Ductectatic mucinous cystadenocarcinoma of the pancreas: a rare variant

A rare case of the ductectatic variant of mucinous pancreatic cystadenocarcinoma in a 64 year-old man, presenting with painless obstructive jaundice, is reported. CT scan revealed a multicystic lesion of the pancreatic head, which caused biliary obstruction. Endoscopic retrograde pancreatography (ERP) revealed the characteristic grapelike cluster pattern of pancreatic ductectatic neoplasms. Pancreaticoduodenectomy was then successfully performed. Pancreatic ductectatic mucinous cystadenocarcinoma is a rare entity, presenting, usually, with obstructive pancreatitis, and is histologically indistinguishable from the classic malignant mucinous cystic neoplasm. ERP is the diagnostic method of choice and should be performed in any case of susceptible pancreatic lesions.     

MR cholangiopancreatography of pancreas divism and anomalous arrangement of the pancreaticobiliary ducts

The purpose of this study was to evaluate the usefulness of MR cholangiopancreatography (MRCP) for pancreas divism and anomalous arrangement of pancreaticobiliary ducts (APBD). In 214 patients, MRCP was performed. In 204 patients (94%), pancreaticobiliary ductal junction could be recognized. Pancreas divism was observed in 13 of 204 patients (6%), and APBD was observed in 10 of 204 patients (5%). Dynamic MRCP after secretin stimulation was useful for diagnosing pancreas divism and APBD.     

Mucin-hypersecreting intraductal neoplasms of the pancreas: a precursor to cystic pancreatic malignancies

BACKGROUND: Muncin-hypersecreting intraductal pancreatic neoplasms were first described in 1982 and have been observed in increasing numbers since. They are observed primarily by endoscopic retrograde cholangiopancreatography (ERCP) and are characterized by an intraductal papillary neoplasm that secretes thick mucin, causing pancreatic duct dilatation and obstructive pancreatitis. METHODS: Twenty patients are presented, 14 male and six female, with an average age of 59 +/- 11 years. All patients presented with abdominal pain, and most had nausea and vomiting, weight loss, and documented pancreatitis. Of the preoperative studies, ERCP was positive in all patients. Computed tomography scan, endoscopic ultrasonogram, and cytologic findings were less sensitive. Tumor markers were only positive in one patient. All 20 patients were treated surgically. Nine underwent Whipple procedure, one patient had a total pancreatectomy, and nine had distal pancreatic resections. The first patient in the series did not have a pancreatic resection, and his disease evolved into a lethal cystadenocarcinoma causing his death 99 months later. RESULTS: Histopathologic findings were interpreted as borderline malignant in 17 of the 20 patients, and three patients had evidence of invasive adenocarcinoma. Two of these three patients had nodal or distant metastases at the time of diagnosis, and all three died of adenocarcinoma. Seventeen of the patients are alive and well, although two of three with positive pancreatic margins have had recurrent symptoms and have been successfully reresected. CONCLUSIONS: The mucin-producing intraductal papillary tumor of the pancreas is a newly described variant of pancreatic cancer. It presents with symptoms of pancreatitis and has a progressive but more indolent course than the more lethal invasive ductal cancers. Patients with unexplained pancreatitis should undergo ERCP investigation, and aggressive surgical therapy should be carried out because the prognosis for this lesion, when appropriately treated, is more favorable than the usual pancreatic cancer.     

Intraductal papillary tumors and mucinous cystic tumors of the pancreas: clinicopathologic study of 38 cases

Clinicopathological features of 28 patients with intraductal papillary tumor (IDPT) and 10 patients with mucinous cystic tumor (MCT) of the pancreas were studied. Both IDPT and MCT showed papillary projections of the epithelium with abundant mucus secretion in the ectatic ducts or cystic spaces. The patients with IDPT comprised 19 men and 9 women with a mean age of 64.9 years. Three fourths of the IDPTs were located in the pancreatic head, and the mean tumor size was 3.5 cm. Local recurrence was observed in one patient, but none died of IDPT. In contrast, all patients with MCT were women, with a mean age of 49.4 years. None of the MCTs arose in the head, and the mean tumor size was 7.1 cm. One patient died of MCT, but all of the others survived without recurrence. Eight IDPTs and three MCTs showed invasion into the surrounding pancreatic tissue. Muconodular infiltration was mainly observed in five IDPTs and one MCTs and tubular infiltration in three IDPTs and two MCTs. A characteristic histological finding associated with the muconodular infiltration in IDPT was subepithelial "mucin droplets" that appeared to represent a change in polarity of mucus secretion. The formation of such subepithelial "mucin droplets" may be the initial step of muconodular infiltration in IDPT. Muconodular infiltration in IDPT appears different morphologically and biologically from the mucinous carcinoma subtype of conventional invasive ductal carcinoma.     

Magnetic resonance cholangiopancreatography: a novel approach to the evaluation of suspected pancreaticobiliary neoplasms

BACKGROUND: Magnetic resonance cholangiopancreatography (MRCP) is a new noninvasive diagnostic method for pancreaticobiliary (PB) imaging without endoscopy, sedation, or iodinated contrast. The purpose of this study was to evaluate the ability of MRCP to depict pancreatic and biliary ductal anatomy compared to that of endoscopic retrograde cholangiopancreatography (ERCP) and to evaluate the ability of MRCP to accurately diagnose PB neoplasms. METHODS: Twenty patients had MRCP, and 17 also had ERCP. All studies were read prospectively by experienced reviewers blinded to other imaging data. Pathologic diagnosis was made in all patients. RESULTS: Bile duct dilatation seen by ERCP in 14 of 17 patients was correctly identified by MRCP in all 14 patients, and normal ducts were correctly identified by MRCP in the other 3 patients. The pancreatic duct was visible on MRCP in the pancreatic head in 17 of 20 patients, the body in 17 of 20 patients, and the tail in 15 of 20 patients. At ERCP, pancreatic duct dilatation was present in 11 cases and was identified by MRCP in 10 of them. Eighteen of 20 patients had malignant PB neoplasms. MRCP indicated PB neoplasm in 19 patients. Seventeen of these 19 patients had histologically confirmed malignant neoplasms pathologically, whereas 2 had benign pathology (both chronic pancreatitis). Among the 17 patients who also had ERCP, MRCP and ERCP correctly agreed on a final diagnosis of malignant neoplasm in 14 cases. In the three cases in which MRCP and ERCP disagreed on a final diagnosis, MRCP was correct in one and incorrect in two. CONCLUSIONS: MRCP can accurately and noninvasively delineate PB ductal anatomy and diagnose PB neoplasms comparably to ERCP. MRCP is an interesting new noninvasive method for evaluating patients with suspected PB neoplasms.     

MR cholangiopancreatography with single-shot fast-spin-echo sequences]

Imaging quality of MR cholangiopancreatography (MRCP) has recently made a great advance, and MRCP plays an important part in the diagnosis of pancreticobiliary diseases. To obtaining excellent-quality MRCP images, three conditions are required: fluid-to-background contrast, high spatial resolution, and suppression of respiratory motion artifacts. Respiratory motion artifacts, whose suppression is especially important for MRCP, can be controlled by the use of breath-holding, signal averaging, or respiratory triggering. These images are implemented in either single-slice technique or multi-slice technique. We have performed MRCP prior to endoscopic retrograde cholangiopancreatography (ERCP) in more than 100 patients. MRCP images were obtained as maximum-intensity-projection (MIP) reconstruction images and thick-slice projection images by using single-shot fast-spin-echo sequence, and MIP reconstruction images by using respiratory-triggered fast-spin-echo sequence. We reviewed MRCP imaging with single-shot fast-spin-echo sequences.     

Optimization of pulse sequences for MR cholangiopancreatography with FASE

Various types of pulse sequences for MR cholangiopancreatography (MRCP) have been developed in the past ten years. FASE (fast advanced spin echo) is one of the single-shot fast spin-echo sequences developed by Toshiba. By using this sequence, 2D single slice, 2D multiple slice and 3D methods can be provided. We routinely employ 2D single slice and 3D methods. The merit of 2D single slice method is conveniently obtained projection imaging within short data acquisition time. On the other hand, 3D method can yield detailed evaluation of various anatomical structures and abnormalities by using thin-slice source images. O2-inhalation study is especially recommended in case of 3D method. With the proper knowledge of sequence characteristics, MRCP using FASE can provide valuable informations of pancreatico-biliary diseases.     

Findings of MR and MR cholangiopancreatography in acute cholecystitis

We retrospectively reviewed magnetic resonance cholangiopancreatography (MRCP) of 25 patients with acute cholecystitis based on clinical, sonographic and surgical findings. Intramural high signal intensity on MRCP was demonstrated in 22 of the 25 patients (88%), and pericholedochal high signal intensity was observed in 6 of the 25 patients (24%). Pericholecystic or perihepatic fluid was demonstrated in 6 of the 25 patients (24%). Gallbladder stones were identified in all 21 patients (100%) by sonography, in 19 of the 21 (90%) by MRCP and in 11 of 18 patients by CT (CT was not performed in other 3 patients). Common bile duct calculi were detected in all 6 patients (100%) by MRCP, in 2 of the 6 (33%) by sonography, and in 5 of the 6 (50%) by CT with confirmation of surgical finding or endoscopic retrograde cholangiography (ERC). MRCP had a high accuracy in diagnosing acute cholecystitis with the finding of intramural high signal intensity. MRCP is an excellent method to evaluate acute biliary disease and may replace CT and ERC in the preoperative evaluation of acute cholecystitis.     

MR cholangiopancreatography: technique, indications and clinical results

INTRODUCTION: MR cholangiopancreatography (MRCP) is a new noninvasive imaging technique for the study of biliopancreatic disorders, providing projectional images of the biliary tree and pancreatic duct without any contrast agent. MATERIAL AND METHODS: We used different sequences, with both breath-hold and nonbreath-hold techniques, to acquire MRCP images, first based on GE and then on FSE sequences. FSE images provide higher SNR and are less susceptible to artifacts (metal objects, motion and blood flow artifacts). At the Department of Radiology of the University of Rome La Sapienza, we acquired MRCP images with non breath-hold, 3D fat-suppressed TSE sequences (TR = 3000-2000, TE 700, turbo factor 128) optimized on a .5T magnet with 15 mT/m gradients. No patient preparation or sedation was required, although antiperistaltic drugs and oral administration of tap water were preferred. Four hundred and thirty patients were examined, all of them with an indication to conventional cholangiography. RESULTS: MRCP depicted the whole common bile duct and the first-order intrahepatic branches in all the normal cases. Its accuracy in identifying biliary obstruction level and site was 100%, versus 94.6% in characterizing its cause. MRCP had 96.3% diagnostic accuracy in choledocholithiasis, with some false positives and false negatives caused by: 1) small stones missed on MIP reconstructions; 2) signal loss due to complete CBD obstruction by stones; 3) pneumobilia; 4) differential diagnosis between small stones and air bubbles. The main role of MRCP in benign strictures is to provide a detailed map of the biliary tract for better treatment planning. In particular, MRCP is extremely useful in hepaticojejunostomy patients, where ERC is not indicated because of postoperative anatomical changes. Both conventional MRI and MRCP are important in malignant strictures to identify the lesion and to characterize and stage it. Finally, MR pancreatography is very useful to follow up chronic pancreatitis patients because it shows Wirsung duct strictures and dilatations, intraductal filling defects and, in some cases, the communication between the pseudocyst and the pancreatic duct. CONCLUSIONS: MRCP combined with conventional MRI can completely replace CT and ERCP in bilio-pancreatic disorders.     

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.     

Solitary cystic tumor of the pancreas: EUS-pathologic correlation

BACKGROUND: It is clinically important to distinguish neoplastic from non-neoplastic pancreatic cysts. METHODS: Retrospective correlations were made between pathologic and EUS data from 52 pancreatic solitary cystic tumors: mucinous cystadenoma (10), mucinous cystadenocarcinoma (7), serous cystadenoma (5), ductectatic mucinous cystic tumor (10), solid and papillary epithelial neoplasm (5), and non-neoplastic cyst (15). The mean tumor size was 3.5 cm (range, 1.2 cm to 6.0 cm). RESULTS: Six classifications of the internal structures of these cysts were developed: thick wall type, tumor protruding type, thick septal type, microcystic type, thin septal type, and simple type. Although all neoplastic cysts belonged to the first four types, all non-neoplastic cysts belonged to the last two types. The accuracy of EUS for differentiating tumors was estimated at 96% and 92%, respectively, by two observers. CONCLUSIONS: EUS may become a mandatory modality for differentiating pancreatic solitary cystic tumors and choosing an optimal treatment.     

Pancreatic adenocarcinoma: combination of MR imaging, MR angiography and MR cholangiopancreatography for the diagnosis and assessment of resectability

BACKGROUND: Enteropancreatic malignancy is an important cause of morbidity and mortality associated with multiple endocrine neoplasia type 1 (MEN 1). However, the risk factors and mechanisms of the tumorigenesis of this malignancy are poorly understood. METHODS: The authors conducted a retrospective study of factors associated with the development of malignant enteropancreatic tumor in 69 patients with MEN 1 belonging to a single family. RESULTS: Metastatic enteropancreatic tumor and gastrinoma were identified in 20% and 36% of patients, respectively. Compared with MEN 1 patients who did not have an immediate family history of enteropancreatic malignancy, MEN 1 patients with a first-degree relative affected by enteropancreatic malignancy had an increased risk of developing disseminated tumor (odds ratio, 3.7; P < 0.05). In addition, hypergastrinemia and advanced age were both associated with a significant increase in the risk of enteropancreatic malignancy. Elevated serum glycoprotein alpha subunit levels were associated with enterochromaffin-like cell hyperplasia, gastric carcinoid formation, and disseminated enteropancreatic tumor in hypergastrinemic patients (P < 0.05). CONCLUSIONS: Disease modifier factors act in concert with the MEN 1 gene to modulate the development of enteropancreatic neoplasia. It is possible to identify MEN 1 patients at high risk for developing aggressive enteropancreatic tumors. Heritable disease modifier factor(s) affecting enteropancreatic malignancy appear to reside at loci distinct from that of the MEN 1 gene.     

Dermoid cyst of the pancreas: a rare cystic neoplasm

Dermoid cysts of the pancreas, also called cystic teratomas, are a rare entity and are included in the group of neoplasms with a germ cell origin. Only twelve cases have been described in the world literature. The symptomatology is due to tumor compression of the neighboring tissues. Ultrasonography and computed tomography may be helpful, but there are no pathognomonic data for their preoperative recognition. The differential diagnosis should include all other cystic tumors of the pancreas. Complete surgical removal is mandatory. We describe the diagnostic and surgical procedures in a 74 year-old man with a pre-operatively unsuspected dermoid cyst. We review the previously published cases and emphasize the appropriate therapeutical management.     

Intraductal papillary mucinous tumors of the pancreas: imaging studies and treatment strategies

Heat shock proteins (hsp's) isolated from murine cancer cells can elicit protective immunity and specific cytotoxic T lymphocytes (CTLs) by channeling tumor-derived peptides bound to hsp's to the major histocompatibility class I antigen presentation pathway. Here we have investigated if hsp70 can be used in a novel peptide vaccine for the induction of protective antiviral immunity and memory CTLs. A CTL epitope from the well-defined lymphocytic choriomeningitis virus (LCMV) system was mixed with recombinant hsp70 in vitro under conditions that optimize peptide binding to hsp70. Mice were immunized with the hsp70-peptide mixture and challenged with LCMV. Virus titers were reduced 10-100-fold in these mice compared to control mice. Immunization with the hsp70-peptide mixture resulted in the development of CTL memory cells that could be reactivated during LCMV infection, and that in a 51Cr-release assay could lyse cells pulsed with the same peptide, but not cells pulsed with another LCMV peptide. These results show that hsp70 can be used with CTL epitopes to induce efficient protective antiviral immunity and the generation of peptide-specific CTLs. The results also demonstrate the usefulness of hsp70 as an alternative to adjuvants and DNA vectors for the delivery of CTL epitopes to antigen-presenting cells.     

MRI cholangiopancreatography in the pathology of the bile ducts and pancreas

MR cholangiopancreatography (MRCP) is a recent and exciting imaging modality that allows visualization of bile and pancreatic ducts without morbidity. Although the technique of MRCP is in its early stages of development and MRCP technology is progressing MRCP will undoubtedly replace traditional techniques such as diagnostic ERCP. This article describes MRCP findings in bile or pancreatic duct diseases, analyzes the accuracy of MRCP in these diseases, and discusses the potential role of MRCP in evaluating the pathology of the biliary tract and pancreas.     

Pediatric musculoskeletal neoplasms. Evaluation with MR imaging

MR imaging is an essential tool for the evaluation of musculoskeletal neoplasms in children. It provides useful information for diagnosis, determination of extent of disease, assessment of response to treatment, and detection of complications and effects of therapy. This article reviews the current role of MR imaging in each of these situations. A protocol for the evaluation of these lesions is suggested. Also addressed are issues related to differentiating pathologic conditions, normal marrow, and cartilaginous structures of the pediatric skeleton.     

Basic principles and historical consideration of MR cholangiopancreatography

Basic principle of MR cholangiopancreatography (MRCP) is heavily T2-weighted imaging (hydrography) to use bile and pancreatic juice as "natural contrast medium". Firstly developed sequence for MRCP was a CE-FAST sequence, which employed time-reversed FID signal. The current most popular sequences for MRCP are single-shot fast spin-echo sequences, which are divided into three types (2D single slice, 2D mutiple slice and 3D methods). The advantage of 2D single slice method is conveniently obtained projection imaging within a few seconds of examination time. Both 2D multiple slice and 3D methods consists of a MIP image and a series of source images. The MIP image creates global images of pancreatico-biliary system. The source images provide detailed evaluation of various anatomical structures and abnormalities. By using these sequences properly, MRCP can yield valuable informations of pancreatico-biliary diseases non-invasively.     

Mucinous biliary obstruction associated with a cystic adenocarcinoma of the pancreas

Obstruction of the biliary tree by large amounts of mucinous material is reported in a patient with a mucin-producing cystic adenocarcinoma of the pancreas invading the common bile duct. Although preoperative endoscopic retrograde cholangiography suggested bile duct invasion, mucinous obstruction, as in the previous cases in which it has been reported, was not suspected. Mucinous obstruction, although unusual, should be considered in patients with cystic carcinomas of the pancreas in the presence of jaundice or episodes of cholangitis.