Pancreatic cancer: ESMO clinical practice guideline for diagnosis, treatment and follow-up

The opportunity to detect pancreatic cancer (PC) when potentially curable depends on early diagnosis and an ability to identify and screen high-risk populations before symptoms arise. Identification of a high-risk population is challenging and optimal screening tools remain unclear.1 Older age is the strongest risk factor; incidence peaks at 65-69 years in males and 75-79 years in females.2 A pooled analysis of 117 meta-analyses assigned a relative risk to a number of common risk factors (Supplementary Table S1, available at https://doi.org/10.1016/j.annonc.2023.08.009).3 The vast majority (>80%) of PCs arise due to sporadically occurring somatic mutations. Only a small proportion are due to inherited deleterious germline mutations.1 Familial PC, defined as at least two first-degree relatives with PC, accounts for only 4%-10% of all cases. Variants in BRCA2 are the most common genetic abnormalities seen in familial PC. Other familial syndromes linked to PC are listed in Supplementary Table S2, available at https://doi.org/10.1016/j.annonc.2023.08.009. Individuals from families at risk should receive genetic counselling and be considered for enrolment in investigational screening registries. Currently, in high-risk individuals, annual endoscopic ultrasound (EUS) and/or pancreatic magnetic resonance imaging (MRI) are the procedures of choice for surveillance.4 Surveillance programmes usually begin at age 50 years (or 10 years earlier than the age of the youngest affected relative). Prospective surveillance data in high-risk individuals demonstrated high rates of resectability and encouraging observations of long-term survival.5, 6, 7, 8, 9 In sporadic PC, the major risk factors are tobacco, Helicobacter pylori infection and factors related to dietary habits (high red meat, high alcohol intake, low fruit and vegetable intake, overweight/obesity and type 2 diabetes mellitus).2,3,10 Chronic pancreatitis, irrespective of the cause (alcohol abuse, smoking, genetic mutations), is a risk factor for PC. A proportion of the risk factors associated with PC are potentially modifiable, affording a unique opportunity for primary prevention that is yet to be realised.

Hepatospecific MR contrast agent uptake on hepatobiliary phase can be used as a biomarker of marked ß-catenin activation in hepatocellular adenoma.

OBJECTIVES: To assess the value of hepatospecific MR contrast agent uptake on hepatobiliary phase (HBP) images to detect marked activation of the ß-catenin pathway in hepatocellular adenomas (HCAs). METHODS: This multicentric retrospective IRB-approved study included all patients with a pathologically proven HCA who underwent gadobenate dimeglumine-enhanced liver MRI with HBP. Tumor signal intensity on HBP was first assessed visually, and lesions were classified into three distinct groups-hypointense, isointense, or hyperintense-according to the relative signal intensity to liver. Uptake was then quantified using the lesion-to-liver contrast enhancement ratio (LLCER). Finally, the accuracy of HBP analysis in depicting marked ß-catenin activation in HCA was evaluated. RESULTS: A total of 124 HCAs were analyzed including 12 with marked ß-catenin activation (HCA B+). Visual analysis classified 94/124 (76%), 12/124 (10%), and 18/124 (14%) HCAs as being hypointense, isointense, and hyperintense on HBP, respectively. Of these, 1/94 (1%), 3/12 (25%), and 8/18 (44%) were HCA B+, respectively (p < 0.001). The LLCER of HCA B+ was higher than that of HCA without marked ß-catenin activation in the entire cohort (means 4.9 ± 11.8% vs. - 19.8 ± 11.4%, respectively, p < 0.001). A positive LLCER, i.e., LLCER ≥ 0%, had 75% (95% CI 43-95%) sensitivity and 97% (95% CI 92-99%) specificity, with a LR+ of 28 (95% CI 8.8-89.6) for the diagnosis of HCA B+. CONCLUSIONS: Hepatospecific contrast uptake on hepatobiliary phase is strongly associated with marked activation of the ß-catenin pathway in hepatocellular adenoma, and its use might improve hepatocellular adenoma subtyping on MRI. KEY POINTS: • Tumor uptake on hepatobiliary phase in both the visual and quantitative analyses had a specificity higher than 90% for the detection of marked ß-catenin activation in hepatocellular adenoma. • However, the sensitivity of visual analysis alone is inferior to that of LLCER quantification on HBP due to the high number of HCAs with signal hyperintensity on HBP, especially those developed on underlying liver steatosis.

Morphological imaging and CT histogram analysis to differentiate pancreatic neuroendocrine tumor grade 3 from neuroendocrine carcinoma.

PURPOSE: To compare morphological imaging features and CT texture histogram parameters between grade 3 pancreatic neuroendocrine tumors (G3-NET) and neuroendocrine carcinomas (NEC). MATERIALS AND METHODS: Patients with pathologically proven G3-NET and NEC, according to the 2017 World Health Organization classification who had CT and MRI examinations between 2006-2017 were retrospectively included. CT and MRI examinations were reviewed by two radiologists in consensus and analyzed with respect to tumor size, enhancement patterns, hemorrhagic content, liver metastases and lymphadenopathies. Texture histogram analysis of tumors was performed on arterial and portal phase CT images. images. Morphological imaging features and CT texture histogram parameters of G3-NETs and NECs were compared. RESULTS: Thirty-seven patients (21 men, 16 women; mean age, 56±13 [SD] years [range: 28-82 years]) with 37 tumors (mean diameter, 60±46 [SD] mm) were included (CT available for all, MRI for 16/37, 43%). Twenty-three patients (23/37; 62%) had NEC and 14 patients (14/37; 38%) had G3-NET. NECs were larger than G3-NETs (mean, 70±51 [SD] mm [range: 18 - 196mm] vs. 42±24 [SD] mm [range: 8 - 94mm], respectively; P=0.039), with more tumor necrosis (75% vs. 33%, respectively; P=0.030) and lower attenuation on precontrast (30±4 [SD] HU [range: 25-39 HU] vs. 37±6 [SD] [range: 25-45 HU], respectively; P=0.002) and on portal venous phase CT images (75±18 [SD] HU [range: 43 - 108 HU] vs. 92±19 [SD] HU [range: 46 - 117 HU], respectively; P=0.014). Hemorrhagic content on MRI was only observed in NEC (P=0.007). The mean ADC value was lower in NEC ([1.1±0.1 (SD)]×10-3 mm2/s [range: (0.91 - 1.3)×10-3 mm2/s] vs. [1.4±0.2 (SD)]×10-3 mm2/s [range: (1.1 - 1.6)×10-3 mm2/s]; P=0.005). CT histogram analysis showed that NEC were more heterogeneous on portal venous phase images (Entropy-0: 4.7±0.2 [SD] [range: 4.2-5.1] vs. 4.5±0.4 [SD] [range: 3.7-4.9]; P=0.023). CONCLUSION: Pancreatic NECs are larger, more frequently hypoattenuating and more heterogeneous with hemorrhagic content than G3-NET on CT and MRI.

Relevance of liver surface nodularity for preoperative risk assessment in patients with resectable hepatocellular carcinoma.

BACKGROUND: Quantification of liver surface nodularity (LSN) on routine preoperative CT images allows detection of cirrhosis and clinically significant portal hypertension. This study aimed to assess the relevance of LSN in preoperative assessment of operative risks for patients with resectable hepatocellular carcinoma (HCC). METHODS: All patients undergoing hepatectomy for HCC between 2012 and 2017 were analysed retrospectively. LSN was assessed at the liver-fat interface on the left liver lobe on preoperative CT images. The feasibility of LSN quantification was assessed. The association between LSN and outcomes (severe complications and posthepatectomy liver failure (PHLF)) was evaluated by multivariable analysis and after propensity score matching. RESULTS: Among 210 patients, LSN measurement was successful in 187 (89·0 per cent). Among these, the median LSN score was 2·42 (i.q.r. 2·21-2·66) and 52·9 per cent had severe fibrosis, including 33·7 per cent with cirrhosis. LSN score increased with hepatic venous pressure gradient (P = 0·048), severity of steatosis (P = 0·011) and fibrosis grade (P = 0·001). LSN score was independently associated with severe complications (odds ratio (OR) 5·25; P = 0·006) and PHLF (OR 6·78; P = 0·003). After matching with respect to model for end-stage liver disease, aspartate aminotransferase-to-platelet ratio index and fibrosis-4 score, patients with a LSN score of 2·63 or higher retained an increased risk of PHLF (OR 5·81; P = 0·018). In the subgroup of patients without severe fibrosis, LSN was accurate in predicting severe complications (P = 0·005). Patients with (P = 0·039) or without (P = 0·018) severe fibrosis with increased LSN score had a higher comprehensive complication index score. Among patients with cirrhosis who had clinically significant portal hypertension, a LSN value below 2·63 ruled out the risk of PHLF. CONCLUSION: LSN measurement represents a practical tool that may allow improvement in the preoperative evaluation and management of patients with HCC.

ANTECEDENTES: La cuantificación de la nodularidad de la superficie hepática (liver surface nodularity, LSN) en las imágenes de la tomografía computarizada (TC) de rutina preoperatoria permite detectar la cirrosis y la hipertensión portal clínicamente significativa (clinically significant portal hypertension, CSPH). Este estudio tuvo como objetivo evaluar la relevancia de la LSN en la evaluación preoperatoria del riesgo quirúrgico en pacientes con carcinoma hepatocelular resecable (hepatocellular carcinoma, HCC). MÉTODOS: Todos los pacientes sometidos a hepatectomía por HCC entre 2012 y 2017 fueron analizados de forma retrospectiva. La LSN se evaluó en la interfase hígado-grasa en el lóbulo hepático izquierdo en la TC preoperatoria. Se evaluó la viabilidad de la cuantificación de la LSN. La asociación entre la LSN y los resultados (complicaciones graves e insuficiencia hepática poshepatectomía (post-hepatectomy liver failure, PHLF) se analizó en un análisis multivariable y después del método de emparejamiento por puntaje de propensión. RESULTADOS: Del total de 210 pacientes, la medición de la LSN fue exitosa en 187 (89,0%). En estos pacientes, la mediana de LSN fue de 2,42 (rango intercuartílico 2,21-2,66) y el 53,0% tenía fibrosis severa, incluyendo un 33,7% con cirrosis. La LSN aumentó con el gradiente de presión venosa hepática (P = 0,048), la gravedad de la esteatosis (P = 0,011) y el grado de fibrosis (P = 0,001). La LSN se asoció de forma independiente con complicaciones graves (razón de oportunidades, odds ratio, OR = 5,25; P = 0,006) y PHLF (OR = 6,78; P = 0,003). Después de emparejar para el modelo de enfermedad hepática terminal, el índice de relación aspartato amino transferase-plaquetas y el grado de fibrosis-4, los pacientes con LSN ≥ 2,63 mantuvieron un mayor riesgo de PHLF (OR = 5,81; P = 0,018). Dentro del subgrupo de pacientes sin fibrosis severa, la LSN fue precisa en predecir complicaciones graves (P = 0,005). Los pacientes con (P = 0,039) y sin (P = 0,018) fibrosis severa con aumento de la LSN tuvieron un índice de complicación global más alto. De los pacientes cirróticos con CSPH, un valor de LSN de 2,63 descartó el riesgo de PHLF. CONCLUSIÓN: La LSN representa una herramienta práctica, que puede permitir mejorar la evaluación preoperatoria y el manejo de pacientes con HCC.

Unenhanced CT for clinical triage of elderly patients presenting to the emergency department with acute abdominal pain.

PURPOSE: The purpose of this study was to compare the diagnostic accuracy and inter-reader agreement of unenhanced computed tomography (CT) to those of contrast-enhanced CT for triage of patients older than 75years admitted to emergency department (ED) with acute abdominal pain (AAP). PATIENTS AND METHODS: Two hundred and eight consecutive patients presenting with AAP to the ED who underwent CT with unenhanced and contrast-enhanced images were retrospectively included. There were 90 men and 118 women with a mean age of 85.4±4.9 (SD) (range: 75-101.4years). Three readers reviewed unenhanced CT images first, and then unenhanced and contrast-enhanced CT images as a single set. Diagnostic accuracy was compared to the standard of reference defined as the final diagnosis obtained after complete clinico-biological and radiological evaluation. Correctness of the working diagnosis proposed by the ED physician was evaluated. Intra- and inter-reader agreements were calculated using the kappa test and interclass correlation. Subgroup analyses were performed for patients requiring only conservative management and for those requiring intervention. RESULTS: Diagnostic accuracy ranged from 64% (95% CI: 62-66%) to 68% (95% CI: 66-70%) for unenhanced CT, and from 68% (95% CI: 66-70%) to 71% (95% CI: 69-73%) for both unenhanced and contrast-enhanced CT. Contrast-enhanced CT did not significantly improve the diagnostic accuracy (P=0.973-0.979). CT corrected the working diagnosis proposed by the ED physician in 59.1% (range: 58.1-60.0%) and 61.2% (range: 57.6-65.5%) of patients before and after contrast injection (P>0.05). Intra-observer agreement was moderate to substantial (k=0.513-0.711). Inter-reader agreement was substantial for unenhanced (kappa=0.745-0.789) and combined unenhanced and contrast-enhanced CT (kappa=0.745-0.799). Results were similar in subgroup analyses. CONCLUSION: Unenhanced CT alone is accurate and associated with high degrees of inter-reader agreement for clinical triage of patients older than 75years with AAP in the emergency setting.

Suspicious liver nodule in chronic liver disease: Usefulness of a second biopsy.

PURPOSE: To assess the usefulness of a second biopsy when the first one was inconclusive in patients with a liver nodule found during the follow-up for chronic liver disease. MATERIALS AND METHODS: Among 381 patients (544 nodules) included in a prospective study designed to evaluate the accuracy of imaging for the diagnosis of small hepatocellular carcinoma (HCC) in chronic liver disease, 254 nodules were biopsied. The following histological results were considered as conclusive: HCC, dysplastic or regenerative nodule, and other identified tumors (benign or malignant). For nodules with inconclusive results (e.g. fibrosis or no definite focal lesion), a second biopsy was suggested, but was not mandatory. RESULTS: A total of 242 patients (194 men, 48 women; mean age, 61.9±9.5 [SD]; range: 40.2-89.0years) with 254 nodules underwent a first biopsy. Mean nodule diameter was 19.2±5.4mm (range: 10-33mm). The first biopsy was conclusive in 189/254 nodules (74.4%): 157 HCCs (83.1%), 11 regenerative nodules (5.8%), 10 dysplastic nodules (5.3%), 3 cholangiocarcinomas (1.6%), and 8 other tumors (4.2%). Among the 65 nodules for which the first biopsy was inconclusive, a second biopsy was performed for 17 nodules in 16 patients within 6 months of the first one. It was conclusive in 13/17 nodules (76.5%): 10 HCCs (76.9%), 2 dysplastic nodules (15.4%), and 1 other tumor (7.7%). In 4/17 nodules (23.5%), no definitive diagnosis could be provided. CONCLUSION: The diagnostic yield of a second biopsy of a suspicious lesion suggestive of HCC in chronic liver disease is not decreased compared to the first one. Repeated biopsy after a first negative one could be an alternative option to the follow-up of patients with chronic liver disease.

Acute mesenteric ischemia: A critical role for the radiologist.

Acute mesenteric ischemia is defined as an inadequate blood supply to the gastrointestinal tract resulting in ischemic and inflammatory injury that may progress to necrosis of the bowel wall. Prognosis is poor with a mortality rate greater than 95% without treatment, dropping to around 70% when surgical treatment is performed. Contrast-enhanced computed tomography (CT) has become the cornerstone of the diagnosis by showing features of vascular disorders (occlusion and/or insufficient blood supply) and features of intestinal ischemic injury. CT should be performed as rapidly as possible. Imaging-based patient management is required, and multimodal and multidisciplinary management should be introduced. The treatment involves multidisciplinary management by gastroenterologists, vascular and digestive surgeons, cardiologists, intensivists, and diagnostic and interventional radiologists. Based on our experience at a dedicated mesenteric stroke center, this article gives an overview of the diagnosis of acute mesenteric ischemia. The goal of this review is to improve the understanding of the imaging-based diagnosis to further improve the management of this life-threatening condition.

Non-invasive evaluation of portal hypertension using shear-wave elastography: analysis of two algorithms combining liver and spleen stiffness in 191 patients with cirrhosis.

BACKGROUND: Two algorithms based on sequential measurements of liver and spleen stiffness using two-dimensional shearwave elastography (2D-SWE) have been recently proposed to estimate clinically significant portal hypertension (hepatic venous pressure gradient [HVPG] ≥10 mm Hg) in patients with cirrhosis, with excellent diagnostic accuracy. AIM: To validate externally these algorithms in a large cohort of patients with cirrhosis. METHODS: One hundred and ninety-one patients with stable cirrhosis (Child-Pugh class A 39%, B 29% and C 31%) who underwent liver and spleen stiffness measurements using 2D-SWE at the time of HVPG measurement were included. Diagnostic accuracy of the 2 algorithms was assessed by calculating sensitivity, specificity, positive and negative predictive values. RESULTS: The first algorithm, using liver stiffness <16.0 kilopascals (kPa) and then spleen stiffness <26.6 kPa, was used to rule-out HVPG ≥10 mm Hg. In our population, its sensitivity and negative predictive value were 95% and 63% respectively. The second algorithm, using liver stiffness >38.0 kPa, or liver stiffness ≤38.0 kPa but spleen stiffness >27.9 kPa, was used to rule-in HVPG ≥10 mm Hg. In our population, its specificity and positive predictive value were 52% and 83% respectively. Restricting the analyses to the 74 patients without any history of decompensation of cirrhosis or to the 65 patients with highly reliable liver stiffness measurement did not improve the results. CONCLUSION: In our population, diagnostic accuracies of non-invasive algorithms based on sequential measurements of liver and spleen stiffness using 2D-SWE were acceptable, but not good enough to replace HVPG measurement or to base clinical decisions.

Volumetric measurement of hepatic tumors: Accuracy of manual contouring using CT with volumetric pathology as the reference method.

PURPOSE: The purpose of this study was to assess the accuracy of liver tumor volumetry by manual contouring on computed tomography (CT) compared to pathological tumor volume determined from surgical specimen that served as a reference method. PATIENTS AND METHOD: Thirty-eight patients with planned liver surgery and a total of 41 liver tumors were included. There were 24 men and 14 women (mean age: 57 years; range: 32-85 years). Two readers calculated tumor volume by manual contouring on axial CT images. The reference tumor volume was calculated by manual contouring with dedicated software applied to the liver specimen slice. CT and pathology volumes were compared and the percentage of error (PE%) was calculated. Intraobserver and interobserver variabilities were calculated using Bland and Altman plots, and intraclass correlation coefficients (ICC). RESULTS: A strong correlation was found between CT tumor volumes and pathology tumor volumes (r=0.994; P<0.001 for both readers). The mean (±SD) and median (range) PE% were 19%±12% and 16% (1%, +42%) and 19%±15% and 17% (0%, +55%) for readers 1 and 2, respectively. Readers 1 and 2 significantly overestimated tumor volume (i.e., PE%>40%) in 3 (7%) and 2 (5%) tumors on CT, respectively. Tumor volume was not significantly underestimated in any of the patients (i.e. PE%>33%). Tumor size, CT attenuation, time between imaging and surgery, contours and margin definition did not influence the results of PE% values (all P values>0.05 for both readers). The bias and limits of agreement between the two readers were +4.6% and (-24%, +33%) with an ICC of 0.997. CONCLUSION: There was a strong correlation between tumor volume measured on CT and that assessed with surgical specimen. Tumor size, visibility of contours and tumor margins and the time between CT and surgery did not influence the results.

Cholangiopathy in critically ill patients surviving beyond the intensive care period: a multicentre survey in liver units.

BACKGROUND: The outcome of cholangiopathy developing in intensive care unit (ICU) is not known in patients surviving their ICU stay. AIM: To perform a survey in liver units, in order to clarify the course of cholangiopathy after surviving ICU stay. METHODS: The files of the liver units affiliated to the French network for vascular liver disease were screened for cases of ICU cholangiopathy developing in patients with normal liver function tests on ICU admission, and no prior history of liver disease. RESULTS: Between 2005 and 2015, 16 cases were retrieved. Extensive burns were the cause for admission to ICU in 11 patients. Serum alkaline phosphatase levels increased from day 11 (2-46) to a peak of 15 (4-32) × ULN on day 81 (12-511). Magnetic resonance cholangiography showed irregularities or frank stenosis of the intrahepatic ducts, and proximal extrahepatic ducts contrasting with a normal aspect of the distal common bile duct. Follow-up duration was 20.6 (4.7-71.8) months. Three patients were lost to follow-up; 2 patients died from liver failure and no patient was transplanted. One patient had worsening strictures of the intrahepatic bile ducts with jaundice. Nine patients had persistent but minor strictures of the intrahepatic bile ducts on MR cholangiography, and persistent cholestasis without jaundice. One patient had normal liver function tests. CONCLUSIONS: In patients surviving their ICU stay, ICU cholangiopathy is not uniformly fatal in the short term or clinically symptomatic in the medium term. Preservation of the distal common bile duct appears to be a finding differentiating ICU cholangiopathy from other diffuse cholangiopathies.

Simultaneous MR quantification of hepatic fat content, fatty acid composition, transverse relaxation time and magnetic susceptibility for the diagnosis of non-alcoholic steatohepatitis.

Non-alcoholic steatohepatitis (NASH) is characterized at histology by steatosis, hepatocyte ballooning and inflammatory infiltrates, with or without fibrosis. Although diamagnetic material in fibrosis and inflammation can be detected with quantitative susceptibility imaging, fatty acid composition changes in NASH relative to simple steatosis have also been reported. Therefore, our aim was to develop a single magnetic resonance (MR) acquisition and post-processing scheme for the diagnosis of steatohepatitis by the simultaneous quantification of hepatic fat content, fatty acid composition, T2 * transverse relaxation time and magnetic susceptibility in patients with non-alcoholic fatty liver disease. MR acquisition was performed at 3.0 T using a three-dimensional, multi-echo, spoiled gradient echo sequence. Phase images were unwrapped to compute the B0 field inhomogeneity (ΔB0 ) map. The ΔB0 -demodulated real part images were used for fat-water separation, T2 * and fatty acid composition quantification. The external and internal fields were separated with the projection onto dipole field method. Susceptibility maps were obtained after dipole inversion from the internal field map with single-orientation Bayesian regularization including spatial priors. Method validation was performed in 32 patients with biopsy-proven, non-alcoholic fatty liver disease from which 12 had simple steatosis and 20 NASH. Liver fat fraction and T2 * did not change significantly between patients with simple steatosis and NASH. In contrast, the saturated fatty acid fraction increased in patients with NASH relative to patients with simple steatosis (48 ± 2% versus 44 ± 4%; p < 0.05) and the magnetic susceptibility decreased (-0.30 ± 0.27 ppm versus 0.10 ± 0.14 ppm; p < 0.001). The area under the receiver operating characteristic curve for magnetic susceptibility as NASH marker was 0.91 (95% CI: 0.79-1.0). Simultaneous MR quantification of fat content, fatty acid composition, T2 * and magnetic susceptibility is feasible in the liver. Our preliminary results suggest that quantitative susceptibility imaging has a high diagnostic performance for the diagnosis of NASH.

Selection of an early biomarker for vascular normalization using dynamic contrast-enhanced ultrasonography to predict outcomes of metastatic patients treated with bevacizumab.

BACKGROUND: Dynamic contrast-enhanced ultrasonography (DCE-US) has been used for evaluation of tumor response to antiangiogenic treatments. The objective of this study was to assess the link between DCE-US data obtained during the first week of treatment and subsequent tumor progression. PATIENTS AND METHODS: Patients treated with antiangiogenic therapies were included in a multicentric prospective study from 2007 to 2010. DCE-US examinations were available at baseline and at day 7. For each examination, a 3 min perfusion curve was recorded just after injection of a contrast agent. Each perfusion curve was modeled with seven parameters. We analyzed the correlation between criteria measured up to day 7 on freedom from progression (FFP). The impact was assessed globally, according to tumor localization and to type of treatment. RESULTS: The median follow-up was 20 months. The mean transit time (MTT) evaluated at day 7 was the only criterion significantly associated with FFP (P = 0.002). The cut-off point maximizing the difference between FFP curves was 12 s. Patients with at least a 12 s MTT had a better FFP. The results according to tumor type were significantly heterogeneous: the impact of MTT on FFP was more marked for breast cancer (P = 0.004) and for colon cancer (P = 0.025) than for other tumor types. Similarly, the differences in FFP according to MTT at day 7 were marked (P = 0.004) in patients receiving bevacizumab. CONCLUSION: The MTT evaluated with DCE-US at day 7 is significantly correlated to FFP of patients treated with bevacizumab. This criterion might be linked to vascular normalization. AFSSAPS NO: 2007-A00399-44.

ESGAR consensus statement on liver MR imaging and clinical use of liver-specific contrast agents.

OBJECTIVES: To develop a consensus and provide updated recommendations on liver MR imaging and the clinical use of liver-specific contrast agents. METHODS: The European Society of Gastrointestinal and Abdominal Radiology (ESGAR) formed a multinational European panel of experts, selected on the basis of a literature review and their leadership in the field of liver MR imaging. A modified Delphi process was adopted to draft a list of statements. Descriptive and Cronbach's statistics were used to rate levels of agreement and internal reliability of the consensus. RESULTS: Three Delphi rounds were conducted and 76 statements composed on MR technique (n = 17), clinical application of liver-specific contrast agents in benign, focal liver lesions (n = 7), malignant liver lesions in non-cirrhotic (n = 9) and in cirrhotic patients (n = 18), diffuse and vascular liver diseases (n = 12), and bile ducts (n = 13). The overall mean score of agreement was 4.84 (SD ±0.17). Full consensus was reached in 22 % of all statements in all working groups, with no full consensus reached on diffuse and vascular diseases. CONCLUSIONS: The consensus provided updated recommendations on the methodology, and clinical indications, of MRI with liver specific contrast agents in the study of liver diseases. KEY POINTS: • Liver-specific contrast agents are recommended in MRI of the liver. • The hepatobiliary phase improves the detection and characterization of hepatocellular lesions. • Liver-specific contrast agents can improve the detection of HCC.

Cystic form of paraduodenal pancreatitis (cystic dystrophy in heterotopic pancreas (CDHP)): a potential link with minor papilla abnormalities? A study in a large series.

OBJECTIVES: To analyze the association between cystic dystrophy in the heterotopic pancreas (CDHP) and minor papilla abnormalities. MATERIAL AND METHODS: Seventy-six patients with CDHP were retrospectively included over 14 years. Two radiologists searched for MDCT signs of CDHP (cysts and thickened intestinal wall, inflammatory changes), and minor papilla abnormalities (Santorini duct dilatation, luminal calcifications of the minor papilla). Other pancreatic abnormalities (parenchymal calcifications, main pancreatic duct dilatation) or bile duct dilatation were also analysed. RESULTS: CDHP was mostly located in the second part of the duodenum (71/76, 93.5 %). Median duodenal wall thickness was 20 mm (range 10-46). There were multiple cysts in 86 % (65/76, median = 3), measuring 2-60 mm. No cysts were identified in four patients (5 %). Inflammatory changes were found in 87 % (66/76). Minor papilla abnormalities were found in 37 % (28/76) and calcifications in the minor papilla without calcifications in the major papilla were only observed in three patients (4 %). Abnormalities of the pancreas and main bile duct dilatation were identified in 78 % (59/76) and 38 % (29/76). CONCLUSION: Previously described CT features were seen in most patients with CDHP. However, minor papilla abnormalities were seen in a minority of patients and, therefore, do not seem to be a predisposing factor for CDHP. KEY POINTS: Imaging features suggesting a CDHP diagnosis are confirmed in a large series. Minor papilla abnormalities do not seem to be a predisposing factor for CDHP. Most patients did not have any isolated minor papilla abnormalities.

Academic productivity of French radiology residents: Where do we stand?

RATIONALE AND OBJECTIVES: Although medical research by French radiology residents is encouraged, their publication productivity remains unknown. Thus, we aimed to assess and analyze the publication rate of medical theses and the overall academic productivity of radiology residents who graduated in 2009 and 2010. MATERIALS AND METHODS: The list of radiology residents and imaging theses were obtained from the French internet database of university theses. The main characteristics of the theses were recorded and correlated with associated publications identified by scanning the PubMed database. All other publications by French radiology residents not related to the theses were also obtained, described and compared to published theses. RESULTS: Seventy-nine out of 224 (35.3%) medical theses written by French radiology residents in 2009 and 2010 were transformed into articles published in Medline-indexed journals. Residents were first authors in 69% (60/87) of these articles. The factors associated with publication of the thesis were a prospective design (P=0.01) and the publication as a first author of an original study not related to the thesis (P=0.01). Seventy-one percent of the residents had published at least one other article, including 36.6% as first authors. CONCLUSION: Academic productivity of French radiology residents is high thanks to published theses and other articles.

Analysis of subsequent publication of scientific orally presented abstracts of the French National Congress of Radiology. Part II: Focus on the French abstracts.

AIM: To evaluate the publication rate of scientific abstracts that were presented orally at the 2008, 2009, and 2010 annual meetings of the French Society of Radiology by French radiologists, and to perform a French regional analysis. MATERIAL AND METHODS: Orally presented abstracts were identified by examining online abstract books of the 2008, 2009, and 2010 annual meetings of the French Society of Radiology, and cross-checked by reviewing the paper version of abstracts for the same period. Only abstracts from French teams were selected. The administrative region of submission was noted for each abstract and for each region the total population, the number of active radiologists, the number of active members of the French Society of Radiology and the number of academic radiologists were noted. Imaging subspecialties were also noted. RESULTS: 625 abstracts were identified resulting in 268 publications (publication rate: 43%). The median number of presentations and publications per region was 18 (range: 1-255) and 7 (range: 0-101), respectively. The ratio per million inhabitants was 7.5 and 3 respectively. The median number of presentations and publications per 100 active radiologists (respectively members of the FSR) was 7 and 3 (respectively 10 and 4). The median number of presentations and publications per academic radiologist were 2.6, and 1.2, respectively. The regional variations for each indicator were high (40-180%). Three subspecialties had a publication rate of more than 50%: thoracic imaging (58%), abdominal imaging (52%), and genitourinary imaging (51%). CONCLUSION: The publication rate of orally presented French scientific abstracts was high, with important variations according to the regions of origin and imaging subspecialties.