Intraductal oncocytic papillary neoplasm (IOPN): two case reports and review of the literature

Background: Intraductal oncocytic papillary neoplasms (IOPNs) place at the oncocytic extreme of the intraductal pancreatic neoplasm spectrum and display typical morphological features. Their identification in 1996 by Adsay et al. has been followed by a growing number of cases, paving the way for a deeper understanding of this underestimated entity. Contrarily to intraductal papillary mucinous neoplasms (IPMNs), most IOPNs run an indolent course and surgery is usually curative. Pancreatic IOPNs tend to develop from the main pancreatic duct (MPD) and their diagnosis is either incidental or subsequent to mass-related symptoms. Up to 30% of cases show concomitant areas of minimal stromal invasion and loco-regional or systemic spread are confined to a minority of cases. Biological hallmarks of IOPNs are being identified, including recurrent kinase gene rearrangements. Morphological and biological traits of IOPNs seem to overlap with those of other malignancies. A deeper understanding of these entities is needed in order to shed light upon the nature of pancreato-biliary oncocytic neoplasms. This case report describes two patients with a diagnosis of IOPN-one of them accounting for the largest IOPN ever described-and provides a brief review of recent discoveries on the subject. Case description: We describe two cases of IOPN occurring in adult male patients, respectively in their 60s and 70s. Both patients had unremarkable clinical history. In case 1 the diagnosis was coincidental to a right renal colic; case 2 complained a right lumbar pain radiating to the homolateral groin. In both cases imaging analyses revealed a voluminous pancreatic mass, posing the indication to laparoscopic pancreatectomy. Gross and histological features were consistent with the diagnosis of IOPN. Surgical margin were free from disease and the patient did not undergo further treatment. After a 10- and 7-month follow-up respectively, patients did not experience relapse. Conclusions: Recent immunohistochemical (IHC) and molecular data reveal unique characteristics of IOPNs, highlighting the substantial differences from IPMNs. Further research is needed in order to identify novel prognostic and predictive markers applicable to oncocytic neoplasms of the pancreato-biliary tract

Hepatic adrenal rest tumor in a patient with multifactorial liver cirrhosis: a case report with CT and MRI findings and pathologic correlation

AbstractBackgroundAdrenal rest tumor is an ectopic collection of adrenocortical cells in an extra-adrenal site, more frequently located around the kidney, retroperitoneum, spermatic cord, para-testicular region and broad ligament, but very rarely occurring also in the liver. Hepatic adrenal rest tumor poses a diagnostic challenge in differentiating it from hepatocellular carcinoma, particularly in a cirrhotic liver.Case presentationAn 83-years-old male was referred to our hospital by his family doctor for hepatological evaluation due to multifactorial liver cirrhosis. Ultrasound revealed a centimetric hypoechoic nodule in the VI hepatic segment in the context of a liver with signs of cirrhosis and steatosis. The patient first underwent MRI and then CT, which showed a fat containing focal liver lesion in the subcapsular location of the right lobe, strictly adjacent to the homolateral adrenal gland. The nodule was hypervascular in the arterial phase, washed out in the portal-venous and transitional phases, resulting hypointense in the hepato-biliary phase at MR imaging. In the suspicion of a hepatocellular carcinoma, the nodule was surgically removed, and the patient's postoperative course was unremarkable. The final histopathological diagnosis was of adrenal rest tumor of the liver.ConclusionsHepatic adrenal rest tumor is an extremely rare hepatic tumor, often without any clinical manifestation, that can also occur in the cirrhotic liver as in our case. Although there are not specific imaging findings, the possible diagnosis of HART should be considered when we observe a well-defined lesion in the subcapsular location of the right lobe, with fat containing, hypervascularity after contrast medium injection and vascular supply from the right hepatic artery

Chemotherapy-Induced Liver Injury in Patients with Colorectal Liver Metastases: Findings from MR Imaging

Chemotherapy-induced liver injury has been found to be quite common in cancer patients undergoing chemotherapy. Being aware of chemotherapy-induced hepatotoxicity is important for avoiding errors in detecting liver metastases and for defining the most appropriate clinical management strategy. MRI imaging has proven to be a useful troubleshooting tool that helps overcome false negatives in tumor response imaging after chemotherapy due to liver parenchyma changes. The purpose of this review is, therefore, to describe the characteristics of magnetic resonance imaging of the broad spectrum of liver damage induced by systemic chemotherapeutic agents in order to avoid misdiagnoses of liver metastases and disease progression and to define the most appropriate clinical management strategy

Biliary complications following orthotopic liver transplantation: May contrast-enhanced MR Cholangiography provide additional information?

Purpose: To assess whether contrast-enhanced T1-weighted MR Cholangiography may provide additional information in the evaluation of biliary complications in orthotopic liver transplant recipients. Material and methods: Eighty liver transplant patients with suspicion of biliary adverse events underwent MR imaging at 1.5 T scanner. After acquisition of axial T1-/T2-weighted images and conventional T2-weighted MR Cholangiography (image set 1), 3D gradient-echo T1-weighted fat-suppressed LAVA (Liver Acquisition with Volume Acceleration) sequences were obtained about 30 min after intravenous infusion of mangafodipir trisodium (Mn-DPDP,Teslascan®) (image set 2). The diagnostic value of mangafodipir trisodium-enhanced MR Cholangiography in the detection of biliary complications was tested by separate analysis results of image set 1 alone and image set 1 and 2 together. MRI results were correlated with direct cholangiography in 46 patients, surgery in 14 and/or clinical-radiological follow-up in the remaining 20 cases. Results: The level of confidence in the assessment of biliary adverse events was significantly increased by the administration of mangafodipir trisodium (p < 0.05). Particularly, contrast-enhanced T1-weighted LAVA sequences tended to out-perform conventional T2-weighted MR Cholangiography in the delineation of anastomotic and non-anastomotic biliary strictures and in the diagnosis of biliary leak. Conclusions: Contrast-enhanced T1-weighted MR Cholangiography may improve the level of diagnostic confidence provided by conventional T2-weighted MR Cholangiography in the evaluation of biliary complications after orthotopic liver transplantation. Keywords: Liver transplantation, Biliary complications, MR Cholangiography, Contrast-enhanced MR Cholangiography, Mangafodipir trisodium (Mn-DPDP

A Splenic IgG4+ Sclerosing Angiomatoid Nodular Transformation (SANT) Treated by Hemisplenectomy: A Radiologic, Histochemical, and Immunohistochemical Study

Introduction: Sclerosing angiomatoid nodular transformation (SANT) is a rare benign lesion of unknown origin for which total splenectomy is the standard treatment. Case Presentation: A 54-year-old man with a history of recurrent pancreatitis, bicuspid aortic valve, and aortic dissection underwent abdominal ultrasound, Computed tomography and magnetic resonance imaging, which revealed a 6-cm hypoechoic splenic mass diagnosed as cavernous hemangioma. Owing to his relevant past history, he was considered eligible for emisplenectomy and not for total excision, which is associated with long-term risks, especially infections. Results: Histologic examination revealed several nodules of varying size separated by sclerotic stroma with scattered inflammatory cells rich in IgG4+ in a background of splenic red pulp. Immunohistochemical stains showed a characteristic panel for CD34, CD31, and CD8. Conclusions: The diagnosis of SANT should be considered in any patient presenting with a splenic lesion containing an angiomatoid or inflammatory component. The only method able to establish a correct diagnosis is histologic and immunohistochemical evaluation. Complete splenectomy is generally considered the best approach. However, if the patient is at high risk of infection and localization of the lesion allows for selective devascularization of the affected part of the spleen, the lesion could be removed by hemisplenectomy. In some patients SANT is related to high blood levels of IgG4. Thus, corticosteroids might be useful for treating IgG4+ SANT and for preventing other IgG4-related diseases

Chemotherapy-Induced Liver Injury in Patients with Colorectal Liver Metastases: Findings from MR Imaging

Chemotherapy-induced liver injury has been found to be quite common in cancer patients undergoing chemotherapy. Being aware of chemotherapy-induced hepatotoxicity is important for avoiding errors in detecting liver metastases and for defining the most appropriate clinical management strategy. MRI imaging has proven to be a useful troubleshooting tool that helps overcome false negatives in tumor response imaging after chemotherapy due to liver parenchyma changes. The purpose of this review is, therefore, to describe the characteristics of magnetic resonance imaging of the broad spectrum of liver damage induced by systemic chemotherapeutic agents in order to avoid misdiagnoses of liver metastases and disease progression and to define the most appropriate clinical management strategy

Cystic Lesions of the Pancreas: Is Apparent Diffusion Coefficient Value Useful at 3 T Magnetic Resonance Imaging?

Objective: The objective of this study is to determine the role of apparent diffusion coefficient (ADC) value at 3T magnetic resonance imaging (MRI) in the characterization of pancreatic cystic lesions. Methods: We retrospectively selected a total number of 223 patients with a conclusive diagnosis of pancreatic cystic lesion, previously undergoing MR examination on a 3 T system. The MRI protocol first included axial T1/T2-weighted sequences and magnetic resonance cholangiopancreatography. Diffusion-weighted MRI was performed using a spin-echo echo-planar sequence with multiple b values (0, 150, 500, 1000, and 1500 s/mm2) in all diffusion directions, obtaining an ADC map. Contrast-enhanced T1-weighted sequences were performed during the initial work-up of a pancreatic cystic lesion and when signs of malignancy were suspected during the MRI follow-up. The ADC value of each pancreatic lesion was measured using a monoexponential curve fitting with all the multiple b. Results: The final diagnosis of our study group included the following: serous cystadenomas (n = 42), mucinous cystadenomas (n = 14), intraductal papillary mucinous neoplasms (IPMNs) (n = 121), IPMNs with signs of malignancy at histopathologic examination (n = 24), pseudocysts (n = 9), other cystic lesions (n = 13). A statistically significant difference was observed between the ADC values of malignant IPMNs and those of each other group of pancreatic lesions (P &lt; 0.001). The ADC value of benign IPMN was significantly higher than that of serous cystadenomas (P = 0.024). A statistically significant difference was observed between the ADCs of all mucinous cystic tumors (benign IPMNs together to mucinous cystadenomas) and the ADCs of serous cystadenomas (P = 0.014). Conclusions: Fitted ADC value obtained at 3T MRI may be helpful in the characterization of pancreatic cystic lesions with particular regards of differential diagnosis between mucinous and serous cystic tumors and between malignant and benign IPMNs

3T diffusion-weighted MRI in the response assessment of colorectal liver metastases after chemotherapy: Correlation between ADC value and histological tumour regression grading

Purpose The purpose of the study was to correlate the apparent diffusion coefficient (ADC) values of diffusion-weighted MR imaging (DW-MRI) by 3T device with the histological tumour regression grading (TRG) analysis of colorectal liver metastases after preoperative chemotherapy. Materials and methods Our study included thirty-five patients with colorectal liver metastases who had undergone MRI by 3T device (GE DISCOVERY MR750; GE Healthcare) after preoperative chemotherapy. DW-MRI was performed using a single-shot spin-echo echo-planar sequence with multiple b-values (0, 150, 500, 1000, 1500 s/mm2), thus obtaining an ADC map. For each liver lesion (more than 1 cm in diameter) the fitted ADC values were calculated by two radiologists in conference and three ROIs were drawn: around the entire tumour (ADCe), at the tumour periphery (ADCp) and at the tumour center (ADCc). All ADC values were correlated with histopathological findings after surgery. Hepatic metastases were pathologically classified into five groups on the basis of TRG. Statistical analysis was performed on a per-lesion basis utilizing the one-way analysis of variance (ANOVA). This retrospective study was approved by our institutional review board; written informed consent was obtained from all patients. Results A total of 106 colorectal liver metastases were included for image analysis. TRG1, TRG2, TRG3, TRG4 and TRG5 were observed in 4, 14, 36, 35 and 17 lesions, respectively. ADCeand ADCpvalues were significantly higher in lesions classified as TRG1 (2.40 ± 0.12 Ã\u97 10â\u88\u929 m2/s and 2.28 ± 0.26 Ã\u97 10â\u88\u929 m2/s, respectively) and as TRG2 (1.40 ± 0.31 Ã\u97 10â\u88\u929 m2/s and 1.44 ± 0.35 Ã\u97 10â\u88\u929 m2/s), compared to TRG3 (1.16 ± 0.13 Ã\u97 10â\u88\u929 m2/s and 1.01 ± 0.18 Ã\u97 10â\u88\u929 m2/s), TRG4 (1.10 ± 0.26 Ã\u97 10â\u88\u929 m2/s and 0.97 ± 0.24 Ã\u97 10â\u88\u929 m2/s), and TRG5 (0.93 ± 0.17 Ã\u97 10â\u88\u929 m2/s and 0.82 ± 0.28 Ã\u97 10â\u88\u929 m2/s). ADCe, ADCpand ADCcvalues were significantly different in TRG classes (p < 0.0001). Statistical correlations were found between the ADCe, ADCp, ADCcvalues and the TRG classes (Spearman correlation coefficient were â\u88\u920.568, â\u88\u920.542 and â\u88\u920.554, respectively). Conclusion Our study showed a significant correlation between ADC values of 3T DW-MRI and histological TRG of colorectal liver metastases after preoperative chemotherapy

T and N staging of colorectal cancer: usefulness of structured MRI report templates proposed by the European Society of Gastrointestinal and Abdominal Radiology (ESGAR)

Background: The definition of T and N stage is crucial for a correct therapeutic management of patients with colorectal cancer. Nowadays, MR imaging is considered the best available tool for rectal cancer staging, allowing an accurate evaluation of the disease extent, up to, beyond and over the mesorectal fascia, and of the lymph nodes involvement. MRI is also routinely performed after neoadjuvant chemo-radiation therapy (nCRT) for the evaluation of the response to treatments and for surgical planning. In 2012, the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) initiated an expert consensus meeting on magnetic resonance imaging (MRI) for the clinical management of rectal cancer. In 2016, the ESGAR updated the previous recommendations and proposed a novel report template (both for primary staging and for restaging after nCRT) based on the additional information obtained by the diffusion weighted images sequence in the MR protocol. Moreover, in the 2016 recommendation more attention was paid to the morphological and signal characteristic of the lymph node, in order to better identify the N stage. The aim of this study was to evaluate the usefulness and to compare the 2012 and 2016 structured MRI report templates proposed by the European Society of Gastrointestinal and Abdominal Radiology (ESGAR), for the staging of the rectal cancer. Material and Methods: Forty-seven consecutive patients (M:F, 34:13; mean age 63.9±12.4 years, range 30-86 years) affected by biopsy-proven rectal cancer were included in this retrospective study. Nineteen out of 47 had undergone nCRT (Capecitabine and Oxaliplatin, plus a total of 50.4Gy radiation dose) before surgery due to the locally advanced stage. All patients performed a MR examination within 20 days before surgery. In 44/47 cases the rectal anterior resection (RAR) was performed; in the remaining 3 cases the abdominoperineal resection (APR) was preferred. Twelve resections were performed by using the open-approach (10 RARs and 2 APRs), 10 by laparoscopy (all RARs) and 25 by the robotic-approach (24 RARs and one APR). A comparison between the radiological TN staging obtained according to the 2012 as well as the 2016 ESGAR guidelines, and the pathological TN staging was performed. Results: The radiological T stage did not differ between 2012 and 2016 ESGAR guidelines. In the directly resected group the radiological T stage was T1, T2, T3 and T4 in 1, 5, 20 and 2 patients, respectively. As to the patients who underwent nCRT, it was T0 (complete response without lesion detection or residual fibrotic tissue), T2, T3 and T4 in 4, 7, 6 and 2 patients, respectively. A statistical correlation was found between the radiological and pathological T stage (p&lt;0.0001; ρ of Spearman=0.62). As to the radiological N stage, according to 2012 and 2016 guidelines: no metastatic lymph nodes were found in 24 and 32 patients, respectively; N1 stage was assessed in 22 and 14 patients respectively. The N2 stage was assessed only in one patient, according to both guidelines. The pathological N stage was N0, N1 and N2 in 27, 16 and 4 patients, respectively. A statistical correlation was found between the radiological-pathological N stage comparison by applying both the 2012 (p=0.009) and the 2016 guidelines (p&lt;0.0001); however, the updated 2016 version showed a stronger correlation (ρ of Spearman=0.60). Conclusion: Both the 2012 and the 2016 ESGAR structured MRI report templates were reliable tools to assess the radiological T and N stage of the rectal cancer; the 2016 report template was more accurate in estimating lymph-nodes involvement