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Pancreatic masses: the weird and the wild

L. Shen1, T. Choy1, E. Felker1, D. Margolis2, D. Lu1, S. Raman1, B. Kadell3; 1 Los Angeles/US 2 New York/US 3 LOS ANGELES/US

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Learning objectives: 1) To learn uncommon presentations of common masses in the pancreas. 2) To learn rare path-proven masses with histopathology correlation. 3) To recognize two different entities in one pancreas. 4) To be familiar with secondary involvement of the pancreas.

Background: Pancreas is a relative small organ in the retroperitoneum, but a variety of masses occur there. Common masses such as intraductal papillary mucinous neoplasm (IPMN) or solid pseudopapillary neoplasm (SPN) can present in uncommon ways. Rare pathologies and multiple co-existing etiologies can also occ[...]

Findings and procedure details: Common Masses Gone Wild Common pancreatic masses:   • Exocrine: 99% of all primary pancreatic neoplasm Pancreatic ductal adenocarcinoma: 90-95% Cystic neoplasm: Intraductal papillary mucinous neoplasms (IPMN) Serous cystadenoma Mucinous cystadenoma Solid pseudopapillary neoplasm (SPN) • End[...]

Conclusion: Many masses and etiologies occur in the pancreas. We have used a collection of cases to show the common masses that have gone wild or the rare entities that are not well known. It is important for radiologists to recognize the uncommon presentations of the common masses and to continue to learn the [...]

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References: De la Santa, Luis Gijón et al. “Radiology of pancreatic neoplasms: an update.” World Journal of Gastrointestinal Oncology 2014. 6(9): 330–343. Morgan, MA; Gaillard, F et al. “Pancreatic neoplasms.” Radiopaedia.org. Oct. 17, 2016. Triantopoulou, Charikleia et al. “Metastatic disease to the pancreas: [...]


Visually Isoattenuating Pancreatic Adenocarcinoma. Diagnostic Imaging tools.

C. Carrera, A. Zanfardini, S. De Luca, L. Alarcón, V. BLANCHET, E. P. Eyheremendy; Buenos Aires/AR

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Learning objectives: To characterize the imaging findings of visually isoattenuating pancreatic adenocarcinoma in MDCT, their secondary signs and their correlation with MRI and US.

Background: Isoattenuating pancreatic adenocarcinoma represent a small but significant percentage of pancreatic cancer (5,4 %) (1,2). Histologically, these tumors are characterized by lower tumor cellularity, more frequent association with intratumoral acinar tissues and islet cells and less frequent tumor necr[...]

Findings and procedure details: We reviewed MDTC performed in 85 patients with a suspected pancreatic mass between September 2009 and May 2016. We obtained in all the cases multiplanar dynamic dual-phase scan, and MIP reformatted images. Isoattenuating tumors were found in 10 of them, all histologically confirmed at surgery (n= 7)[...]

Conclusion: Isoattenuating pancreatic tumors are a small percentage of pancreatic adenocarcinoma with a higher postsurgical survival. Therefore, the detection of secondary signs in MDTC is useful to achieve an early diagnosis. Although US may be a more sensitive method in the detection of these tumors in cases [...]

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References: Kim JH, Park SH, Yu ES, et al. Visually Isoattenuating Pancreatic Adenocarcinoma at Dynamic – Enhanced CT: Frequency, Clinical and Pathological Characteristics, and Diagnosis at Imaging Examinations. Radiology 2010; 257: 87-96. Yoon SH, Lee JM, Cho JY, et al. Small (<20 mm) Pancreatic Adenocarcin[...]


Ultrasound of the hollow viscera: normal patterns vs red flags

F. Matos1, P. F. M. Azevedo1, D. Cardoso1, A. C. Mota1, B. M. T. Rodrigues2, J. Ruivo Rodrigues1, C. Santiago1, D. Silva1; 1 Viseu/PT 2 Quinto-Parada Monção/PT

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Learning objectives: Identifying the normal gut signature and providing a step by step hollow viscera ultrasound (US) technique. Providing a pictorial review of some of the most frequent gut US findings in the radiologist’s routine.  

Background: The assessment of the gut through US is not as widely accepted as the study of solid viscera, although it can demonstrate a variety of bowel related diseases through the recognition of patterns of its wall. US has the advantage of providing real time assessment of the gut wall motility and its vascu[...]

Findings and procedure details: Hollow viscera ultrasound - normal patterns and technique Ideally a 6-hour fast is ideal before the US. In some cases, especially in a context of an acute abdominal pain, this cannot be provided. Recognizing the layering of the bowel wall is the first step to start the hollow viscera ultrasound[...]

Conclusion: Hollow viscera US is a modality for diagnosis and management of hollow viscera disease in an emergency context, providing ionizing radiation free diagnosis, which is important in children and pregnant women. It has a particularly important role in the recurring assessment of IBD ambulatory patients.[...]

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References: Ares D, Berrenechea M, Ruzo J et al. The value of abdominal ultrasound in the diagnosis of colon cancer. Rev Esp Enferm Dig 2005 Dec;97(12):877-86.  Hata J, Haruma K, Yamanaka H, et al: Ultrasonographic evaluation of the bowel wall in inflammatory bowel disease: comparison of in vivo and i[...]


When does a benign focal hepatic lesion undergo surgical resection? The image is on the case.

M. Rodríguez Eiriz, D. Torres Gamboa, E. Usamentiaga, A. Ballester, S. L. Barrero Varon, R. Grau Sola; Palma de Mallorca/ES

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Learning objectives: To review patients who underwent a liver resection for a benign focal hepatic lesion in our hospital between 2010 and 2015.   To describe their imaging features.   To identify the indications for the surgery.

Background: Introduction: Benign space-occupying lesions of the liver are a common finding in the general population due to the increase number of imaging studies performed.   Solid or cystic, they are usually incidental findings in an imaging study performed for another reason. Occasionally, they become[...]

Findings and procedure details: We made a retrospective review of the liver resections of benign focal liver lesions in our hospital between 2010 and 2015. There were a total of 219 lesions, 120 were metastatic and 99 were primary, and of the last, 56 were malignant and 43 benign. Patients with benign lesions were mostly women ([...]

Conclusion: CT and RM are basic in the management of focal liver lesions, as they safely and confidently diagnose the majority of benign lesions, set their intrinsic risks and reject other causes of abdominal pain. So, they are crucial for the decision-making process and for avoiding any unnecessary surgeries.

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References: 1. Jonathan B. Koea. Hepatic incidentaloma: the rule of tens. HPB 2013, 15, 379-383.   2. Katrin Hoffmann, Michael Unsinn, Ulf Hinz et al. Outcome after a liver resection of benign lesions. HPB 2015, 17, 994-1000.   3. Belle V. van Rosmalen, Matthanja Bieze, Marc G. H. Besselink, et al. L[...]


Role of Secretin administration during MRCP in Patients after duodeno-pancreatectomy

C. Fabris, E. Boninsegna, R. Negrelli, S. Mehrabi, G. A. Zamboni, R. Manfredi, R. Pozzi-Mucelli; Verona/IT

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Aims and objectives: Duodeno-pancreatectomy is a complex and laborious surgery, which could carry to several complications, in particular anastomotic leakage, pancreatic fistula and stenosis of the anastomosis between the residual pancreas and the bowel. The postoperative anastomotic obstruction leads to chronic pancrea[...]

Methods and materials: Patient population We considered for inclusion patients who had previously underwent a duodeno-pancreatectomy (DP) in our hospital between Jenuary 2012 and November 2016. The reasons of interventions were several, including malignant adenocarcinoma (5 Patients), autoimmune pancreatitis (2), intraduc[...]

Results: Upstream MPD caliber was 4,18 mm (mean) in basal conditions and 5,6 mm after secretin administration. Dilated side branches were present in 5/12 Patients (41,67%) in basal condition and in 7/12 after secretin stimulation (58,33%). Impaired jejunal filling of pancreatic juice was depicted in 8/12 cas[...]

Conclusion: Secretin-enhanced MRCP is a safe and accurate method for the evaluation of the residual pancreatic gland after duodeno-pancreatectomy; it allows a morphological and functional evaluation of the main pancreatic duct. Also it evaluates the surgical anastomosis, the pancreatic secretion and the jejuna[...]

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References: Reuther G, Kiefer B, Tuchmann A, Pesendorfer FX. Imaging findings of pancreaticobiliary duct diseases with single-shot MR cholangiopancreatography. AJR 1997;168:453–459 Josep Monill, Juan Pernas, Juan Clavero et al… Pancreatic Duct After Pancreatoduodenectomy: Morphologic and Functional Evaluation[...]


Imaging findings in primary and secondary sclerosing cholangiopathy

S. P. D. Vella1, C. Cannataci2, S. Aquilina2, G. Marrone3, F. Crinò3, R. Miraglia3, K. Cortis4; 1 Birkirkara/MT 2 Msida/MT 3 Palermo/IT 4 Zebbug/MT

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Learning objectives: To illustrate MRI and CT features of primary and secondary sclerosing cholangiopathy (SC). To highlight clinicoradiological features that might indicate the aetiology in secondary SC.

Background: Sclerosing cholangiopathies are chronic inflammatory disorders characterised by stricturing mural fibrosis of the intra and/or extra­hepatic biliary tree resulting in variably progressive cholestatic liver disease. These disorders are classified under two broad categories based on their aetiology: [...]

Findings and procedure details: Primary sclerosing cholangiopathy (PSC) PSC is a chronic, fibrosing inflammatory disease of the biliary tree that eventually results in bile duct obliteration, cholestasis, biliary cirrhosis and portal hypertension. The aetiology of PSC remains unknown however an autoimmune process is postulated.&[...]

Conclusion: A thorough knowledge of the imaging features of primary and secondary SC might lead to non­invasive diagnosis. Management options for the different aetiologies differ significantly.

Personal information: S.P.D. Vella - Foundation Year 2 Doctor, Mater Dei Hospital, Malta, EU. C. Cannataci - Radiologist, Medical Imaging Department, Mater Dei Hospital, Malta, EU.    S. Aquilina - Radiologist, Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplant[...]

References: Nieun S. et al. Sclerosing Cholangitis: Clinicopathologic Features, Imaging Spectrum, and Systemic Approach to Differential Diagnosis. Korean J Radiol. 2016 Jan-Feb; 17(1): 25–38. Abdalian R, Heathcote EJ. Sclerosing cholangitis: a focus on secondary causes. Hepatology. 2006 Nov;44(5):1063-74. Vitel[...]


Top 10 Emphysematous Infections of the Abdomen Not to Forget

E. Teiga1, S. Carbullanca Toledo1, A. Radosevic1, L. Bazan1, J. Sánchez Parrilla1, M. Busto1, B. Consola2, D. Flores1, A. Zugazaga1; 1 Barcelona/ES 2 Sabadell/ES

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Learning objectives: Discuss the clinical manifestations and predisposing conditions To be aware of its importance and to describe its characteristic radiologic features Recognize typical pitfalls and differentiate benign conditions that resemble life-threatening emphysematous diseases.

Background: Emphysematous conditions of the abdomen conform a wide range of not only gas-forming infectious diseases but comprises also ischemia or local tissue necrosis and some benign conditions including fistulous connections to hollow viscera or iatrogenic manipulations.   The clinical manifestations o[...]

Findings and procedure details: Our selected Top 10 Emphysematous Infections of the Abdomen were classified into four different groups according to the compromised system.            VASCULAR SYSTEM   Pylephlebitis ( Fig. 1, Fig. 2 ) is a septic thrombophlebitis of[...]

Conclusion: Gas-forming infections within the abdomen are potentially life-threatening conditions. Altough rare, they carry a higher mortality and complications rate when compared to their non-emphysematous variety. Due to its often insidious clinical manifestations and rapid progression to sepsis, early diagno[...]

Personal information: Dr. Eduardo Teiga Radiology Resident at Hospital del Mar, Barcelona

References: 1. GraysonDE, Abbott RM, Levy AD, Sherman PM (2002). Emphysematous infections of the abdomen and pelvis: a pictorial review. RadioGraphics 22: 543–561 2. Vanamo K , Kiekara O. Pylephlebitis after appendicitis in a child. J Pediatr Surg 2001;36(10):1574–1576    3. Asad J. Choudhry, Yaser [...]

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