review of literature on clinical pancreatology - The Pancreapedia

IPMN were studied. Two-dimensional MRCP protocol included multiplanar thin- and thickslabsingle-shot fast spin-echo imaging, coronal single-shot fast spin-echo, and transverseT2-weighted fast spin-echo imaging. Three-dimensional MRCP was performed using a fastrecoveryfast spin-echo sequence with single-volume acquisition and maximum intensityprojection reconstructions. Using a 5-point scale, 2 readers independently evaluated MRCPsfor image quality, visualization <strong>of</strong> the pancreatic duct, and visualization <strong>of</strong> the cystic lesions.Intraductal papillary mucinous neoplasm's morphological features (septa, mural nodules, andduct communication) were also graded similarly to predict benignity or malignancy. Apancreatic surgeon <strong>review</strong>ed the 21 MRCPs to determine the usefulness <strong>of</strong> 3D MRCPcompared with that <strong>of</strong> 2D MRCP for surgical planning. Of the 21 IPMNs, 11 were side-branchIPMNs and 10 were main-duct-lesions IPMNs with side-branch involvement. A statisticallysignificant improvement in image quality and visualization <strong>of</strong> the PD and cystic lesion wasdemonstrated with 3D MRCP in comparison with that demonstrated with 2D MRCP. Themorphological details <strong>of</strong> IPMN were also identified, with higher confidence with 3D MRCP incomparison with that using 2D MRCP. Two-dimensional and 3D MRCPs performed similarlyfor predicting benign and malignant lesions, with sensitivity ranging from 50 to 67 percentand specificity ranging from 87 to 93 percent. The pancreatic surgeon preferred 3D to 2DMRCP for surgical evaluation and planning in 14 <strong>of</strong> 21 cases. It was thus concluded thatcompared with 2D MRCP, 3D MRCP provides better image quality, <strong>of</strong>fers superior evaluation<strong>of</strong> the pancreatic duct and morphological details <strong>of</strong> IPMN, and is preferred for surgicalplanning [591].EUSBecause <strong>of</strong> greater recognition and improved imaging capabilities, intraductal papillarymucinous neoplasms (IPMNs) are being diagnosed with increasing frequency. IPMNs <strong>of</strong> themain pancreatic duct cause symptoms and lead to pancreatitis. Side-branch IPMNs arethought to cause symptoms less frequently, and their association with pancreatitis is not welldefined. A total <strong>of</strong> 305 patients underwent EUS examinations between 2002 and 2006 forpancreatic cystic lesions. The main outcome measure was the frequency <strong>of</strong> acute or chronicpancreatitis that was not procedurally related. Thirty-two patients had side-branch IPMNs,and 11 (34 %) had pancreatitis. Three patients reported a single episode, and 8 patientsreported having recurrent episodes <strong>of</strong> pancreatitis. Overall, 17 (53 %) patients had symptomspossibly attributable to side-branch IPMN. Female sex (73 % vs 38 %) and multiplepancreatic lesions (54 % vs 24 %) were more commonly seen in those with pancreatitis, butwere not statistically significant factors. Larger cyst size or cyst fluid marker levels did notappear associated with pancreatitis occurrence. EUS-FNA demonstrated communicationwith the pancreatic duct in 94 percent and thick, mucinous fluid in 84 percent. It wasconcluded that pancreatitis was frequently associated with the presence <strong>of</strong> side-branchIPMNs in our referral practice. Side-branch IPMNs should be considered in the differentialdiagnosis <strong>of</strong> patients with recurrent pancreatitis with cystic lesions seen on imaging studies.EUS-FNA was the most useful modality in helping to differentiate side-branch IPMNs fromother lesions [592].Differential diagnosesCystic and neuroendocrine pancreatic neoplasms are quite rare tumors which diagnosis is<strong>of</strong>ten difficult due to their non specific symptomatology and limited diagnostic accuracy <strong>of</strong>conventional diagnostic instruments. A young woman was now admitted with abdominal painand dyspepsia. Instrumental diagnosis revealed a cystic pancreatic lesion which seems to bemalignant as CEA <strong>of</strong> pancreatic liquid was increased. The patient underwent distal splenopancreatectomyand postoperative histological examination found IPMN associated withMCN and furthermore there was occasional diagnosis <strong>of</strong> a small neuroendocrine tumor in thepancreatic tail. Radical surgical treatment is indicated in many cases <strong>of</strong> main duct IPMN andin case <strong>of</strong> MCN with signs <strong>of</strong> malignant transformation. Surgical treatment is also the goldstandard for pancreatic neuroendocrine tumors if they are singular and in M0 stage [593].