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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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Autoimmune pancreatitis masquerading as carcinoma head of pancreas: A case report and review of literature. Ann Med Surg (Lond) 2019; 45:82-85. [PMID: 31440370 PMCID: PMC6698257 DOI: 10.1016/j.amsu.2019.07.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 07/17/2019] [Accepted: 07/23/2019] [Indexed: 12/11/2022] Open
Abstract
Introduction Autoimmune pancreatitis (AIP) is a rare form of chronic inflammatory pancreatic disease secondary to an underlying autoimmune mechanism. It is now considered as pancreatic manifestation of IgG4 related disease, which is a multisystem disease. Case report We are reporting a patient who presented with obstructive jaundice and mass head of pancreas on Computed Tomography (CT) scan. Considering a strong clinical suspicion of pancreatic cancer, Whipple procedure was done. Histopathological report revealed intense lymphoplasmacytic infiltrate and fibrosis with collagenisation, so possibility of AIP was suggested. Serum IgG4 levels were advised and found to be increased. Diagnosis of AIP was made and patient responded to steroids. Discussion Pre-operative core biopsy of the pancreas and Serum IgG4 levels are sufficient to make the diagnosis and resection is usually not recommended in AIP. Conclusion Awareness of the entity and use of ancillary techniques in making the pre-operative diagnosis could have saved the patient from an extensive surgical procedure. Autoimmune Pancreatitis is a pancreatic manifestation of IgG4 related disorders. It can clinically and radiologically present as pancreatic malignancy. Resection is not required in Autoimmune Pancreatitis. Pre-operative investigations can save the patient from morbidity due to Whipples. Whipples procedure is undesired in these patients. This entity should be kept in mind while dealing with mass lesions in head of pancreas.
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Syed A, Babich O, Rao B, Singh S, Carleton N, Gulati A, Kulkarni A, Garg M, Farah K, Kochhar G, Morrissey S, Mitre M, Kulkarni A, Dhawan M, Silverman JF, Pharaon M, Thakkar S. Endoscopic ultrasound guided fine-needle aspiration vs core needle biopsy for solid pancreatic lesions: Comparison of diagnostic accuracy and procedural efficiency. Diagn Cytopathol 2019; 47:1138-1144. [PMID: 31313531 DOI: 10.1002/dc.24277] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 05/17/2019] [Accepted: 06/25/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Endoscopic ultrasound (EUS) guided core needle biopsies (CNB) are increasingly being performed to diagnose solid pancreatic lesions. However, studies have been conflicting in terms of CNB improving diagnostic accuracy and procedural efficiency vs fine-needle aspiration (FNA), which this study aims to elucidate. METHODS Data were prospectively collected on consecutive patients with solid pancreatic or peripancreatic lesions at a single tertiary care center from November 2015 to November 2016 that underwent either FNA or CNB. Patient demographics, characteristics of lesions, diagnostic accuracy, final and follow-up pathology, use of rapid on-site evaluation (ROSE), complications, and procedure variables were obtained. RESULTS A total of 75 FNA and 48 CNB were performed; of these, 13 patients had both. Mean passes were lower with CNB compared to FNA (2.4 vs 2.9, P = .02). Use of ROSE was higher for FNA (97.3% vs 68.1%, P = .001). Mean procedure time was shorter with CNB (34.1 minutes vs 51.2 minutes, P = .02) and diagnostic accuracy was similar (89.2% vs 89.4%, P = .98). There was no difference in diagnostic accuracy when ROSE was performed for CNB vs not performed (93.5% vs 85.7%, P = .58). Additionally, diagnostic accuracy of combined FNA and CNB procedures was 92.3%, which was comparable to FNA (P = .73) or CNB (P = .52) alone. CONCLUSION FNA and CNB had comparable safety and diagnostic accuracy. Use of CNB resulted in less number of passes and shorter procedure time as compared to FNA. Moreover, diagnostic accuracy for CNB with or without ROSE was similar.
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Affiliation(s)
- Aslam Syed
- Division of Gastroenterology, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Olivia Babich
- Division of Gastroenterology, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Bharat Rao
- Division of Gastroenterology, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Shailendra Singh
- Division of Gastroenterology, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Neil Carleton
- Division of Gastroenterology, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Abhishek Gulati
- Division of Gastroenterology, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Archana Kulkarni
- Division of Gastroenterology, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Mrinal Garg
- Division of Gastroenterology, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Katie Farah
- Division of Gastroenterology, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Gursimran Kochhar
- Division of Gastroenterology, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Suzanne Morrissey
- Division of Gastroenterology, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Marcia Mitre
- Division of Gastroenterology, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Abhijit Kulkarni
- Division of Gastroenterology, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Manish Dhawan
- Division of Gastroenterology, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Jan F Silverman
- Department of Pathology, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Majed Pharaon
- Department of Pathology, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Shyam Thakkar
- Division of Gastroenterology, Allegheny Health Network, Pittsburgh, Pennsylvania
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De Marchi G, Paiella S, Luchini C, Capelli P, Bassi C, Frulloni L. Very high serum levels of CA 19-9 in autoimmune pancreatitis: Report of four cases and brief review of literature. J Dig Dis 2016; 17:697-702. [PMID: 27579898 DOI: 10.1111/1751-2980.12403] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 08/09/2016] [Accepted: 08/24/2016] [Indexed: 02/06/2023]
Affiliation(s)
- Giulia De Marchi
- Department of Gastroenterology B, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Salvatore Paiella
- Unit of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Luchini
- Department of Diagnostics and Public Health, University of Verona Hospital Trust, Verona, Italy.,ARC-NET Research Center, University of Verona Hospital Trust, Verona, Italy
| | - Paola Capelli
- Department of Diagnostics and Public Health, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Luca Frulloni
- Department of Gastroenterology B, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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Abstract
Immunoglobulin G4-related sclerosing cholangitis (IgG4-SC) is a recently defined disease entity characterized by elevated serum IgG4, chronic progressive obstructive jaundice, and diffuse or mass-forming inflammatory reaction rich in IgG4-positive plasma cells and lymphocytes associated with fibrosclerosis and obliterative phlebitis, which shares a number of clinical, biochemical, and radiological features with primary sclerosing cholangitis (PSC) or cholangiocarcinoma (CC). IgG4-SC is commonly associated with autoimmune pancreatitis (AIP). Steroid therapy comprises the mainstay of treatment for IgG4-SC patients. However, liver transplantation is the only useful treatment for PSC patients, and CC patients require surgical therapy. Therefore, the accurate discrimination between IgG4-SC and PSC or CC is a very important issue. In this article, we will review the features and role of immunoglobulin G4 (IgG4), the diagnosis and therapy of IgG4-SC, and the relations between IgG4-SC and AIP, PSC or CC.
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