Cross-sectional imaging-based severity scoring of chronic pancreatitis: why it is necessary and how it can be done

Chronic pancreatitis (CP) remains a diagnostic challenge as clinical symptoms are non-specific, histopathological appearances are varied and pathogenesis remains incompletely understood. Multiple classifications and grading systems have been proposed for CP, but none leverage the full capabilities of cross-sectional imaging modalities and are not widely accepted or validated. CT and MRI/MRCP are useful in identifying a wide spectrum of histopathological changes in CP and can also assess exocrine reserve of pancreas. Advanced MRI techniques such as T1 mapping and extracellular volume fraction can potentially identify early CP. Cross-sectional imaging-based severity scoring can quantify CP disease burden and may have positive implications for clinicians and researchers. In this review, we discuss the need for cross-sectional imaging-based severity scoring for CP, role of CT, and MRI/MRCP in assessment of CP and how these modalities can be used to obtain severity scoring for CP. We summarize relevant information from recently published CT and MRI/MRCP reporting standards for CP, and from international guidelines for cross-sectional imaging and severity scoring for CP

Inter-observer variability of radiologists for Cambridge classification of chronic pancreatitis using CT and MRCP: results from a large multi-center study

Purpose: Determine inter-observer variability among radiologists in assigning Cambridge Classification (CC) of chronic pancreatitis (CP) based on magnetic resonance imaging (MRI)/magnetic resonance cholangiopancreatography (MRCP) and contrast-enhanced CT (CECT). Methods: Among 422 eligible subjects enrolled into the PROCEED study between 6/2017 and 8/2018, 39 were selected randomly for this study (chronic abdominal pain (n = 8; CC of 0), suspected CP (n = 22; CC of 0, 1 or 2) or definite CP (n = 9; CC of 3 or 4). Each imaging was scored by the local radiologist (LRs) and three of five central radiologists (CRs) at other consortium sites. The CRs were blinded to clinical data and site information of the participants. We compared the CC score assigned by the LR with the consensus CC score assigned by the CRs. The weighted kappa statistic (K) was used to estimate the inter-observer agreement. Results: For the majority of subjects (34/39), the group assignment by LR agreed with the consensus composite CT/MRCP score by the CRs (concordance ranging from 75 to 89% depending on cohort group). There was moderate agreement (63% and 67% agreed, respectively) between CRs and LRs in both the CT score (weighted Kappa [95% CI] = 0.56 [0.34, 0.78]; p-value = 0.57) and the MR score (weighted Kappa [95% CI] = 0.68 [0.49, 0.86]; p-value = 0.72). The composite CT/MR score showed moderate agreement (weighted Kappa [95% CI] = 0.62 [0.43, 0.81]; p-value = 0.80). Conclusion: There is a high degree of concordance among radiologists for assignment of CC using MRI and CT

Pancreaticoportal Fistula Formation as a Consequence of Recurrent Acute Pancreatitis: Clinical and Imaging Considerations

A pancreatic-portal vein fistula (PPVF) is an extremely rare complication of pancreatitis. In this report, we present a patient with a PPVF in the setting of recurrent pancreatitis and portal vein thrombosis diagnosed by cross-sectional imaging and endoscopic retrograde cholangio-pancreatography, who responded to medical management and anticoagulation. A critical review of this disease process is explored to highlight pathology, imaging characteristics, and essential alternative diagnostic considerations. We also discuss potential complications and current treatment strategies. PPVFs pose a unique diagnostic challenge and awareness of its clinical presentation can further improve patient outcomes

Predictive value of multi-detector computed tomography for accurate diagnosis of serous cystadenoma: Radiologic-pathologic correlation

AIM: To identify multi-detector computed tomography (MDCT) features most predictive of serous cystadenomas (SCAs), correlating with histopathology, and to study the impact of cyst size and MDCT technique on reader performance

A Comparison of Single Dimension and Volume Measurements in the Risk Stratification of Pancreatic Cystic Lesions

The incidence of pancreatic cystic lesions (PCLs) has been rising due to improvements in imaging. Of these, intraductal papillary mucinous neoplasms (IPMNs) are the most common and are thought to contribute to almost 20% of pancreatic adenocarcinomas. All major society guidelines for the management of IPMNs use size defined by maximum diameter as the primary determinant of whether surveillance or surgical resection is recommended. However, there is no consensus on how these measurements should be obtained or whether a single imaging modality is superior. Furthermore, the largest diameter may fail to capture the complexity of PCLs, as most are not perfectly spherical. This article reviews current PCL measurement techniques in CT, MRI, and EUS and posits volume as a possible alternative to the largest diameter

Reporting Standards for Chronic Pancreatitis by Using CT, MRI, and MR Cholangiopancreatography: The Consortium for the Study of Chronic Pancreatitis, Diabetes, and Pancreatic Cancer

Chronic pancreatitis is an inflammatory condition of the pancreas with clinical manifestations ranging from abdominal pain, acute pancreatitis, exocrine and/or endocrine dysfunction, and pancreatic cancer. There is a need for longitudinal studies in well-phenotyped patients to ascertain the utility of cross-sectional imaging findings of chronic pancreatitis for diagnosis and assessment of disease severity. CT and MR cholangiopancreatography are the most common cross-sectional imaging studies performed for the evaluation of chronic pancreatitis. Currently, there are no universal reporting standards for chronic pancreatitis. Several features of chronic pancreatitis are applied clinically, such as calcifications, parenchymal T1 signal changes, focal or diffuse gland atrophy, or irregular contour of the gland. Such findings have not been incorporated into standardized diagnostic criteria. There is also lack of consensus on quantification of disease severity in chronic pancreatitis, other than by using ductal features alone as described in the Cambridge classification. The Consortium for the Study of Chronic Pancreatitis, Diabetes, and Pancreatic Cancer (CPDPC) was established by the National Institute of Diabetes and Digestive and Kidney Diseases and the National Cancer Institute in 2015 to undertake collaborative studies on chronic pancreatitis, diabetes mellitus, and pancreatic adenocarcinoma. CPDPC investigators from the Adult Chronic Pancreatitis Working Group were tasked with development of a new consensus approach to reporting features of chronic pancreatitis aimed to standardize diagnosis and assessment of disease severity for clinical trials. This consensus statement presents and defines features of chronic pancreatitis along with recommended reporting metrics