A Rare Cause of Pancreatic Head Mass: Metastatic Prostate Cancer - A Case Report and Review of Literature.

Metastases to the pancreas account for less than 5 percent of all malignancies affecting the pancreas. The most common secondary malignancy of the pancreas is renal cell carcinoma. We report a patient presented with abdominal pain and weight loss. Computed tomography (CT) imaging showed pancreatic head mass. Biopsy from the mass showed prostate metastasis after 13 years from radical prostatectomy and Leuprolide therapy. This case demonstrates a rare location for prostate metastasis which was the pancreas. To our knowledge there are only six cases reported in literature. Due to increased long-term survival of prostate cancer patients, the frequency of metastases to the pancreas will likely increase. Therefore, clinicians need to be aware the pancreatic tumor may be secondary to an extrapancreatic malignancy.

Duct Diameter and Size of Stones Predict Successful Extracorporeal Shock Wave Lithotripsy and Endoscopic Clearance in Patients With Chronic Pancreatitis and Pancreaticolithiasis.

OBJECTIVES: The need for endoscopic therapy before extracorporeal shock wave lithotripsy (SWL) to facilitate pancreatic duct stone removal is unclear. Predictive factors associated with successful fragmentation and subsequent complete duct clearance are variable. We hypothesize pancreatic duct strictures and large stones, but not pre-SWL endotherapy, correlate with successful fragmentation and complete duct clearance. METHODS: A retrospective cohort study of patients with pancreaticolithiasis who underwent SWL and endoscopic retrograde cholangiopancreatography between January 2009 and June 2014 was evaluated. RESULTS: Thirty-seven patients were treated. Technical success (TS) of fragmentation was achieved in 22 patients (60%). Technical success was associated with fewer stones and SWL sessions and smaller stone and duct size. By multivariate logistic regression, only duct dilation was associated with TS. Endoscopic success of complete duct clearance was achieved in 29 patients (80%). Endoscopic success was more frequent with stones 12 mm or less and with successful TS. By multivariate logistic regression, stones greater than 12 mm were associated with endoscopic failure. CONCLUSIONS: Pre-SWL endotherapy does not affect stone fragmentation. Patients with a dilated duct (>8 mm) and pancreatic stones 12 mm or greater were associated with unsuccessful TS and endoscopic success, respectively, and may benefit from early referral for surgical decompression.

Transpapillary drainage has no added benefit on treatment outcomes in patients undergoing EUS-guided transmural drainage of pancreatic pseudocysts: a large multicenter study.

BACKGROUND AND AIMS: The need for transpapillary drainage (TPD) in patients undergoing transmural drainage (TMD) of pancreatic fluid collections (PFCs) remains unclear. The aims of this study were to compare treatment outcomes between patients with pancreatic pseudocysts undergoing TMD versus combined (TMD and TPD) drainage (CD) and to identify predictors of symptomatic and radiologic resolution. METHODS: This is a retrospective review of 375 consecutive patients with PFCs who underwent EUS-guided TMD from 2008 to 2014 at 15 academic centers in the United States. Main outcome measures included TMD and CD technical success, treatment outcomes (symptomatic and radiologic resolution) at follow-up, and predictors of treatment outcomes on logistic regression. RESULTS: A total of 375 patients underwent EUS-guided TMD of PFCs, of which 174 were pseudocysts. TMD alone was performed in 95 (55%) and CD in 79 (45%) pseudocysts. Technical success was as follows: TMD, 92 (97%) versus CD, 35 (44%) (P = .0001). There was no difference in adverse events between the TMD (15%) and CD (14%) cohorts (P = .23). Median long-term (LT) follow-up after transmural stent removal was 324 days (interquartile range, 72-493 days) for TMD and 201 days (interquartile range, 150-493 days) (P = .37). There was no difference in LT symptomatic resolution (TMD, 69% vs CD, 62%; P = .61) or LT radiologic resolution (TMD, 71% vs CD, 67%; P = .79). TPD attempt was negatively associated with LT radiologic resolution of pseudocyst (odds ratio, 0.11; 95% confidence interval, 0.02-0.8; P = .03). CONCLUSIONS: TPD has no benefit on treatment outcomes in patients undergoing EUS-guided TMD of pancreatic pseudocysts and negatively affects LT resolution of PFCs.

Minor Papilla Adenoma Management in Patients with Pancreas Divisum and Familial Adenomatous Polyposis.

Several case reports on endoscopic resection of minor papilla adenomas exist in the literature. However, there are no reported cases of endoscopic resection in patients with minor papilla adenomas with associated familial adenomatous polyposis (FAP) and pancreas divisum. We report a case of a minor papilla adenoma in a patient with FAP and pancreas divisum. The case demonstrates a new association between these disease processes. Defining pancreatic ductal anatomy prior to endoscopic intervention is essential. In addition, we demonstrate the safety and feasibility of endoscopic management of minor papilla tumors in patients with FAP and associated pancreas divisum.

Acute cholestatic hepatitis a virus infection presenting with hemolytic anemia and renal failure: a case report.

Hepatitis A virus is the most common acute viral hepatitis worldwide with approximately 1.5 million cases annually. Hepatitis A virus infection in general is self-limited. In rare cases, hepatitis A virus infection may cause renal failure, hemolytic anemia, and/or cholestasis. We report the first case of acute cholestatic hepatitis A virus infection complicated by hemolytic anemia, and renal failure in one patient. A 42-year-old Caucasian male presented with cholestasis, hemolytic anemia and renal failure after consuming street tacos in Central and South America while on a business trip. His protracted course required corticosteroid therapy, multiple sessions of plasma exchange, and numerous units of packed red blood cells. This case demonstrates the importance of vaccination in high-risk adults. A prompt diagnosis of acute hepatitis A virus infection is essential, as uncommon presentations may delay diagnosis leading to permanent morbidity and potentially death in fulminant cases. We also demonstrate the efficacy of treatment of cholestatic hepatitis A virus infection, hemolytic anemia, and renal failure with corticosteroids and plasma exchange.

Low-dose cardio-respiratory phase-correlated cone-beam micro-CT of small animals.

PURPOSE: Micro-CT imaging of animal hearts typically requires a double gating procedure because scans during a breath-hold are not possible due to the long scan times and the high respiratory rates, Simultaneous respiratory and cardiac gating can either be done prospectively or retrospectively. True five-dimensional information can be either retrieved with retrospective gating or with prospective gating if several prospective gates are acquired. In any case, the amount of information available to reconstruct one volume for a given respiratory and cardiac phase is orders of magnitud lower than the total amount of information acquired. For example, the reconstruction of a volume from a 10% wide respiratory and a 20% wide cardiac window uses only 2% of the data acquired. Achieving a similar image quality as a nongated scan would therefore require to increase the amount of data and thereby the dose to the animal by up to a factor of 50. METHODS: To achieve the goal of low-dose phase-correlated (LDPC) imaging, the authors propose to use a highly efficient combination of slightly modified existing algorithms. In particular, the authors developed a variant of the McKinnon-Bates image reconstruction algorithm and combined it with bilateral filtering in up to five dimensions to significantly reduce image noise without impairing spatial or temporal resolution. RESULTS: The preliminary results indicate that the proposed LDPC reconstruction method typically reduces image noise by a factor of up to 6 (e.g., from 170 to 30 HU), while the dose values lie in a range from 60 to 500 mGy. Compared to other publications that apply 250-1800 mGy for the same task [C. T. Badea et al., "4D micro-CT of the mouse heart," Mol. Imaging 4(2), 110-116 (2005); M. Drangova et al., "Fast retrospectively gated quantitative four-dimensional (4D) cardiac micro computed tomography imaging of free-breathing mice," Invest. Radiol. 42(2), 85-94 (2007); S. H. Bartling et al., "Retrospective motion gating in small animal CT of mice and rats," Invest. Radiol. 42(10), 704-714 (2007)], the authors' LDPC approach therefore achieves a more than tenfold dose usage improvement. CONCLUSIONS: The LDPC reconstruction method improves phase-correlated imaging from highly undersampled data. Artifacts caused by sparse angular sampling are removed and the image noise is decreased, while spatial and temporal resolution are preserved. Thus, the administered dose per animal can be decreased allowing for long-term studies with reduced metabolic inference.

Clinical utility of positron emission tomography/computed tomography in inflammatory bowel disease.

PURPOSE: The clinical utility of positron emission tomography/computed tomography (PET/CT) in comparison to standard workup in patients with known or suspected inflammatory bowel disease (IBD) is unknown. PROCEDURES: Clinical data were collected on seven patients with known or suspected IBD undergoing PET/CT. Standard workup included history, physical exam, laboratory tests, colonoscopy and/or cross-sectional imaging. We divided the intestine into five regions [small bowel and four colon (ascending, transverse, descending and rectosigmoid)] and graded relative standard uptake values 0, 1, 2 or 3 by comparison to the liver, using a region-of-interest analysis (0 = no activity, 1 = liver, 2 and 3 = significant inflammation). RESULTS: In patients 1 and 2, PET/CT demonstrated more activity than we thought clinically present. The other patients avoided unnecessary escalation or initiation of IBD therapy based on PET/CT results. Compared with standard workup, all seven patients had superior results when therapeutic decisions were based on PET/CT. CONCLUSIONS: We found PET/CT to be very useful in diagnosis and management in patients with known or suspected IBD.

Respiratory phase-correlated micro-CT imaging of free-breathing rodents.

We provide a dedicated phase-correlated imaging procedure for respiratory gating in micro-CT imaging with automatic detection of the optimal data window providing the least amount of motion blurring. A rawdata-based motion function (kymogram) was used for synchronization purposes and for identification of the optimal data window used for phase-correlated image reconstruction. Measurements were performed on a dual-source micro-CT scanner. Projection data were acquired over ten rotations for multi-segment phase-correlated reconstruction. Visual assessment was performed on datasets of ten free-breathing subjects. The kymogram approach provided a reliable synchronization signal for phase-correlated image reconstruction. Also, it allowed for the identification of phase intervals of increased and decreased motion and the corresponding detection of the optimal reconstruction phase. Phase-correlated images showed a strong improvement with respect to motion blurring compared to standard image reconstruction. A reconstruction for the calculated optimal data window provided the least amount of motion blurring and even allowed for the assessment of small structures in the lung. The dedicated retrospective phase-correlated image reconstruction procedure for respiratory gating is a feasible approach for motion-free imaging. A subject-specific optimal reconstruction phase can minimize motion blurring and further improve image quality.

Cardiac phase-correlated image reconstruction and advanced image processing in pulmonary CT imaging.

Image quality in pulmonary CT imaging is commonly degraded by cardiac motion artifacts. Phase-correlated image reconstruction algorithms known from cardiac imaging can reduce motion artifacts but increase image noise and conventionally require a concurrently acquired ECG signal for synchronization. Techniques are presented to overcome these limitations. Based on standard and phase-correlated images that are reconstructed using a raw data-derived synchronization signal, image-merging and temporal-filtering techniques are proposed that combine the input images automatically or interactively. The performance of the approaches is evaluated in patient and phantom datasets. In the automatic approach, areas of strong motion and static areas were well detected, providing an optimal combination of standard and phase-correlated images with no visible border between the merged regions. Image noise in the non-moving regions was reduced to the noise level of the standard reconstruction. The application of the interactive filtering allowed for an optimal adaptation of image noise and motion artifacts. Noise content after interactive filtering decreased with increasing temporal filter width used. We conclude that a combination of our motion-free merging approach and a dedicated interactive filtering procedure can highly improve pulmonary imaging with respect to motion artifacts and image noise.

Interactively variable isotropic resolution in computed tomography.

An individual balancing between spatial resolution and image noise is necessary to fulfil the diagnostic requirements in medical CT imaging. In order to change influencing parameters, such as reconstruction kernel or effective slice thickness, additional raw-data-dependent image reconstructions have to be performed. Therefore, the noise versus resolution trade-off is time consuming and not interactively applicable. Furthermore, isotropic resolution, expressed by an equivalent point spread function (PSF) in every spatial direction, is important for the undistorted visualization and quantitative evaluation of small structures independent of the viewing plane. Theoretically, isotropic resolution can be obtained by matching the in-plane and through-plane resolution with the aforementioned parameters. Practically, however, the user is not assisted in doing so by current reconstruction systems and therefore isotropic resolution is not commonly achieved, in particular not at the desired resolution level. In this paper, an integrated approach is presented for equalizing the in-plane and through-plane spatial resolution by image filtering. The required filter kernels are calculated from previously measured PSFs in x/y- and z-direction. The concepts derived are combined with a variable resolution filtering technique. Both approaches are independent of CT raw data and operate only on reconstructed images which allows for their application in real time. Thereby, the aim of interactively variable, isotropic resolution is achieved. Results were evaluated quantitatively by measuring PSFs and image noise, and qualitatively by comparing the images to direct reconstructions regarded as the gold standard. Filtered images matched direct reconstructions with arbitrary reconstruction kernels with standard deviations in difference images of typically between 1 and 17 HU. Isotropic resolution was achieved within 5% of the selected resolution level. Processing times of 20-100 ms per frame allow for interactive use.

A new weighting function to achieve high temporal resolution in circular cone-beam CT with shifted detectors.

The size of the field of measurement (FOM) in computed tomography is limited by the size of the x-ray detector. In general, the detector is mounted symmetrically with respect to the rotation axis such that the transaxial FOM diameter approximately equals the lateral dimensions of the detector when being demagnified to the isocenter. To enlarge the FOM one may laterally shift the detector by up to 50% of its size. Well-known weighting functions must then be applied to the raw data prior to convolution and backprojection. In this case, a full scan or a scan with more than 360 degrees angular coverage is required to obtain complete data. However, there is a small region, the inner FOM, that is covered redundantly and where a partial scan reconstruction may be sufficient. A new weighting function is proposed that allows one to reconstruct partial scans in that inner FOM while it reconstructs full scan or overscan data for the outer FOM, which is the part that contains no redundancies. The presented shifted detector partial scan algorithm achieves a high temporal resolution in the inner FOM while maintaining truncation-free images for the outer part. The partial scan window can be arbitrarily shifted in the angular direction, what corresponds to shifting the temporal window of the data shown in the inner FOM. This feature allows for the reconstruction of dynamic CT data with high temporal resolution. The approach presented here is evaluated using simulated and measured data for a dual source micro-CT scanner with rotating gantry.

Rawdata-based detection of the optimal reconstruction phase in ECG-gated cardiac image reconstruction.

In order to achieve diagnostically useful CT (computed tomography) images of the moving heart, the standard image reconstruction has to be modified to a phase-correlated reconstruction, which considers the motion phase of the heart and generates a quasi-static image in one defined motion phase. For that purpose a synchronization signal is needed, typically a concurrent ECG recording. Commonly, the reconstruction phase is adapted by the user to the patient-specific heart motion to improve the image quality and thus the diagnostic value. The purpose of our work is to automatically identify the optimal reconstruction phase for cardiac CT imaging with respect to motion artifacts. We provide a solution for a patient- and heart rate-independent detection of the optimal phase in the cardiac cycle which shows a minimum of cardiac movement. We validated our method by the correlation with the reconstruction phase selected visually on the basis of ECG-triggering and used for the medical diagnosis. The mean difference between both reconstruction phases was 12.5% with respect to a whole cardiac motion cycle indicating a high correlation. Additionally, reconstructed cardiac images are shown which confirm the results expressed by the correlation measurement and in some cases even indicating an improvement using the proposed method.