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Zen Y. Autoimmune pancreatitis: Biopsy interpretation and differential diagnosis. Semin Diagn Pathol 2024; 41:79-87. [PMID: 38184420 DOI: 10.1053/j.semdp.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 01/02/2024] [Indexed: 01/08/2024]
Abstract
Autoimmune pancreatitis (AIP) is classified into type 1 (IgG4-related) and type 2 (IgG4-unrelated) and the interpretation of pancreatic biopsy findings plays a crucial role in their diagnosis. Needle biopsy of type 1 AIP in the acute or subacute phase shows a diffuse lymphoplasmacytic infiltrate, storiform fibrosis, obliterative phlebitis, and the infiltration of many IgG4-positive plasma cells. In a later phase, changes become less inflammatory and more fibrotic, making interpretations more challenging. Confirmation of the lack of 'negative' findings that are unlikely to occur in type 1 AIP (e.g., neutrophilic infiltration, abscess) is important to avoid an overdiagnosis. The number of IgG4-positive plasma cells increases to >10 cells/high-power field (hpf), and the IgG4/IgG-positive plasma cell ratio exceeds 40 %. However, these are minimal criteria and typical cases show >30 positive cells/hpf and a ratio >70 % even in biopsy specimens. Therefore, cases with a borderline increase in this number or ratio need to be diagnosed with caution. In cases of ductal adenocarcinoma, the upstream pancreas rarely shows type 1 AIP-like changes; however, the ratio of IgG4/IgG-positive plasma cells is typically <40 %. Although the identification of a granulocytic epithelial lesion (GEL) is crucial for type 2 AIP, this finding needs to be interpreted in conjunction with a background dense lymphoplasmacytic infiltrate. An isolated neutrophilic duct injury can occur in peritumoral or obstructive pancreatitis. Drug-induced pancreatitis in patients with inflammatory bowel disease often mimics type 2 AIP clinically and pathologically. IL-8 and PD-L1 are potential ancillary immunohistochemical markers for type 2 AIP, requiring validation studies.
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Affiliation(s)
- Yoh Zen
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK.
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2
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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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Wessling J, Juchems M, Grenacher L, Schreyer AG. [Autoimmune pancreatitis versus pancreatic cancer]. RADIOLOGIE (HEIDELBERG, GERMANY) 2023; 63:886-893. [PMID: 37947862 DOI: 10.1007/s00117-023-01240-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/27/2023] [Indexed: 11/12/2023]
Abstract
CLINICAL ISSUE Autoimmune pancreatitis (AIP) is classified as a distinct form of pancreatitis according to the guidelines. It is characterized by imaging morphologic and histologic features and is associated with extrapancreatic manifestations in type 1 IgG 4-associated disease. Symptoms and findings almost always improve with administration of steroids. Differentiation from pancreatic ductal adenocarcinoma is required, particularly in the presence of AIP with focal parenchymal involvement. STANDARD RADIOLOGIC PROCEDURES If AIP is suspected, abdominal ultrasound and/or endosonography, computed tomography (CT), and preferably magnetic resonance imaging (MRI) are indicated. A distinction is made between parenchymal and ductal changes that specifically indicate the presence of AIP. METHODOLOGICAL INNOVATIONS AND EVALUATION The diagnosis of autoimmune pancreatitis should be made based on the International Consensus Criteria (ICDC), in which the five main features (imaging, serology, histology, other organ involvement, response to steroid medication) are assessed. In type 1 AIP, typical imaging changes are sufficient to establish the diagnosis even with negative histology, whereas for type 2 AIP, histologic evidence is required. Imaging changes help in the differential diagnosis from pancreatic cancer. PRACTICAL RECOMMENDATIONS The following article addresses and evaluates crucial imaging diagnostic CT and MRI criteria for correct classification of findings, description of results, and differentiation of autoimmune pancreatitis from pancreatic cancer.
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Affiliation(s)
- J Wessling
- Zentrum für Radiologie, Neuroradiologie und Nuklearmedizin, Clemenshospital, Raphaelsklinik und EVK Münster, Düesbergweg 124, 48153, Münster, Deutschland.
| | - M Juchems
- Diagnostische und Interventionelle Radiologie, Klinikum Konstanz, Konstanz, Deutschland
| | | | - A G Schreyer
- Institut für diagnostische und interventionelle Radiologie, Medizinische Hochschule Brandenburg Theodor Fontane Klinikum Brandenburg, Brandenburg, Deutschland
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Yoon SB, Jeon TY, Moon SH, Shin DW, Lee SM, Choi MH, Min JH, Kim MJ. Differentiation of autoimmune pancreatitis from pancreatic adenocarcinoma using CT characteristics: a systematic review and meta-analysis. Eur Radiol 2023; 33:9010-9021. [PMID: 37466708 DOI: 10.1007/s00330-023-09959-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 05/15/2023] [Accepted: 05/23/2023] [Indexed: 07/20/2023]
Abstract
OBJECTIVES To determine informational CT findings for distinguishing autoimmune pancreatitis (AIP) from pancreatic ductal adenocarcinoma (PDAC) and to review their diagnostic accuracy. METHODS A systematic and detailed literature review was performed through PubMed, EMBASE, and the Cochrane library. Similar descriptors to embody the identical image finding were labeled as a single CT characteristic. We calculated the pooled diagnostic odds ratios (DORs) of each CT characteristic using a bivariate random-effects model. RESULTS A total of 145 various descriptors from 15 studies (including 562 AIP and 869 PDAC patients) were categorized into 16 CT characteristics. According to the pooled DOR, 16 CT characteristics were classified into three groups (suggesting AIP, suggesting PDAC, and not informational). Seven characteristics suggesting AIP were diffuse pancreatic enlargement (DOR, 48), delayed homogeneous enhancement (DOR, 46), capsule-like rim (DOR, 34), multiple pancreatic masses (DOR, 16), renal involvement (DOR, 15), retroperitoneal fibrosis (DOR, 13), and bile duct involvement (DOR, 8). Delayed homogeneous enhancement showed a pooled sensitivity of 83% and specificity of 85%. The other six characteristics showed relatively low sensitivity (12-63%) but high specificity (93-99%). Four characteristics suggesting PDAC were discrete pancreatic mass (DOR, 23), pancreatic duct cutoff (DOR, 16), upstream main pancreatic duct dilatation (DOR, 8), and upstream parenchymal atrophy (DOR, 7). CONCLUSION Eleven CT characteristics were informational to distinguish AIP from PDAC. Diffuse pancreatic enlargement, delayed homogeneous enhancement, and capsule-like rim suggested AIP with the highest DORs, whereas discrete pancreatic mass suggested PDAC. However, pooled sensitivities of informational CT characteristics were moderate. CLINICAL RELEVANCE STATEMENT This meta-analysis underscores eleven distinctive CT characteristics that aid in differentiating autoimmune pancreatitis from pancreatic adenocarcinoma, potentially preventing misdiagnoses in patients presenting with focal/diffuse pancreatic enlargement. KEY POINTS • Diffuse pancreatic enlargement (pooled diagnostic odds ratio [DOR], 48), delayed homogeneous enhancement (46), and capsule-like rim (34) were CT characteristics suggesting autoimmune pancreatitis. • The CT characteristics suggesting autoimmune pancreatitis, except delayed homogeneous enhancement, had a general tendency to show relatively low sensitivity (12-63%) but high specificity (93-99%). • Discrete pancreatic mass (pooled diagnostic odds ratio, 23) was the CT characteristic suggesting pancreatic ductal adenocarcinoma with the highest pooled DORs.
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Affiliation(s)
- Seung Bae Yoon
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Tae Yeon Jeon
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sung-Hoon Moon
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 22 Gwanpyeong-ro 170 beon-gil, Dongan-gu, Anyang, Gyeonggi-do, 14068, South Korea.
| | - Dong Woo Shin
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 22 Gwanpyeong-ro 170 beon-gil, Dongan-gu, Anyang, Gyeonggi-do, 14068, South Korea
| | - Sang Min Lee
- Department of Radiology, Cha Gangnam Medical Center, Seoul, South Korea
| | - Moon Hyung Choi
- Department of Radiology, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Ji Hye Min
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Min-Jeong Kim
- Department of Radiology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, South Korea
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Miller FH, Lopes Vendrami C, Hammond NA, Mittal PK, Nikolaidis P, Jawahar A. Pancreatic Cancer and Its Mimics. Radiographics 2023; 43:e230054. [PMID: 37824413 DOI: 10.1148/rg.230054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
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.
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Affiliation(s)
- Frank H Miller
- From the Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair St, Ste 800, Chicago, IL 60611 (F.H.M., C.L.V., N.A.H., P.N., A.J.); and Department of Radiology and Imaging, Medical College of Georgia, Augusta, GA (P.K.M.)
| | - Camila Lopes Vendrami
- From the Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair St, Ste 800, Chicago, IL 60611 (F.H.M., C.L.V., N.A.H., P.N., A.J.); and Department of Radiology and Imaging, Medical College of Georgia, Augusta, GA (P.K.M.)
| | - Nancy A Hammond
- From the Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair St, Ste 800, Chicago, IL 60611 (F.H.M., C.L.V., N.A.H., P.N., A.J.); and Department of Radiology and Imaging, Medical College of Georgia, Augusta, GA (P.K.M.)
| | - Pardeep K Mittal
- From the Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair St, Ste 800, Chicago, IL 60611 (F.H.M., C.L.V., N.A.H., P.N., A.J.); and Department of Radiology and Imaging, Medical College of Georgia, Augusta, GA (P.K.M.)
| | - Paul Nikolaidis
- From the Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair St, Ste 800, Chicago, IL 60611 (F.H.M., C.L.V., N.A.H., P.N., A.J.); and Department of Radiology and Imaging, Medical College of Georgia, Augusta, GA (P.K.M.)
| | - Anugayathri Jawahar
- From the Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair St, Ste 800, Chicago, IL 60611 (F.H.M., C.L.V., N.A.H., P.N., A.J.); and Department of Radiology and Imaging, Medical College of Georgia, Augusta, GA (P.K.M.)
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6
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Harindranath S, Sundaram S. Approach to Pancreatic Head Mass in the Background of Chronic Pancreatitis. Diagnostics (Basel) 2023; 13:diagnostics13101797. [PMID: 37238280 DOI: 10.3390/diagnostics13101797] [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: 03/20/2023] [Revised: 05/12/2023] [Accepted: 05/17/2023] [Indexed: 05/28/2023] Open
Abstract
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.
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Affiliation(s)
- Sidharth Harindranath
- Department of Gastroenterology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai 400012, India
| | - Sridhar Sundaram
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai 400012, India
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Kowa JY, Kim TK, Khalili K, Elbanna KY. Patterns of Relapse and Complications of Immunoglobulin G4-Related Disease. J Clin Rheumatol 2023:00124743-990000000-00115. [PMID: 37157124 DOI: 10.1097/rhu.0000000000001975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND Immunoglobulin G4-related disease (IgG4-RD) is a multisystemic fibroinflammatory condition potentially resulting in organ dysfunction. We aimed to evaluate imaging characteristics of disease relapse and complications in this cohort of patients. METHODS This was a cohort study of IgG4-RD patients imaged between 2010 and 2020. Radiological manifestations of disease activity (remission/stability vs. relapse and complications) were correlated with clinical symptoms. Univariate analyses were performed with χ2, Fisher exact, and Mann-Whitney U tests. Times to relapse and organ atrophy were studied with Kaplan-Meier analyses. RESULTS A total of 69 patients had imaging surveillance over a median duration of 47 months. Radiological relapse occurred in 50.7% (35/69) with median time to relapse at 74 months (95% confidence interval, 45-122 months); 42.8% (15/35) of this cohort had different-site relapse with the following recognized primary-secondary patterns: pancreas-hepatobiliary (p = 0.005), hepatobiliary-pancreas (p = 0.013), and periaortitis-mesenteric (p = 0.006). Clinical symptoms were significantly associated with imaging characteristics (p < 0.001). Abdominal complications were detected in 52.2% (36/69) of patients, mostly solid organ atrophy (97.2% [35/36]). New-onset diabetes was more likely in pancreatic IgG4-RD (n = 51) when accompanied by gland atrophy (4/21 vs. 0/30 nonatrophy, p = 0.024). CONCLUSION Radiological relapse of IgG4-RD is common over prolonged imaging surveillance and is significantly associated with symptomatic relapse. A multisystem review to detect new/different sites of disease and abdominal complications may help predict future organ dysfunction.
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Affiliation(s)
- Jie-Ying Kowa
- From the University Medical Imaging Toronto, University Health Network, Toronto, Ontario, Canada
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Capurso G, Pedica F, Palumbo D, Della-Torre E. IgG4-related autoimmune liver disease. Minerva Gastroenterol (Torino) 2023; 69:23-49. [PMID: 33267565 DOI: 10.23736/s2724-5895.20.02794-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
The term IgG4-related autoimmune liver disease (AILD) refers to hepato-biliary manifestations of Immunoglobin G4-related disease (IgG4-RD) including IgG4-related sclerosing cholangitis and IgG4-related pseudotumor. The association of some forms of autoimmune hepatitis to IgG4-RD remains controversial. Although autoimmune phenomena have not been clearly observed in IgG4-AILD, perturbation of the adaptive immune system and activation of the humoral response represent established pathophysiological hallmarks and potential therapeutic targets. Clinical manifestations of IgG4-AILD are virtually indistinguishable from bile duct cancer or primary sclerosing cholangitis and are due to mass forming lesions and thickening of the biliary tract that progressively lead to biliary ducts obstruction. There are no current reliable biomarkers for IgG4-AILD and diagnosis should rely on the integration of clinical, serological, radiological, and histological findings. In analogy to most IgG4-RD manifestations, and in contrast to its major mimickers, IgG4-AILD promptly responds to glucocorticoids but frequently relapses, thus requiring long-term maintenance therapy to avoid progressive fibrosclerotic disease and liver cirrhosis. Accumulating evidence on the efficacy of B-cell depletion therapy in patients with systemic IgG4-RD is gradually changing the treatment paradigm of IgG4-AILD and biologics will be increasingly used also for gastroenterological manifestations of IgG4-RD to spare glucocorticoids and traditional immunosuppressive agents. Looking ahead, identification of reliable biomarkers and of mini-invasive strategies to obtain informative biopsies from the biliary tree represent unavoidable priorities to optimize diagnosis and management of IgG4-AILD.
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Affiliation(s)
- Gabriele Capurso
- IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy - .,Division of Pancreato-Biliary Endoscopy and Endosonography, IRCCS San Raffaele Hospital, Milan, Italy - .,Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Hospital, Milan, Italy -
| | - Federica Pedica
- IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy.,Unit of Pathology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Diego Palumbo
- IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy.,Unit of Clinical and Experimental Radiology, Experimental Imaging Center, IRCCS San Raffaele Hospital, Milan, Italy
| | - Emanuel Della-Torre
- IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy.,Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Hospital, Milan, Italy.,Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, Milan, Italy
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9
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Yoon SB, Jeon TY, Moon SH, Lee SM, Kim MH. Systematic review and meta-analysis of MRI features for differentiating autoimmune pancreatitis from pancreatic adenocarcinoma. Eur Radiol 2022; 32:6691-6701. [PMID: 35486167 DOI: 10.1007/s00330-022-08816-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 04/03/2022] [Accepted: 04/13/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To identify reliable MRI features for differentiating autoimmune pancreatitis (AIP) from pancreatic ductal adenocarcinoma (PDAC) and to summarize their diagnostic accuracy. METHODS We conducted a systematic literature review and meta-analysis using PubMed, EMBASE, and the Cochrane Library to identify original articles published between January 2006 and July 2021. The pooled diagnostic accuracy, including the diagnostic odds ratios (DORs) with 95% confidence intervals (CIs) of the identified features, was calculated using a bivariate random effects model. RESULTS Twelve studies were included, and 92 overlapping descriptors were subsumed under 16 MRI features. Ten features favoring AIP were diffuse enlargement (DOR, 75; 95% CI, 9-594), capsule-like rim (DOR, 52; 95% CI, 20-131), multiple main pancreatic duct (MPD) strictures (DOR, 47; 95% CI, 17-129), homogeneous delayed enhancement (DOR, 46; 95% CI, 21-104), low apparent diffusion coefficient value (DOR, 30), speckled enhancement (DOR, 30), multiple pancreatic masses (DOR, 29), tapered narrowing of MPD (DOR, 15), penetrating duct sign (DOR, 14), and delayed enhancement (DOR, 13). Six features favoring PDAC were target type enhancement (DOR, 41; 95% CI, 11-158), discrete pancreatic mass (DOR, 35; 95% CI, 15-80), upstream MPD dilatation (DOR, 13), peripancreatic fat infiltration (DOR, 10), upstream parenchymal atrophy (DOR, 5), and vascular involvement (DOR, 3). CONCLUSION This study identified 16 informative MRI features to differentiate AIP from PDAC. Among them, diffuse enlargement, capsule-like rim, multiple MPD strictures, and homogeneous delayed enhancement favored AIP with the highest DORs, whereas discrete mass and target type enhancement favored PDAC. KEY POINTS • The MRI features with the highest pooled diagnostic odds ratios (DORs) for autoimmune pancreatitis were diffuse enlargement of the pancreas (75), capsule-like rim (52), multiple strictures of the main pancreatic duct (47), and homogeneous delayed enhancement (46). • The MRI features with the highest pooled DORs for pancreatic ductal adenocarcinoma were target type enhancement (41) and discrete pancreatic mass (35).
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Affiliation(s)
- Seung Bae Yoon
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Tae Yeon Jeon
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sung-Hoon Moon
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 22, Gwanpyeong-ro 170 beon-gil, Dongan-gu, Anyang, Gyeonggi-do, 14068, South Korea.
| | - Sang Min Lee
- Department of Radiology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, South Korea
| | - Myung-Hwan Kim
- Department of Internal Medicine, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, South Korea
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10
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Ha J, Choi SH, Kim KW, Kim JH, Kim HJ. MRI features for differentiation of autoimmune pancreatitis from pancreatic ductal adenocarcinoma: A systematic review and meta-analysis. Dig Liver Dis 2022; 54:849-856. [PMID: 34903501 DOI: 10.1016/j.dld.2021.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/12/2021] [Accepted: 11/15/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS The accurate differential diagnosis between autoimmune pancreatitis (AIP) and pancreatic ductal adenocarcinoma (PDAC) is clinically important. We aimed to determine significant MRI features for differentiating AIP from PDAC, including assessment of diffusion-weighted imaging (DWI). METHODS We performed a systematic search using three databases. The pooled diagnostic odds ratio was calculated using a bivariate random effects model to determine significant MRI features for differentiating AIP from PDAC. The pooled sensitivity and specificity were calculated. The qualitative systematic review for DWI assessment was performed. RESULTS Of nine studies (775 patients), multiple main pancreatic duct (MPD) strictures, absence of upstream marked MPD dilatation, peripancreatic rim, and duct penetration sign were significant MRI features for differentiating AIP from PDAC. Absence of MPD dilatation had the highest pooled sensitivity (87%, 95% CI=68-96%), whereas peripancreatic rim had the highest pooled specificity (100%, 95% CI=88-100%). Of 12 studies evaluating DWI, seven reported statistically significant differences in apparent diffusion coefficient (ADC) values between AIP and PDAC; however, four reported lower ADC values in AIP than in PDAC, but three reported the opposite result. CONCLUSION The four significant MRI features can be useful to differentiate AIP from PDAC, but DWI assessment might be limited.
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Affiliation(s)
- Jiyeon Ha
- Department of Radiology, Kangdong Seong-Sim Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Sang Hyun Choi
- Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Korea.
| | - Kyung Won Kim
- Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Korea
| | - Jin Hee Kim
- Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Korea
| | - Hyoung Jung Kim
- Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Korea
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11
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Beyer G, Hoffmeister A, Michl P, Gress TM, Huber W, Algül H, Neesse A, Meining A, Seufferlein TW, Rosendahl J, Kahl S, Keller J, Werner J, Friess H, Bufler P, Löhr MJ, Schneider A, Lynen Jansen P, Esposito I, Grenacher L, Mössner J, Lerch MM, Mayerle J. S3-Leitlinie Pankreatitis – Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – September 2021 – AWMF Registernummer 021-003. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:419-521. [PMID: 35263785 DOI: 10.1055/a-1735-3864] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Georg Beyer
- Medizinische Klinik und Poliklinik II, LMU Klinikum, Ludwig-Maximilians-Universität München, Deutschland
| | - Albrecht Hoffmeister
- Bereich Gastroenterologie, Klinik und Poliklinik für Onkologie, Gastroenterologie, Hepatologie Pneumologie und Infektiologie, Universitätsklinikum Leipzig, Deutschland
| | - Patrick Michl
- Universitätsklinik u. Poliklinik Innere Medizin I mit Schwerpunkt Gastroenterologie, Universitätsklinikum Halle, Deutschland
| | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Deutschland
| | - Wolfgang Huber
- Comprehensive Cancer Center München TUM, II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Hana Algül
- Comprehensive Cancer Center München TUM, II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Albrecht Neesse
- Klinik für Gastroenterologie, gastrointestinale Onkologie und Endokrinologie, Universitätsmedizin Göttingen, Deutschland
| | - Alexander Meining
- Medizinische Klinik und Poliklinik II Gastroenterologie und Hepatologie, Universitätsklinikum Würzburg, Deutschland
| | | | - Jonas Rosendahl
- Universitätsklinik u. Poliklinik Innere Medizin I mit Schwerpunkt Gastroenterologie, Universitätsklinikum Halle, Deutschland
| | - Stefan Kahl
- Klinik für Innere Medizin m. Schwerpkt. Gastro./Hämat./Onko./Nephro., DRK Kliniken Berlin Köpenick, Deutschland
| | - Jutta Keller
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - Jens Werner
- Klinik für Allgemeine, Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Universitätsklinikum München, Deutschland
| | - Helmut Friess
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar, München, Deutschland
| | - Philip Bufler
- Klinik für Pädiatrie m. S. Gastroenterologie, Nephrologie und Stoffwechselmedizin, Charité Campus Virchow-Klinikum - Universitätsmedizin Berlin, Deutschland
| | - Matthias J Löhr
- Department of Gastroenterology, Karolinska, Universitetssjukhuset, Stockholm, Schweden
| | - Alexander Schneider
- Klinik für Gastroenterologie und Hepatologie, Klinikum Bad Hersfeld, Deutschland
| | - Petra Lynen Jansen
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS), Berlin, Deutschland
| | - Irene Esposito
- Pathologisches Institut, Heinrich-Heine-Universität und Universitätsklinikum Duesseldorf, Duesseldorf, Deutschland
| | - Lars Grenacher
- Conradia Radiologie München Schwabing, München, Deutschland
| | - Joachim Mössner
- Bereich Gastroenterologie, Klinik und Poliklinik für Onkologie, Gastroenterologie, Hepatologie Pneumologie und Infektiologie, Universitätsklinikum Leipzig, Deutschland
| | - Markus M Lerch
- Klinik für Innere Medizin A, Universitätsmedizin Greifswald, Deutschland.,Klinikum der Ludwig-Maximilians-Universität (LMU) München, Deutschland
| | - Julia Mayerle
- Medizinische Klinik und Poliklinik II, LMU Klinikum, Ludwig-Maximilians-Universität München, Deutschland
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CT Radiomics Features in Differentiation of Focal-Type Autoimmune Pancreatitis from Pancreatic Ductal Adenocarcinoma: A Propensity Score Analysis. Acad Radiol 2022; 29:358-366. [PMID: 34108115 DOI: 10.1016/j.acra.2021.04.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 03/31/2021] [Accepted: 04/01/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE To evaluate the diagnostic performance of the radiomics score (rad-score) for differentiating focal-type autoimmune pancreatitis (fAIP) from pancreatic ductal adenocarcinoma (PDAC). METHODS This retrospective review included 42 consecutive patients with fAIP diagnosed according to the International Consensus Diagnostic Criteria between January 2011 and December 2018. Furthermore, 334 consecutive patients with PDAC confirmed by pathology were also reviewed during the same period. Patients with PDAC and fAIP were matched via propensity score matching (PSM). All patients underwent multidetector computed tomography (MDCT). For each patient, 1409 radiomics features of the portal phase were extracted and reduced using the least absolute shrinkage and selection operator (LASSO) logistic regression algorithm. The portal rad-score performance was assessed based on its discriminative ability. RESULTS After PSM, we matched 55 patients with PDAC to 42 patients with fAIP, based on clinical and CT characteristics (e.g., patient age, sex, body mass index, location, size, enhanced mode). A rad-score for discriminating fAIP from PDAC, which contained four CT derived radiomic features, was developed (area under the curve = 0.97). The sensitivity, specificity, and accuracy of the radiomics model were 95.24%, 92.73% and 0.94, respectively. CONCLUSION The portal rad-score can accurately and noninvasively differentiate fAIP from PDAC.
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13
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Qiu YJ, Zhao GC, Shi SN, Zuo D, Zhang Q, Dong Y, Lou WH, Wang WP. Application of dynamic contrast enhanced ultrasound in distinguishing focal-type autoimmune pancreatitis from pancreatic ductal adenocarcinoma. Clin Hemorheol Microcirc 2022; 81:149-161. [PMID: 35253737 DOI: 10.3233/ch-221390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To explore the value of dynamic contrast enhanced ultrasound (DCE-US) in preoperative differential diagnosis of focal-type autoimmune pancreatitis (AIP) and pancreatic ductal adenocarcinoma (PDAC). PATIENTS AND METHODS From May 2016 to March 2020, patients with biopsy and histopathologically confirmed focal-type AIP (n = 9) were retrospectively included. All patients received contrast enhanced ultrasound (CEUS) examinations one week before surgery/biopsy. Dynamic analysis was performed by VueBox® software (Bracco, Italy). Eighteen cases of resection and histopathologically proved PDAC lesions were also included as control group. B mode ultrasound (BMUS) features, CEUS enhancement patterns, time intensity curves (TICs) and CEUS quantitative parameters were obtained and compared between AIP and PDAC lesions. RESULTS After injection of ultrasound contrast agents, most focal-type AIP lesions displayed hyper-enhancement (2/9, 22.2%) or iso-enhancement (6/9, 66.7%) during arterial phase of CEUS, while most of PDAC lesions showed hypo-enhancement (88.9%) (P < 0.01). During late phase, most of AIP lesions showed iso-enhancement (8/9, 88.9%), while most of PDAC lesions showed hypo-enhancement (94.4%) (P < 0.001). Compared with PDAC lesions, TICs of AIP lesions showed delayed and higher enhancement. Among all CEUS perfusion parameters, ratio of PE (peak enhancement), WiAUC (wash-in area under the curve), WiR (wash-in rate), WiPI (wash-in perfusion index, WiPI = WiAUC/ rise time), WoAUC (wash-out area under the curve), WiWoAUC (wash-in and wash-out area under the curve) and WoR (wash-out rate) between pancreatic lesion and surrounding normal pancreatic tissue were significantly higher in AIP lesions than PDAC lesions (P < 0.05). CONCLUSION DCE-US with quantitative analysis has the potential to make preoperative differential diagnosis between focal-type AIP and PDAC non-invasively.
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Affiliation(s)
- Yi-Jie Qiu
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-Chao Zhao
- Department of Pancreas Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shuai-Nan Shi
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Dan Zuo
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Medical Imaging, Shanghai, China
| | - Qi Zhang
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yi Dong
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wen-Hui Lou
- Department of Pancreas Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wen-Ping Wang
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
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14
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Masood M. Autoimmune pancreatitis: What we know so far. JGH Open 2021; 6:3-10. [PMID: 35071782 PMCID: PMC8762623 DOI: 10.1002/jgh3.12688] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 11/12/2021] [Accepted: 11/20/2021] [Indexed: 12/19/2022]
Abstract
Autoimmune pancreatitis (AIP) is a rare, often‐missed disease that involves inflammation of the pancreas and strictures of the pancreatic duct. Its prevalence and incidence in the United States remain scarce. The disease has a varied presentation and often mimics pancreatic malignancy, which can make the diagnosis challenging. Most patients have an excellent response to corticosteroid therapy. Immunomodulators may be used in some cases. Rituximab is an effective, emerging treatment in steroid‐refractory cases. This study aims to review the two distinct types of AIP and provide a detailed analysis of the diagnostic approach and treatment modalities.
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Affiliation(s)
- Muaaz Masood
- Department of Internal Medicine Medical College of Georgia at Augusta University Augusta Georgia USA
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15
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Lu S, Liang J, Liao S, Wu D, Wu F, Li H. Use of MRI signal intensity ratio to differentiate between autoimmune pancreatitis and pancreatic ductal adenocarcinoma. Clin Radiol 2021; 77:e84-e91. [PMID: 34756699 DOI: 10.1016/j.crad.2021.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 10/01/2021] [Indexed: 11/03/2022]
Abstract
AIM To evaluate the accuracy of the lesion-to-erector spinae signal intensity ratio (SIR) on magnetic resonance imaging (MRI) for distinguishing autoimmune pancreatitis (AIP) from pancreatic ductal adenocarcinoma (PDA). MATERIALS AND METHODS The MRI data of 21 patients with AIP and 27 patients with PDA were analysed retrospectively, and the signal intensity in pancreatic lesions and erector spinae muscles at the same level on T2-weighted imaging (T2WI), arterial phase (AP) imaging, and delayed phase (DP) imaging was measured for calculation of SIRs. RESULTS The mean SIRs of the pancreatic lesions and erector spinae from T2WI, AP, and DP images of AIP patients were 0.96, 1.27, and 1.42, respectively, while those of PDA patients were 1.35, 0.80, and 0.91, respectively. The differences in the SIRs between the AIP and PDA groups were statistically significant (p<0.001), with corresponding area under curve (AUC) values of 0.925, 0.906, and 0.961, respectively. The optimal cut-off values for the SIRs on T2WI, AP and DP images were 1.21, 1.01, and 1.08, respectively. SIR values < 1.21 on T2WI, >1.01 on AP imaging, and >1.08 on DP imaging identified AIP with sensitivities of 85.7%, 90.5%, and 90.5%, respectively, and specificities of 81.5%, 74.6%, and 81.5%, respectively. The AUC values for SIRs did not differ significantly between T2WI and DP imaging or AP and DP imaging (Z = 0.778, p=0.436; Z = 1.279, p=0.201). CONCLUSION The SIRs of pancreatic lesions and erector spinae on T2WI, AP, and DP images can be used to differentiate AIP from PDA.
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Affiliation(s)
- S Lu
- Department of Radiology, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, China; Department of Radiology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, 341000, China
| | - J Liang
- Department of Radiology, Shenzhen Baoan Hospital, Southern Medical University, Shenzhen, 518101, China
| | - S Liao
- Department of Radiology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, 341000, China
| | - D Wu
- Department of Radiology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, 341000, China
| | - F Wu
- Department of Radiology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, 341000, China
| | - H Li
- Department of Radiology, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, China.
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16
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Abstract
Autoimmune pancreatitis (AIP) has attracted much attention in the last two decades, and due to the diagnostic value of immunoglobulin G4 (IgG4), the number of cases diagnosed in clinical practice has markedly increased. However, in contrast to prototypic IgG4-related type 1 AIP, a minor subtype of AIP, referred to as type 2 AIP, is less widely known and has thus not yet been characterized in detail. Type 2 AIP is unrelated to IgG4 and is a completely distinct entity from type 1 AIP. One confusing factor is that the two types of AIP share patterns of clinical presentation (e.g., acute pancreatitis and painless jaundice) and imaging abnormalities (e.g., diffuse or segmental enlargement). Since there are currently no established serum markers, the diagnosis of type 2 AIP is highly challenging and requires the tissue confirmation of neutrophilic injury to the pancreatic ducts, a finding designated as a granulocytic epithelial lesion. Approximately one-third of cases are associated with inflammatory bowel disease, particularly ulcerative colitis; however, the pathological relationship between these two conditions has not yet been clarified. Unanswered questions relate to its pathophysiology, the potential development of a similar granulocytic injury in other organs, and the characteristics of pediatric cases. This review summarizes consensus and controversies surrounding type 2 AIP, with the aim of increasing awareness and highlighting the unmet needs of this underrecognized condition.
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Affiliation(s)
- Yoh Zen
- Institute of Liver Studies, King's College Hospital & King's College London, London, UK
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17
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Jia H, Li J, Huang W, Lin G. Multimodel magnetic resonance imaging of mass-forming autoimmune pancreatitis: differential diagnosis with pancreatic ductal adenocarcinoma. BMC Med Imaging 2021; 21:149. [PMID: 34654379 PMCID: PMC8518199 DOI: 10.1186/s12880-021-00679-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 09/28/2021] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Huihui Jia
- Department of Radiology, Huadong Hospital Affiliated to Fudan University, 221 West Yanan Road, Shanghai, 200040, China
| | - Jialin Li
- Department of General Surgery, Center of Pancreaticobiliary Disease, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Wenjun Huang
- Department of Radiology, Huadong Hospital Affiliated to Fudan University, 221 West Yanan Road, Shanghai, 200040, China
| | - Guangwu Lin
- Department of Radiology, Huadong Hospital Affiliated to Fudan University, 221 West Yanan Road, Shanghai, 200040, China.
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18
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Qureshi A, Ghobrial Y, De Castro J, Siami-Namini K, Newman KA. Autoimmune pancreatitis - What we know and what do we have to know? Autoimmun Rev 2021; 20:102912. [PMID: 34280553 DOI: 10.1016/j.autrev.2021.102912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 05/28/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Ammar Qureshi
- Eisenhower Health, Internal Medicine Residency Program, 39000 Bob Hope Dr, Rancho Mirage, CA 92270, United States of America.
| | - Youssef Ghobrial
- Eisenhower Health, Internal Medicine Residency Program, 39000 Bob Hope Dr, Rancho Mirage, CA 92270, United States of America
| | - Joline De Castro
- Eisenhower Health, Internal Medicine Residency Program, 39000 Bob Hope Dr, Rancho Mirage, CA 92270, United States of America
| | - Koushan Siami-Namini
- Eisenhower Health, Department of Pathology, 39000 Bob Hope Dr, Rancho Mirage, CA 92270, United States of America.
| | - Kam A Newman
- University of California, Riverside (UCR), School of Medicine, Eisenhower Health, Internal Medicine Residency Program, Division of Rheumatology, 39000 Bob Hope Dr, Rancho Mirage, CA 92270, United States of America.
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19
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Marya NB, Powers PD, Chari ST, Gleeson FC, Leggett CL, Abu Dayyeh BK, Chandrasekhara V, Iyer PG, Majumder S, Pearson RK, Petersen BT, Rajan E, Sawas T, Storm AC, Vege SS, Chen S, Long Z, Hough DM, Mara K, Levy MJ. Utilisation of artificial intelligence for the development of an EUS-convolutional neural network model trained to enhance the diagnosis of autoimmune pancreatitis. Gut 2021; 70:1335-1344. [PMID: 33028668 DOI: 10.1136/gutjnl-2020-322821] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/10/2020] [Accepted: 09/15/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The diagnosis of autoimmune pancreatitis (AIP) is challenging. Sonographic and cross-sectional imaging findings of AIP closely mimic pancreatic ductal adenocarcinoma (PDAC) and techniques for tissue sampling of AIP are suboptimal. These limitations often result in delayed or failed diagnosis, which negatively impact patient management and outcomes. This study aimed to create an endoscopic ultrasound (EUS)-based convolutional neural network (CNN) model trained to differentiate AIP from PDAC, chronic pancreatitis (CP) and normal pancreas (NP), with sufficient performance to analyse EUS video in real time. DESIGN A database of still image and video data obtained from EUS examinations of cases of AIP, PDAC, CP and NP was used to develop a CNN. Occlusion heatmap analysis was used to identify sonographic features the CNN valued when differentiating AIP from PDAC. RESULTS From 583 patients (146 AIP, 292 PDAC, 72 CP and 73 NP), a total of 1 174 461 unique EUS images were extracted. For video data, the CNN processed 955 EUS frames per second and was: 99% sensitive, 98% specific for distinguishing AIP from NP; 94% sensitive, 71% specific for distinguishing AIP from CP; 90% sensitive, 93% specific for distinguishing AIP from PDAC; and 90% sensitive, 85% specific for distinguishing AIP from all studied conditions (ie, PDAC, CP and NP). CONCLUSION The developed EUS-CNN model accurately differentiated AIP from PDAC and benign pancreatic conditions, thereby offering the capability of earlier and more accurate diagnosis. Use of this model offers the potential for more timely and appropriate patient care and improved outcome.
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Affiliation(s)
- Neil B Marya
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Suresh T Chari
- Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ferga C Gleeson
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Cadman L Leggett
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Prasad G Iyer
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Shounak Majumder
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Randall K Pearson
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Bret T Petersen
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth Rajan
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Tarek Sawas
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew C Storm
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Santhi S Vege
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Shigao Chen
- Diagnostic Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Zaiyang Long
- Diagnostic Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - David M Hough
- Diagnostic Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristin Mara
- Biomedical Statistics and Informatics, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Michael J Levy
- Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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20
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Russo L, Avesani G, Gui B, Trombadori CML, Salutari V, Perri MT, Di Paola V, Rodolfino E, Scambia G, Manfredi R. Immunotherapy-Related Imaging Findings in Patients with Gynecological Malignancies: What Radiologists Need to Know. Korean J Radiol 2021; 22:1310-1322. [PMID: 34047505 PMCID: PMC8316780 DOI: 10.3348/kjr.2020.1299] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 01/26/2021] [Accepted: 03/05/2021] [Indexed: 01/15/2023] Open
Abstract
Immunotherapy is an effective treatment option for gynecological malignancies. Radiologists dealing with gynecological patients undergoing treatment with immune checkpoint inhibitors should be aware of unconventional immune-related imaging features for the evaluation of tumor response and immune-related adverse events. In this paper, immune checkpoint inhibitors used for gynecological malignancies and their mechanisms of action are briefly presented. In the second part, patterns of pseudoprogression are illustrated, and different forms of immune-related adverse events are discussed.
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Affiliation(s)
- Luca Russo
- UOC Radiologia Generale ed Interventistica Generale, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Area Diagnostica per Immagini, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giacomo Avesani
- UOC Radiologia Generale ed Interventistica Generale, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Area Diagnostica per Immagini, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Benedetta Gui
- UOC Radiologia Generale ed Interventistica Generale, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Area Diagnostica per Immagini, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | | | - Vanda Salutari
- UOC Ginecologia Oncologica, Dipartimento per la Salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maria Teresa Perri
- Istituto di Ginecologia e Ostetricia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Valerio Di Paola
- UOC Radiologia Generale ed Interventistica Generale, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Area Diagnostica per Immagini, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Elena Rodolfino
- UOC Radiologia Generale ed Interventistica Generale, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Area Diagnostica per Immagini, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanni Scambia
- UOC Ginecologia Oncologica, Dipartimento per la Salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto di Ginecologia e Ostetricia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Riccardo Manfredi
- UOC Radiologia Generale ed Interventistica Generale, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Area Diagnostica per Immagini, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Dipartimento Universitario di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
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21
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DWI of Autoimmune Pancreatitis: Is It an Imaging Biomarker for Disease Activity? AJR Am J Roentgenol 2021; 216:1240-1246. [PMID: 33760653 DOI: 10.2214/ajr.20.23368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE. The purpose of this article was to evaluate the DWI features of autoimmune pancreatitis (AIP) at baseline, under treatment, and at relapse, and to assess the diagnostic accuracy of the ADC for determining disease activity. MATERIALS AND METHODS. This retrospective study was approved by the institutional review board. Sixty-two patients with AIP (48 at initial attack and 14 at relapse) underwent MRI with DWI (b = 0 and 800 s/mm2) at 3 T before receiving corticosteroid therapy (CST) and during follow-up. Seventeen patients had disease relapse during follow-up, whereas the others remained clinically stable. Forty age- and sex-matched patients without pancreatic disease served as the control group. RESULTS. The ADC value of AIP at baseline was significantly lower than that for a disease-free pancreas (0.99 ± 0.12 vs 1.26 ± 0.10 × 10-3 mm2/s, p < .001). Under CST, the ADC value increased gradually at the short-term and long-term follow-up (1.16 ± 0.12 and 1.23 ± 0.12 × 10-3 mm2/s, respectively, both p < .001). At relapse, the ADC had a relative decrease (1.11 ± 0.20 × 10-3 mm2/s) but was significantly higher compared with the initial attack (p = .003). The AUC of ADC serum IgG4 level at ROC analysis for baseline versus clinically stable AIP was 0.867 and 0.700, the AUC for clinically active AIP versus clinically stable AIP was 0.762 and 0.686, and the AUC for relapsed AIP versus clinically stable AIP was 0.648 and 0.669. CONCLUSION. DWI reflected the dynamic change of AIP under CST, and the ADC value for DWI outperformed the serum IgG4 value for determining disease activity. However, relapsed disease showed less diffusion restriction, and the ADC value was less accurate for predicting relapse.
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22
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Wang Y, Chen X, Wang J, Cui W, Wang C, Chen X, Wang Z. Differentiation between non-hypervascular pancreatic neuroendocrine tumors and mass-forming pancreatitis using contrast-enhanced computed tomography. Acta Radiol 2021; 62:190-197. [PMID: 32375515 DOI: 10.1177/0284185120921503] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Non-hypervascular pancreatic neuroendocrine tumors (PNETs) showed slight or iso-enhancement in contrast-enhanced computed tomography (CE-CT), which shared similar imaging findings with mass-forming pancreatitis (MFPs). PURPOSE To explore the value of CT imaging features in differentiating the two diseases. MATERIAL AND METHODS Fifty-one patients with histologically proved MFPs (n = 27) or non-hypervascular PNETs (n = 24) were included. Two radiologists reviewed CT imaging findings and clinical features. Logistic regression analysis was performed to identify relevant features in differentiating non-hypervascular PNETs and MFPs. Receiver operating characteristic (ROC) curve analysis was used to show the performance of the optimal parameters in differentiating non-hypervascular PNETs and MFPs. RESULTS A well-defined margin was more common in non-hypervascular PNETs (P < 0.05) than that in MFPs. MFPs often occurred in older people (P < 0.01) and the head-neck of the pancreas compared with non-hypervascular PNETs (P < 0.05). Metastases only presented in non-hypervascular PNETs (P < 0.05). CT values at venous phase and delay phase of MFPs were higher (P = 0.010 and P = 0.029) than those in non-hypervascular PNETs. Logistic analysis showed gender, tumor margin, CT values at venous phase, and tumor components were independent predictors in differentiating the two lesions. The area under the curve (AUC) was 0.938 with a sensitivity of 87.5% and specificity of 92.6% for combined predicators. CONCLUSION Gender, tumor margin, CT values at venous phase, and tumor components were useful predicators in differentiating non-hypervascular PNETs and MFPs.
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Affiliation(s)
- Yajie Wang
- Department of Radiology, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, PR China
| | - Xin Chen
- Department of Radiology, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, PR China
- Department of Graduate, Bengbu Medical College, Bengbu, Anhui Province, PR China
| | - Jianhua Wang
- Department of Radiology, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, PR China
| | - Wenjing Cui
- Department of Radiology, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, PR China
| | - Cheng Wang
- Department of Radiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, PR China
| | - Xiao Chen
- Department of Radiology, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, PR China
| | - Zhongqiu Wang
- Department of Radiology, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, PR China
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Ogawa H, Takehara Y, Naganawa S. Imaging diagnosis of autoimmune pancreatitis: computed tomography and magnetic resonance imaging. J Med Ultrason (2001) 2021; 48:565-571. [PMID: 34698963 PMCID: PMC8578112 DOI: 10.1007/s10396-021-01145-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 08/14/2021] [Indexed: 02/07/2023]
Abstract
Autoimmune pancreatitis (AIP) is a pancreatic phenotype of IgG4-related systemic disease. Since its first description in the literature, characteristic imaging features have gradually become known to many clinicians encompassing various specialties in the past quarter century. CT and MRI have been the workhorses for imaging diagnosis of AIP. Typical features include sausage-like swelling of the focal or entire pancreas, duct-penetrating sign, a capsule-like rim of the affected lesions, and homogeneous delayed enhancement or enhanced duct sign after contrast administration, as well as characteristic combined findings reflecting coexisting pathologies in the other organs as a systemic disease. In this review, recent and future developments in CT and MRI that may help diagnose AIP are discussed, including restricted diffusion and perfusion and increased elasticity measured using MR.
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Affiliation(s)
- Hiroshi Ogawa
- Department of Radiology, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa, Nagoya 466-8550 Japan
| | - Yasuo Takehara
- Department of Radiology, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa, Nagoya 466-8550 Japan ,Department of Fundamental Development for Advanced Low Invasive Diagnostic Imaging, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa, Nagoya 466-8550 Japan
| | - Shinji Naganawa
- Department of Radiology, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa, Nagoya 466-8550 Japan
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Ha J, Choi SH, Byun JH, Kim KW, Kim SY, Kim JH, Kim HJ. Meta-analysis of CT and MRI for differentiation of autoimmune pancreatitis from pancreatic adenocarcinoma. Eur Radiol 2020; 31:3427-3438. [PMID: 33146798 DOI: 10.1007/s00330-020-07416-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 08/28/2020] [Accepted: 10/13/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To systematically determine the diagnostic performance of computed tomography (CT) and magnetic resonance imaging (MRI) for differentiating autoimmune pancreatitis (AIP) from pancreatic ductal adenocarcinoma (PDAC), with a comparison between the two imaging modalities. METHODS Literature search was conducted using PubMed and EMBASE databases to identify original articles published between 2009 and 2019 reporting the diagnostic performance of CT and MRI for differentiating AIP from PDAC. The meta-analytic sensitivity and specificity of CT and MRI were calculated, and compared using a bivariate random effects model. Subgroup analysis for differentiating focal AIP from PDAC was performed. RESULTS Of the 856 articles screened, 11 eligible articles are remained, i.e., five studies for CT, four for MRI, and two for both. The meta-analytic summary sensitivity and specificity of CT were 59% (95% confidence interval [CI], 41-75%) and 99% (95% CI, 88-100%), respectively, while those of MRI were 84% (95% CI, 68-93%) and 97% (95% CI, 87-99%). MRI had a significantly higher meta-analytic summary sensitivity than CT (84% vs. 59%, p = 0.02) but a similar specificity (97% vs. 99%, p = 0.18). In the subgroup analysis for focal AIP, the sensitivity for distinguishing between focal AIP and PDAC was lower than that for the overall analysis. MRI had a higher sensitivity than CT (76% vs. 50%, p = 0.28) but a similar specificity (97% vs. 98%, p = 0.07). CONCLUSION MRI might be clinically more useful to evaluate patients with AIP, particularly for differentiating AIP from PDAC. KEY POINTS • MRI had an overall good diagnostic performance to differentiate AIP from PDAC with a meta-analytic summary estimate of 83% for sensitivity and of 97% for specificity. • CT had a very high specificity (99%), but a suboptimal sensitivity (59%) for differentiating AIP from PDAC. • Compared with CT, MRI had a higher sensitivity, but a similar specificity.
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Affiliation(s)
- Jiyeon Ha
- Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 138-736, South Korea
| | - Sang Hyun Choi
- Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 138-736, South Korea.
| | - Jae Ho Byun
- Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 138-736, South Korea
| | - Kyung Won Kim
- Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 138-736, South Korea
| | - So Yeon Kim
- Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 138-736, South Korea
| | - Jin Hee Kim
- Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 138-736, South Korea
| | - Hyoung Jung Kim
- Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 138-736, South Korea
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25
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IgG4-related disease in the abdomen and pelvis: atypical findings, pitfalls, and mimics. Abdom Radiol (NY) 2020; 45:2485-2499. [PMID: 32300834 DOI: 10.1007/s00261-020-02526-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
IgG4-related disease (IgG4-RD) is a systemic, autoimmune, fibroinflammatory disease that can cause multi-organ damage. Although there have been many trials and studies since its recognition in 2003, there is still much that is unknown. Furthermore, IgG4-RD can affect any organ in the body and often has many mimics and alternative diagnoses, which can make for a challenging workup. Imaging plays a substantial role in the diagnosis of IgG4-RD and is often the first occasion where IgG4-RD comes into consideration. Thus, knowledge about the imaging findings of various manifestations of IgG4-RD can aid in the diagnosis and have a significant impact on patient management. In this article, we review the wide array of imaging findings, both typical and atypical, as well as possible mimics of IgG4-RD in the abdomen and pelvis.
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26
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E L, Xu Y, Wu Z, Li L, Zhang N, Yang H, Schwartz LH, Lu L, Zhao B. Differentiation of Focal-Type Autoimmune Pancreatitis From Pancreatic Ductal Adenocarcinoma Using Radiomics Based on Multiphasic Computed Tomography. J Comput Assist Tomogr 2020; 44:511-518. [PMID: 32697521 PMCID: PMC9165686 DOI: 10.1097/rct.0000000000001049] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The aim of this study was to develop a radiomics model for a differential diagnosis of focal-type autoimmune pancreatitis (AIP) from pancreatic ductal adenocarcinoma. METHODS A total of 96 patients, 45 with AIP and 51 with pancreatic ductal adenocarcinoma, were retrospectively evaluated. All patients underwent pretreatment abdominal computed tomography imaging acquired at noncontrast, arterial, and venous phases. Furthermore, 1160 radiomics features were extracted from each phasic image to build radiomics models. The performance of radiomics model was evaluated by sensitivity, specificity, and accuracy. The results of radiomics model were also compared with those of radiologists' visual assessments. RESULTS The sensitivity, specificity, and accuracy of the optimal radiomics model were 93.3%, 96.1%, and 94.8%, respectively. They were higher than those of the radiologists' assessments with sensitivity of 57.78% and 73.33%, specificity of 88.24% and 90.20%, and accuracy of 75.00% and 81.25%, respectively. CONCLUSION Radiomics is helpful for a differential diagnosis of AIP in clinical practice as a noninvasive and quantitative method.
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Affiliation(s)
- Linning E
- Department of Radiology, Shanxi DAYI Hospital, 99 Longcheng Street, Taiyuan, Shanxi, 10032, China
| | - Yan Xu
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Zhifeng Wu
- Department of Radiology, Shanxi DAYI Hospital, 99 Longcheng Street, Taiyuan, Shanxi, 10032, China
| | - Li Li
- Department of Pathology, Shanxi DAYI Hospital, 99 Longcheng Street, Taiyuan, Shanxi, 10032, China
| | - Na Zhang
- Department of Radiology, Shanxi DAYI Hospital, 99 Longcheng Street, Taiyuan, Shanxi, 10032, China
| | - Hao Yang
- Department of Radiology, Columbia University Medical Center, 622 West 168th Street, New York, NY, 10032, USA
| | - Lawrence H. Schwartz
- Department of Radiology, Columbia University Medical Center, 622 West 168th Street, New York, NY, 10032, USA
| | - Lin Lu
- Department of Radiology, Columbia University Medical Center, 622 West 168th Street, New York, NY, 10032, USA
| | - Binsheng Zhao
- Department of Radiology, Columbia University Medical Center, 622 West 168th Street, New York, NY, 10032, USA
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27
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Löhr JM, Beuers U, Vujasinovic M, Alvaro D, Frøkjær JB, Buttgereit F, Capurso G, Culver EL, de-Madaria E, Della-Torre E, Detlefsen S, Dominguez-Muñoz E, Czubkowski P, Ewald N, Frulloni L, Gubergrits N, Duman DG, Hackert T, Iglesias-Garcia J, Kartalis N, Laghi A, Lammert F, Lindgren F, Okhlobystin A, Oracz G, Parniczky A, Mucelli RMP, Rebours V, Rosendahl J, Schleinitz N, Schneider A, van Bommel EF, Verbeke CS, Vullierme MP, Witt H. European Guideline on IgG4-related digestive disease - UEG and SGF evidence-based recommendations. United European Gastroenterol J 2020; 8:637-666. [PMID: 32552502 DOI: 10.1177/2050640620934911] [Citation(s) in RCA: 101] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The overall objective of these guidelines is to provide evidence-based recommendations for the diagnosis and management of immunoglobulin G4 (IgG4)-related digestive disease in adults and children. IgG4-related digestive disease can be diagnosed only with a comprehensive work-up that includes histology, organ morphology at imaging, serology, search for other organ involvement, and response to glucocorticoid treatment. Indications for treatment are symptomatic patients with obstructive jaundice, abdominal pain, posterior pancreatic pain, and involvement of extra-pancreatic digestive organs, including IgG4-related cholangitis. Treatment with glucocorticoids should be weight-based and initiated at a dose of 0.6-0.8 mg/kg body weight/day orally (typical starting dose 30-40 mg/day prednisone equivalent) for 1 month to induce remission and then be tapered within two additional months. Response to initial treatment should be assessed at week 2-4 with clinical, biochemical and morphological markers. Maintenance treatment with glucocorticoids should be considered in multi-organ disease or history of relapse. If there is no change in disease activity and burden within 3 months, the diagnosis should be reconsidered. If the disease relapsed during the 3 months of treatment, immunosuppressive drugs should be added.
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Affiliation(s)
- J-Matthias Löhr
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden and Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Ulrich Beuers
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Miroslav Vujasinovic
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden and Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Domenico Alvaro
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | | | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité University Medicine Berlin, Berlin, Germany
| | - Gabriele Capurso
- PancreatoBiliary Endoscopy and EUS Division Pancreas Translational and Clinical Research Center IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Emma L Culver
- Translational Gastroenterology Unit, John Radcliffe Hospital and Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Enrique de-Madaria
- Gastroenterology Department, Alicante University General Hospital, ISABIAL, Alicante, Spain
| | - Emanuel Della-Torre
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Unit of Immunology, Rheumatology, Allergy and Rare Disease (UnIRAR), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sönke Detlefsen
- Department of Pathology, Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
| | - Enrique Dominguez-Muñoz
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Piotr Czubkowski
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Nils Ewald
- Institute of Endocrinology, Diabetology and Metabolism, Johannes Wesling University hospital, Minden, Germany and Justus Liebig University Giessen, Giessen, Germany
| | - Luca Frulloni
- Department of Medicine, Pancreas Institute, University of Verona, Verona, Italy
| | - Natalya Gubergrits
- Department of Internal Medicine, Donetsk National Medical University, Lyman, Ukraine
| | - Deniz Guney Duman
- Department of Gastroenterology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Julio Iglesias-Garcia
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Nikolaos Kartalis
- Department of Abdominal Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Andrea Laghi
- Department of Surgical and Medical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy
| | - Frank Lammert
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany
| | - Fredrik Lindgren
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Karolinska University Hospital, Stockholm, Sweden
| | | | - Grzegorz Oracz
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Andrea Parniczky
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; Heim Pál National Insitute of Pediatrics, Budapest, Hungary
| | | | - Vinciane Rebours
- Pancreatology Department, Beaujon Hospital, Clichy, Université de Paris, France
| | - Jonas Rosendahl
- Department of Internal Medicine I, Martin Luther University, Halle, Germany
| | - Nicolas Schleinitz
- Département de Médicine Interne Timone, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France
| | - Alexander Schneider
- Department of Gastroenterology and Hepatology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany
| | - Eric Fh van Bommel
- Department of Internal Medicine, Dutch National Center of Expertise Retroperitoneal Fibrosis, Albert Schweitzer hospital, Dordrecht, the Netherlands
| | | | | | - Heiko Witt
- Else Kröner-Fresenius-Zentrum für Ernährungsmedizin, Paediatric Nutritional Medicine, Technische Universität München, Freising, Germany
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- See list at the end of this article
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28
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Ling J, Wang H, Pan W, Li S, Guan J, Zhang X, Guo Y. Clinical and imaging features of IgG4-related kidney disease. Abdom Radiol (NY) 2020; 45:1915-1921. [PMID: 32179977 DOI: 10.1007/s00261-020-02477-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE To assess the clinical and imaging features of IgG4-RKD for understanding and diagnosis of this disease. METHODS CT and MR images of 34 patients with IgG4-RKD were retrospectively analyzed by two radiologists in consensus. RESULTS The serum IgG4 level was found being increased in all patients. Renal involvement was bilateral (24/34, 70.6%) or unilateral (10/34,29.4%), multiple (29/34, 85.3%) or solitary (5/34, 14.7%). The lesions were wedge-shaped (21) or mass-like (4) in the renal parenchyma, whereas diffusely decreased renal density was noted in 2 patients. All lesions showed progressive contrast enhancement. The 4 mass-like lesions were misdiagnosed as renal malignancy. In 15 patients with follow-up imaging examinations, the number and size of renal lesions decreased after oral hormone treatment. The serum IgG4 levels were significantly decreased after therapy in all patients. CONCLUSION IgG4-RKD has various imaging appearances. Although the mass-like appearance mimics renal malignancy in some patients, progressive contrast enhancement in the lesion with elevated serum IgG4 suggests IgG4-RKD.
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Affiliation(s)
- Jian Ling
- Department of Radiology, The Eastern Hospital of the First Affiliated Hospital, Sun Yat-Sen University, No.183 Huangpu Eastern Road, Guangzhou, 510700, Guangdong, People's Republic of China
| | - Huanjun Wang
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, No.58 Zhongshan Road 2, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Weibin Pan
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, No.58 Zhongshan Road 2, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Shurong Li
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, No.58 Zhongshan Road 2, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Jian Guan
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, No.58 Zhongshan Road 2, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Xiaoling Zhang
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, No.58 Zhongshan Road 2, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Yan Guo
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, No.58 Zhongshan Road 2, Guangzhou, 510080, Guangdong, People's Republic of China.
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Lopes Vendrami C, Shin JS, Hammond NA, Kothari K, Mittal PK, Miller FH. Differentiation of focal autoimmune pancreatitis from pancreatic ductal adenocarcinoma. Abdom Radiol (NY) 2020; 45:1371-1386. [PMID: 31493022 DOI: 10.1007/s00261-019-02210-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Camila Lopes Vendrami
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Joon Soo Shin
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Nancy A Hammond
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Kunal Kothari
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Pardeep K Mittal
- Department of Radiology and Imaging, Medical College of Georgia, 1120 15th Street BA-1411, Augusta, GA, 30912, USA
| | - Frank H Miller
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA.
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Abstract
OBJECTIVE Since the time of inception of autoimmune pancreatitis (AIP), our knowledge of autoimmune pancreatitis has expanded significantly. The aim of this review is to provide an update on clinical manifestations, diagnosis, imaging features, and treatment of AIP. BACKGROUND AND CLINICAL SIGNIFICANCE Type 1 AIP is the pancreatic manifestation of IgG4-related systemic disease, which can be diagnosed using a combination of clinical, histopathological, pancreatic imaging findings in conjunction with manifestation in other organs, as well of responsiveness to steroid treatment. It is vital to differentiate AIP from pancreatic cancer since both can mimic each other clinically and radiologically. Type 2 AIP is a rare but distinct subtype of AIP which occurs mostly in the younger patient. CONCLUSION AIP is steroid-responsive chronic pancreatitis with distinct manifestations on imaging.
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Affiliation(s)
- Ashish Khandelwal
- Department of Radiology, Mayo Clinic, 200 First St, Rochester, MN, 55902, USA
| | - Dai Inoue
- Department of Radiology, Kanazawa Univeristy, 1192 Kakumamachi, Kanazawa, Ishikawa, 920-1192, Japan
| | - Naoki Takahashi
- Department of Radiology, Mayo Clinic, 200 First St, Rochester, MN, 55902, USA.
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Relationship of pancreas volume to tobacco smoking and alcohol consumption following pancreatitis. Pancreatology 2020; 20:60-67. [PMID: 31708473 DOI: 10.1016/j.pan.2019.10.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/02/2019] [Accepted: 10/30/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Tobacco smoking and alcohol consumption are established risk factors for diseases of the pancreas. With the recent advances in imaging modalities (such as magnetic resonance (MR) imaging), opportunities have arisen to study pancreas size, in both health and disease. Studies investigating the relationship between tobacco smoking, alcohol consumption, and total pancreas volume (TPV) - a holistic measure of pancreatic exocrine reserve - are lacking. The aim of the present study was to investigate the associations between MR-derived TPV and tobacco smoking/alcohol consumption. METHODS This cross-sectional study recruited individuals with a history of pancreatitis and healthy controls. A validated questionnaire was used to ascertain current and lifetime tobacco smoking and alcohol consumption. TPV was quantified using MR images by two independent raters. Generalized additive models and linear regression analyses were conducted and adjusted for demographic, metabolic, and pancreatitis-related factors. RESULTS A total of 107 individuals following pancreatitis and 38 healthy controls were included. There was no statistically significant difference in TPV between any of the tobacco smoking/alcohol consumption categories of individuals following pancreatitis and healthy controls, in both unadjusted and adjusted analyses. In individuals following pancreatitis, multivariate linear regression found no association between TPV and 7 smoking- and alcohol-related variables. Sensitivity analyses constrained to individuals who did not abstain from either smoking or drinking following their first attack of pancreatitis did not yield statistical significance with TPV. In post-hoc analysis, age was significantly inversely associated with TPV in the most adjusted model (p = 0.016). CONCLUSIONS This is the first study to investigate the association between tobacco smoking, alcohol consumption, and MR-derived TPV following pancreatitis. It appears that age, but not tobacco smoking or alcohol consumption, is associated with a significantly reduced TPV.
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de Pretis N, Vieceli F, Brandolese A, Brozzi L, Amodio A, Frulloni L. Autoimmune pancreatitis not otherwise specified (NOS): Clinical features and outcomes of the forgotten type. Hepatobiliary Pancreat Dis Int 2019; 18:576-579. [PMID: 31248720 DOI: 10.1016/j.hbpd.2019.05.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 05/29/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Autoimmune pancreatitis (AIP) is a well-recognized fibroinflammatory disease of the pancreas. Despite the significant number of studies published on AIP type 1 and 2, no studies have been focused on AIP type not otherwise specified (NOS) and therefore very little is known about clinical features and long-term outcomes of these patients. The aim of this study was to investigate clinical and radiological features of AIP type NOS-patients. METHODS Patients classified as AIP type NOS at clinical onset included in our database prospectively maintained since 1995 were evaluated. Epidemiological, clinical data were collected and analyzed. RESULTS Forty-six patients were included in the study. The clinical onset was mainly characterized by weight loss, jaundice and acute pancreatitis. Eight patients (17.4%) were reclassified as AIP type 2 during follow-up because of the development of ulcerative colitis. Seven patients (15.2%) experienced relapse after steroid treatment but only one (2.2%) needed immunosuppressive drugs because of recurrent relapses. CONCLUSIONS AIP type NOS shares clinical features similar to AIP type 2 and a relevant proportion of patients was reclassified as AIP type 2 during follow-up because of the development of ulcerative colitis. The risk of relapse is low but not irrelevant.
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Affiliation(s)
- Nicolò de Pretis
- Gastroenterology Unit, Pancreas Center, University of Verona, Piazzale L.A. Scuro 10, 37134, Verona, Italy.
| | - Filippo Vieceli
- Gastroenterology Unit, Pancreas Center, University of Verona, Piazzale L.A. Scuro 10, 37134, Verona, Italy
| | - Alessandro Brandolese
- Gastroenterology Unit, Pancreas Center, University of Verona, Piazzale L.A. Scuro 10, 37134, Verona, Italy
| | - Lorenzo Brozzi
- Gastroenterology Unit, Pancreas Center, University of Verona, Piazzale L.A. Scuro 10, 37134, Verona, Italy
| | - Antonio Amodio
- Gastroenterology Unit, Pancreas Center, University of Verona, Piazzale L.A. Scuro 10, 37134, Verona, Italy
| | - Luca Frulloni
- Gastroenterology Unit, Pancreas Center, University of Verona, Piazzale L.A. Scuro 10, 37134, Verona, Italy
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Pancreaticobiliary involvement in treated type 1 autoimmune pancreatitis: Imaging pattern and risk factors for disease relapse. Eur J Radiol 2019; 120:108673. [DOI: 10.1016/j.ejrad.2019.108673] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/31/2019] [Accepted: 09/12/2019] [Indexed: 01/04/2023]
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Wolske KM, Ponnatapura J, Kolokythas O, Burke LMB, Tappouni R, Lalwani N. Chronic Pancreatitis or Pancreatic Tumor? A Problem-solving Approach. Radiographics 2019; 39:1965-1982. [PMID: 31584860 DOI: 10.1148/rg.2019190011] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Kristy Marie Wolske
- From the Departments of Radiology of Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC 27157 (K.M.W., J.P., R.T., N.L.); University of Washington, Seattle, Wash (O.K.); and University of North Carolina at Chapel Hill, Chapel Hill, NC (L.M.B.B.)
| | - Janardhana Ponnatapura
- From the Departments of Radiology of Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC 27157 (K.M.W., J.P., R.T., N.L.); University of Washington, Seattle, Wash (O.K.); and University of North Carolina at Chapel Hill, Chapel Hill, NC (L.M.B.B.)
| | - Orpheus Kolokythas
- From the Departments of Radiology of Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC 27157 (K.M.W., J.P., R.T., N.L.); University of Washington, Seattle, Wash (O.K.); and University of North Carolina at Chapel Hill, Chapel Hill, NC (L.M.B.B.)
| | - Lauren M B Burke
- From the Departments of Radiology of Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC 27157 (K.M.W., J.P., R.T., N.L.); University of Washington, Seattle, Wash (O.K.); and University of North Carolina at Chapel Hill, Chapel Hill, NC (L.M.B.B.)
| | - Rafel Tappouni
- From the Departments of Radiology of Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC 27157 (K.M.W., J.P., R.T., N.L.); University of Washington, Seattle, Wash (O.K.); and University of North Carolina at Chapel Hill, Chapel Hill, NC (L.M.B.B.)
| | - Neeraj Lalwani
- From the Departments of Radiology of Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC 27157 (K.M.W., J.P., R.T., N.L.); University of Washington, Seattle, Wash (O.K.); and University of North Carolina at Chapel Hill, Chapel Hill, NC (L.M.B.B.)
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Xiang P, Zhang X, Wang C, Lang Y, Xu L, Huang L, Shen J, Feng ST. Pancreatic tumor in type 1 autoimmune pancreatitis: a diagnostic challenge. BMC Cancer 2019; 19:814. [PMID: 31419961 PMCID: PMC6698045 DOI: 10.1186/s12885-019-6027-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 08/08/2019] [Indexed: 02/06/2023] Open
Abstract
Background The co-occurrence of type 1 autoimmune pancreatitis (AIP) and pancreatic tumor (PaT) has been previously reported. Pure AIP cases have favorable prognosis and are primarily treated with steroids, while AIP cases with PaT are associated with poor prognosis where the primary management is pancreatic resection. However, it’s a challenge to timely identify the concurrent PaT in AIP because of their similar clinical and radiological manifestations. Methods We retrospectively reviewed the data in two medical centers from January 2010 to April 2019. The inclusion criteria were as follows: 1) completion of abdominal CT imaging before invasive procedures to the pancreas, 2) a final diagnosis of type 1 AIP using the 2011 international consensus diagnostic criteria, 3) follow-up duration of at least one month unless AIP and PaT were identified simultaneously. The presence of PaT in AIP was made based on histopathological confirmation, and the absence of PaT in AIP was defined as no pathological or radiological evidence of concurrent PaT. Clinical and radiological characteristics including gender, age, surveillance period, serum IgG4 and Ca-199 levels, biopsy, extrapancreatic involvement, CT and MR (if performed) imaging characteristics were compared between AIP with and without PaT. The Fisher’s exact test was used for qualitative variables, and nonparametric Mann-Whitney test for quantitative variables. A p value ≤0.05 was considered statistically significant. Results A total of 74 patients with type 1 AIP were included, of which 5 (6.7%) had the concurrent PaT. The subtypes were pancreatic ductal adenocarcinoma (3/5), solitary extramedullary plasmacytoma in the pancreas (1/5) and cholangiocarcinoma in the pancreatic segment (1/5), respectively. Gender (p = 0.044), the pattern of pancreatic enlargement (p = 0.003), heterogeneity (p = 0.015), low-density (p = 0.004) on CT and rim enhancement on MRI (p = 0.050) differed significantly between AIP with and without PaT. None of the low-density characteristics on CT or other assessed MRI characteristics could significantly differentiate the two groups (p>0.05). Conclusions Female, focal pancreatic enlargement, pancreatic heterogeneity, low-density on CT and rim enhancement on MRI are suggestive of the concurrent PaT in type 1 AIP. The characteristics of low-density on CT or other MRI characteristics did not provide further diagnostic values.
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Affiliation(s)
- Pei Xiang
- Department of Radiology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, Guangdong, 510080, People's Republic of China
| | - Xiaoling Zhang
- Department of Radiology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, Guangdong, 510080, People's Republic of China
| | - Chaoyang Wang
- Department of Radiology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, Guangdong, 510080, People's Republic of China
| | - Yuejiao Lang
- Department of Pathology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, Guangdong, 510080, People's Republic of China
| | - Ling Xu
- Faculty of Medicine and Dentistry, University of Western Australia, Perth, Australia
| | - Li Huang
- Department of Pancreatobiliary Surgery, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, Guangdong, 510080, People's Republic of China
| | - Jingxian Shen
- Department of Radiology, State Key Laboratory of Oncology in South China, The Cancer Center, Sun Yat-sen University, 651 Dongfeng East Road, Guangzhou, Guangdong, 510060, People's Republic of China.
| | - Shi-Ting Feng
- Department of Radiology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, Guangdong, 510080, People's Republic of China.
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Ahn S, Lee JC, Hwang JH, Yoon YS, Lee KH, Zen Y. Duct-obstructive pancreatitis with granulocytic epithelial lesion in a patient with ulcerative colitis: An atypical manifestation of type 2 autoimmune pancreatitis? Pathol Int 2019; 69:420-426. [PMID: 31219205 DOI: 10.1111/pin.12805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 03/08/2019] [Accepted: 04/01/2019] [Indexed: 02/06/2023]
Abstract
Type 2 autoimmune pancreatitis (AIP) typically presents with diffuse or focal enlargement of the pancreas; however, its diverse clinical presentation has not yet been clarified. We herein described a 46-year-old man with a 1-month history of ulcerative colitis who presented with imaging features of a mass-like lesion in the pancreatic body with upstream duct dilatation and serum CA19-9 elevation. He underwent laparoscopic distal pancreatectomy with splenectomy for suspected malignancy. Histologically, the area radiologically suspected to be duct dilatation consisted of necrotic tissue, in which the disrupted main pancreatic duct was involved. The area radiologically suspected to be the mass lesion showed features of pancreatitis without discrete mass. In addition, several ducts showed neutrophilic duct injury similar to granulocytic epithelial lesions observed in type 2 AIP. Immunohistochemistry revealed the aberrant expression of IL-8 in the pancreatic ductules and infiltrating CD3-positive T-lymphocytes, findings recently identified in type 2 AIP. The present case is not typical for either type 2 AIP or other known conditions, but extreme examples of type 2 AIP may present with ductal obstruction because of severe neutrophilic duct injury. IL-8 immunostaining may also assist in establishing a diagnosis of type 2 AIP with an atypical presentation.
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Affiliation(s)
- Soomin Ahn
- Department of Pathology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jong-Chan Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jin-Hyeok Hwang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Kyoung Ho Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Yoh Zen
- Institute of Liver Studies, King's College Hospital & King's College London, London, UK
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Kwon JH, Kim JH, Kim SY, Byun JH, Kim HJ, Lee MG, Lee SS. Differentiating focal autoimmune pancreatitis and pancreatic ductal adenocarcinoma: contrast-enhanced MRI with special emphasis on the arterial phase. Eur Radiol 2019; 29:5763-5771. [PMID: 31028441 DOI: 10.1007/s00330-019-06200-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/21/2019] [Accepted: 03/25/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To compare focal-type autoimmune pancreatitis (AIP) and pancreatic ductal adenocarcinoma (PDA) using contrast-enhanced MR imaging (CE-MRI), and to assess diagnostic performance of the lesion contrast at arterial phase (AP) (ContrastAP) for differentiating between the two diseases. METHODS Thirty-six patients with focal-type AIP and 72 patients with PDA were included. All included patients underwent CE-MRI with triple phases. The signal intensity (SI) of the mass and normal pancreas was measured at each phase, and the lesion contrast (SIpancreas/SImass) was compared between AIP and PDA groups. The sensitivity and specificity of ContrastAP using an optimal cutoff point were compared with those of key imaging features specific to AIP and PDA. RESULTS The lesion contrast differed significantly between AIP and PDA groups at all phases of CE-MRI; the maximum difference was observed at AP. For AIP, the sensitivity (94.4%) and specificity (87.5%) of ContrastAP (cutoff ≤ 1.41) were comparable or significantly higher than those of all key imaging features (sensitivity, 38.9-88.9%; specificity, 48.6-95.8%), except for the halo sign. For PDA, the sensitivity (87.5%) and specificity (94.4%) of ContrastAP (cutoff > 1.41) were comparable or significantly higher than those of all key imaging features (sensitivity, 40.3-68.1%; specificity, 72.2-94.4%), except for the discrete mass. CONCLUSIONS Quantitative analysis of the lesion contrast using CE-MRI, particularly at AP, was helpful to differentiate focal-type AIP from PDA. The diagnostic performance of ContrastAP was mostly comparable or higher than those of the key imaging features. KEY POINTS • Diagnosis of focal-type AIP vs. PDA using imaging techniques is extremely challenging. • Lesion contrast in the arterial-phase MRI differs significantly between focal-type AIP and PDA. • Quantitative analysis of lesion contrast using CE-MRI, particularly at the arterial phase, is helpful to differentiate focal-type AIP from PDA.
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Affiliation(s)
- Ji Hye Kwon
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, South Korea
| | - Jin Hee Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, South Korea.
| | - So Yeon Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, South Korea
| | - Jae Ho Byun
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, South Korea
| | - Hyoung Jung Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, South Korea
| | - Moon-Gyu Lee
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, South Korea
| | - Seung Soo Lee
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, South Korea
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Native T1 mapping of autoimmune pancreatitis as a quantitative outcome surrogate. Eur Radiol 2019; 29:4436-4446. [DOI: 10.1007/s00330-018-5987-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 12/01/2018] [Accepted: 12/18/2018] [Indexed: 12/19/2022]
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Type 1 and Type 2 Autoimmune Pancreatitis: Distinctive Clinical and Pathological Features, But Are There Any Differences at Magnetic Resonance? Experience From a Referral Center. Pancreas 2018; 47:1115-1122. [PMID: 30141780 DOI: 10.1097/mpa.0000000000001142] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES This study aimed to evaluate magnetic resonance imaging findings of autoimmune pancreatitis (AIP) and to find radiological patterns that could differentiate type 1 and type 2 AIP. METHODS Eighty-four patients with diagnosis of AIP were enrolled. Image analysis included pancreatic signal intensity abnormalities, enhancement pattern, extrapancreatic involvement, and main pancreatic duct alterations. RESULTS Pancreatic parenchyma resulted in hypointensity on T1-weighted images in 65 (98.5%) of 66 cases in type 1 and in 17 (94.5%) of 18 in type 2 (P > 0.05) and in hyperintensity on T2-weighted images in 41 (62%) of 66 and in 15 (83.4%) of 18, respectively (P > 0.05). Lesions were hypovascular in 64 (97%) of 66 cases in type 1 and in 16 (88.9%) of 18 in type 2 with delayed contrast retention in 56 (84.8%) of 66 and in 17 (94.5%) of 18, respectively (P > 0.05). Autoimmune cholangitis was found in 29 (43.9%) of 66 patients with type 1 and in 3 (16.7%) of 18 with type 2 (P = 0.02); renal involvement was observed in 20 (30.3%) of 66 and 1 (5.5%) of 18, respectively (P = 0.02). Both subtypes presented with multiple stenoses (P > 0.05). Dilation of upstream duct was more frequent in type 1 (P = 0.02). CONCLUSIONS Magnetic resonance imaging is useful in detecting extrapancreatic involvement, typically seen in type 1. Dilation of the upstream duct suggests type 1 AIP.
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Juarez LA, Gupta RR, Ruhnke GW. Gastric varices and splenic vein obstruction during steroid treatment for autoimmune pancreatitis: A case report and literature review. Medicine (Baltimore) 2018; 97:e11940. [PMID: 30142813 PMCID: PMC6112881 DOI: 10.1097/md.0000000000011940] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
RATIONALE Few cases of autoimmune pancreatitis (AIP) complicated by gastric varices, in the absence of splenic vein obstruction, have been described in the medical literature. The findings in this case parallel those of 3 previously described cases from Japan and support a pathologic explanation for the evolution of gastric varices in relation to early splenomegaly and the role of steroid therapy for AIP. PATIENT CONCERNS A 50-year-old male with a history of transfusion-requiring erosive gastritis and recently diagnosed AIP on steroid therapy for 2 weeks presented with a 2-day history of lightheadedness, abdominal pain, and melena. DIAGNOSIS Esophagogastroduodenoscopy (EGD) revealed prominent varices in the gastric fundus. An abdominal ultrasound with Doppler demonstrated patency of the splenic, hepatic, and portal veins. Review of previous imaging revealed that the splenic vein and the superior mesenteric vein (SMV) were occluded prior to the diagnosis of AIP and steroid therapy initiation. OUTCOME Following resolution of hemodynamic instability through fluid resuscitation and blood transfusion, the remainder of his hospital course was uneventful. Subsequent to discontinuation of steroid therapy, he developed near total reocclusion of both the splenic vein and SMV. LESSON Early steroid treatment should be considered in patients with uncomplicated AIP to prevent the occlusive vascular complications that are frequently associated with the pathophysiology of this disease process.
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Affiliation(s)
| | - Roop R. Gupta
- Gastroenterology, Department of Internal Medicine, Mercy Hospital and Medical Center
| | - Gregory W. Ruhnke
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL
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DeSouza SV, Singh RG, Yoon HD, Murphy R, Plank LD, Petrov MS. Pancreas volume in health and disease: a systematic review and meta-analysis. Expert Rev Gastroenterol Hepatol 2018; 12:757-766. [PMID: 29972077 DOI: 10.1080/17474124.2018.1496015] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The pancreas plays a central role in metabolism and is involved in the pathogenesis of several diseases. Pancreas volume is a holistic quantitative measure of pancreas size but the clinical relevance of pancreas volumetry is poorly understood. Areas covered: The aim was to systematically review studies in adults that used computed tomography or magnetic resonance imaging to measure pancreas volume in health and disease, to determine normal pancreas volume range, and to quantify changes in pancreas volume that are associated with disease. Expert commentary: The normal pancreas volume range in adults is 71-83 cm3, with no statistically significant difference between men and women. Type 2 diabetes and type 1 diabetes are associated with a progressively reduced pancreas volume. Overweight and obesity are associated with a progressively increased pancreas volume. There is a paucity of studies on pancreas volume in the setting of diseases of the exocrine pancreas, which should become a research priority in the future.
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Affiliation(s)
- Steve V DeSouza
- a School of Medicine , University of Auckland , Auckland , New Zealand
| | - Ruma G Singh
- a School of Medicine , University of Auckland , Auckland , New Zealand
| | - Harry D Yoon
- a School of Medicine , University of Auckland , Auckland , New Zealand
| | - Rinki Murphy
- a School of Medicine , University of Auckland , Auckland , New Zealand
| | - Lindsay D Plank
- a School of Medicine , University of Auckland , Auckland , New Zealand
| | - Maxim S Petrov
- a School of Medicine , University of Auckland , Auckland , New Zealand
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Comparison of diagnostic performance between CT and MRI in differentiating non-diffuse-type autoimmune pancreatitis from pancreatic ductal adenocarcinoma. Eur Radiol 2018; 28:5267-5274. [PMID: 29948075 DOI: 10.1007/s00330-018-5565-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 05/16/2018] [Accepted: 05/24/2018] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To intraindividually compare the diagnostic performance of CT and MRI in differentiating non-diffuse-type autoimmune pancreatitis (AIP) from pancreatic ductal adenocarcinoma (PDA). METHODS Sixty-one patients with non-diffuse-type AIP and 122 patients with PDA, who underwent dynamic contrast-enhanced CT and MRI with MR pancreatography, were included. Two blinded radiologists independently rated their confidence in differentiating the two diseases on a 5-point scale, and the diagnostic performances of CT and MRI were compared. The presence of key imaging features to differentiate AIP and PDA were compared between CT and MRI. RESULTS The area under the receiver operating characteristic curve was significantly greater on MRI (0.993-0.995) than on CT (0.953-0.976) for both raters (p≤0.035). The sensitivities of MRI were higher than those of CT for the diagnosis of AIP (88.5-90.2% vs. 77-80.3%, p≤0.07) and PDA (97.5-99.2% vs. 91.8-94.3%, p≤0.031) for both raters, although the difference for AIP was statistically marginal (p=0.07) for rater 1. In AIP, multiple pancreatic masses, delayed homogeneous enhancement of the pancreatic mass, and multiple main pancreatic duct (MPD) strictures were observed significantly more frequently using MRI than CT (p≤0.008). In PDA, discrete pancreatic mass and MPD stricture were observed significantly more frequently using MRI than CT (p≤0.012). CONCLUSIONS The diagnostic performance of MRI is better for differentiating non-diffuse-type AIP from PDA, which is due to the superiority of MRI over CT in demonstrating the key distinguishing features of both diseases. KEY POINTS • Imaging differential diagnosis of non-diffuse-type AIP and PDA is challenging. • MRI has better diagnostic performance than CT in differentiating non-diffuse-type AIP from PDA. • MRI is superior to CT in demonstrating key distinguishing features of non-diffuse-type AIP and PDA.
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Hafezi-Nejad N, Singh VK, Fung C, Takahashi N, Zaheer A. MR Imaging of Autoimmune Pancreatitis. Magn Reson Imaging Clin N Am 2018; 26:463-478. [PMID: 30376982 DOI: 10.1016/j.mric.2018.03.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Autoimmune pancreatitis (AIP) is characterized by autoimmune inflammatory destruction of the pancreatic tissue. Imaging plays an essential role in the diagnosis. AIP type 1 is the pancreatic manifestation of immunoglobulin G4 (IgG4)-related disease and is associated with IgG4-positive plasma cell infiltration and fibrosis of multiple organ systems. Type 2 is a related disease with pancreatic inflammation with or without concurrent inflammatory bowel disease. The authors demonstrate the imaging findings that are associated with the pancreatic and extra-pancreatic manifestations of AIP. They emphasize the common MR imaging and magnetic resonance cholangiopancreatography findings to help make the diagnosis of AIP.
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Affiliation(s)
- Nima Hafezi-Nejad
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University, 600 North Wolfe Street, Baltimore, MD 21287, USA
| | - Vikesh K Singh
- Department of Internal Medicine, Pancreatitis Center, Johns Hopkins Medical Institutions, 1800 Orleans Street, Sheikh Zayed Tower, Baltimore, MD 21287, USA; Division of Gastroenterology, Johns Hopkins University, School of Medicine, 1800 Orleans Street, Sheikh Zayed Tower, Baltimore, MD 21287, USA
| | - Christopher Fung
- Department of Radiology and Diagnostic Imaging, University of Alberta, 2J2.00 WC Mackenzie Health Sciences Centre, 8440 112 Street Northwest, Edmonton, Alberta T6G 2R7, Canada
| | - Naoki Takahashi
- Department of Radiology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Atif Zaheer
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University, 600 North Wolfe Street, Baltimore, MD 21287, USA; Department of Internal Medicine, Pancreatitis Center, Johns Hopkins Medical Institutions, 1800 Orleans Street, Sheikh Zayed Tower, Baltimore, MD 21287, USA.
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Tang CSW, Sivarasan N, Griffin N. Abdominal manifestations of IgG4-related disease: a pictorial review. Insights Imaging 2018; 9:437-448. [PMID: 29696607 PMCID: PMC6108972 DOI: 10.1007/s13244-018-0618-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 03/07/2018] [Accepted: 03/15/2018] [Indexed: 12/11/2022] Open
Abstract
In the last decade, autoimmune pancreatitis has become recognised as part of a wider spectrum of IgG4-related disease, typically associated with elevated serum IgG4 levels and demonstrating a response to corticosteroid therapy. Radiologically, there is imaging overlap with other benign and neoplastic conditions. This pictorial review discusses the intra-abdominal manifestations of this disease on cross-sectional imaging before and after steroid treatment and the main radiological features which help to distinguish it from other key differentials. TEACHING POINTS • Autoimmune pancreatitis is part of a spectrum of IgG4-related disease. • Diagnosis is based on raised serum IgG4, clinical, radiological and histopathological findings. • Cross-sectional imaging can demonstrate the typical findings of abdominal IgG4-related disease. • Cross-sectional imaging can be used to monitor response to corticosteroid treatment.
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Affiliation(s)
- Christopher Siew Wai Tang
- Department of Radiology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK.
| | - Nishanth Sivarasan
- Department of Radiology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Nyree Griffin
- Department of Radiology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
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Hota P, Patel T, Zhao X, Jhala N, Agosto O. A Rare Multifocal Pattern of Type 2 Autoimmune Pancreatitis with Negative IgG4: A Potential Diagnostic Pitfall That May Mimic Multifocal Pancreatic Adenocarcinoma. Case Rep Gastroenterol 2018; 12:46-55. [PMID: 29681791 PMCID: PMC5903122 DOI: 10.1159/000486443] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 12/21/2017] [Indexed: 12/28/2022] Open
Abstract
Autoimmune pancreatitis (AIP) is an increasingly recognized form of acute pancreatitis characterized by obstructive jaundice with a rapid and dramatic treatment response to steroid therapy. Recently, AIP has been divided into two distinct phenotypes: lymphoplasmocytic sclerosing pancreatitis AIP (type 1) and idiopathic duct-centric pancreatitis AIP (type 2); each of which have their own distinct demographics, diagnostic criteria, and histopathological features. We report, to the best of our knowledge, the first case of a multifocal pattern of type 2 AIP characterized with both CT and MR imaging. This rare imaging pattern of AIP may mimic the appearance of more worrisome malignant etiologies such as multifocal pancreatic adenocarcinoma or lymphoma, with overlapping imaging characteristics potentially complicating or delaying diagnosis. Therefore, recognition of this atypical pattern of AIP and avoidance of this potential diagnostic pitfall is crucial.
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Affiliation(s)
- Partha Hota
- Department of Radiology, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Tejas Patel
- Atlantic Medical Imaging, Galloway, New Jersey, USA
| | - Xiaofeng Zhao
- Department of Radiology, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Nirag Jhala
- Department of Radiology, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Omar Agosto
- Department of Radiology, Temple University Hospital, Philadelphia, Pennsylvania, USA
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Toumi N, Harbi H, Mourad A, Kchaou A, Chtourou L, Boujelben S, Ben Mahfoudh K. [A retentional jaundice in a healthy sixty-seven year old man]. Presse Med 2018; 47:192-196. [PMID: 29366604 DOI: 10.1016/j.lpm.2017.11.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 11/28/2017] [Accepted: 11/29/2017] [Indexed: 01/07/2023] Open
Affiliation(s)
- Nozha Toumi
- Habib Bourguiba Hospital, Radiology Department, avenue Majida-Boulila, 3029 Sfax, Tunisie.
| | - Houssem Harbi
- Habib Bourguiba Hospital, General Surgery Department, Sfax, Tunisie
| | - Ahmedi Mourad
- Habib Bourguiba Hospital, Radiology Department, avenue Majida-Boulila, 3029 Sfax, Tunisie
| | - Ali Kchaou
- Habib Bourguiba Hospital, General Surgery Department, Sfax, Tunisie
| | - Lassaad Chtourou
- Hédi Chaker Hospital, Gastro-enterolology Department, Sfax, Tunisie
| | - Salah Boujelben
- Habib Bourguiba Hospital, General Surgery Department, Sfax, Tunisie
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Abstract
BACKGROUND IgG4-related diseases are rare systemic multiorgan diseases and can thus affect any organ system. The incidence of diagnosis has significantly increased due to increasing awareness. OBJECTIVE In the abdomen the hepatopancreaticobiliary system provides an essential organ system for the expression of IgG4-associated autoimmune diseases. The focus here is autoimmune pancreatitis type 1 but IgG4-associated sclerosing cholangitis and IgG4-associated hepatopathy, which can also occur in combination are less well-known. METHODS Various mostly Asiatic, histologically-based diagnostic systems, such as HISORt or international consensus diagnostic criteria (ICDC) are available for the diagnostics of hepatopancreaticobiliary IgG4-related autoimmune diseases, in which imaging techniques playing an increasingly important role. RESULTS In addition to generalized organ swelling further morphological and also functional imaging criteria have become increasingly well-known for autoimmune pancreatitis, such as late enhancement or the imaging response to steroid therapy. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERP) can provide valuable information for the diagnostics of IgG4-related diseases in the hepatopancreaticobiliary system. CONCLUSION IgG4-related autoimmune diseases of the hepatopancreaticobiliary system are a rare group of diseases in which increasing knowledge of the radiological appearance also leads to an increasingly frequency of diagnosis. IgG4-related diseases must be distinguished from non-necrotizing pancreatitis and pancreatic cancer, which is often difficult but has significant therapeutic consequences for the patients.
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Affiliation(s)
- L Grenacher
- Diagnostik München, Augustenstraße 115, 80798, München, Deutschland.
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48
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de Pretis N, Amodio A, Bernardoni L, Campagnola P, Capuano F, Chari ST, Crinò S, Gabbrielli A, Massella A, Topazian M, Frulloni L. Azathioprine Maintenance Therapy to Prevent Relapses in Autoimmune Pancreatitis. Clin Transl Gastroenterol 2017; 8:e90. [PMID: 28448071 PMCID: PMC5543465 DOI: 10.1038/ctg.2017.17] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 02/11/2017] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Steroids are used to induce remission in autoimmune pancreatitis (AIP). Low-dosage steroid therapy or immunosuppressant (IMs) has been proposed as maintenance therapy to prevent AIP relapse. Few and conflicting data have been published on the efficacy of azathioprine (AZA) in preventing AIP relapse. The aim of this study was to evaluate the indication and efficacy of AZA as maintenance therapy to prevent disease relapse in AIP. METHODS Patients suffering from AIP diagnosed according to the ICDC in type 1, type 2, and not otherwise specified (NOS) were divided in those treated with AZA (AZA+ group) as maintenance therapy and not treated with maintenance therapy (AZA- group). Exclusion criteria were: previous pancreatic surgery, other autoimmune diseases as indication for AZA treatment, and use of IMs different from AZA. Drug safety, clinical and instrumental outcome of AZA+ patients were evaluated. RESULTS A total of 23 patients (18 Males and 5 Females, mean age 54±11 years) in AZA+ group and 97 (58 Males and 39 Females, mean age 45±18 years) in AZA- group were compared. In AZA+ group, patients were significantly older (P=0.043), type 1 AIP was more frequently diagnosed (87 vs. 51%, P=0.006), sIgG4 higher (758±625 vs. 311±409 mg/dl, P<0.001), other organ involvement (OOI) more frequently observed (83 vs. 48%, P=0.002), with higher frequency of relapse before AZA treatment (78 vs. 14%, P<0.001). Three patients in AZA+ group required drug discontinuation because of adverse events. Twenty patients were therefore evaluated for outcome. Six out of 20 patients (30%) relapsed after 24±15 months (5 in pancreas and 1 on biliary tract). They were retreated with steroids and continued AZA. Two out of 6 patients (33%) had a second relapse,after respectively 11 months (in pancreas and kidney) and 22 months (in kidney). CONCLUSIONS AZA is an effective and safe treatment to prevent AIP relapses.
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Affiliation(s)
- Nicolò de Pretis
- Gastroenterology Unit, Department of Medicine, Pancreas Center, University of Verona, Verona, Italy
| | - Antonio Amodio
- Gastroenterology Unit, Department of Medicine, Pancreas Center, University of Verona, Verona, Italy
| | - Laura Bernardoni
- Gastroenterology Unit, Department of Medicine, Pancreas Center, University of Verona, Verona, Italy
| | - Pietro Campagnola
- Gastroenterology Unit, Department of Medicine, Pancreas Center, University of Verona, Verona, Italy
| | - Fabiana Capuano
- Gastroenterology Unit, Department of Medicine, Pancreas Center, University of Verona, Verona, Italy
| | - Suresh T Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Stefano Crinò
- Gastroenterology Unit, Department of Medicine, Pancreas Center, University of Verona, Verona, Italy
| | - Armando Gabbrielli
- Gastroenterology Unit, Department of Medicine, Pancreas Center, University of Verona, Verona, Italy
| | - Arianna Massella
- Gastroenterology Unit, Department of Medicine, Pancreas Center, University of Verona, Verona, Italy
| | - Mark Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Luca Frulloni
- Gastroenterology Unit, Department of Medicine, Pancreas Center, University of Verona, Verona, Italy
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49
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Abstract
Autoimmune pancreatitis (AIP) is a rare and underdiagnosed fibrosclerosing inflammatory variant of chronic pancreatitis. Its true incidence and prevalence in the general population is still not confirmed despite advances in medicine. Differentiating it from pancreatic cancer is of paramount importance. In this imaging review, we highlight the imaging findings of this intriguing entity.
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Affiliation(s)
- Binit Sureka
- Department of Radiology/Interventional Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Archana Rastogi
- Department of Pathology, Institute of Liver and Biliary Sciences, New Delhi, India
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50
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Autoimmune Pancreatitis Masquerading as Pancreatic Cancer: when in Doubt, Cut It Out. J Gastrointest Cancer 2017; 49:365-372. [PMID: 28197777 DOI: 10.1007/s12029-017-9924-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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