Purpose
To determine if the T1 relaxation time of the pancreas can detect parenchymal changes in mild chronic pancreatitis (CP).
Materials and Methods
This Institutional Review Board (IRB)‐approved, ...Health Insurance Portability and Accountability Act (HIPAA)‐compliant retrospective study analyzed 98 patients with suspected mild CP. Patients were grouped as normal (n = 53) or mild CP (n = 45) based on history, presenting symptomatology, and concordant findings on both the secretin‐enhanced magnetic resonance cholangiopancreatography (S‐MRCP) and endoscopic retrograde cholangiopancreatography (ERCP). T1 maps were obtained in all patients using the same 3D gradient echo technique on the same 3T scanner. T1 relaxation times, fat signal fraction (FSF), and anterior–posterior (AP) diameter were correlated with the clinical diagnosis of CP.
Results
There was a significant difference (P < 0.0001) in the T1 relaxation times between the control (mean = 797 msec, 95% confidence interval CI: 730, 865) and mild CP group (mean = 1099 msec, 95% CI: 1032, 1166). A T1 relaxation time threshold value of 900 msec was 80% sensitive (95% CI: 65, 90) and 69% specific (95% CI: 56, 82) for the diagnosis of mild CP (area under the curve AUC: 0.81). Multiple regression analysis showed that T1 relaxation time was the only statistically significant variable correlating with the diagnosis of CP (P < 0.0001). T1 relaxation times showed a weak positive correlation with the pancreatic FSF (ρ = 0.33, P = 0.01) in the control group, but not in the mild CP group.
Conclusion
The T1 relaxation time of the pancreatic parenchyma was significantly increased in patients with mild CP. Therefore, T1 mapping might be used as a practical quantitative imaging technique for the evaluation of suspected mild CP.
Level of Evidence: 3
J. Magn. Reson. Imaging 2017;45:1171–1176
To determine if the T
relaxation time of the pancreas can detect parenchymal changes in mild chronic pancreatitis (CP).
This Institutional Review Board (IRB)-approved, Health Insurance Portability ...and Accountability Act (HIPAA)-compliant retrospective study analyzed 98 patients with suspected mild CP. Patients were grouped as normal (n = 53) or mild CP (n = 45) based on history, presenting symptomatology, and concordant findings on both the secretin-enhanced magnetic resonance cholangiopancreatography (S-MRCP) and endoscopic retrograde cholangiopancreatography (ERCP). T
maps were obtained in all patients using the same 3D gradient echo technique on the same 3T scanner. T
relaxation times, fat signal fraction (FSF), and anterior-posterior (AP) diameter were correlated with the clinical diagnosis of CP.
There was a significant difference (P < 0.0001) in the T
relaxation times between the control (mean = 797 msec, 95% confidence interval CI: 730, 865) and mild CP group (mean = 1099 msec, 95% CI: 1032, 1166). A T
relaxation time threshold value of 900 msec was 80% sensitive (95% CI: 65, 90) and 69% specific (95% CI: 56, 82) for the diagnosis of mild CP (area under the curve AUC: 0.81). Multiple regression analysis showed that T
relaxation time was the only statistically significant variable correlating with the diagnosis of CP (P < 0.0001). T
relaxation times showed a weak positive correlation with the pancreatic FSF (ρ = 0.33, P = 0.01) in the control group, but not in the mild CP group.
The T
relaxation time of the pancreatic parenchyma was significantly increased in patients with mild CP. Therefore, T
mapping might be used as a practical quantitative imaging technique for the evaluation of suspected mild CP.
3 J. Magn. Reson. Imaging 2017;45:1171-1176.
Background and Aims Management of branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) remains challenging. We determined factors associated with malignancy in BD-IPMNs and long-term ...outcomes. Methods This retrospective cohort study included all patients with established BD-IPMNs by the International Consensus Guidelines (ICG) 2012 and/or pathologically confirmed BD-IPMNs in a tertiary care referral center between 2001 and 2013. Main outcome measures were the association between high-risk stigmata (HRS)/worrisome features (WFs) of the ICG 2012 and malignant BD-IPMNs, performance characteristics of EUS-FNA for the diagnosis of malignant BD-IPMNs, and recurrence and long-term outcomes of BD-IPMN patients undergoing surgery or imaging surveillance. Results Of 364 BD-IPMN patients, 229 underwent imaging surveillance and 135 underwent surgery. Among the 135 resected BD-IPMNs, HRS/WFs on CT/magnetic resonance imaging (MRI) were similar between the benign and malignant groups, but main pancreatic duct (MPD) dilation (5-9 mm) was more frequently identified in malignant lesions. On EUS-FNA, mural nodules, MPD features suspicious for involvement, and suspicious/positive malignant cytology were more frequently detected in the malignant group with a sensitivity, specificity, and accuracy of 33%, 94%, and 86%; 42%, 91%, and 83%; and 33% 91%, and 82%, respectively. Mural nodules identified by EUS were missed by CT/MRI in 28% in the malignant group. Patients with malignant lesions had a higher risk of any IPMN recurrence during a mean follow-up period of 131 months ( P = .01). Conclusions Among HRS and WFs of the ICG 2012, an MPD size of 5 to 9 mm on CT/MRI was associated with malignant BD-IPMNs. EUS features including mural nodules, MPD features suspicious for involvement, and suspicious/malignant cytology were accurate and highly specific for malignant BD-IPMNs. Our study highlights the incremental value of EUS-FNA over imaging in identifying malignant BD-IPMNs, particularly in patients without WFs and those with smaller cysts. Benign IPMN recurrence was observed in some patients up to 8 years after resection.
Background The feasibility of single-operator cholangioscopy (SOC) for biliary diagnostic and therapeutic procedures was previously reported. Objective To confirm the utility of SOC in more ...widespread clinical use. Design Prospective clinical cohort study. Setting Fifteen endoscopy referral centers in the United States and Europe. Patients Two hundred ninety-seven patients requiring evaluation of bile duct disease or biliary stone therapy. Interventions SOC examination and, as indicated, SOC-directed stone therapy or forceps biopsy. Main Outcome Measurements Procedural success defined as ability to (1) visualize target lesions and, if indicated, collect biopsy specimens adequate for histological evaluation or (2) visualize biliary stones and initiate fragmentation and removal. Results The overall procedure success rate was 89% (95% CI, 84%-92%). Adequate tissue for histological examination was secured in 88% of 140 patients who underwent biopsy. Overall sensitivity in diagnosing malignancy was 78% for SOC visual impression and 49% for SOC-directed biopsy. Sensitivity was higher (84% and 66%, respectively) for intrinsic bile duct malignancies. Diagnostic SOC procedures altered clinical management in 64% of patients. Procedure success was achieved in 92% of 66 patients with stones and complete stone clearance during the study SOC session in 71%. The incidence of serious procedure-related adverse events was 7.5% for diagnostic SOC and 6.1% for SOC-directed stone therapy. Limitations The study was observational in design with no control group. Conclusions Evaluation of bile duct disease and biliary stone therapy can be safely performed with a high success rate by using the SOC system.
In this trial involving patients at increased risk for pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP), rectal indomethacin reduced the incidence of this condition, as ...compared with placebo (9% vs. 17%).
Acute pancreatitis is the most common major complication of endoscopic retrograde cholangiopancreatography (ERCP),
1
accounting for substantial morbidity, occasional death, and estimated health care expenditures of approximately $150 million annually in the United States.
2
,
3
Given the magnitude of this problem, more than 35 pharmacologic agents have been studied for the prophylaxis of post-ERCP pancreatitis, and many prospective clinical trials addressing chemoprevention have been conducted. To date, however, no medication has proved to be consistently effective in preventing post-ERCP pancreatitis on the basis of data from high-quality clinical trials, and no pharmacologic prophylaxis for post-ERCP pancreatitis is in widespread clinical use. . . .
Accurate peripheral markers for the diagnosis of pancreatic ductal adenocarcinoma (PDAC) are lacking. We measured the differential expression of select microRNAs (miRNAs) in plasma and bile among ...patients with PDAC, chronic pancreatitis (CP), and controls.
We identified patients (n=215) with treatment-naive PDAC (n=77), CP with bile/pancreatic duct pathology (n=67), and controls (n=71) who had been prospectively enrolled in a Pancreatobiliary Biorepository at the time of endoscopic retrograde cholangiopancreatography or endoscopic ultrasound. Controls were patients with choledocholithiasis but normal pancreata. The sample was separated into training (n=95) and validation (n=120) cohorts to establish and then test the performance of PDAC Signature Panels in diagnosing PDAC. The training cohort (n=95) included age-matched patients with PDAC, CP, and controls. Panels were derived from the differential expression of 10 candidate miRNAs in plasma or bile. We selected miRNAs having excellent accuracy for inclusion in regression models.
Using the training cohort, we confirmed the differential expression of 9/10 miRNAs in plasma (miR-10b, -30c, -106b, -132, -155, -181a, -181b, -196a, and -212) and 7/10 in bile (excluding miR-21, -132, and -181b). Of these, five (miR-10b, -155, -106b, -30c, and -212) had excellent accuracy for distinguishing PDAC. In the training and validation cohorts, the sensitivity/specificity for a PDAC Panel derived from plasma was 95/100% and 100/100%, respectively; in bile, these were 96/100% and 100/100%.
Increased expression of miRNA-10b, -155, and -106b in plasma appears highly accurate in diagnosing PDAC. Additional studies are needed to confirm this Panel and explore its value as a prognostic test.
In this article, we review our multidisciplinary approach for patients with pancreatic cancer. Specifically, we review the epidemiology, diagnosis and staging, biliary drainage techniques, selection ...of patients for surgery, chemotherapy, radiation therapy, and discuss other palliative interventions. The areas of active research investigation and where our knowledge is limited are emphasized.
Background Endoscopic papillectomy is increasingly used as an alternative to surgery for ampullary adenomas and other noninvasive ampullary lesions. Objective To measure short-term safety and ...efficacy of endoscopic papillectomy, define patient and lesion characteristics associated with incomplete endoscopic resection, and measure adenoma recurrence rates during long-term follow-up. Design Retrospective cohort study. Setting Tertiary-care academic medical center. Patients All patients who underwent endoscopic papillectomy for ampullary lesions between July 1995 and June 2012. Intervention Endoscopic papillectomy. Main Outcome Measurements Patient and lesion characteristics associated with incomplete endoscopic resection and ampullary adenoma-free survival analysis. Results We identified 182 patients who underwent endoscopic papillectomy, 134 (73.6%) having complete resection. Short-term adverse events occurred in 34 (18.7%). Risk factors for incomplete resection were jaundice at presentation (odds ratio OR 0.21; 95% confidence interval CI 0.07-0.69; P = .009), occult adenocarcinoma (OR 0.06; 95% CI, 0.01-0.36; P = .002), and intraductal involvement (OR 0.29; 95% CI, 0.11-0.75; P = .011). The en bloc resection technique was strongly associated with a higher rate of complete resection (OR 4.05; 95% CI, 1.71-9.59; P = .001). Among patients with ampullary adenoma who had complete resection (n = 107), 16 patients (15%) developed recurrence up to 65 months after resection. Limitations Retrospective analysis. Conclusion Jaundice at presentation, occult adenocarcinoma in the resected specimen, and intraductal involvement are associated with a lower rate of complete resection, whereas en bloc papillectomy increases the odds of complete endoscopic resection. Despite complete resection, recurrence was observed up to 5 years after papillectomy, confirming the need for long-term surveillance.
Chronic pancreatitis (CP) has a profound independent effect on quality of life (QOL). Our aim was to identify factors that impact the QOL in CP patients.
We used data on 1,024 CP patients enrolled in ...the three NAPS2 studies. Information on demographics, risk factors, co-morbidities, disease phenotype, and treatments was obtained from responses to structured questionnaires. Physical and mental component summary (PCS and MCS, respectively) scores generated using responses to the Short Form-12 (SF-12) survey were used to assess QOL at enrollment. Multivariable linear regression models determined independent predictors of QOL.
Mean PCS and MCS scores were 36.7±11.7 and 42.4±12.2, respectively. Significant (P<0.05) negative impact on PCS scores in multivariable analyses was noted owing to constant mild-moderate pain with episodes of severe pain or constant severe pain (10 points), constant mild-moderate pain (5.2), pain-related disability/unemployment (5.1), current smoking (2.9 points), and medical co-morbidities. Significant (P<0.05) negative impact on MCS scores was related to constant pain irrespective of severity (6.8-6.9 points), current smoking (3.9 points), and pain-related disability/unemployment (2.4 points). In women, disability/unemployment resulted in an additional 3.7 point reduction in MCS score. Final multivariable models explained 27% and 18% of the variance in PCS and MCS scores, respectively. Etiology, disease duration, pancreatic morphology, diabetes, exocrine insufficiency, and prior endotherapy/pancreatic surgery had no significant independent effect on QOL.
Constant pain, pain-related disability/unemployment, current smoking, and concurrent co-morbidities significantly affect the QOL in CP. Further research is needed to identify factors impacting QOL not explained by our analyses.
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