-HYNIC-TOC imaging provides reasonable accuracy in the evaluation pancreatic mass suspected to be neuroendocrine tumors.