CT texture analysis in the differentiation of major renal cell carcinoma subtypes and correlation with Fuhrman grade.

OBJECTIVE: CT texture analysis (CTTA) using filtration-histogram-based parameters has been associated with tumor biologic correlates such as glucose metabolism, hypoxia, and tumor angiogenesis. We investigated the utility of these parameters for differentiation of clear cell from papillary renal cancers and prediction of Fuhrman grade. METHODS: A retrospective study was performed by applying CTTA to pretreatment contrast-enhanced CT scans in 290 patients with 298 histopathologically confirmed renal cell cancers of clear cell and papillary types. The largest cross section of the tumor on portal venous phase axial CT was chosen to draw a region of interest. CTTA comprised of an initial filtration step to extract features of different sizes (fine, medium, coarse spatial scales) followed by texture quantification using histogram analysis. RESULTS: A significant increase in entropy with fine and medium spatial filters was demonstrated in clear cell RCC (p = 0.047 and 0.033, respectively). Area under the ROC curve of entropy at fine and medium spatial filters was 0.804 and 0.841, respectively. An increased entropy value at coarse filter correlated with high Fuhrman grade tumors (p = 0.01). The other texture parameters were not found to be useful. CONCLUSION: Entropy, which is a quantitative measure of heterogeneity, is increased in clear cell renal cancers. High entropy is also associated with high-grade renal cancers. This parameter may be considered as a supplementary marker when determining aggressiveness of therapy. KEY POINTS: • CT texture analysis is easy to perform on contrast-enhanced CT. • CT texture analysis may help to separate different types of renal cancers. • CT texture analysis may enhance individualized treatment of renal cancers.

Quantitative MR Evaluation of Chronic Pancreatitis: Extracellular Volume Fraction and MR Relaxometry.

OBJECTIVE: The purpose of this study was to determine if extracellular volume fraction and T1 mapping can be used to diagnose chronic pancreatitis (CP). MATERIALS AND METHODS: This HIPAA-compliant study analyzed 143 consecutive patients with and without CP who underwent MR imaging between May 2016 and February 2017. Patients were selected for the study according to inclusion and exclusion criteria that considered history and clinical and laboratory findings. Eligible patients (n = 119) were grouped as normal (n = 60) or with mild (n = 22), moderate (n = 27), or severe (n = 10) CP on the basis of MRCP findings using the Cambridge classification as the reference standard. T1 maps were acquired in unenhanced and late contrast-enhanced phases using a 3D dual flip-angle gradient-echo sequence. All patients were imaged on the same 3-T scanner using the same imaging parameters, contrast agent, and dosage. RESULTS: Mean extracellular volume fractions and T1 relaxation times were significantly different within the study groups (one-way ANOVA, p < 0.001). Using the AUC curve analysis, extracellular volume fraction of > 0.27 showed 92% sensitivity (54/59) and 77% specificity (46/60) for the diagnosis of CP (AUC = 0.90). A T1 relaxation time of > 950 ms revealed 64% sensitivity (38/59) and 88% specificity (53/60) (AUC = 0.80). Combining extracellular volume fraction and T1 mapping yielded sensitivity of 85% (50/59) and specificity of 92% (55/60) (AUC = 0.94). CONCLUSION: Extracellular volume fraction and T1 mapping may provide quantitative metrics for determining the presence and severity of acinar cell loss and aid in the diagnosis of CP.

Sarcoidosis from Head to Toe: What the Radiologist Needs to Know.

Sarcoidosis is a multisystem granulomatous disorder characterized by development of noncaseating granulomas in various organs. Although the etiology of this condition is unclear, environmental and genetic factors may be substantial in its pathogenesis. Clinical features are often nonspecific, and imaging is essential to diagnosis. Abnormalities may be seen on chest radiographs in more than 90% of patients with thoracic sarcoidosis. Symmetric hilar and mediastinal adenopathy and pulmonary micronodules in a perilymphatic distribution are characteristic features of sarcoidosis. Irreversible pulmonary fibrosis may be seen in 25% of patients with the disease. Although sarcoidosis commonly involves the lungs, it can affect virtually any organ in the body. Computed tomography (CT), magnetic resonance imaging, and positron emission tomography/CT are useful in the diagnosis of extrapulmonary sarcoidosis, but imaging features may overlap with those of other conditions. Familiarity with the spectrum of multimodality imaging findings of sarcoidosis can help to suggest the diagnosis and guide appropriate management. ©RSNA, 2018.

Tumors in von Hippel-Lindau Syndrome: From Head to Toe-Comprehensive State-of-the-Art Review.

Von Hippel-Lindau syndrome (VHL) is an autosomal-dominant hereditary tumor disease that arises owing to germline mutations in the VHL gene, located on the short arm of chromosome 3. Patients with VHL may develop multiple benign and malignant tumors involving various organ systems, including retinal hemangioblastomas (HBs), central nervous system (CNS) HBs, endolymphatic sac tumors, pancreatic neuroendocrine tumors, pancreatic cystadenomas, pancreatic cysts, clear cell renal cell carcinomas, renal cysts, pheochromocytomas, paragangliomas, and epididymal and broad ligament cystadenomas. The VHL/hypoxia-inducible factor pathway is believed to play a key role in the pathogenesis of VHL-related tumors. The diagnosis of VHL can be made clinically when the characteristic clinical history and findings have manifested, such as the presence of two or more CNS HBs. Genetic testing for heterozygous germline VHL mutation may also be used to confirm the diagnosis of VHL. Imaging plays an important role in the diagnosis and surveillance of patients with VHL. Familiarity with the clinical and imaging manifestations of the various VHL-related tumors is important for early detection and guiding appropriate management. The purpose of this article is to discuss the molecular cytogenetics and clinical manifestations of VHL, review the characteristic multimodality imaging features of the various VHL-related tumors affecting multiple organ systems, and discuss the latest advances in management of VHL, including current recommendations for surveillance and screening. ©RSNA, 2018 An earlier incorrect version of this article appeared online. This article was corrected on April 9, 2018.

T1 mapping for diagnosis of mild chronic pancreatitis.

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.

Heterotopic Pancreas: Histopathologic Features, Imaging Findings, and Complications.

Heterotopic pancreas is a congenital anomaly in which pancreatic tissue is anatomically separate from the main gland. The most common locations of this displacement include the upper gastrointestinal tract-specifically, the stomach, duodenum, and proximal jejunum. Less common sites are the esophagus, ileum, Meckel diverticulum, biliary tree, mesentery, and spleen. Uncomplicated heterotopic pancreas is typically asymptomatic, with the lesion being discovered incidentally during an unrelated surgery, during an imaging examination, or at autopsy. The most common computed tomographic appearance of heterotopic pancreas is that of a small oval intramural mass with microlobulated margins and an endoluminal growth pattern. The attenuation and enhancement characteristics of these lesions parallel their histologic composition. Acinus-dominant lesions demonstrate avid homogeneous enhancement after intravenous contrast material administration, whereas duct-dominant lesions are hypovascular and heterogeneous. At magnetic resonance imaging, the heterotopic pancreas is isointense to the orthotopic pancreas, with characteristic T1 hyperintensity and early avid enhancement after intravenous gadolinium-based contrast material administration. Heterotopic pancreatic tissue has a rudimentary ductal system in which an orifice is sometimes visible at imaging as a central umbilication of the lesion. Complications of heterotopic pancreas include pancreatitis, pseudocyst formation, malignant degeneration, gastrointestinal bleeding, bowel obstruction, and intussusception. Certain complications may be erroneously diagnosed as malignancy. Paraduodenal pancreatitis is thought to be due to cystic degeneration of heterotopic pancreatic tissue in the medial wall of the duodenum. Recognizing the characteristic imaging features of heterotopic pancreas aids in differentiating it from cancer and thus in avoiding unnecessary surgery. © RSNA, 2017.

Computerized tomography of the acute left upper quadrant pain.

The purpose of this study was to evaluate the clinical utility of computerized tomography (CT) of the abdomen in the emergent setting of left upper quadrant pain. One hundred patients (average age: 45, range: 19-93 years, female: 57 %, male: 43 %) who presented to the emergency department (ED) and underwent CT scanning of abdomen with the given indication of left upper quadrant pain were included in this study. The results from CT examinations were compared to final diagnoses determined by either ED physician or clinician on a follow-up visit. Sensitivity of CT was 69 % (95 %CI: 52-83 %) for 39 patients who eventually were diagnosed with an acute abdominal abnormality. Twenty-seven patients had an acute abnormal finding on abdominal CT that represented the cause of the patient's pain (positive predictive value of 100 %, 95 %CI: 87-100 %). Of the remaining 73 patients with negative CT report, 12 were diagnosed clinically (either in the ED or on follow-up visit to specialist) with a pathology that was undetectable on the CT imaging (negative predictive value of 83 %, 95 %CI: 73-91 %). None of the remaining 61 patients with negative CT were found to have pathology by clinical evaluation (specificity of 100 %, 95 %CI: 94-100 %). CT is a useful examination for patients with acute left upper quadrant pain in the emergency department setting with moderate sensitivity and excellent specificity.

Three-dimensional conformal radiation therapy in the liver: MRI findings along a time continuum.

Recent development of 3-dimensional conformal radiation therapies provides a concentrated radiation dose to the tumor. To achieve this goal, a complex design of multiple narrow beamlets is used to shape the radiation exposure to conform to the shape of the tumor. Imaging findings after novel radiation therapy techniques differ from those of conventional radiation therapy. This article discusses changes in the liver parenchyma and tumor after conformal radiation therapy focusing on magnetic resonance imaging.

Value of magnetic resonance imaging in evaluating the pancreatic allograft transplant complications.

PURPOSE: To retrospectively investigate the value of magnetic resonance imaging (MRI) in detecting complications following pancreas transplant. MATERIALS AND METHODS: Institutional review board approved this retrospective HIPAA-compliant study and waived informed patient consent. We identified all allograft pancreas transplant patients at our institution from 2001 to January 2014 who had all pertinent post-transplant imaging and clinical data available. Transplant type was documented. Patients were divided into two groups according to post-transplant period (group A; <12 months, group B; ≥12 months). We evaluated the parenchymal enhancement using contrast-enhanced MRI of the allograft and determined the mean percentage of parenchymal enhancement (MPPE) overall and in various abnormalities, the vessel patency, any peripancreatic fluid collection, and the ductal anatomy. We correlated these with clinical results using t test, χ (2), and Fisher's exact test; p < 0.05 was considered significant. RESULTS: 51 patients (34 male, mean age 43.7 years) were identified, 28 (55%) of whom had abnormal imaging findings; transplant rejection-related necrosis (n = 7), fluid collections (n = 7), vascular stenosis (n = 4), isolated venous thromboses (n = 3), acute pancreatitis (n = 3), pancreatic and peripancreatic abscesses (n = 2), pseudoaneurysm (n = 1), and small-bowel obstruction (n = 1). Pre vs. post-contrast pancreatic MPPE at 1 min was 120% in the normal allografts and 115% in the allografts with pancreatitis and without necrosis (p > 0.05). MPPE at 1 min was only 9% in the allografts rejections with necrosis/infarction. More complications were found in group A than group B (p < 0.05). CONCLUSIONS: Contrast-enhanced MRI is useful for the non-invasive assessment of pancreas transplant complications.

Recent advances in the diagnosis and management of autoimmune pancreatitis.

OBJECTIVE: Autoimmune pancreatitis (AIP) is a rare chronic relapsing steroid-responsive fibroinflammatory disorder of the pancreas that is likely caused by immune dysregulation. It is now thought that AIP consists of two distinct clinicopathologic syndromes currently designated as types 1 and 2. CONCLUSION: A current update on etiopathogenesis, pathology, and clinical and imaging findings of AIP is provided with an emphasis on diagnosis and management.

Acinarization (parenchymal blush) observed during secretin-enhanced MRCP: clinical implications.

OBJECTIVE: T2 hyperintensity of pancreatic acini during secretin-enhanced MRCP is called "acinarization." We sought to determine the clinical significance of this finding. MATERIALS AND METHODS: Patients were selected if the radiology report included the phrases "acin*" (where * represented a wild card search) or "blush" using the institution's customized lexicon-search software. Sixty-seven consecutive patients without acinarization on secretin-enhanced MRCP who also underwent ERCP were enrolled as the control group. The intensity of acinarization was classified into three groups: grade 0, no visible acinarization; grade 1, barely visible parenchymal hyperintensity; or grade 2, easily visible parenchymal hyperintensity. ERCP findings of ductal abnormalities and basal pancreatic sphincter manometry were recorded. RESULTS: There were higher frequencies of divisum (p = 0.001) and of a clinical history of recurrent acute pancreatitis (p < 0.001) and higher basal pancreatic sphincter of Oddi manometric pressure measurements (p = 0.008) in the acinarization group. There was no difference in the frequency of ERCP-defined chronic pancreatitis (p = 0.10) between the groups. In patients with acinarization, a higher mean sphincter pressure was seen in patients with more intense acinarization than in those with faint acinarization, but this difference was not significant (p = 0.22). Ampullary tumors were found in four patients with acinarization. CONCLUSION: Acinarization probably occurs in patients with a propensity for increased pancreatic ductal pressure (i.e., patients with divisum, elevated basal pancreatic sphincter pressure, ampullary tumor) and adequate exocrine function (absence of severe chronic pancreatitis).

Cystic neoplasms of the pancreas; findings on magnetic resonance imaging with pathological, surgical, and clinical correlation.

Pancreatic cysts are increasingly being identified by cross-sectional imaging studies. Pancreatic cystic lesions comprise a spectrum of underlying pathologies ranging from benign and pre-malignant lesions to frank malignancies. Magnetic resonance imaging with cholangiopancreatography is a non-invasive imaging modality used for the characterization of cystic pancreatic lesions. This article will review the most common pancreatic cystic neoplasms and the utility of MR imaging in the characterization of these cysts.

The utility of secretin-enhanced MRCP in diagnosing congenital anomalies.

PURPOSE: To assess the additional value of secretin-enhanced MRCP (SMRCP) over conventional MRCP in diagnosing divisum. METHODS: Retrospective HIPAA-compliant and IRB-approved review found 140 patients with SMRCP and ERCP correlation within 6 months of each other. All studies were anonymized and the SMRCP images (SMRCP image set) were separated from 2D and 3D MRCP and axial and coronal T2-weighted images (conventional MRI image set). Each image set on each patient was assigned different and randomized case numbers. Two reviewers (R1 and R2) independently reviewed the image sets for divisum vs. no divisum, complete divisum vs. incomplete divisum, and the certainty of diagnosis (1 = definitely certain, 2 = moderately certain, and 3 = unsure). ERCP findings were taken as gold standard. RESULTS: There was no difference in age and gender between the divisum (n = 97, with 13 incomplete divisum) and no divisum (n = 43) groups. In diagnosing divisum anatomy, the sensitivity was higher for SMRCP compared to conventional MRI for R1 (84.5 vs. 72.2, p = 0.02) but not R2 (89.7 vs. 84.4, p = 0.25). The specificity was higher in SMRCP image set compared to conventional MRI (R1: 88.1 vs. 76.2, p = 0.01; R2: 81.4 vs. 65.1, p < 0.001). The mean area under ROC curve was higher for SMRCP image set (R1: 0.86 vs. 0.74, p = 0.01; R2: 0.87 vs. 0.74, p = 0.01). The certainty of diagnosis was higher in SMRCP image set compared to conventional MRI (p = 0.02 for both reviewers). SMRCP was not found to be superior in distinguishing incomplete from complete divisum. The main reasons for erroneous SMRCP diagnosis were the presence of an ansa loop in the main duct and ductal strictures due to chronic pancreatitis. CONCLUSION: Even though the reviewers had more sequences (axial and coronal) to evaluate in the non-secretin image set, there was some improvement in diagnosing divisum with SMRCP.

Imaging findings of gastric glomus tumors.

Sparse literature describes the imaging findings of gastric glomus tumors (GGT), focusing on benign tumors. We are not aware of prior radiology reports on malignant GGT. The aim of the study was to determine whether it is possible to differentiate between benign and malignant GGT on CT or MR. Institutional radiology and pathology databases were queried for the diagnosis of GGT between January 2010 to December 2023. Of 22 identified subjects, five were excluded due to non-availability of preoperative CT or MR images and three due to lack of pathological confirmation in our institution. The study cohort comprised of 14 patients (males = 6) with median age of 65 years (range 31 to 79 years). Two abdominal radiologists in consensus reviewed all relevant CT and MR images. There were 10 benign and 4 malignant GGT. Benign tumors were smaller than malignant GGT (median size of 2.0 cm vs. 5.3 cm, p = 0.03), more likely to exhibit homogeneous hyperenhancement (9/10 vs. 0/4, p < 0.01), and demonstrated intramural rather than exophytic growth. There was no substantial difference in T2 signal or diffusion restriction between benign and malignant GGT. On follow up, benign GGT were essentially stable in size, while malignant GGT grew. A biopsy proven GGT larger than 5 cm or showing necrosis is likely to be malignant. This is important since preoperative endoscopic ultrasound-guided fine needle aspiration may be indeterminate for malignancy.

Usefulness of conventional MRI sequences and diffusion-weighted imaging in differentiating malignant from benign portal vein thrombus in cirrhotic patients.

OBJECTIVE: The objective of our study was to determine the value of diffusion-weighted imaging (DWI) and conventional MRI (non-DWI sequences) in differentiating benign portal vein thrombus (PVT) from malignant PVT in cirrhotic patients. MATERIALS AND METHODS: A retrospective search of the department of radiology's MRI database of examinations performed from October 2006 through December 2010 for "portal vein thrombosis" and "cirrhosis" and "hepatocellular cancer" was performed. Patients who underwent diagnostic DWI and had thrombus shown to be rapidly (< 3 months) increasing in size despite anticoagulation therapy were considered to have malignant PVT (n = 16 cases) and patients with MRI findings showing stability or reduction in the extent of thrombus over a 12-month follow-up were considered to have benign PVT (n = 20 cases). Two blinded and independent reviewers analyzed the DW images and conventional MR images. RESULTS: There was no difference in the distribution of patients by age (p = 0.25) or sex (p = 0.68) between the benign and malignant PVT groups. On multivariate analysis, the only parameter to predict the type of PVT was the size of HCC (p = 0.05); other parameters were excluded from the model. There was substantial overlap in apparent diffusion coefficient (ADC) values and PVT/liver ADC ratios of benign PVT and malignant PVT. The presence of at least two of the three following MRI findings had a sensitivity of 100% and specificity of 90% for the diagnosis of malignant PVT: distance from tumor to PVT of less than 2 cm, HCC size of greater than 5 cm, and arterial enhancement of PVT. CONCLUSION: Signal-intensity characteristics on DWI and measured ADC values do not reliably differentiate benign PVT from malignant PVT. On the other hand, careful assessment of conventional MRI findings may allow this distinction, thus obviating biopsy.

Use of diffusion-weighted MRI to differentiate chronic pancreatitis from pancreatic cancer.

OBJECTIVE: The purpose of this study was to compare diffusion-weighted MRI (DWI) and conventional (non-DWI) MRI sequences in differentiating mass-forming chronic pancreatitis from pancreatic cancer. MATERIALS AND METHODS: A retrospective cohort study included 36 patients who underwent pancreatic resection for pancreatic cancer (n = 13) and chronic pancreatitis (n = 23) after preoperative MRI with DWI. Two independent reviewers assessed the DW images for signal intensity and apparent diffusion coefficient (ADC) values. Four weeks later, they reviewed the other MR images for size of mass, double-duct sign, pancreatic duct cutoff, and perivascular soft-tissue cuffing. A score for conventional MRI was given with 1 meaning definitely benign and 5 meaning definitely malignant. Univariate and multivariate analyses and receiver operating characteristic (ROC) curve analysis were performed with surgical pathologic examination as the reference standard. RESULTS: The only finding that differentiated the two groups was the presence of a well-defined mass, favoring the diagnosis of cancer (p = 0.02, p < 0.01). There was no significant difference between the two groups in signal intensity on DW images (p = 0.82, p = 0.85) or ADC (p = 0.51, p = 0.76). Double-duct sign, pancreatic duct cutoff, and perivascular soft-tissue cuffing were not useful in differentiating the two groups. The areas under the ROC curve were 0.873 and 0.878 for the conventional MRI scores, compared with 0.602 and 0.552 for ADC measurements (p = 0.02, p = 0.008). CONCLUSION: The addition of DWI to conventional MRI does not facilitate differentiation of pancreatic cancer from chronic pancreatitis.

MRCP in patient care: a prospective survey of gastroenterologists.

OBJECTIVE: MRCP is increasingly used to evaluate pancreaticobiliary disease, yet its effect on patient care is unknown. The purpose of this study was to measure the effect of MRCP on referring physicians' initial diagnoses, the physicians' confidence in their diagnoses, and the influence of MRCP results on clinical management. SUBJECTS AND METHODS: We prospectively surveyed gastroenterologists who referred patients for nonurgent MRCP for pancreaticobiliary evaluation. Before MRCP, gastroenterologists reported the working diagnosis, confidence level (high, moderate, low), and next step in clinical management if MRCP was unavailable. MRCP was performed with standard protocols, including secretin enhancement. After reviewing MRCP findings and without referring to their previous assessment, gastroenterologists reported a revised diagnosis, confidence level, and next step in clinical management. They then compared pre- and post-MRCP management plans and rated the influence of MRCP on changing management from 1 (none) to 5 (major). Diagnostic confidence and frequency of common diagnoses and recommendation for an invasive next-step procedure (e.g., ERCP) or endoscopic ultrasound were compared between pre- and post-MRCP assessments. RESULTS: Survey data were analyzed on 171 patients (123 women, 48 men; mean age, 50 [SD, 17] years; range, 19-88 years) undergoing MRCP for unexplained abdominal pain (42.9%), suspected pancreaticobiliary neoplasm (20%), recent acute (17.1%) or suspected chronic (14.9%) pancreatitis, and other indications (5.1%). Recommendations of ERCP and endoscopic ultrasound decreased after MRCP (from 49.1% to 35.1%, p=0.03, and from 26.9% to 13.5%, p≤0.01). After MRCP, high confidence in diagnosis increased (from 72/171 to 100/171, p<0.01), as did recommendations for noninvasive therapy (from 18/171 to 56/171, p<0.01). A major or substantial change in clinical management was made in the care of 67 of 171 patients (39.2%). CONCLUSION: Use of MRCP significantly changes gastroenterologists' treatment of patients with suspected pancreaticobiliary disease by increasing diagnostic confidence and reducing the frequency of invasive follow-up procedures.

Secretin-enhanced MR cholangiopancreatography: spectrum of findings.

Magnetic resonance cholangiopancreatography (MRCP) is the most effective, safe, noninvasive magnetic resonance (MR) imaging technique for the evaluation of the pancreaticobiliary ductal system. The MRCP imaging technique has substantially improved during the past 2 decades and is based mainly on the acquisition of heavily T2-weighted MR images, with variants of fast spin-echo sequences. MRCP can also be performed by utilizing the hormone secretin, which stimulates a normal pancreas to secrete a significant amount of fluid while transiently increasing the tone of the sphincter of Oddi. The transient increase in the diameter of the pancreatic duct improves the depiction of the ductal anatomy, which can be useful in patients in whom detailed evaluation of the pancreatic duct is most desired because of a suspicion of pancreatic disease. Improved depiction of the ductal anatomy can be important in (a) the differentiation of side-branch intraductal papillary mucinous neoplasms from other cystic neoplasms and (b) the diagnosis and classification of chronic pancreatitis, the disconnected pancreatic duct syndrome, and ductal anomalies such as anomalous pancreaticobiliary junction and pancreas divisum. In patients examined after pancreatectomy, stimulation with secretin can give information about the patency of the pancreaticoenteric anastomosis. Duodenal filling during the secretin-enhanced phase of the MRCP examination can be used to estimate the excretory reserve of the pancreas. Secretin is well tolerated, and complications are rarely seen. Secretin-enhanced MRCP is most useful in (a) the evaluation of acute and chronic pancreatitis, congenital variants of the pancreaticoduodenal junction, and intraductal papillary mucinous neoplasms and (b) follow-up of patients after pancreatectomy.

Response criteria in oncologic imaging: review of traditional and new criteria.

There has been a proliferation and divergence of imaging-based tumor-specific response criteria over the past 3 decades whose purpose is to achieve objective assessment of treatment response in oncologic clinical trials. The World Health Organization (WHO) criteria, published in 1981, were the first response criteria and made use of bidimensional measurements of tumors. The Response Evaluation Criteria in Solid Tumors (RECIST) were created in 2000 and revised in 2009. The RECIST criteria made use of unidimensional measurements and addressed several pitfalls and limitations of the original WHO criteria. Both the WHO and RECIST criteria were developed during the era of cytotoxic chemotherapeutic agents and are still widely used. However, treatment strategies changed over the past decade, and the limitations of using tumor size alone in patients undergoing targeted therapy (including arbitrarily determined cutoff values to categorize tumor response and progression, lack of information about changes in tumor attenuation, inability to help distinguish viable tumor from nonviable components, and inconsistency of size measurements) necessitated revision of these criteria. More recent criteria that are used for targeted therapies include the Choi response criteria for gastrointestinal stromal tumor, modified RECIST criteria for hepatocellular carcinoma, and Immune-related Response Criteria for melanoma. The Cheson criteria and Positron Emission Tomography Response Criteria in Solid Tumors make use of positron emission tomography to provide functional information and thereby help determine tumor viability. As newer therapeutic agents and approaches become available, it may be necessary to further modify existing anatomy-based response-assessment methodologies, verify promising functional imaging methods in large prospective trials, and investigate new quantitative imaging technologies.