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Introduction: Autoimmune pancreatitis (AIP) is a disease that may mimic malignant pancreatic lesions both in terms of symptomatology and imaging appearance. The aim of the present study is to analyze experiences of surgery in patients with AIP in one of the largest European cohorts., Patients and Methods: We performed a single-center retrospective study of patients diagnosed with AIP at the Department of Abdominal Diseases at Karolinska University Hospital in Stockholm, Sweden, between January 2001 and October 2020., Results: There were 159 patients diagnosed with AIP, and among them, 35 (22.0%) patients had surgery: 20 (57.1%) males and 15 (42.9%) females; median age at surgery was 59 years (range 37-81). Median follow-up period after surgery was 50 months (range 1-235). AIP type 1 was diagnosed in 28 (80%) patients and AIP type 2 in 7 (20%) patients. Malignant and premalignant lesions were diagnosed in 8 (22.9%) patients for whom AIP was not the primary differential diagnosis, but in all cases, it was described as a simultaneous finding and recorded in retrospective analysis in histological reports of surgical specimens., Conclusions: Diagnosis of AIP is not always straightforward, and in some cases, it is not easy to differentiate it from the malignancy. Surgery is generally not indicated for AIP but might be considered in patients when suspicion of malignant/premalignant lesions cannot be excluded after complete diagnostic workup., (© 2021 The Author(s). Published by S. Karger AG, Basel.)

Aim: To correlate the appearance of the retroportal fat plane at preoperative computed tomography (CT) and the pathology findings in resected adenocarcinoma of the pancreatic head (PDAC)., Material and Methods: Forty-eight patients with resected PDAC of the pancreatic head were included (24 men, 24 women, mean age 63 years, median BMI 24.1). All patients underwent CT <30 days before surgery. The state of the retroperitoneal resection margin and the presence of lymphatic or perineural invasion were obtained from pathology reports. CT images were reviewed independently by two radiologists for assessment of the retroportal fat plane and graded in two categories (clear/effaced). Inter-reader discrepancies were solved in consensus. Interobserver agreement was calculated and Fisher's test was used to assess the correlation between CT and pathology findings. Visceral fat areas were measured and correlated with CT findings., Results: A clear retroportal fat plane was significantly associated with a negative retroperitoneal margin at pathology with 100% specificity and PPV (p=0.0001). No association was observed between the appearance of the fat plane at CT and the presence of lymphatic or perineural invasion (p=ns). Interobserver agreement for retroportal fat plane evaluation was good (0.741). False-positive cases had a significantly lower visceral fat area than the correctly classified patients (p=0.0480)., Conclusions: A clear retroportal fat plane is significantly associated with negative retroperitoneal resection margins at pathology. The lack of visceral adipose tissue can lead to overestimation of retroportal fat plane involvement at preoperative CT., (Copyright © 2019 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Objectives: To assess factors associated with radical resection (R0) of pancreatic ductal adenocarcinoma (PDAC) after induction treatment with FOLFIRINOX., Methods: Patients with either locally advanced (LA) and borderline resectable (BR) PDAC undergoing surgical exploration after FOLFIRINOX were retrospectively enrolled. Two pancreatic radiologists reviewed the CT blinded to the final outcome and assessed chemotherapy response and resectability. Patients were then divided into R0 resected (group A) and not resected/R1 resected (group B), which were compared., Results: Of 59 patients included, 19 were defined as unresectable (32%), 33 borderline resectable (56%) and 7 resectable (12%) during the blind radiological evaluation after FOLFIRINOX. Once in a surgical setting, 27% were non-resectable, whereas 73% received surgical resection with a 70% R0 rate. Consequent sensitivity and specificity were 86% and 29%. At imaging review, significant decreases in longest tumour dimension were observed in both groups: from 32 mm (95% CI 15-55) to 21 (10-44) in group A and from 34 (18-70) to 26 (7-60) in group B, p < 0.05. However, a significant increase in tumour attenuation in all phases was only observed for R0 resected, from 52 HU (26-75) to 65 (35-92) in arterial phase (p < 0.001) and from 62 (36-96) to 78 (40-120) in the venous (p = 0.001)., Conclusion: After neoadjuvant FOLFIRINOX, CT predicted resectability with acceptable sensitivity but low specificity. The observation of increased tumour attenuation at CT scan after FOLFIRINOX treatment might represent a reliable predictor of R0 resection., Key Points: • CT drives the assessment of PDAC resectability after FOLFIRINOX • CT predicts resectability with acceptable sensitivity but low specificity • Significant increase in tumour attenuation was only observed for R0 resected PDAC • Tumour attenuation after FOLFIRINOX represents a reliable predictor of R0 resection.

Background: The purpose of the study is to evaluate the utility of acoustic radiation force impulse (ARFI) on pancreatic tissue as a preoperative predictor of postoperative pancreatic fistula (POPF). Studied patients underwent exclusively to pancreaticoduodenectomy (PD) surgery., Methods: Shear wave velocity of pancreas was measured using ARFI in 71 patients scheduled for PD. An intraoperative pancreas palpation was made by surgeons. A postoperative clinical evaluation to detect occurrence of POPF was performed. Sensitivity, specificity, positive and negative predictive values together with the accuracy of the method were investigated., Results: Incidence of fistula observed in 17 patients with soft pancreas was approximately 53% vs. 47% without fistula. Percentage of patients without fistula was higher (66%) among 24 patients with medium parenchymal texture values, and was even higher (69%) in 26 patients with hard pancreas. Comparing ARFI and intraoperative pancreatic palpation, low wave velocity values (≤1.40 m/s) match 60% with soft parenchyma assessed by palpation and high values (>2 m/s) match 59% with hard pancreas on palpation., Conclusions: This study shows that ARFI elastography may be clinically useful as a preoperative predictor of pancreatic fistula following PD., (© 2017 S. Karger AG, Basel.)

Background: Since prognosis and treatment of pancreatic endocrine tumors (pNET) are based on tumor grade, contrast-enhanced multidetector computed tomography (MDCT) features of solid non-functioning pNETs were studied and correlated with pathology tumor grading., Methods: MDCTs of diagnosed pNETs were reviewed retrospectively. Each tumor was analyzed for location, size, homogeneity, margins, arterial and venous phase enhancement, main pancreatic duct diameter, calcifications, vascular invasion, lymph-nodes enlargement, and liver metastases., Results: Of 154 pNETs presenting between January 2000 and May 2016 with available histology from resected specimen or biopsy, there were 65 G1, 72 G2 and 17 G3 pNETs. Tumor diameter varied significantly between the three groups. Tumors >20 mm were more frequently malignant and non-homogeneous than smaller tumors. G1 tumors were more commonly hypervascular and G3 tumors more often non-hypervascular in the arterial phase. Arterial phase non-hyperdensity and tumor non-homogeneity had a higher rate of metastatic lesions. Vascular invasion correlated with presence of metastases and histological grade. G3 tumors were all >20 mm (p = 0.007), more often non-hypervascular in the arterial phase (p = 0.0025), and non-hyperdense in the venous phase (p = 0.009), and showed more often vascular invasion (p = 0.0198)., Conclusion: CT correlated with tumor grade; differentiating low-grade and high-grade pNETs through routine CT imaging might improve patient management., (Copyright © 2017 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Purpose: To evaluate the MRI features of paraduodenal pancreatitis (PDP) and to define useful signs to differentiate PDP from pancreatic ductal adenocarcinoma (PDAC)., Material and Methods: We reviewed the MRI scans of 56 patients, 28 affected by PDP and 28 by PDAC, all pathologically proven. The following parameters were evaluated: signal intensity of the lesion on T1-, T2-WI, DWI (b800) and after contrast medium administration; presence of cysts; dilation of common hepatic duct and main pancreatic duct; focal thickening of the second portion of the duodenum; maximum diameter and volume of the lesion., Results: Both PDPs and PDACs were more frequently hypointense on T1-WI, iso-hyperintense on T2-WI, hypointense in the pancreatic phase and iso-hypointense in the venous phase (p>0.05); in the delayed phase most PDP were hyperintense (p=0.0031); on DWI 71.4% PDPs were isointense and all PDACs were hyperintense (p=0.0041). Cystic components were present in 85.7% PDPs (p=0.0011); double duct sign was present in 50% PDACs (p=0.0048); focal thickening of the duodenum was depicted in 89.3 PDPs (p=0.0012). PDPs were larger than PDACs (p=0.0003)., Conclusion: The most suggestive signs of PDP are: signal hyperintensity in the delayed phase, isointensity on DWI, presence of cysts, focal thickening of the duodenum and large size of the lesion., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Purpose: To define imaging criteria of benign and malignant nature in patients with main pancreatic duct (MPD) stenosis., Materials-Methods: S-MRCPs of 35 patients with pancreatitis and 14 with adenocarcinoma were evaluated., Results: Adenocarcinoma caused higher prevalence of complete stenosis (14/14-100% vs 17/35-49%), dilated side-branches (14/14-100% vs 18/35-51%) and lower prevalence of duct-penetrating sign (0/14-0% vs 31/35-89%). The number of stenoses was higher in benign conditions (mean 1.4 Vs 1). Upstream MPD diameter was higher in cancer-induced stenoses (4.5 vs 2.9mm)., Conclusions: Single complete stenosis with dilated side branches, increased MPD caliber and absent duct-penetrating sign are suggestive of malignancy., (Copyright © 2016 Elsevier Inc. All rights reserved.)

We propose an innovative tool for Pancreatic Ductal AdenoCarcinoma 3D reconstruction from Multi-Detector-Computed Tomography. The tumor mass is discriminated from health tissue, and the resulting segmentation labels are rendered preserving information on different hypodensity levels. The final 3D virtual model includes also pancreas and main peri-pancreatic vessels, and it is suitable for 3D printing. We performed a preliminary evaluation of the tool effectiveness presenting ten cases of Pancreatic Ductal AdenoCarcinoma processed with the tool to an expert radiologist who can correct the result of the discrimination. In seven of ten cases, the 3D reconstruction is accepted without any modification, while in three cases, only 1.88, 5.13, and 5.70 %, respectively, of the segmentation labels are modified, preliminary proving the high effectiveness of the tool.

Objectives: To evaluate the diagnostic accuracy and complication rate of percutaneous ultrasound-guided fine-needle aspiration (US-FNA) of solid pancreatic neoplasms through the analysis of 10-year experiences of two centres., Methods: Clinical, radiological and pathologic data of 2,024 patients with solid pancreatic masses who underwent US-FNAs were retrospectively evaluated. Indications for aspiration were: unresectable lesions before neo-adjuvant therapy; doubtful imaging findings; and suspicion of uncommon neoplasms with prognostic or therapeutic implications such as metastases or lymphoma. US-FNAs were performed using aspiration needles with a cytopathologist present in centre 1. In centre 2, cytologic samples were collected with Chiba needles and separately evaluated by a cytopathologist., Results: US-FNA had a diagnostic sample rate of 92.2 % (centre 1: 95.9 %; centre 2: 87.2 %). US-FNA repetition after non-diagnostic samples provided a diagnosis in 86.3 % of cases. Sensitivity, specificity, positive and negative predictive values, and accuracy were 98.7 %, 100 %, 100 %, 75.5 %, and 98.7 %, respectively. The complication rate was 0.8 %., Conclusions: Percutaneous US-FNA is a sensitive, accurate and safe method for the invasive diagnosis of solid pancreatic neoplasms. The use of aspiration needles and the on-site presence of a cytopathologist may lead to a high rate of diagnostic samples, thus reducing the need for US-FNA repetition., Key Points: • Percutaneous ultrasound-guided fine-needle aspiration of pancreatic neoplasms is sensitive and accurate. • The short-term complication rate of percutaneous ultrasound-guided fine-needle aspiration is low. • Technical aspects may influence the rate of diagnostic samples.

Background: Acoustic Radiation Force Impulse (ARFI) is a new ultrasound technique that evaluates mechanical properties of tissues. To evaluate the use of ARFI with shear waves speed quantification for pancreatic masses characterization during the ultrasound examination., Methods: 123 pancreatic lesions were prospectively evaluated. Median shear waves speeds were compared with Mann-Whitney U test. Two reading methods were applied for the characterization of adenocarcinoma: more than one measurement above the top shear waves speed (SWS) value. Two reading methods were applied to diagnose mucinous lesion: at least 2 (method 1) or 3 (method 2) numerical measurements. Sensitivity, specificity, positive and negative predictive values and accuracy of each reading method were calculated. Forty volunteers were included for normal ARFI values., Results: In the adenocarcinoma group median SWS value was 2.74 m/s. In the volunteers group the median SWS value was 1.17 m/s. Significant difference between SWS median values of adenocarcinoma and normal pancreas was found (P < 0.05). For the diagnosis of pancreatic solid masses if more than one measurement is above the top SWS value of 4.00 m/s results in the study, the diagnosis of ductal adenocarcinoma is highly specific with specificity and PPV of 100%. Good sensitivity (73.3%) and specificity (83.3%) were obtained for the characterization of mucinous cystic lesions., Conclusions: Acoustic Radiation Force Impulse imaging could help in the non-invasive characterization of solid and cystic lesions of the pancreas during a conventional US examination., (Copyright © 2015 IAP and EPC. Published by Elsevier India Pvt Ltd. All rights reserved.)

Objective: To determine the accuracy of MRI in differentiating mucinous cystoadenomas (MCAs) from mucinous cystoadenocarcinomas (MCACs) of the pancreas, with histopathological analysis as the reference standard, for better surgical planning., Methods: A total of 65 patients with histopathologically proven mucinous cystic neoplasms (MCNs) underwent MRI and surgery. Quantitative image analysis included size, septa and wall thickness and number of loculations. Qualitative image analysis included nodules; hyperintensity of the cystic content on T1 weighted images; compression and/or infiltration of adjacent vessels or organs; and metastases. A comparison between MCAs and MCACs was performed with Student's t-test for quantitative variables and with Fisher test for qualitative variables. Receiver operating characteristic analysis was performed to determine the accuracy in the differential diagnosis between MCAs and MCACs on the basis of a score system obtained by giving 1 point for each quantitative and qualitative variable observed in each patient., Results: At histopathology, 43 lesions were MCAs and 22 lesions were MCACs. A statistically significant difference was observed for size >7cm (<0.001), septa and wall thickness >3 mm (<0.0001), number of loculations >4 (<0.0001), nodules (<0.0001), hyperintensity of the cystic content on T1 weighted images (<0.0001), compression (<0.01) and/or infiltration (<0.01) of adjacent vessels or organs and metastases (<0.05). The best cut-off value to discriminate MCAs from MCACs was the presence of three features (p < 0.001), with an accuracy of 91%., Conclusion: MRI has an accuracy of 91% in the differential diagnosis between MCA and MCAC, helping in identifying forms that could undergo parenchyma-sparing surgery (MCAs), reducing post-surgical morbidity and mortality., Advances in Knowledge: In this study, the differentiation between MCAs and MCACs of the pancreas by means of MRI is addressed. The differential diagnosis allows selecting benign forms, susceptible of parenchyma-sparing surgery, with the advantage of reducing post-surgical morbidity and stratifying prognosis of MCNs.

Contrast-enhanced ultrasonography (CEUS) improves the characterization of pancreatic masses. CEUS is in fact a safe and accurate imaging method to evaluate the vascularity of pancreatic lesions. CEUS should be performed when possible immediately after the ultrasound (US) detection of a pancreatic mass. CEUS is accurate in the characterization of ductal adenocarcinoma. The use of CEUS in studying pancreatic lesions found at US, especially in the same session of ultrasound examination, is therefore recommendable to promote faster diagnosis mainly of pancreatic ductal adenocarcinoma., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Importance: Pancreatic cancer is the fourth leading cause of cancer-related death in Western countries. In approximately 10% of all patients with pancreatic cancer, it is possible to define a positive family history for pancreatic cancer or for one of the other related genetic syndromes. A screening program for individuals at risk is recommended; however, surveillance modalities have not been defined yet., Objective: To analyze the short-term results of a prospective clinical surveillance program for individuals at risk for pancreatic cancer using a noninvasive magnetic resonance imaging (MRI)-based screening protocol., Design, Setting and Participants: A prospective observational study of all patients with a genetic risk for developing pancreatic cancer who were referred to Karolinska University Hospital between January 1, 2010, and January 31, 2013, using an MRI-based surveillance program. All patients were investigated for the most common genetic mutations associated with pancreatic cancer., Exposure: A noninvasive MRI-based screening protocol., Main Outcomes and Measures: The ability of MRI to identify potential precancerous or early cancers in individuals at risk for pancreatic cancer., Results: Forty patients (24 women and 16 men) were enrolled. The mean age was 49.9 years. The mean length of follow-up was 12.9 months. The numbers of relatives affected by pancreatic cancer were 5 in 2 patients (5%), 4 in 5 patients (12.5%), 3 in 17 patients (42.5%), 2 in 14 patients (35%), and 1 in 2 patients (5%). In 4 patients (10%), a p16 mutation was found; in 3, a BRCA2 mutation (7.5%); and in 1, a BRCA1 mutation (2.5%). In 16 patients (40%), MRI revealed a pancreatic lesion: intraductal papillary mucinous neoplasia (14 patients, 35%) and pancreatic ductal adenocarcinoma (2 patients, 5%). One patient had a synchronous intraductal papillary mucinous neoplasia and pancreatic ductal adenocarcinoma. Five patients (12.5%) required surgery (3 for pancreatic ductal adenocarcinoma and 2 for intraductal papillary mucinous neoplasia), while the remaining 35 are under continued surveillance., Conclusions and Relevance: During a median follow-up of approximately 1 year, pancreatic lesions were detected in 40% of the patients, of whom 5 underwent surgery. Although the study time was relatively short, the surveillance program in individuals at risk seems to be effective.

Purpose: To identify magnetic resonance (MR)/MR cholangiopancreatography (MRCP) imaging signs helpful in the differential diagnosis between serous cystadenomas (SCAs) and mucinous cystic neoplasms (MCNs), arising from the body/tail of the pancreas., Material and Methods: This retrospective study had institutional review board approval and informed consent was waived. Fifty-three patients with non-communicating cystic pancreatic neoplasm of the body/tail, undergoing MR/MRCP, were included. Qualitative image analysis assessed the macroscopic pattern, number of cysts, presence of central scar, contrast enhancement of peripheral wall, and mural nodules. Quantitative analysis assessed the maximum diameter of the neoplasm, thickness of the peripheral wall, and calibre of the upstream main pancreatic duct., Results: Histopathology results revealed that 27/53 (51 %) were SCAs, 26/53 (49 %) were MCNs. Microcystic pattern was observed in 88.2 % of SCAs and 11.8 % of MCNs; macrocystic pattern was observed in 90.5 % of MCNs and 9.5 % of SCAs (p < 0.0001). Central scar was detected in 29.6 % of SCAs and no MCNs (p = 0.003). Contrast enhancement of the peripheral wall was evident in 99.5 % of MCNs and 11.5 % of SCAs (p < 0.0001); mural nodules were depicted in 94.1 % of MCNs and 5.9 % of SCAs (p < 0.0001). Median maximum diameter was 54 mm for MCNs, 32 mm for SCAs (p = 0.001); median wall thickness was 4 mm for MCNs, 2 mm for SCAs (p < 0.0001)., Conclusions: Macrocystic pattern, enhancement of a peripheral wall and mural nodules are suggestive of MCNs; whereas microcystic pattern, lack of peripheral wall and central scar are suggestive of SCAs., Key Points: • MCNs have macrocystic patterns, contrast enhancement of the peripheral wall and mural nodules • Microcystic pattern and central scar are suggestive of SCA • Mural nodules detected in MCNs correlate with epithelial dysplasia • Chronic obstructive pancreatitis is equally depicted in patients with MCNs and SCAs.

Purpose: To evaluate the magnetic resonance imaging (MRI) findings of solid pseudopapillary neoplasm (SPN) of the pancreas., Methods and Materials: From January 2006 to December 2013, 41 patients with SPN of the pancreas were retrospectively evaluated. Inclusion criteria were the execution of an MR examination and tumor resection with an histopathological evaluation at our Institute. Exclusion criteria were the execution of an MR examination at other centers (14/41) and the execution of CT or ultrasonography (10/41) at our Institute. The qualitative analysis evaluated: location (head/body-tail), shape (round/oval/lobulated), margins (regular/irregular), and signal intensity on T1- and T2-weighted images compared to the surrounding pancreas (hypo-, iso-, or hyperintense and homogeneous or heterogeneous), appearance of MPD and the secondary ducts, and the presence of metastases and/or vascular involvement. The quantitative analysis included: maximum size of the lesion, wall thickness, and maximum diameter of the main pancreatic duct (MPD)., Results: The population comprised 17 women (median age: 31 year) with a median tumor size of 50.6 mm, a median wall thickness of 2 mm and median diameter of the MPD of 1.8 mm. 9/17 were at the head; 8/17 on the body/tail: respectively, 8/17 round, 6/17 oval, and 3/17 lobulated. All showed regular margins. On T1-weighted images 8/17 appeared homogeneously hypointense, 7/17 heterogeneously hypointense, and 2/17 heterogeneously hyperintense. On T2-weighted images 1/17 appeared homogeneously hyperintense and 16/17 heterogeneously hyperintense. No secondary ducts dilatations were detected. During the follow-up, one patient presented disease recurrence 48 months after surgery., Conclusions: MR imaging features can be highly suggestive for the diagnosis of SPN.

Background: Diagnostic errors in the evaluation of cystic neoplasms of the pancreas (PCNs) are quite common. Few data are available regarding the impact of these errors on clinical management. The aim of this study was to determine the accuracy of a pancreatic multidisciplinary conference in diagnosing PCNs, to assess the potential risk of misdiagnosis, and to evaluate the clinical impact of these errors., Methods: A retrospective consecutive series of patients undergoing surgery for PCNs at Karolinska University Hospital between 2004 and 2012 was analyzed., Results: During the study period, a total of 141 patients had undergone pancreatic resection for PCN. The overall accuracy of the preoperative diagnosis was 60.9 %. The rate of concordance between preoperative diagnosis and histology was similar for asymptomatic and symptomatic lesions (62.8 vs. 59.1 %; p = NS). The rate of correct diagnosis increased over time (54.5 % in 2004-2006, 61.7 % in 2007-2012, 63.5 % in 2010-2012). Univariate analysis identified the location of the lesion (diffuse pancreatic involvement) and a mucinous nature of the lesion as factors conducive to a correct diagnosis. Reevaluation of the original indication for surgery in light of the exact diagnosis showed that a surgical procedure should not have been performed in 12 patients (8.5 %)., Conclusions: This study confirms that diagnostic errors are fairly common in the preoperative assessment of PCNs, but the errors are clinically relevant in <10 % of patients.

Purpose: To test a single-energy low-voltage CT protocol for pancreatic adenocarcinoma., Methods and Materials: A total of 30 patients with pathology-proven pancreatic adenocarcinoma underwent 64-row MDCT with arterial phase at 80 kV and were compared to a similar group of 30 patients scanned with a 120 kV protocol. Scans were compared for quantitative image parameters (attenuation and standard deviation in the pancreas, tumor, aorta), CTDI and DLP using an unpaired t-test. Image noise values for each protocol (SD of the psoas) were compared using an unpaired t-test. Effective dose was calculated for each protocol. CNR (=conspicuity/SDnoise) and FOM (CNR2/ED) were calculated. The Catphan600 phantom was used to evaluate image non-uniformity, noise, spatial resolution, and low contrast detectability., Results: Mean patient weight was 68 kg in the study group and 73 kg in the control group (p=0.0355), while patient diameters at the celiac axis were not significantly different. Mean attenuation was significantly higher at 80 kV in the aorta (517.5±116.4 vs 290.3±76.4 HU) and normal pancreas (154.0±39.95 vs 90.02±19.01 HU) (all p<0.0001), while no significant difference was observed for adenocarcinoma (61.43±35.61 vs 47.45±18.95; p=n.s.). CTDI and DLP were significantly lower at 80 kV (6.00±0.90 mGy vs 10.24±2.93 mGy, and 180.4±35.49 mGy cm vs 383.8±117 mGy cm, respectively; all p<0.0001). Tumor conspicuity (HUpancreas-HUtumor) was significantly higher at 80 kV (94.2±39.3 vs 39.5±22 HU; p<0.0001). Mean image noise was significantly higher at 80kV (28.32±10.06 vs 19.7±7.1HU; p<0.0001). Effective dose was significantly lower at 80 kV (1.984±0.39 vs 5.75±1.75 mSv; p<0.0001). The total DLP for the exam was 1024±31.86 mGy cm for the 80 kV protocol and 1357±62.60 mGy cm for the 120 kV protocol (p<0.0001). Phantoms showed higher non-uniformity, slightly higher noise, slightly lower MTF (50%) and slightly higher percentage contrast for the 80 kV protocol., Conclusion: Single-source 80 kV pancreatic phase scanning results in higher conspicuity of pancreatic adenocarcinoma and FOM and in significant dose reduction while maintaining acceptable image quality., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Purpose: The aim of this study is to compare CEUS and MDCT features of pancreatic ductal adenocarcinoma in relation to tumor size., Materials and Methods: All patients with pathological diagnosis of pancreatic adenocarcinoma and studied by means of CEUS and MDCT were enrolled in this study. Two radiologists evaluated tumor size, site and imaging appearance. Patients in which at least one method yielded a positive result were divided into 4 groups on the basis of lesion size. For each dimensional category, sensitivity of the two imaging methods was calculated and compared using McNemar test., Results: One hundred thirty-three patients were included in this study. In 9 of 133 patients neither MDCT nor US/CEUS could identify the lesion, while in 9 of 133 patients only MDCT and in 13 of 133 only US/CEUS could identify the lesion. In the remaining 102 patients, both MDCT and US/CEUS yielded a positive result. US/CEUS sensitivity was 86.47% while MDCT sensitivity was 83.58%, with no statistically significant difference (p = 0.523). For lesions smaller than 2 cm US/CEUS had a 100% sensitivity, while MDCT had a 73.33% sensitivity with no statistically significant difference (p = 0.125). For lesions between 2.1 and 3 cm US/CEUS had a sensitivity of 95.35%, while MDCT had a sensitivity of 83.72% with no statistically significant difference (p = 0.180). For lesions between 3.1 and 4 cm, US/CEUS had a sensitivity of 87.88%, while MDCT had a sensitivity of 93.94% with no statistically significant difference (p = 0.688). For lesions larger than 4 cm US/CEUS, had a sensitivity of 90.91%, while MDCT had a sensitivity of 100% with no statistically significant difference (p = 0.250)., Conclusion: US/CEUS sensitivity in diagnosing pancreatic ductal adenocarcinoma is adequate and does not statistically differ from that of MDCT. US/CEUS sensitivity seems to be higher for small and medium lesions, while MDCT sensitivity is higher for large lesions. By combining both the imaging methods a higher accuracy in diagnosing pancreatic ductal adenocarcinoma can be expected., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: The authors sought to determine magnetic resonance/magnetic resonance cholangiopancreatography (MR/MRCP) imaging features of incidentally discovered benign, noncommunicating cystic neoplasms (BNCNs) of the pancreas to assess their evolution over time and identify MR/MRCP imaging features predictive of tumour growth., Material and Methods: This was a retrospective study, so informed consent was waived. Sixty-two patients with a diagnosis of BNCN were assessed. Inclusion criteria were incidentally discovered cystic neoplasm of the pancreas with nonmeasurable walls, no mural nodules and no communication with the pancreatic ductal system and who underwent ≥ 1 MR/MRCP examination. Image analysis, performed at diagnosis and during follow-up, included macroscopic pattern (microcystic/macrocystic/mixed), number of cysts (unicystic/oligocystic/multicystic), BNCN maximum diameter and tumour growth rates., Results: A total of 64 BNCNs was detected. Macroscopic pattern was mixed in 31/64 (48%), microcystic in 28/64 (44%) and macrocystic in 5/64 (8%). BNCNs appeared multicystic in 38/64 (59%) cases, oligocystic in 22/64 (35%) and unicystic in 4/64(6%). All qualitative parameters remained unchanged during follow-up. At diagnosis, the median maximum BNCN diameter was 35.0 mm and 38.0 mm at the final examination (p<0.001). BNCNs showed a tumour growth rate of 2 mm/year., Conclusions: Mixed and microcystic patterns were the most common, accounting for 48% and 44% of cases, respectively, and showed no change over time. MR/MRCP features predictive of lesion enlargement were a mixed/ macrocystic pattern, and lesion size was >3 cm (both p<0.001).

Objectives: To describe perfusion CT features of locally advanced pancreatic ductal adenocarcinoma and to evaluate correlation with tumor grading., Methods: Thirty-two patients with locally advanced pancreatic adenocarcinoma were included in this study. Lesions were evaluated by P-CT and biopsy after patient's informed consent. P-CT parameters have been assessed on a large single and on 6 small intratumoral ROIs. Values obtained have been compared and related to the tumor grading using Mann-Whitney U test. Sensibility, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy in predicting tumor grading have been calculated for cut-off values chosen by using ROC curves., Results: Out of 32 lesions, 12 were classified as low grade and 20 as high grade. A statistically significant difference between high and low grade neoplasms were demonstrated for PEI and BV parameters. PEI and BV cut-off values were respectively 17.8 HU and 14.8 ml/100g. PEI identified high grade neoplasms with a 65% sensitivity, 92% specificity, 93% PPV, 61% NPV and 75% accuracy. BV identified high grade neoplasms with a 80% sensitivity, 75% specificity, 84% PPV, 69% NPV, 78% accuracy. Considering both PEI and BV, P-CT identified high grade lesions with a 60% sensitivity, 100% specificity, 100% PPV, 60% NPV and 75% accuracy., Conclusions: PEI and BV perfusion CT parameters proved their efficiency in identifying high grade pancreatic adenocarcinoma., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objective: To evaluate the usefulness of fistulography as a diagnostic and management tool for clinically suspected pancreatic fistulas (PF) after pancreaticoduodenectomy (PD)., Methods: 84 consecutive fistulographies were performed for clinical suspicion of PF and retrospectively analysed. We radiologically defined two types of PF by means of fistulography, PF1 in the case of primary filling with contrast agent of the jejunal loop or stomach and PF2 in the case of secondary filling of the jejunal loop or stomach through a fistulous tract or a fluid collection., Results: In 35/84 (41.7%) of the fistulograms, a PF1 was demonstrated owing to an instantaneous opacification of the intestinal lumen or the stomach, without evidence of a fistulous tract or fluid collection. In 49/84 (58.3%) fistulograms, a PF2 was demonstrated by the depiction of a fluid collection and/or a fistulous tract and a communication with the intestinal loop or the stomach anastomised with the pancreas. The mean healing time of a PF after PD was 2.7 days for PF1, and 9.8 days for PF2., Conclusion: Fistulography helps in the confirmation of clinically suspect PF, and can distinguish PF1 and PF2, thus decreasing post-operative morbidity significantly.

Pancreatic carcinoma is the fourth cause of death from cancer in the United States, with a survival rate at 5 years of less than 5%. About 60% of tumors originate at the head of the pancreas, 15% in the body, 5% in the tail; 20% are diffuse within the pancreas. This article discusses the imaging and staging of pancreatic cancer.

The role of imaging in functioning endocrine tumours (FETs) is primarily to detect the tumour, that is, to verify lesion number and location. Radiological detection of carcinoid tumours is limited by typical tumour location throughout the gastrointestinal tract or appendix and is therefore dependent on the tumour being large enough to make it recognisable in that site. The most common FET is insulinoma, which is commonly characterised by the typical appearance of a hypervascular lesion at multidetector-row computed tomography and magnetic resonance imaging. A particularly important role is played by intraoperative ultrasound in defining the exact number of lesions, their relationship with adjacent vascular structures and the pancreatic duct for the purposes of correct surgical planning (enucleation or resection). In the setting of nonfunctioning endocrine tumours (NFETs), which manifest late as large masses causing compression symptoms or as incidental findings, imaging is not primarily aimed at tumour detection, as this is relatively easy given the large size of the lesions. Rather, its role is to characterise the tumour and, in particular, to differentiate pancreatic NFET from ductal adenocarcinoma, as in comparison, malignant NFETs have a more favourable prognosis (5-year survival rate 40% compared with 3%-5% for adenocarcinoma) and therefore require different treatment approaches. As NFET are often malignant, they also require accurate staging and appropriate follow-up. In 80% of cases, NFETs have a "typical" imaging appearance: location in the pancreatic head, large dimensions (diameter between 5 and 15 cm, >10 cm in 30% of cases), capsule, sharp and regular margins owing to the expansile and noninfiltrative growth pattern, solid density and arterial hypervascularity. Some 20% of NFETs display different imaging characteristics ("atypical" appearance) as a result of arterial hypovascularity due to the presence of abundant fibrous stroma. Lastly, a small percentage of NFETs has yet a different appearance ("unusual") due to the cystic nature and/or diffuse location throughout the pancreatic parenchyma.

Tissue confirmation of the diagnosis is required either for unresectable pancreatic masses or for resectable masses when the diagnosis is uncertain. In this article, we review indications, technique, and clinical results of percutaneous fine-needle aspiration of focal pancreatic lesions.

Conventional ultrasonography represents the first diagnostic imaging modality for the study of pancreatic tumors. Contrast-enhanced ultrasound has significantly improved the accuracy of first-line examination and may influence the choice of second-line investigations: multidetector computed tomography is considered the gold standard for studying pancreatic solid lesions and tumor staging, while MRI with magnetic resonance cholangiopancreatography allows better study of pancreatic cystic lesions and the ductal system. To definitely diagnose a pancreatic lesion, image-guided fine-needle-aspiration or biopsy are very often required. PET with 18-fluorodeoxyglucose, endoscopic ultrasound and intraoperative ultrasonography remain techniques often employed in the third line. This article reviews the imaging techniques generally used for diagnosing the main pancreatic tumors, and a work-up algorithm is finally proposed.

Purpose: To retrospectively determine the accuracy of magnetic resonance (MR) imaging combined with MR cholangiopancreatography (CP) in differentiating benign from malignant intraductal papillary mucinous neoplasms (IPMNs) involving the main pancreatic duct (MPD), with histopathologic analysis as the reference standard., Materials and Methods: The informed consent requirement was waived for this institutional review board-approved study. A total of 51 patients with histopathologically proved IPMNs (MPD IPMN, n = 29; mixed type IPMN, n = 22), underwent MR imaging, MR CP, and surgery, with a mean interval of 2.6 months between MR examination and surgery. Qualitative image analysis included assessment of the site of MPD dilatation (head of the pancreas, body and/or tail of the pancreas, or diffuse), presence or absence of duct wall nodules, and contrast enhancement of the MPD walls. Quantitative image analysis included measurement of the maximum diameter of the MPD. A comparison of adenomas and borderline IPMNs with cancerous IPMNs was performed with the Student t test or the Mann-Whitney U test for continuous variables., Results: At histopathologic analysis, 27 IPMNs were classified as carcinomas; 13, as borderline tumors; and 11, as adenomas. MPD wall nodules were observed in 16 carcinomas involving the MPD and one adenoma or borderline neoplasm (P < .00001). Duct wall enhancement was observed in 20 MPD or mixed type carcinomas and five adenomas or borderline neoplasms (P = .0001). The median maximal diameter of the MPD was 18 mm in malignant MPD or mixed type IPMNs and 11 mm in benign borderline IPMNs (P = .038). No significant difference in the overall 5-year survival rate of patients with MPD IPMNs and those with mixed type IPMNs was observed (P = .813)., Conclusion: Duct wall nodules and enhancement of the MPD walls are signs of malignant MPD or mixed type IPMNs., Supplemental Material: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.2531080604/-/DC1.

Context: Acoustic radiation force impulse imaging is an emerging imaging modality. The study of the pancreas is a new and promising application of ultrasound acoustic radiation force impulse imaging., Case Report: We present the first case of pancreatic serous cystadenoma which mimics a solid neoplasm at conventional imaging (US and CT), correctly diagnosed as cystic at ultrasound acoustic radiation force impulse imaging., Conclusion: The "XXXX" values always measured at Virtual Touch tissue quantification allow the diagnosis of a pancreatic cystic lesion with simple fluid content suggesting the diagnosis of serous cystadenoma.

Context: To present the case of an unusual presentation at imaging of a very small solid undifferentiated pancreatic adenocarcinoma which mimics a side-branch intraductal papillary mucinous neoplasm., Case Report: The patient came to our hospital for a revaluation of a cystic pancreatic lesion. Ultrasound (US) and contrast-enhanced ultrasound (CEUS) examinations were carried out. A small cystic lesion of about 1.5 cm in diameter was seen in the posterior aspect of the pancreatic uncinate process A very small, solid, vascularized nodule was detected at CEUS within the lesion. Consequently, the patient underwent CT and MRI. MRI confirmed the presence of an intralesional nodule and communication with the main pancreatic duct was demonstrated, suggesting the diagnosis of intraductal papillary mucinous neoplasm with solid intralesional tissue. A pylorus preserving pancreaticoduodenectomy was carried out. An undifferentiated adenocarcinoma having a notable peripheral inflammatory reaction and dilated branch duct was finally diagnosed., Conclusion: To our knowledge, we present for the first time, the case of a very small solid undifferentiated pancreatic adenocarcinoma of the uncinate process which mimicked a side-branch intraductal papillary mucinous neoplasm at imaging. The cystic appearance may be an epiphenomenon of a solid lesion and this possibility has to be considered when one encounters incidental cystic lesions at imaging.

Purpose: This paper describes the magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) pattern of multifocal intraductal papillary mucinous tumours (IPMT) of the pancreatic side branches and its evolution during followup., Materials and Methods: Twenty-six patients with multifocal IPMT of the side branches were included in this retrospective study. Inclusion criteria were > or =2 ectasic side branches, presence of communication with the main pancreatic duct, and > or =2 MRI/MRCP examinations after > or = 6-12 months. Exclusion criteria were IPMT involving both the main pancreatic duct and its branch ducts, previous surgery and lack of follow-up MRI examinations. Median follow-up was 27 (range 6-59) months. Images were assessed qualitatively and quantitatively. Qualitative assessment considered: the number of cystic lesions of the branch ducts, morphology of the communication between the cystic lesion and the main duct (direct or neck), presence of intraluminal filling defects within the cystic lesions, presence of mural nodules and mural enhancement of the cystic lesion. quantitative assessment considered mean maximal diameter of the cystic lesions and mean length of the communication neck., Results: At diagnosis, the mean number of cystic lesions of the side branches was 7.5. a communication neck was detected in 16/26 patients (60%). Intraluminal filling defects in the side branches were present in 6/26 patients (23%). Mural nodules were seen in 1/26 patients (4%). The mean diameter of the cystic lesions was 18.8 mm. The mean length of the communication neck was 6.9 mm. At follow-up, the mean number of cystic lesions of the side branches was 8.4. A communication neck was detected in 20/26 patients (77%). Intraluminal filling defects in the side branches were detected in 7/26 patients (27%); mural nodules were seen in 2/26 patients (8%). Mural enhancement of the branch duct was detected in 2/26 patients (8%). The mean diameter of the cystic lesions increased to 22.3 mm (p < 0.05), and the mean length of the communication neck was 8.6 mm., Conclusions: MultifocaL IPMT of the side branches shows a constant but very slow progression over time. In our series, only 2/26 patients showed mural nodules.

In 246 controlled jaundiced patients, the value of ultrasonography was confirmed. The differentiation of medical from surgical jaundice was 96% accurate. There was an increase in the overall accuracy due to technological developments and better scanning techniques. Nevertheless important diagnostic problems are still unresolved. Although the precise location of the obstructing lesion was determined in 86% of surgical case, the cause was established in only 69%. In medical jaundice diagnostic findings were observed only in congestive liver due to chronic heart failure and in some cases of cirrhosis.

The authors refer the results of angiography in 46 patients with proven pancreatic carcinoma. Based on the prospective report there were 40 correct diagnoses, giving an overall accuracy of 86.95%. The incidence of the angiographic features has been investigated; basing on these findings the possibility of a radical surgery was suggested. 24 of these patients have undergone echotomography. The authors compare the results of the two investigations, concluding that these are complementary in diagnosis and prediction of resectability (invasion of great vessels, secondary deposits to the liver). Echotomography allows to recognize a large number of small dimension carcinomas, suggesting its use in the screening of those patients with suspected pancreatic neoplasm. Angiography is still essential to perform radical surgery.