Magnetic resonance (MR) for mural nodule detection studying Intraductal papillary mucinous neoplasms (IPMN) of pancreas: Imaging-pathologic correlation.

PURPOSE: Magnetic Resonance (MR) is recommended to diagnose Intraductal Papillary Mucinous Neoplasms (IPMN) and in the follow-up of borderline lesions. The purpose of this work is to evaluate the diagnostic accuracy of dynamic MR with Diffusion Weighted Imaging (DWI) in the identification of mural nodules of pancreatic IPMN by using pathological analysis as gold standard. MATERIALS AND METHODS: Ninety-one preoperative MR with histopathological diagnosis of IPMN were reviewed by two radiologists. Presence, number and size of mural nodule, signal intensity of the nodule on T1-weighted imaging (T1-WI) after contrast medium administration and on DWI. Inter-observer agreement was evaluated. RESULTS: Significant correlation (p < 0.0001) were found for presence of nodules > 5 mm on MR and pathological specimen, size and number of mural nodules evaluated on pathological review and degree of dysplasia, size and number of mural nodules evaluated on MR and tumoral dysplasia, presence of nodule > 5 mm with enhancement after contrast medium administration and hyperintensity on DWI and degree of dysplasia. Interobserver agreement was moderate for the presence of mural nodule (K = 0.56), for the presence of high signal intensity on DWI (K = 0.57) and enhancement of mural nodule (K = 0.58). Apparent Diffusion Coefficient (ADC) map histogram analysis showed a correlation between Entropy of the entire cystic lesion and the degree of dysplasia (p < 0.034). CONCLUSIONS: MR with dynamic and DWI sequences was an accurate method for the identification of ≥ 5 mm solid nodules of the IPMNs and correlate with the lesion malignancy. Entropy, calculated from the histogram analysis of the IPMN ADC map, correlated with the lesion dysplasia.

Clinical use of contrast-enhanced ultrasound beyond the liver: a focus on renal, splenic, and pancreatic applications.

Contrast-enhanced ultrasound (CEUS) is a relatively novel, but increasingly used, diagnostic imaging modality. In recent years, due to its safety, quickness, and repeatability, several studies have demonstrated the accuracy, specificity, and sensitivity of CEUS. The European Federation of Societies for Ultrasound in Medicine and Biology has recently updated the previous guidelines from 2012 for the use of CEUS in non-hepatic applications. This review deals with the clinical use and applications of CEUS for the evaluation of non-hepatic abdominal organs, focusing on renal, splenic, and pancreatic applications.

The Actual Prevalence of Symptoms in Pancreatic Cystic Neoplasms: A Prospective Propensity Matched Cohort Analysis.

BACKGROUND: The prevalence of symptoms in pancreatic cystic neoplasms (PCNs) is mainly based on retrospective surgical series. The aim of this study is to describe the actual prevalence of symptoms in PCNs under surveillance. METHODS: Patients with PCNs under surveillance observed from 2015 to 2017 were submitted to magnetic resonance imaging (MRI) and a specific interview. An identical survey was carried out on a control population matched for age, sex, and comorbidities in which any pancreatic disease was excluded by MRI. RESULTS: Two groups of 184 individuals were compared. Patients with PCNs have a similar prevalence of abdominal pain when compared to controls (35.2 vs. 28.8, p = 0.2). PCNs in the distal pancreas experienced a significantly increased prevalence of abdominal pain (42.3 vs. 28.8%, p = 0.04), whereas size and presumed connection with the ductal system did not affect the prevalence of abdominal pain. PCNs associated with abdominal pain did not differ in terms of clinical and radiological features from asymptomatic ones. CONCLUSION: Patients with PCNs under surveillance have a similar prevalence of abdominal pain when compared to a matched population of controls. Abdominal pain might not correlate with radiological signs of malignancy.

Association Between Changes in Body Composition and Neoadjuvant Treatment for Pancreatic Cancer.

Importance: Sarcopenia and sarcopenic obesity have been associated with poor outcomes in unresectable pancreatic cancer (PC). Neoadjuvant treatment (NT) is used increasingly to improve resectability; however, its effects on fat and muscle body composition have not been characterized. Objectives: To evaluate whether NT affects muscle mass and adipose tissue in patients with borderline resectable PC (BRPC) and locally advanced PC (LAPC) and determine whether there were potential differences between patients who ultimately underwent resection and those who did not. Design, Setting, and Participants: In this retrospective cohort study conducted at 4 academic medical centers, 193 patients with BRPC and LAPC undergoing surgical exploration after NT who had available computed tomographic scans (both at diagnosis and preoperatively) and confirmed pancreatic ductal adenocarcinoma were evaluated. The study was conducted from January 2013 to December 2015. Data analysis was performed from September 2016 to May 2017. Measurement of body compartments was evaluated with volume assessment software before and after NT. A radiologist blinded to the patient outcome assessed the areas of skeletal muscle, total adipose tissue, and visceral adipose tissue through a standardized protocol. Exposures: Receipt of NT. Main Outcomes and Measures: Achievement of pancreatic resection at surgical exploration after the receipt of NT. Results: Of the 193 patients with complete radiologic imaging available after NT, 96 (49.7%) were women; mean (SD) age at diagnosis was 64 (11) years. Most patients received combined therapy with fluorouracil, irinotecan, oxaliplatin, leucovorin, and folic acid (124 [64.2%]) and 86 (44.6%) received chemoradiotherapy as well. The median interval between pre-NT and post-NT imaging was 6 months (interquartile range [IQR], 4-7 months). All body compartments significantly changed. The adipose compound decreased (median total adipose tissue area from 284.0 cm2; IQR, 171.0-414.0 to 250.0 cm2; IQR, 139.0-363.0; P < .001; median visceral adipose tissue area from 115.2 cm2; IQR, 59.9-191.0 to 97.7 cm2; IQR, 48.0-149.0 cm2; P < .001), whereas the lean mass slightly improved (median skeletal muscle from 122.1 cm2; IQR, 99.3-142.0 to 123 cm2; IQR 104.8-152.5 cm2; P = .001). Surgical resection was achievable in 136 (70.5%) patients. Patients who underwent resection had experienced a 5.9% skeletal muscle area increase during NT treatment, whereas those who did not undergo resection had a 1.7% decrease (P < .001). Conclusions and Relevance: Patients with PC experience a significant loss of adipose tissue during neoadjuvant chemotherapy, but no muscle wasting. An increase in muscle tissue during NT is associated with resectability.

Paraduodenal pancreatitis as a mimicker of pancreatic adenocarcinoma: MRI evaluation.

PURPOSE: To evaluate the MRI features of paraduodenal pancreatitis (PDP) and to define useful signs to differentiate PDP from pancreatic ductal adenocarcinoma (PDAC). MATERIAL AND METHODS: We reviewed the MRI scans of 56 patients, 28 affected by PDP and 28 by PDAC, all pathologically proven. The following parameters were evaluated: signal intensity of the lesion on T1-, T2-WI, DWI (b800) and after contrast medium administration; presence of cysts; dilation of common hepatic duct and main pancreatic duct; focal thickening of the second portion of the duodenum; maximum diameter and volume of the lesion. RESULTS: Both PDPs and PDACs were more frequently hypointense on T1-WI, iso-hyperintense on T2-WI, hypointense in the pancreatic phase and iso-hypointense in the venous phase (p>0.05); in the delayed phase most PDP were hyperintense (p=0.0031); on DWI 71.4% PDPs were isointense and all PDACs were hyperintense (p=0.0041). Cystic components were present in 85.7% PDPs (p=0.0011); double duct sign was present in 50% PDACs (p=0.0048); focal thickening of the duodenum was depicted in 89.3 PDPs (p=0.0012). PDPs were larger than PDACs (p=0.0003). CONCLUSION: The most suggestive signs of PDP are: signal hyperintensity in the delayed phase, isointensity on DWI, presence of cysts, focal thickening of the duodenum and large size of the lesion.

A comparative cost analysis of robotic-assisted surgery versus laparoscopic surgery and open surgery: the necessity of investing knowledgeably.

BACKGROUND: Robotic surgery has been proposed as a minimally invasive surgical technique with advantages for both surgeons and patients, but is associated with high costs (installation, use and maintenance). The Health Technology Assessment Unit of the Bambino Gesù Children's Hospital sought to investigate the economic sustainability of robotic surgery, having foreseen its impact on the hospital budget METHODS: Break-even and cost-minimization analyses were performed. A deterministic approach for sensitivity analysis was applied by varying the values of parameters between pre-defined ranges in different scenarios to see how the outcomes might differ. RESULTS: The break-even analysis indicated that at least 349 annual interventions would need to be carried out to reach the break-even point. The cost-minimization analysis showed that robotic surgery was the most expensive procedure among the considered alternatives (in terms of the contribution margin). CONCLUSIONS: Robotic surgery is a good clinical alternative to laparoscopic and open surgery (for many pediatric operations). However, the costs of robotic procedures are higher than the equivalent laparoscopic and open surgical interventions. Therefore, in the short run, these findings do not seem to support the decision to introduce a robotic system in our hospital.

Decision-Oriented Health Technology Assessment: One Step Forward in Supporting the Decision-Making Process in Hospitals.

OBJECTIVES: This article outlines the Decision-Oriented Health Technology Assessment: a new implementation of the European network for Health Technology Assessment Core Model, integrating the multicriteria decision-making analysis by using the analytic hierarchy process to introduce a standardized methodological approach as a valued and shared tool to support health care decision making within a hospital. METHODS: Following the Core Model as guidance (European network for Health Technology Assessment. HTA core model for medical and surgical interventions. Available from: http://www.eunethta.eu/outputs/hta-core-model-medical-and-surgical-interventions-10r. [Accessed May 27, 2014]), it is possible to apply the analytic hierarchy process to break down a problem into its constituent parts and identify priorities (i.e., assigning a weight to each part) in a hierarchical structure. Thus, it quantitatively compares the importance of multiple criteria in assessing health technologies and how the alternative technologies perform in satisfying these criteria. The verbal ratings are translated into a quantitative form by using the Saaty scale (Saaty TL. Decision making with the analytic hierarchy process. Int J Serv Sci 2008;1:83-98). An eigenvectors analysis is used for deriving the weights' systems (i.e., local and global weights' system) that reflect the importance assigned to the criteria and the priorities related to the performance of the alternative technologies. RESULTS: Compared with the Core Model, this methodological approach supplies a more timely as well as contextualized evidence for a specific technology, making it possible to obtain data that are more relevant and easier to interpret, and therefore more useful for decision makers to make investment choices with greater awareness. CONCLUSIONS: We reached the conclusion that although there may be scope for improvement, this implementation is a step forward toward the goal of building a "solid bridge" between the scientific evidence and the final decision maker's choice.