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CT IN PATIENTS WITH RESECTABLE PANCREATIC CANCER: A PROSPECTIVE STUDY
S160
Abstracts of the 19th National Congress of Digestive Diseases / Digestive and Liver Disease 45S (2013) S55–S218
P.10.5 FREQUENCY AND CHARACTERIZATION OF BENIGN LESIONS IN PANCREATIC SPECIMENS OF PATIENTS OPERATED FOR THE SUSPICION OF PANCREATIC CANCER F. Vitali ∗ ,1 , T. Hansen 2 , R. Kiesslich 3 , S. Heinrich 4 , S. Mildenberger 5 , A. Kumar 5 , I. Vantini 1 , C.J. Kirkpatrick 2 , L. Frulloni 1 1 Department of Medicine, University of Verona, Verona, Italy; 2 Institute of Pathology, University of Mainz, Mainz, Germany; 3 Institute of Internal Medicine, University of Mainz, Mainz, Germany; 4 Institute of Surgery, University of Mainz, Mainz, Germany; 5 Institute of Radiology, University of Mainz, Mainz, Germany
Background and aim: A final diagnosis of benign lesions is reported in up to 21% of patients who underwent duodenocefalopancreasectomy for neoplasia, whereas no data have yet been published for resection of the body-tail. Aim of the study was to investigate the frequency and to characterize the benign lesions mimicking a neoplasia in the head and in the body-tail of the pancreas. Material and methods: We retrospectively reviewed all the pancreatic specimens collected from 2005 to 2011 in the database of the Institute of Pathology of Mainz. Patients with a final diagnosis excluding malignancy were analyzed by histological, clinical and imaging findings. Results: 373 pts were identified. A final diagnosis of benign disease was observed in 33 pts (8.8%), in 25 out of 298 (8.4%) in the resections of the pancreatic head and in 8 out of 75 (10.7%) of the body-tail. Among them we found paraduodenal pancreatitis (PP) in 13 cases (39.4%), autoimmune pancreatitis (AIP) in 11 (33.3%), chronic pancreatitis (CP) in 6 (18.2%) and accessory spleen in 3 (9.1%). In the head of the pancreas the most frequent diagnosis is PP and AIP, whereas in the body-tail accessory spleen and CP. Patients with benign lesions were more likely to be males, younger, smokers and drinkers, with longer lasting pain. Lower serum levels of Ca 19-9 and lower frequency of jaundice were more frequently observed in this group. Pancreatic calcifications were more frequently associated with benign lesions whereas a larger dilation of common bile duct in the malignant lesions. AIP and PP have different clinical and radiological profiles. Conclusions: Benign lesions are observed with the same frequency in specimens of the head or body-tail of the pancreas, while the type of final diagnosis is different.
P.10.6 ECTOPIC PANCREATIC TISSUE IN THE GASTRIC ANTRUM: A SPECTRUM OF IMAGING FINDINGS D. Gambaccini ∗ , G. Laino, P. Giusti, S. D’Imporzano, G. Materazzi, M. Nervi, M. Bertini, M. Bellini, F. Costa, B. Solito, S. Marchi Ospadale Cisanello, Pisa, Italy Background and aim: Ectopic pancreatic tissue is an uncommon congenital anomaly defined as the presence of pancreatic tissue outside the normal location of the main gland and without any anatomic and vascular connection with it. The most common sites are stomach, duodenum, proximal jejunum and ileum. Although rarely clinically significant, ectopic pancreas (EP) has been associated with inflammation, bleeding, intussusceptions and even adenocarcinoma. The resection is indicated when it is symptomatic, but whether to remove EP that is found incidentally remains controversial. To describe radiological and endosonographic findings of suspected EP in the gastric antrum detected by endoscopy, in order to identify features useful for a correct diagnosis and for an appropriate and safe management. Material and methods: From October 2011 to January 2012 barium contrast upper gastrointestinal series and endoscopic ultrasonography (EUS) were performed in 6 consecutive patients (2f, 3m; age: 30–52 years) with endoscopic diagnosis of suspected EP in the gastric antrum. Patients’ data and symptoms were also recorded. Results: In 5 upper digestive endoscopies and in 5 radiographic scans, lesions suspected for EP presented similar features (little nodular masses with central umbilication located in the gastric antrum on the greater curvature). In all cases, the echo pattern was heterogeneous: hypoechoic images with internal small hyperechoic areas were located in the second and in the third endosono-
graphic layers (deep mucosa and submucosa). In one case the umbilication was particularly large and deep appearing at RX series as a gastric diverticulum. Another patient showed at radiographic study the presence of a thin blind-fistula but the CT scan showed no connection with the adjacent organs and revealed an enhancement similar to normal pancreatic parenchyma. An endoscopic resection was performed only in one patient because of the EUS marked heterogeneity, the size of the mass and the severe and frequent pain. The histopatology study confirmed the presence of ectopic pancreatic tissue. Conclusions: Submucosal lesions in the gastric antrum suspected for EP are not such a rare finding and are often undervalued. The imaging appearance and symptoms reported reflect a great variability of features. Our study confirms that further investigations are required in order to obtain a better characterization of each lesion and to perform an individual and safe management.
P.10.7 THE VALUE OF (18)FDG-PET/CT IN PATIENTS WITH RESECTABLE PANCREATIC CANCER: A PROSPECTIVE STUDY S. Crippa ∗ ,1 , M. Salgarello 2 , S. Laiti 1 , S. Partelli 1 , C. Zardini 1 , P. Castelli 3 , G. Zamboni 3 , M. Falconi 1 1 Department
of Surgery Ospedale Sacro Cuore, Negrar (VR), Italy; of Nuclear Medicine, Negrar (VR), Italy; 3 Department of Pathology Ospedale Sacro Cuore, Negrar (VR), Italy
2 Department
Background and aim: Whole-body (18)fluor-deoxyglucose positron emission tomography/computed tomography (PET/CT) has emerged as a promising diagnostic modality in different tumors. The role and the utility of (18)FDG-PET/CT in resectable pancreatic cancer is debated. Aim of the present work was to assess prospectively the value of (18)FDG-PET/CT in addition to conventional imaging as a staging modality in candidates for resection of resectable pancreatic cancer. Material and methods: Whole-body (18)FDG-PET/CT was performed in 72 patients with pancreatic ductal adenocarcinoma who were judged resectable at high-resolution imaging. Neoadjuvant therapy was performed in the 20% of cases. Maximum standardized uptake value (SUVmax) was evaluated 60 minutes after FDG injection. PET/TC was considered “positive” for pancreatic cancer when SUV >3. Results: 8/72 (11%) patients were spared unwarranted resection since (18)FDG-PET/CT detected synchronous advanced lung cancer (n=1) or metastatic disease (n=7). Median CA 19.9 was 48.8 U/mL for the entire cohort and 292 U/mL for seven patients with metastases (p=0.112). In other two patients (18)FDG-PET/CT identified one colon carcinoma and a thoracic neurinoma. 15/72 (21%) patients had low metabolic activity (SUVmax<3), and 60% of these patients had undergone neoadjuvant treatment (p=0.0001). At laparotomy 3/64 (5%) patients did not undergo resection because of locally-advanced (n=1) or metastatic disease (n=2). 61 patients underwent pancreatic resections with curative intent. N1 rate was 77%, with a median of 33 resected nodes. In 8/61 (13%) patients (18)FDG-PET/CT identified metastatic lymph nodes that required an extension of lymphadenectomy. Sensitivity and specificity of (18)FDG-PET/CT for the detection of metastatic disease were 78% and 100%, respectively. Conclusions: 18)FDG-PET/CT findings resulted in changes of therapeutic management/operative procedures in one third of patients. (18)FDG-PET/CT improves staging of patients with resectable pancreatic cancer. Neoadjuvant treatment is significantly associated with low metabolic activity limiting the value of (18)FDG-PET/CT in this setting.
P.10.8 THREE DIMENSIONAL CONTRAST ENHANCED ULTRASONOGRAPHY VS. MAGNETIC RESONANCE IMAGING IN THE DIAGNOSIS OF IPMN OF THE PANCREAS R. Pezzilli ∗ , C. Serra, L. Calculli, F. Ferroni, A. Paccapelo, R. Casadei Sant’Orsola-Malpighi Hospital, Bologna, Italy Background and aim: The IPMNs of the pancreas represent a challenge for
Abstracts of the 19th National Congress of Digestive Diseases / Digestive and Liver Disease 45S (2013) S55–S218
P.10.5 FREQUENCY AND CHARACTERIZATION OF BENIGN LESIONS IN PANCREATIC SPECIMENS OF PATIENTS OPERATED FOR THE SUSPICION OF PANCREATIC CANCER F. Vitali ∗ ,1 , T. Hansen 2 , R. Kiesslich 3 , S. Heinrich 4 , S. Mildenberger 5 , A. Kumar 5 , I. Vantini 1 , C.J. Kirkpatrick 2 , L. Frulloni 1 1 Department of Medicine, University of Verona, Verona, Italy; 2 Institute of Pathology, University of Mainz, Mainz, Germany; 3 Institute of Internal Medicine, University of Mainz, Mainz, Germany; 4 Institute of Surgery, University of Mainz, Mainz, Germany; 5 Institute of Radiology, University of Mainz, Mainz, Germany
Background and aim: A final diagnosis of benign lesions is reported in up to 21% of patients who underwent duodenocefalopancreasectomy for neoplasia, whereas no data have yet been published for resection of the body-tail. Aim of the study was to investigate the frequency and to characterize the benign lesions mimicking a neoplasia in the head and in the body-tail of the pancreas. Material and methods: We retrospectively reviewed all the pancreatic specimens collected from 2005 to 2011 in the database of the Institute of Pathology of Mainz. Patients with a final diagnosis excluding malignancy were analyzed by histological, clinical and imaging findings. Results: 373 pts were identified. A final diagnosis of benign disease was observed in 33 pts (8.8%), in 25 out of 298 (8.4%) in the resections of the pancreatic head and in 8 out of 75 (10.7%) of the body-tail. Among them we found paraduodenal pancreatitis (PP) in 13 cases (39.4%), autoimmune pancreatitis (AIP) in 11 (33.3%), chronic pancreatitis (CP) in 6 (18.2%) and accessory spleen in 3 (9.1%). In the head of the pancreas the most frequent diagnosis is PP and AIP, whereas in the body-tail accessory spleen and CP. Patients with benign lesions were more likely to be males, younger, smokers and drinkers, with longer lasting pain. Lower serum levels of Ca 19-9 and lower frequency of jaundice were more frequently observed in this group. Pancreatic calcifications were more frequently associated with benign lesions whereas a larger dilation of common bile duct in the malignant lesions. AIP and PP have different clinical and radiological profiles. Conclusions: Benign lesions are observed with the same frequency in specimens of the head or body-tail of the pancreas, while the type of final diagnosis is different.
P.10.6 ECTOPIC PANCREATIC TISSUE IN THE GASTRIC ANTRUM: A SPECTRUM OF IMAGING FINDINGS D. Gambaccini ∗ , G. Laino, P. Giusti, S. D’Imporzano, G. Materazzi, M. Nervi, M. Bertini, M. Bellini, F. Costa, B. Solito, S. Marchi Ospadale Cisanello, Pisa, Italy Background and aim: Ectopic pancreatic tissue is an uncommon congenital anomaly defined as the presence of pancreatic tissue outside the normal location of the main gland and without any anatomic and vascular connection with it. The most common sites are stomach, duodenum, proximal jejunum and ileum. Although rarely clinically significant, ectopic pancreas (EP) has been associated with inflammation, bleeding, intussusceptions and even adenocarcinoma. The resection is indicated when it is symptomatic, but whether to remove EP that is found incidentally remains controversial. To describe radiological and endosonographic findings of suspected EP in the gastric antrum detected by endoscopy, in order to identify features useful for a correct diagnosis and for an appropriate and safe management. Material and methods: From October 2011 to January 2012 barium contrast upper gastrointestinal series and endoscopic ultrasonography (EUS) were performed in 6 consecutive patients (2f, 3m; age: 30–52 years) with endoscopic diagnosis of suspected EP in the gastric antrum. Patients’ data and symptoms were also recorded. Results: In 5 upper digestive endoscopies and in 5 radiographic scans, lesions suspected for EP presented similar features (little nodular masses with central umbilication located in the gastric antrum on the greater curvature). In all cases, the echo pattern was heterogeneous: hypoechoic images with internal small hyperechoic areas were located in the second and in the third endosono-
graphic layers (deep mucosa and submucosa). In one case the umbilication was particularly large and deep appearing at RX series as a gastric diverticulum. Another patient showed at radiographic study the presence of a thin blind-fistula but the CT scan showed no connection with the adjacent organs and revealed an enhancement similar to normal pancreatic parenchyma. An endoscopic resection was performed only in one patient because of the EUS marked heterogeneity, the size of the mass and the severe and frequent pain. The histopatology study confirmed the presence of ectopic pancreatic tissue. Conclusions: Submucosal lesions in the gastric antrum suspected for EP are not such a rare finding and are often undervalued. The imaging appearance and symptoms reported reflect a great variability of features. Our study confirms that further investigations are required in order to obtain a better characterization of each lesion and to perform an individual and safe management.
P.10.7 THE VALUE OF (18)FDG-PET/CT IN PATIENTS WITH RESECTABLE PANCREATIC CANCER: A PROSPECTIVE STUDY S. Crippa ∗ ,1 , M. Salgarello 2 , S. Laiti 1 , S. Partelli 1 , C. Zardini 1 , P. Castelli 3 , G. Zamboni 3 , M. Falconi 1 1 Department
of Surgery Ospedale Sacro Cuore, Negrar (VR), Italy; of Nuclear Medicine, Negrar (VR), Italy; 3 Department of Pathology Ospedale Sacro Cuore, Negrar (VR), Italy
2 Department
Background and aim: Whole-body (18)fluor-deoxyglucose positron emission tomography/computed tomography (PET/CT) has emerged as a promising diagnostic modality in different tumors. The role and the utility of (18)FDG-PET/CT in resectable pancreatic cancer is debated. Aim of the present work was to assess prospectively the value of (18)FDG-PET/CT in addition to conventional imaging as a staging modality in candidates for resection of resectable pancreatic cancer. Material and methods: Whole-body (18)FDG-PET/CT was performed in 72 patients with pancreatic ductal adenocarcinoma who were judged resectable at high-resolution imaging. Neoadjuvant therapy was performed in the 20% of cases. Maximum standardized uptake value (SUVmax) was evaluated 60 minutes after FDG injection. PET/TC was considered “positive” for pancreatic cancer when SUV >3. Results: 8/72 (11%) patients were spared unwarranted resection since (18)FDG-PET/CT detected synchronous advanced lung cancer (n=1) or metastatic disease (n=7). Median CA 19.9 was 48.8 U/mL for the entire cohort and 292 U/mL for seven patients with metastases (p=0.112). In other two patients (18)FDG-PET/CT identified one colon carcinoma and a thoracic neurinoma. 15/72 (21%) patients had low metabolic activity (SUVmax<3), and 60% of these patients had undergone neoadjuvant treatment (p=0.0001). At laparotomy 3/64 (5%) patients did not undergo resection because of locally-advanced (n=1) or metastatic disease (n=2). 61 patients underwent pancreatic resections with curative intent. N1 rate was 77%, with a median of 33 resected nodes. In 8/61 (13%) patients (18)FDG-PET/CT identified metastatic lymph nodes that required an extension of lymphadenectomy. Sensitivity and specificity of (18)FDG-PET/CT for the detection of metastatic disease were 78% and 100%, respectively. Conclusions: 18)FDG-PET/CT findings resulted in changes of therapeutic management/operative procedures in one third of patients. (18)FDG-PET/CT improves staging of patients with resectable pancreatic cancer. Neoadjuvant treatment is significantly associated with low metabolic activity limiting the value of (18)FDG-PET/CT in this setting.
P.10.8 THREE DIMENSIONAL CONTRAST ENHANCED ULTRASONOGRAPHY VS. MAGNETIC RESONANCE IMAGING IN THE DIAGNOSIS OF IPMN OF THE PANCREAS R. Pezzilli ∗ , C. Serra, L. Calculli, F. Ferroni, A. Paccapelo, R. Casadei Sant’Orsola-Malpighi Hospital, Bologna, Italy Background and aim: The IPMNs of the pancreas represent a challenge for