OBJECTIVE: To present computed tomography findings observed in four patients submitted to radical nephrectomy for renal cell carcinoma who developed pancreatic metastases afterwards. MATERIALS AND METHODS: The four patients underwent radical nephrectomy for stage T1 (n=2) and stage T3a (n=2) renal cell carcinoma. The mean interval between nephrectomy and detection of pancreatic metastases was eight years. Two asymptomatic patients presented with solitary pancreatic metastases (confined to the pancreas). Two symptomatic patients presented with single and multiple pancreatic metastases, both with tumor recurrence in the contralateral kidney. RESULTS: Computed tomography studies demonstrated pancreatic metastases as solitary (n=2), single (n=1) or multiple (n=1) hypervascular lesions. Partial pancreatectomy was performed in two patients with solitary pancreatic metastases and both are free of disease at four and two years after surgery. CONCLUSION: Pancreatic metastases from renal cell carcinoma are rare and can occur many years after the primary tumor presentation. Multiple pancreatic metastases and pancreatic metastases associated with tumor recurrence in the contralateral kidney are uncommon. Usually, on computed tomography images pancreatic metastases are visualized as solitary hypervascular lesions, simulating islet-cell tumors. Surgical management should be considered for patients with solitary pancreatic lesions.

Keywords: Pancreatic metastases, Renal cell carcinoma, Computed tomography

OBJECTIVE: To evaluate the reproducibility of unenhanced and contrast-enhanced computed tomography in the assessment of patients with acute pancreatitis. MATERIALS AND METHODS: Fifty-one unenhanced and contrast-enhanced abdominal computed tomography studies of patients with acute pancreatitis were blindly reviewed by two radiologists (observers 1 and 2). The morphological index was separately calculated for unenhanced and contrast-enhanced computed tomography and the disease severity index was established. Intraobserver and interobserver reproducibility of computed tomography was measured by means of the kappa index (kappa). RESULTS: Interobserver agreement was kappa = 0.666, 0.705, 0.648, 0.547 and 0.631, respectively for unenhanced and contrast-enhanced morphological index, presence of pancreatic necrosis, pancreatic necrosis extension, and disease severity index. Intraobserver agreement (observers 1 and 2, respectively) was kappa = 0.796 and 0.732 for unenhanced morphological index; kappa = 0.725 and 0.802 for contrast-enhanced morphological index; kappa = 0.674 and 0.849 for presence of pancreatic necrosis; kappa = 0.606 and 0.770 for pancreatic necrosis extension; and kappa = 0.801 and 0.687 for disease severity index at computed tomography. CONCLUSION: Computed tomography for determination of morphological index and disease severity index in the staging of acute pancreatitis is a quite reproducible method. The absence of contrast-enhancement does not affect the computed tomography morphological index reproducibility.

Keywords: Pancreatitis, X-ray computed tomography, Disease severity index, Prognosis, Contrast media, Necrosis

Pancreatic cystic lesions, particularly small lesions, are more easily diagnosed nowadays with the use of imaging methods. In some cases, the diagnosis represents a challenge to establish the treatment, as it can range from inflammatory pseudocysts to primary or metastatic cystic neoplasms. In order to choose the treatment, it is necessary to determine if the lesion is benign, borderline, or malignant. Currently, echoendoscopy is considered the gold standard procedure for pancreatic evaluation as it clearly shows the morphology of the lesion, and also allows the acquisition of pancreatic material for cytological and tumor markers studies using fine needle aspiration biopsy. This procedure is considered safe and efficient with high rates of sensibility and specificity and low rates of complications and morbidity. The presence of septa, mural nodules and irregularities in the parenchyma are the most significant predictive factors for the differential diagnosis of mucinous pancreatic-cystic lesions for which sensibility, specificity and accuracy rates are 94%, 85% and 88%, respectively. The aim of the authors in this study is to review the major primary-cystic-pancreatic neoplasms with emphasis in the application of echoendoscopy for the definite diagnosis of these lesions.

Keywords: Echoendoscopy, Endoscopic ultrasound, Endosonography, Pancreatic cystic neoplasm

We analyzed the ultrasonographic findings of 21 patients with mild acute pancreatitis. The presence or absence of pancreatic hypoechogenicity and peripancreatic fluid collection was assessed. Pancreatic hypoechogenicity was identified in 19 patients (90.5%) whereas small sac fluid collection was identified in 3 (15.8%) of these patients. No abnormality was seen in 2 patients (9.5%). Regarding the etiology of acute pancreatitis, cholelithiasis was identified in 15 patients (71.5%), alcohol abuse was identified in 4 patients (19.0%), and in 2 patients (9.5%) no probable etiology could be found. The authors conclude that ultrasonography may identify abnormalities in the majority of patients with mild acute pancreatitis and can be used to assess patients with peripancreatic fluid collections.

Keywords: Acute pancreatitis, Complications, Ultrasonography

OBJECTIVE: The aim of this prospective study was to investigate the feasibility of using a negative oral contrast agent to null the bowel signal during magnetic resonance cholangiopancreatography. MATERIAL AND METHOD: Fifteen healthy volunteers with no previous history of pancreaticobiliary disease or surgery were imaged with a single-shot fast spin-echo pulse sequence, using a magnetic resonance imaging system operating at 1.0 T. Data acquisition was started before and after administration of oral contrast agent. Using the magnetic resonance images obtained before and after administration of oral contrast agent, the common bile duct, pancreatic duct and papilla were assessed and graded by two radiologists. The frequency of adverse effects and the tolerance of the contrast were also evaluated. RESULTS: All patients that found negative oral contrast agent unpleasant (73% of the cases) tolerated well the oral contrast agent. Adverse effects as abdominal pain and diarrhea were noted in 30% of the patients. In all patients the high signal intensity from the intestinal fluid was completely suppressed. The depictions of the common hepatic duct were slightly improved, whereas the depictions of the choledochus, papilla and pancreatic duct were markedly improved by the negative oral contrast agent administration. CONCLUSION: Negative oral magnetic resonance contrast agent can be an effective and safe contrast media in eliminating signal intensity of the gastrointestinal tract, thus improving the depiction of the biliary system in magnetic resonance cholangiopancreatography.

Keywords: Magnetic resonance imaging, Biliary system, Pancreatic duct, Contrast media

The authors present a case of a patient with primary pancreatic leiomyosarcoma and describe the ultrasound findings during intraoperative ultrasonography. Although ultrasound, computed tomography and magnetic resonance features of primary pancreatic leiomyosarcomas have been previously described, there is no report on the ultrasonographic appearance of these tumors during intraoperative ultrasonography. The authors also stress the importance of intraoperative ultrasonography in establishing vascular invasion by the tumor.

Keywords: Intraoperative ultrasonography, Pancreas, Pancreatic tumors, Pancreatic leiomyosarcoma

Pulmonary pseudocysts are uncommon cavitary lesions that develop in the lung parenchyma as a consequence of blunt thoracic trauma, whose diagnosis is based on an association of clinical history and imaging findings. The present report describes the case of a pulmonary pseudocyst observed in the parenchyma contralateral to the trauma site in a 31year-old man presenting with hemoptysis after falling during a soccer match.

Keywords: Pulmonary pseudocyst; Post-traumatic pseudocyst; Post-traumatic pneumatoceles.

OBJECTIVE: To assess the impact of oral ranitidine on the imaging quality in magnetic resonance cholangiopancreatography (MRCP). MATERIALS AND METHODS: Thirty-two patients underwent MRCP with 3D and 2D acquisitions, and three strategies for suppression of the gastrointestinal fluid signal: a) only at fasting; b) 12 hours after ingestion of 300 mg ranitidine; c) after oral administration of gadolinium solution. Three observers reviewed the images with a focus on the degree of visualization of the biliopancreatic tree. The interobserver agreement was evaluated with the kappa test. The difference between techniques and acquisition modalities were evaluated by means of average grading scores. RESULTS: The three strategies for suppression of the gastrointestinal fluid signal presented high reproducibility. The results with suppression of the gastrointestinal fluid signal with ranitidine where similar to those obtained with fasting, and both were worse than those obtained with gadolinium solution. The 3D acquisitions surpassed 2D only in terms of visibility of the cystic duct and gallbladder, and were inferior or equivalent in the other biliopancreatic ductal segments. CONCLUSION: The use of ranitidine does not seem justified in the evaluation of the biliopancreatic tree at MRCP, since 2D MRCP with fasting allows the visualization of ductal structures with high quality and reproducibility in the majority of cases.

Keywords: Ranitidine; Diagnostic use; Magnetic resonance cholangiopancreatography; Contrast media; Bile ducts; Pancreatic ducts.

OBJECTIVE: To describe the technique of computed tomography-guided percutaneous biopsy of pancreatic tumors with pneumodissection. MATERIALS AND METHODS: In the period from June 2011 to May 2012, seven computed tomography-guided percutaneous biopsies of pancreatic tumors utilizing pneumodissection were performed in the authors' institution. All the procedures were performed with an automatic biopsy gun and coaxial system with Tru-core needles. The biopsy specimens were histologically assessed. RESULTS: In all the cases the pancreatic mass could not be directly approached by computed tomography without passing through major organs and structures. The injection of air allowed the displacement of adjacent structures and creation of a safe coaxial needle pathway toward the lesion. Biopsy was successfully performed in all the cases, yielding appropriate specimens for pathological analysis. CONCLUSION: Pneumodissection is a safe, inexpensive and technically easy approach to perform percutaneous biopsy in selected cases where direct access to the pancreatic tumor is not feasible.

Keywords: Pancreatic neoplasms; Needle biopsy; Computed tomography.

Acute pancreatitis is an inflammatory condition caused by intracellular activation and extravasation of inappropriate proteolytic enzymes determining destruction of pancreatic parenchyma and peripancreatic tissues. This is a fairly common clinical condition with two main presentations, namely, endematous pancreatitis - a less severe presentation -, and necrotizing pancreatitis - the most severe presentation that affects a significant part of patients. The radiological evaluation, particularly by computed tomography, plays a fundamental role in the definition of the management of severe cases, especially regarding the characterization of local complications with implications in the prognosis and in the definition of the therapeutic approach. New concepts include the subdivision of necrotizing pancreatitis into the following presentations: pancreatic parenchymal necrosis with concomitant peripancreatic tissue necrosis, and necrosis restricted to peripancreatic tissues. Moreover, there was a systematization of the terms acute peripancreatic fluid collection, pseudocyst, post-necrotic pancreatic/peripancreatic fluid collections and walled-off pancreatic necrosis. The knowledge about such terms is extremely relevant to standardize the terminology utilized by specialists involved in the diagnosis and treatment of these patients.

Keywords: Pancreatitis; Pseudocyst; Walled-off pancreatic necrosis.

We present a case of immunoglobulin G4 (IgG4)-related disease with pancreatic and extrapancreatic involvement, including the biliary and renal systems. Given the importance of imaging methods for the diagnosis of IgG4-related disease and its differentiation from pancreatic adenocarcinoma, we emphasize important abdominal computed tomography and magnetic resonance imaging findings related to this recently recognized systemic autoimmune disease.

Keywords: Pancreatitis; Autoimmune diseases; Pancreas; Computed tomography; Magnetic resonance imaging.

OBJECTIVE: To create a structured computed tomography (CT) report for the systematic evaluation of pancreatic ductal adenocarcinoma (PDAC), based on the opinions of clinicians and surgeons. MATERIALS AND METHODS: This was a prospective study in which we applied a 21-item questionnaire to experts in pancreatic diseases in order to create a model of a structured abdominal CT report. The questionnaire addressed the location and size of PDACs, as well as their effects on adjacent structures and on the vasculature, together with metastases. We used a Likert scale to determine which of those parameters should be included in the model. RESULTS: A total of 18 experts (12 surgeons and 6 clinicians) from 9 institutions completed the questionnaire. All of the experts agreed that the following (if present) should be described in the CT report on a PDAC: the degree of enhancement; the diameter and location of the lesion; pancreatic duct obstruction; biliary dilatation; pancreatic atrophy; liver metastases; peritoneal nodules; ascites; lymph node enlargement; and invasion of adjacent structures. More than 80% of the experts agreed that the report should also describe the relationship between the PDAC and the surrounding vasculature. CONCLUSION: We have developed a template for a CT report on patients with PDAC, based on the opinions of experts involved in the treatment of such patients.

Keywords: Pancreatic neoplasms/diagnostic imaging; Tomography, X-ray computed; Neoplasm staging; Consensus.