This document discusses advanced imaging techniques for pancreatic lesions. It begins by introducing new concepts in pancreatic imaging including downstaging of adenocarcinoma and prognostic stratification of neuroendocrine tumors. It then describes the multi-parametric MR protocol used, highlighting the added value of different sequences for detecting and characterizing lesions. Advanced techniques such as texture analysis of downstaged tumors on CT and 3D texture analysis of neuroendocrine neoplasms are also mentioned. The document emphasizes that imaging is becoming more quantitative and able to provide prognostic information beyond simple detection and characterization of lesions.

1. ADVANCED IMAGING IN
PANCREATIC LESIONS
Department of Radiology
University Hospital G.B. Rossi, Verona, Italy
Prof. Mirko D'Onofrio
1ST ITALIAN-FRENCH UPDATE IMAGING – IFUPI
MILAN March 23-24 2018
www.jfim.org

2. NEW
Concepts
NEW
Imaging
Techniques
NEW
Imaging
Analysis
ADVANCED PANCREATIC IMAGING

3. Settembre 2013 Ottobre 2014
Radiologist
«I need to see»
NEW CONCEPTS
Adenocarcinoma downstaging
ADVANCED PANCREATIC IMAGING

5. NEW CONCEPTS
Adenocarcinoma downstaging
Kim YE et al.
Radiology 2009
Cassinotto et al.
Eur J Radiol 2013
ADVANCED PANCREATIC IMAGING

6. Size ≈ Y
N = 0
R = 0
33 R0 / 47 Pts (70%)
NEW CONCEPTS
Adenocarcinoma downstaging
ADVANCED PANCREATIC IMAGING

7. NEW CONCEPTS
Prognostic Stratification
Adenocarcinoma
LOW GRADE
HIGH GRADE
ADVANCED PANCREATIC IMAGING

8. NEUROENDOCRINE
NEOPLASMS
QUALITATIVE
EVALUATION
QUANTITATIVE
EVALUATION
COMPUTED
ANALYSIS
GRADING
PROGNOSIS
BIOMARKER
NEW CONCEPTS
CT / MR
ADVANCED PANCREATIC IMAGING

9. NEW
Concepts
NEW
Imaging
Techniques
NEW
Imaging
Analysis
ADVANCED PANCREATIC IMAGING

10. IMAGING METHODS
MR
Protocol
SEQ PLN TR (ms) TE (ms) ST (mm)
T2 TSE HF AXIAL CORONAL 2500 90 6
T2 TSE FS AXIAL 2900 85 6
T1 GRE Dixon FS AXIAL 4,5 2,4 3
DWI EPI AXIAL 5000 75 6
T1 GRE Dixon MDC AXIAL 4,5 2,4 3
2D/3D CPRM CORONAL OBLIQUE 2000 700 2
T1 GRE Dixon MDC AXIAL 4,5 2,4 3
ADVANCED PANCREATIC IMAGING

11. SEQ PLN CLINICAL ADDED VALUE
T2 TSE HF AXIAL CORONAL Detection / Characterization
T2 TSE FS AXIAL Detection / Characterization
T1 GRE Dixon FS AXIAL Detection
DWI EPI AXIAL Detection / Staging
T1 GRE Dixon MDC AXIAL Detection / Characterization
2D/3D CPRM CORONAL OBLIQUE Detection
T1 GRE Dixon MDC AXIAL Detection / Staging
IMAGING METHODS
MULTIPARAMETRIC MR
Added value
ADVANCED PANCREATIC IMAGING

12. MULTIPARAMETRIC MR
Added value
T2 Imaging
Serous
Cystadenomas
ADVANCED PANCREATIC IMAGING

13. MULTIPARAMETRIC MR
Added value
T2 Imaging
Neuroendocrine
Neoplasms
ADVANCED PANCREATIC IMAGING

14. MULTIPARAMETRIC MR
Added value
T1 Imaging
Ductal Adenocarcinoma
ADVANCED PANCREATIC IMAGING

15. MULTIPARAMETRIC MR
Added value
T1 Imaging
Neuroendocrine Neoplasm
ADVANCED PANCREATIC IMAGING

16. MULTIPARAMETRIC MR
Added value
DWI Imaging
Neuroendocrine Neoplasm
ADVANCED PANCREATIC IMAGING

18. Ductal Adenocarcinoma

19. PANCREAS
MRI IMAGING
DWI
CONSPICUITY Iƭ = fibrosi =
enh (CT) cellularità/MVD
MRI
Ductal Adenocarcinoma

20. PANCREAS
MRI IMAGING
DWI

21. Ductal Adenocarcinoma

22. > detection
= staging

23. PANCREAS
MRI IMAGING

24. Ductal Adenocarcinoma

25. Ductal Adenocarcinoma

26. PANCREAS
IMAGING

27. Ductal Adenocarcinoma

28. Ductal Adenocarcinoma

29. Adenok ≤ 2 cm 27% isodense CT
Well differenziated 58% isodense CT
Secondary signs 76% < 20 mm vs 99% 21-30 mm (p < 0.05)
Isodense Adenok pathology:
Well-differentiating cancer and loose fibrosis

30. Clinical Picture:
- 50 yo woman
- follow up after thiroidectomy
- incidentaloma
- asymptomatic

31. Ductal adenocarcinoma
Incidentaloma characterization
Contrast-enhanced Ultrasound
1921
EARLY DIAGNOSIS
FOR A
BETTER PROGNOSIS

33. Contrast-enhanced Ultrasound
Ductal adenocarcinoma
characterization
Clinical scenario: incidental pancreatic solid mass
MR (MDCT staging)

34. Ductal adenocarcinoma
characterization
Clinical scenario: incidental pancreatic solid mass
Contrast-enhanced Ultrasound
Dietrich CF et al. Improved characterisation of solitary solid
pancreatic tumours using contrast enhanced transabdominal
ultrasound. J Cancer Res Clin Oncol 2008

35. Ductal adenocarcinoma
MRI

36. MULTIPARAMETRIC MR
Added value
DWI Imaging
DWI
CEMRI
Hepato
biliary
phase
ADVANCED PANCREATIC IMAGING

38. PANCREAS
IMAGING
Days before surgery US CT MR CEUS
Unpaired t test
P value 0.3664 0.2219 0.0783 0.0241
Mean ± SEM Concordance 6.818 ± 1.668, n=44 20.24 ± 3.258, n=29 17.75 ± 1.376, n=124 11.84 ± 1.557, n=117
Mean ± SEM Discordance 3.500 ± 1.985, n=10 11.00 ± 3.733, n=6 23.38 ± 3.267, n=32 2.188 ± 0.5494, n=16
Difference between means -3.318 ± 3.642 -9.241 ± 7.423 5.625 ± 3.174 -9.650 ± 4.229
95% CI -10.63 to 3.989 -24.34 to 5.860 -0.6444 to 11.89 -18.02 to -1.285
Days before surgery (Metastasis) US CT MR CEUS
Unpaired t test
P value 0.1945 0.8346 0.0166 0.1839
Mean ± SEM of Concordance 5.435 ± 1.435, n=46 18.93 ± 3.120, n=29 17.83 ± 1.328, n=139 13.91 ± 1.515, n=139
Mean ± SEM of Discordance 10.63 ± 4.751, n=8 17.33 ± 7.182, n=6 27.71 ± 4.277, n=17 5.889 ± 2.574, n=9
Difference between means 5.190 ± 3.949 -1.598 ± 7.590 9.879 ± 4.077 -8.018 ± 6.005
95% CI -2.733 to 13.11 -17.04 to 13.84 1.824 to 17.93 -19.89 to 3.851
The best concordance between preoperative MR and surgery was
obtained with imaging performed 17.83 days before surgery.

39. MULTIPARAMETRIC MR
Added value
MRCP
BD IPMN
ADVANCED PANCREATIC IMAGING

40. MULTIPARAMETRIC MR
Added value
MRCP
BD IPMN
ADVANCED PANCREATIC IMAGING

41. Ductal adenocarcinoma

42. MULTIPARAMETRIC MR
Added value
MRCP
ADVANCED PANCREATIC IMAGING

43. Ductal adenocarcinoma
Imaging appearance: iso T2/iso T1

44. NEW IMAGING TECHNIQUES
MR
b800
T2FS-b800 fusion
ADVANCED PANCREATIC IMAGING
Neuroendocrine
Neoplasms

45. Contrast-enhanced ultrasonography
IMAGE METHOD
MICROBUBBLES
TEMPORAL RESOLUTION
SPATIAL RESOLUTION
NO BACKGROUND SIGNAL
CONTRAST RESOLUTION

46. NEW IMAGING TECHNIQUES MR
INNOVATIONS PANCREATIC IMAGING

47. NEW IMAGING TECHNIQUES CT
ADVANCED PANCREATIC IMAGING

48. NEW
Concepts
NEW
Imaging
Techniques
NEW
Imaging
Analysis
ADVANCED PANCREATIC IMAGING

49. CT texture analysis of
downstaged ductal
adenocarcinoma
ECR 2017
Imaging Research corner
Images are more than pictures
PDAC STAGING: CT/MR
DOWNSIZED
GROUP
CT1 vs CT2
Mean Value Variance Skewness Kurtosis Entropia
Exact p-value 0.3778 0.4586 0.0087 <0.0001 0.6441

50. TEXTURE ANALYSIS
G1 vs G2 G2 vs G3 G1 vs G3
Mean Value p= 0,2123 p= 0,0842 p= 0,0113
Variance p= 0,8580 p= 0,1032 p= 0,1922
Skewness p= 0,4457 p= 0,3580 p= 0,2958
Kurtosis p= 0,0063 p< 0,0001 p< 0,0001
Entropia p= 0,2623 p= 0,0084 p= 0,0013
3D TEXTURE ANALYSIS OF
PANCREATIC
NEUROENDOCRINE
NEOPLASMS
ESGAR 2017
Top 20 abstracts

51. Smad4(Dpc4)
DETECTION
CHARACTERIZATION
PROGNOSTIC
STRATIFICATION
STAGING
RESTAGING

52. mirko.donofrio@univr.it
VERONA PANCREAS CENTER

53. mirko.donofrio@univr.it