Spiral computed tomography assessment of resectability of pancreatic ductal adenocarcinoma: analysis of results.

BACKGROUND: Despite more recent technical advances, single detector spiral computed tomography is still the most widely used imaging technique for the detection and staging of pancreatic adenocarcinoma. Many reports have recently focused on single detector spiral computed tomography imaging findings indicative of unresectability AIM: To evaluate the ability of single detector spiral computed tomography in the pre-operative staging of ductal adenocarcinoma of the pancreas in selecting surgically resectable versus unresectable cases, considering different parameters (vascular and local infiltration, liver metastases, lymphadenopathy, and peritoneal carcinomatosis). PATIENTS AND METHODS: A total of 100 patients diagnosed with ductal adenocarcinoma of the pancreas, pathologically verified, and examined with single detector spiral computed tomography were considered. Of these, 63 underwent surgery; 37 were excluded (imaging evidence of unresectability in biopsy-proven adenocarcinomas). Single detector spiral computed tomography studies, performed at the time of surgery, were retrospectively reviewed by two radiologists. The final results were reached by consensus, without being aware of the operation. All prospective clinical readings were also considered, and tabulated. RESULTS: In the patients undergoing surgery, 44 proved to be unresectable and 19 resectable. Considering the above-mentioned parameters, the prospective assessment of resectability demonstrated a rather low sensitivity (68%), with high specificity (95%). Accordingly, a high positive predictive value (97%) was achieved, while the negative predictive value was 56%. After the retrospective evaluation, the value of sensitivity increased (84%) to the expense of the specificity (84%). Moreover, a positive predictive value of 92.5%, and a negative predictive value of 69.5% were obtained. CONCLUSIONS: The demonstration of many signs of unresectability of pancreatic ductal adenocarcinoma reported in the literature yields a better sensitivity in the diagnosis, but unfortunately, is associated with an inevitable reduction in specificity.

Nonfunctioning endocrine tumors of the pancreas: possibilities of spiral CT characterization.

The aim of this study was to assess the ability of spiral CT to adequately characterize the nonfunctioning endocrine tumors (NFETs) of the pancreas, distinguishing this lesion from the other pancreatic tumors. The spiral CT examinations of 21 cases of histologically proven NFETs, along with those of 29 cases of other pancreatic tumors and tumor-like lesions, were retrospectively reviewed in a blinded fashion by two radiologists, in order to correctly classify the lesions, highlighting the typical signs reported in the literature. Discordant cases were further analyzed in the presence of a third radiologist. The final diagnosis was acquired by means of a majority or overall consensus. The histopathologic examination was considered the gold standard. The sensitivity, specificity, and positive and negative predictive values of CT were calculated. After the consensus evaluation, the correct diagnosis was reached in 72% of cases, with 10% of nonspecific diagnoses of solid pancreatic tumor and 18% of wrong diagnoses. The sensitivity and specificity of spiral CT in identifying NFETs were 66.6 and 82.7%, respectively. The positive and negative predictive values were 73.7 and 77.4%, respectively. In up to 70% of cases the NFET demonstrates a typical aspect of a mass hyperdense in the arterial contrastographic phase eventually associated with hyperdense hepatic metastases in more than half of the patients. This finding does allow the diagnosis of NFET but without certainty indeed, since other tumors can show a similar densitometric behavior and among them particularly the ductal adenocarcinoma. On the other hand, both the solid, hypovascularized NFETs, and the cystic form, cannot be differentiated from the other solid and cystic tumors of the pancreas.

Autoimmune pancreatitis: possibilities of CT characterization.

BACKGROUND: Pancreatitis is defined as an inflammatory disease of the pancreas, leading to morphological and pathological changes. Recently, an autoimmune pathogenesis of this disease has been proposed. This type of pancreatitis should be differentiated from other pancreatic diseases, since appropriate therapy is effective and morphological changes and pancreatic function can recover to normal levels. AIM OF THE STUDY: To assess the possibility of distinguishing autoimmune pancreatitis from other pancreatic diseases with an analogous clinical presentation on the basis of CT findings alone. METHODS: The CT images of 7 patients with proven autoimmune pancreatitis, along with those of 20 patients with other pancreatic diseases, but with an analogous clinical presentation, were retrospectively evaluated in a blinded fashion by 2 radiologists. In particular, the radiologists had to search for the typical signs of autoimmune pancreatitis. Discordant cases were further analyzed in the presence of a 3rd radiologist. The final diagnosis was acquired by means of a majority or overall consensus. The sensitivity, specificity, positive and negative predictive values of CT were calculated against each of the diseases (autoimmune pancreatitis; other pancreatic diseases), in order to evaluate the diagnostic value of the scan. RESULTS: After the consensus evaluation, the correct diagnosis was reached in 25/27 (92.5%) cases, with only 2/27 wrong diagnoses (autoimmune pancreatitis diagnosed as another pancreatic disease and vice versa). The sensitivity and specificity of CT against autoimmune pancreatitis were 86 and 95%, respectively. The positive and negative predictive values were 89 and 93%, respectively. CONCLUSION: Patients with autoimmune pancreatitis demonstrate imaging findings that enable the correct diagnosis by dynamic CT, even in the presence of nonspecific clinical symptoms. The precise classification of the disease is extremely important, since simple steroid therapy then represents the correct treatment, and leads to complete recovery.

Characterization of cystic tumors of the pancreas: CT accuracy.

PURPOSE: The purpose of this work was to evaluate the capabilities of CT to accurately characterize cystic tumors of the pancreas. METHOD: Two observers retrospectively evaluated the CT exams of 100 cystic masses of the pancreas, with pathological confirmation. The two observers, blinded about clinical information and the final diagnosis, tried to categorize the lesions according to well established morphologic features. Statistical analysis was performed to measure the agreement between each radiologist and the consensus diagnosis and to evaluate the usefulness of certain CT findings in differentiating one type of cystic pancreatic neoplasm from another. RESULTS: Serous cystadenoma was better diagnosed by CT [Youden misclassification index (Ymi) = 0.72] than mucinous cystic tumor (Ymi = 0.44) and solid pseudopapillary tumor (cystic variant) (Ymi = 0.47). CONCLUSION: As patients with previous history of pancreatitis were excluded from the study, CT findings allowed correct characterization of only 60% of cystic pancreatic masses. Among the remaining 40%, 15-20% of the wrong diagnoses could not be corrected by means of CT, given the patterns shown by the tumors. In 20-25% of the cases, a nonspecific diagnosis of cystic mass was made.

Blunt pancreatic trauma. Role of CT.

PURPOSE: To define the evolution patterns of blunt pancreatic trauma, and to point out the CT features most significant for the diagnosis. MATERIAL AND METHODS: Ten cases of pancreatic trauma, observed over a period of about 10 years, were analyzed in retrospect. The cases were divided into 3 groups according to the time that had elapsed between trauma and first CT: early phase (within 72 h: n=3/10); late phase (after 10 days: n=3/10); and following pancreatic drainage (n=4/10). RESULTS: In the early phase, one case showed a blood collection surrounding the pancreatic head and duodenum, and displacing the mesenteric vessels to the left. In the 2 other cases it was possible to demonstrate a tear in the pancreas at the neck, perpendicular to the main pancreatic axis. In the late phase in all 3 cases, one cystic lesion was present at the site of the tear, either surrounding the gland or embedded - more or less deeply - within the parenchyma. One of the lesions subsided spontaneously; the 2 others required surgery. In the postoperative phase, an external fistula was demonstrated in 2 cases following percutaneous drainage of pancreatic cysts; the fistula was fed by a cystic lesion in the pancreatic neck. In the 2 other cases a pseudocyst developed. CONCLUSION: Early demonstration of a parenchymal tear was difficult. At a later stage the diagnosis was easier owing to the demonstration of cystic lesions within the parenchyma at the site of the tear. The surgical drainage of this lesion does not usually lead to healing since an external fistula or a pseudocyst may develop.

Serous cystadenoma of the pancreas: report of 30 cases with emphasis on the imaging findings.

PURPOSE: Our goal was to evaluate retrospectively 30 cases of serous cystadenoma (SCA) to determine its main imaging features as well as to discuss the differential diagnosis problems versus the other cystic lesions of the pancreas. METHOD: Thirty SCAs were analyzed; they were all benign lesions, proven at surgery. Twenty-three tumors were evaluated with US, 26 with CT, and 5 with MRI. RESULTS: Three different morphostructural patterns were identified: microlacunar (n = 19), mixed (n = 6), and macrolacunar (n = 5). The diagnosis of SCA, possible in either the microlacunar or the mixed patterns, was achieved in 74% of cases with US (17/23) and in 61.5% with CT (16/26). Among the 19 patients evaluated with both modalities, the joint information allowed a correct diagnosis in 16 cases (84%). The five macrolacunar tumors were undistinguishable from other cystic masses of the pancreas. CONCLUSION: The diagnosis of SCA can be considered certain in the microlacunar, likely in the mixed, and not possible in the macrolacunar type.

Papillary cystic neoplasm of the pancreas: radiological findings.

We report a series of 10 papillary cystic neoplasms of the pancreas evaluated in our institution. The lesions are analyzed in retrospect to define the existence of eventual specific imaging patterns as well as to point out the existing problems of differential diagnosis versus other pancreatic tumors.

Intraductal mucin-producing tumors of the pancreas: imaging findings.

PURPOSE: To evaluate the radiologic characteristics of intraductal mucin-producing tumors of the pancreas. MATERIALS AND METHODS: Sixteen patients with intraductal tumors underwent ultrasound (US); (n = 15), computed tomography (CT); (n = 16), endoscopic retrograde cholangiopancreatography (ERCP); (n = 12), and intraoperative pancreatography (n = 2). Findings were compared with those from surgery (n = 14) or biopsy (n = 2). RESULTS: Lesions were classified as either main duct type or branch duct type tumors. Main duct tumors were characterized at US and CT by either diffuse or segmental dilatation of the Wirsung duct. Pancreatography showed ductal dilatation and filling defects caused by mucin deposits. At US and CT, branch duct tumors, which were mainly located at the uncinate process, were seen as fluid-filled masses with central septa and the pancreatic duct was dilated. ERCP showed partial or complete opacification of the lesion. In four patients, endoscopy showed protrusion of the papilla into the duodenal lumen and mucin leaking from its dilated orifice. CONCLUSION: Imaging modalities, especially US and ERCP, enable early diagnosis of mucin-producing pancreatic tumors.

Spontaneous rupture of a pancreatic pseudocyst into the portal vein.

Spontaneous rupture of a pancreatic pseudocyst into the portal vein is described. This has been previously reported in only five cases. Diagnosis was made by computed tomography (CT) and was confirmed by CT-guided transhepatic portography.

Papillary cystic neoplasm of the pancreas: radiological findings.

We report a series of 10 papillary cystic neoplasms of the pancreas evaluated in our institution. The lesions are analyzed in retrospect to define the existence of eventual specific imaging patterns as well as to point out the existing problems of differential diagnosis versus other pancreatic tumors.

[Invasive pulmonary aspergillosis: possibility of radiologic diagnosis]. / L'aspergillosi polmonare invasiva: possibilità di diagnosi radiologica.

The incidence of invasive pulmonary aspergillosis is increasing in the patients with malignant hematologic diseases; this occurs in the phase of granulocytopenia induced by chemotherapy. In these cases an early diagnosis is mandatory to start a prompt antimycotic treatment. The authors reviewed the personal series of 56 patients with malignant hematologic diseases who, in the phase of granulocytopenia, developed a pulmonary lesion: 32/56 with invasive pulmonary aspergillosis; 8/56 with Candida and 16/56 with bacterial infection. All patients underwent several conventional radiologic controls: 9 cases with invasive pulmonary aspergillosis were also studied with Computed Tomography (CT). After a short pathologic introduction, the conventional radiologic and CT patterns of invasive pulmonary aspergillosis are analyzed, both at onset and over its evolutive phase. The most significant feature for an early conventional radiologic diagnosis is the nodular pattern--single or multiple--; this allowed a correct diagnosis, at onset, of 20/32 (62%) invasive pulmonary aspergillosis cases. CT provided a further diagnostic contribution by showing a peri-nodular halo. Of interest was also the CT demonstration of high-density pleural thickening adjacent to the mycotic lesion, probably due to fungal involvement of the sub-pleural space. The routine chest roentgenogram is the modality of choice; CT may be useful in questionable cases.