Clinical significance of the preoperative main pancreatic duct dilation and neutrophil-to-lymphocyte ratio in pancreatic neuroendocrine tumors (PNETs) of the head after curative resection.

BACKGROUND: The present study aimed to investigate the prognostic significance of preoperative main pancreatic duct dilation and the neutrophil-to-lymphocyte ratio (PD-NLR) in pancreatic neuroendocrine tumors (PNETs) of the head after curative resection. METHODS: Sixty-four consecutive PNETs of the head that underwent curative resection were included in the study. Preoperative main pancreatic duct dilation (PD) was defined as a pancreatic duct dilation greater than 3 mm before surgery. Patients with both PD and an elevated NLR (> 3.13), with PD or elevated NLR, or neither of these characteristics were allocated a PD-NLR score of 2, 1, or 0, respectively. Univariate, multivariate and Kaplan-Meier analyses were used to calculate overall survival (OS) and disease-free survival (DFS). RESULTS: Preoperative PD-NLR score was correlated with tumor size (P = 0.005), T-stage (P = 0.016), lymph node metastasis (P <  0.001), distant metastasis (P = 0.005), type of hormone production (P = 0.006), perineural invasion (P = 0.014), and WHO classification (P <  0.001). Patients with a high PD-NLR score had a significantly poor OS and DFS relative to those with a low PD-NLR score (P <  0.001). In the multivariate analysis, PD-NLR score was an independent predictor of OS and DFS for PNET of the head (both P <  0.05). In the analyses of the various subgroups, preoperative PD-NLR score was also a predictor of OS and DFS. Additionally, the survival predictive capability of PD-NLR score was superior to that of WHO classification. CONCLUSIONS: Despite the retrospective nature and small sample size of the present study, the results suggest that preoperative PD-NLR score can serve as an independent prognostic marker of early survival in patients with PNETs of the head undergoing curative resection. Further large prospective studies are necessary to validate our findings.

Detection of High-Grade Pancreatic Intraepithelial Neoplasia without Morphological Changes of the Main Pancreatic Duct over a Long Period: Importance for Close Follow-Up for Confirmation.

Pancreatic intraepithelial neoplasia (PanIN) is a microscopic papillary noninvasive lesion arising from the pancreatic ductal epithelium. However, the natural history and time to progression of high-grade PanIN remain unclear. Herein, we report 2 cases of high-grade PanIN without morphological changes of the main pancreatic duct (MPD) over relatively long periods. In the first case, a 63-year-old man was identified with MPD dilation. Magnetic resonance cholangiopancreatography showed localized stenosis in the pancreatic body with distal MPD dilation. Endoscopic retrograde pancreatography (ERP) was attempted because of possible high-grade PanIN but was unsuccessful. At 15-month follow-up, there was no change in the form of the MPD in various images. However, ERP was re-performed because of possible high-grade PanIN, and cytology showed adenocarcinoma. Postoperative pathology indicated diffuse lesions corresponding to high-grade PanINs in the MPD stenosis and surrounding branches. Final diagnosis was high-grade PanIN. In the second case, a 77-year-old man was identified with MPD dilation. Magnetic resonance cholangiography showed localized stenosis in the MPD of the pancreatic head with distal MPD dilation. He was diagnosed with MPD stenosis caused by chronic pancreatitis, and further examination was not recommended. At 25 months, the patient was referred to our hospital because of a mild change in MPD dilation. ERP showed localized irregular stenosis in the MPD, and cytology showed suspected adenocarcinoma. Postoperative pathology indicated a localized lesion with high-grade PanIN in the branch duct around the MPD stenosis. Final diagnosis was high-grade PanIN. In conclusion, we report 2 cases of high-grade PanIN without morphological changes of the MPD over relatively long periods. Even if a definite diagnosis is not obtained at initial examination, a strict follow-up observational study should be performed. Re-examination, including ERP, should also be considered in cases with risk factors of pancreatic cancer, even if there is no change in MPD form.

CTG-Net: an efficient cascaded framework driven by terminal guidance mechanism for dilated pancreatic duct segmentation.

Pancreatic duct dilation indicates a high risk of various pancreatic diseases. Segmentation for dilated pancreatic duct (DPD) on computed tomography (CT) image shows the potential to assist the early diagnosis, surgical planning and prognosis. Because of the DPD's tiny size, slender tubular structure and the surrounding distractions, most current researches on DPD segmentation achieve low accuracy and always have segmentation errors on the terminal DPD regions. To address these problems, we propose a cascaded terminal guidance network to efficiently improve the DPD segmentation performance. Firstly, a basic cascaded segmentation architecture is established to get the pancreas and coarse DPD segmentation, a DPD graph structure is build on the coarse DPD segmentation to locate the terminal DPD regions. Then, a terminal anatomy attention module is introduced for jointly learning the local intensity from the CT images, feature cues from the coarse DPD segmentation and global anatomy information from the designed pancreas anatomy-aware maps. Finally, a terminal distraction attention module which explicitly learns the distribution of the terminal distraction regions is proposed to reduce the false positive and false negative predictions. We also propose a new metric called tDice to measure the terminal segmentation accuracy for targets with tubular structures and two other metrics for segmentation error evaluation. We collect our dilated pancreatic duct segmentation dataset with 150 CT scans from patients with five types of pancreatic tumors. Experimental results on our dataset show that our proposed approach boosts DPD segmentation accuracy by nearly 20% compared with the existing results, and achieves more than 9% improvement for the terminal segmentation accuracy compared with the state-of-the-art methods.

Splenic Subcapsular Hematoma After Endoscopic Retrograde Cholangiopancreatography.

The complications of endoscopic retrograde cholangiopancreatography (ERCP) are numerous and mainly intraluminal. We present a unique case of a patient who developed splenic hematoma after ERCP. A 41-year-old woman was hospitalized for evaluation of chronic abdominal pain, for which she underwent an ERCP. The next day, the patient developed hemorrhagic shock. She was found to have a large ruptured subcapsular splenic bleed. Splenic artery embolization was performed, and the patient was stabilized. In conclusion, a high index of suspicion should be kept when managing patients presenting with unstable vital signs and/or acute anemia after ERCP.

A cascaded fully convolutional network framework for dilated pancreatic duct segmentation.

PURPOSE: Pancreatic duct dilation can be considered an early sign of pancreatic ductal adenocarcinoma (PDAC). However, there is little existing research focused on dilated pancreatic duct segmentation as a potential screening tool for people without PDAC. Dilated pancreatic duct segmentation is difficult due to the lack of readily available labeled data and strong voxel imbalance between the pancreatic duct region and other regions. To overcome these challenges, we propose a two-step approach for dilated pancreatic duct segmentation from abdominal computed tomography (CT) volumes using fully convolutional networks (FCNs). METHODS: Our framework segments the pancreatic duct in a cascaded manner. The pancreatic duct occupies a tiny portion of abdominal CT volumes. Therefore, to concentrate on the pancreas regions, we use a public pancreas dataset to train an FCN to generate an ROI covering the pancreas and use a 3D U-Net-like FCN for coarse pancreas segmentation. To further improve the dilated pancreatic duct segmentation, we deploy a skip connection on each corresponding resolution level and an attention mechanism in the bottleneck layer. Moreover, we introduce a combined loss function based on Dice loss and Focal loss. Random data augmentation is adopted throughout the experiments to improve the generalizability of the model. RESULTS: We manually created a dilated pancreatic duct dataset with semi-automated annotation tools. Experimental results showed that our proposed framework is practical for dilated pancreatic duct segmentation. The average Dice score and sensitivity were 49.9% and 51.9%, respectively. These results show the potential of our approach as a clinical screening tool. CONCLUSIONS: We investigate an automated framework for dilated pancreatic duct segmentation. The cascade strategy effectively improved the segmentation performance of the pancreatic duct. Our modifications to the FCNs together with random data augmentation and the proposed combined loss function facilitate automated segmentation.

Metastatic Renal Cell Cancer With Pancreatic Mass.

A pancreatic mass is mostly discovered late in the course of the disease and is usually asymptomatic in the early stages. In rare cases, a pancreatic mass may be metastatic, and presentation may depend on the presence and locations of other metastasis or to the primary lesion. Renal cell cancer is the most common tumor presenting as metastatic pancreatic mass. Most metastases occur within the first ten years after diagnosis. We present a case of metastatic renal cell cancer to the contralateral adrenal and pancreas causing pancreatic duct dilation, 15 years after radical nephrectomy.

The role of endoscopic ultrasound in evaluating patients with bile duct dilation of unclear etiology.

OBJECTIVE: Bile duct dilation (BDD) of unclear etiology is a common indication for further imaging via endoscopic ultrasound (EUS). We aimed to assess the yield of EUS in determining BDD etiology in patients with prior non-diagnostic imaging studies. METHODS: A retrospective chart review was performed at a single, tertiary-care university hospital for patients referred for EUS for BDD with or without pancreatic duct dilation (PDD). EUS-guided fine needle aspiration (FNA) was performed if a focal lesion was identified. Cases with an etiology of BDD diagnosed or strongly suggested by prior imaging were excluded. EUS findings believed to represent a structural cause for BDD included a wide range of pancreaticobiliary and luminal pathology as well as patients' clinical factors. RESULTS: In total, 307 patients were identified. Findings to explain BDD were found by EUS in 213 patients for a diagnostic yield of 69.4%. Patients with jaundice were significantly more likely to receive a diagnosis by EUS than those without (78.8% vs 55.3%, P < 0.01). Notably, 8.1% of patients with normal liver function test (LFT) had a EUS-diagnosed malignancy. Patients' age, narcotic use, concurrent PDD and prior cholecystectomy did not appear to influence the EUS yield. CONCLUSIONS: EUS continues to play a substantial role in evaluating BDD of unclear etiology, most notably in patients with jaundice. In addition, given that 8.1% of asymptomatic patients without jaundice or abnormal LFT had malignancy diagnosed on EUS, the use of EUS for BDD of unclear etiology remains warranted.

Performance of endoscopic ultrasound for diagnosis of agenesis of the dorsal pancreas: a case report.

Agenesis of the dorsal pancreas is a rare congenital pancreatic malformation. We herein describe a 67-year-old woman with a 5-day history of lower back pain who was eventually diagnosed with agenesis of the dorsal pancreas. Abdominal computed tomography showed an enlarged pancreatic head, but the pancreatic body and tail were invisible. The magnetic resonance imaging findings were similar to the computed tomography findings. Magnetic resonance cholangiopancreatography showed that the major pancreatic duct was mildly dilated but otherwise normal. Endoscopic ultrasound revealed absence of the pancreatic body and tail, an enlarged head of the pancreas, and mild pancreatic duct dilation. The final diagnosis was dorsal pancreatic agenesis.

Medical imaging in misdiagnosing serous cystic neoplasms of the pancreas with pancreatic duct dilatation as other pancreatic lessions / 中华肝胆外科杂志

Objective:To analyze the medical imaging in misdiagnosing serous cystic neoplasm(SCN) of the pancreas with pancreatic duct dilatation as other pancreatic lesions.Methods:Data of 21 patients with SCN and pancreatic duct dilatation who underwent surgical resection from January 2011 to November 2021 at the First Affiliated Hospital of Naval Medical University were retrospectively analyzed. There were 9 males and 12 females with ages ranging from 25 to 74, mean ± s. d. (57.4±13.4) years. The clinical features, surgical treatments, CT and MRI imaging features, and misdiagnosis were analyzed.Results:Of 11 patients who presented with abdominal pain, 1 patient had backache, 1 patient was jaundice, 1 patient had weight loss, 1 patinet had fatigue and 6 patients were asymptomatic. Ten patients were operated using pancreaticoduodenectomy, 8 distal pancreatectomy, 2 segmental pancreatectomy and 1 total pancreatectomy. For 11 patients, the lesion was located in the head of pancreas, and for 10 patients in the body and tail of pancreas. The tumor size was 23.0-92.0 (45.8±17.8) mm. All 21 patients had upstream pancreatic duct dilatation but no downstream pancreatic duct dilatation. The inner diameter of the pancreatic duct was 4.0-11.0(7.1±2.0) mm. Of 13 patients showed a low signal intensity on T 1-weighted imaging, 18 patients showed a markedly high signal intensity on T 2-weighted imaging, 13 patients showed no limitation on diffusion weighted imaging. Among the 11 patients who underwent CT examination, 5 patients were diagnosed to have intraductal papillary mucinous neoplesm (IPMN), 3 SCN, 1 pancreatic neuroendocrine tumor, 1 pancreatic cancer and 1 cyst. The misdiagnotic rate of CT was 72.7% (8/11). Among the 18 patients who underwent MRI examination, 9 patients were diagnosed to have IPMN, 3 mucinous cystic neoplasm, 3 SCN, 2 pancreatic cancer and 1 solid pseudopapillary tumor. The misdiagnosis rate of MRI was 83.3% (15/18). Conclusion:SCN with pancreatic duct dilatation was easily misdiagnosed as IPMN or other pancreatic solid tumors. The difference between SCN with pancreatic duct dilatation and IPMN was that the downstream pancreatic duct of SCN was normal. SCN showed a markedly high signal intensity on T 2-weighted imaging and no limitation on diffusion weighted imaging, which can help to distinguish SCN from other pancreatic solid tumors.