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• W2896771873 abstract "HomeRadiologyVol. 290, No. 1 PreviousNext Reviews and CommentaryFree AccessEditorialChronic Pancreatitis: Revisiting Imaging and the Values of Evidence-based Radiologic-Clinical CollaborationAlec J. Megibow Alec J. Megibow Author AffiliationsFrom the Department of Radiology, NYU Langone Health, 550 First Ave, New York, NY 10016.Address correspondence to the author (e-mail: [email protected]).Alec J. Megibow Published Online:Oct 16 2018https://doi.org/10.1148/radiol.2018182166MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In See also the article by Tirkes et al in this issue.IntroductionChronic pancreatitis (CP), first described in 1788, is characterized by progressive and irreversible pancreatic damage from scarring and inflammation with eventual loss of exocrine and endocrine function (1). Although previously believed to be a distinct disease entity, current thinking suggests that the etiology is based on a series of necrosis-fibrosis events leading to chronic parenchymal inflammation (2). There are several etiologies including toxic-metabolic (eg, alcohol, smoking), idiopathic, genetic, autoimmune, recurrent and severe acute pancreatitis, and obstructive (eg, neoplasms and possibly pancreas divisum or sphincter of Oddi dysfunction) (1). The incidence of CP rose from 2.94 per 100 000 in the years 1977–1986 to 4.35 per 100 000 only 1 decade later. Although the incidence is relatively low, CP results in over 150 million dollars in health care costs for the United States per year (3). Beyond the debilitating pain and malabsorption from the disease itself, there is a high rate of associated complications including diabetes and a major risk factor for development of pancreatic adenocarcinoma, among many. Mortality rate is estimated at 50% within 30–35 years of diagnosis (4). Despite the long-term awareness of the disease entity, there is limited success in diagnosing and predicting both clinical symptoms and disease progression.CP should be considered in all patients with typical epigastric pain radiating to the back, steatorrhea, weight loss, or recurrent acute pancreatitis (1). However, because there are no sensitive or specific serum and functional biomarkers, the gap between a suspected diagnosis and an established diagnosis remains wide. Furthermore, there is a long lead time (estimated between 15–25 years) (5) before onset of exocrine and endocrine insufficiency and characteristic structural changes within the pancreas appear.A stepwise approach is suggested to establish the presence of CP, beginning with the least invasive testing and escalating to more invasive procedures. The stepwise imaging workup should start with a standard CT. If this CT is inconclusive, then a pancreatic protocol CT scan or, preferably, secretin-enhanced MRI with MR cholangiopancreatography is recommended. If the diagnosis is still suspected but tests remain inconclusive, then more invasive procedures such as endoscopic US, pancreatic function testing, and finally endoscopic retrograde cholangiopancreatography should be considered (1). Although this is a logical framework for establishing the diagnosis, the actual cross-sectional imaging criteria for CP are not universally established and they have not been reassessed with the availability of current cross-sectional imaging technology. It is intuitive that a formalized assessment of CP imaging features would enhance radiologists’ ability to establish the diagnosis (perhaps at an earlier stage), decrease the need for more invasive diagnostic procedures, and, at least, halt further parenchymal damage.The article by Tirkes et al in this issue of Radiology is the result of collaboration of radiologists and clinicians drawn from the Consortium for the Study of Chronic Pancreatitis, Diabetes, and Pancreatic Cancer (6). Radiologists, surgeons, and gastroenterologists from institutions with wide experience in pancreatic diseases authored this article. The group set out two goals: first, to minimize imaging interpretative variability by offering metrics for reporting features of CP and second, as a result of the first goal, to facilitate classification of disease severity and longitudinal assessment in clinical trials. This multidisciplinary approach represents the most desirable combination of experts that provides high-level experientially derived evidence.When radiologists are currently asked to image and evaluate a patient suspected of having CP, most radiologists attempt to convert main pancreatic ductal alterations as defined by the Marseilles-Cambridge endoscopic retrograde cholangiopancreatography classification findings to what they see on their cross-sectional images, a process that is subject to a widely variable interpretation. This approach does not incorporate additional parenchymal information that is available on today’s imaging equipment.The article by Tirkes et al provides radiologists with a detailed and comprehensive imaging-based classification system for findings in CP. The article includes recommendations on how to perform high-quality multidetector CT or MRI pancreatic evaluation. With carefully chosen high-quality images, the authors have demonstrated unique findings at CT (presence and number of calcifications), followed by common findings at both CT and MRI (distribution; parenchymal thickness; main pancreatic duct narrowing, caliber, and contour; postsurgical appearances) and finally MRI or MR cholangiopancreatography findings (amount of side-branch ectasia before and after secretin administration, degree of duodenal filling following secretin administration, T1 signal intensity, parenchymal enhancement following gadolinium administration) for patients suspected of having CP. Additional tables and references to support each finding are provided. By using these tables, radiologists will be able to judge the presence and severity of the individual patient’s disease status. The authors maintain perspective about the adaptation of this scheme; as stated, a longitudinal study sponsored by the Adult Chronic Pancreatitis Working Group will initially only use the Marseille-Cambridge classification based on main pancreatic duct morphology, whereas this more comprehensive multiparametric image data will simultaneously be collected.In a wider context, this article adds to the large body of literature that emphasizes the inherent value of evidence-based radiology reporting. This type of reporting has the direct benefit of minimizing variability of interpretation and provides increased uniformity in recommending ongoing treatment(s). The problem of individual reporting and/or recommending is well documented in the literature. Examples include a study showing large swings in intramural reporting recommendations for pancreatic cysts (7) and a separate study showing the lack of consensus recommendations for handling common incidental findings in abdominal imaging among experienced radiologists from a variety of institutions (6).Radiologists, in combination with knowledgeable clinicians, have already created and published detailed reporting recommendations that, if followed, will promote the creation of imaging reports that comprehensively focus on key parameters that aid in therapeutic decision making. Several radiology societies have created formal mechanisms that bring together clinical experts and radiologists to develop high-level consensus statements that provide in-depth knowledge of complex diseases (8). Two examples of this type of collaboration are exemplified by the Society of Abdominal Radiology, combining with the American Pancreatic Association and separately with the American Gastroenterological Association, resulting in templates for reporting pancreatic adenocarcinoma (9,10) and Crohn disease (11,12). Both articles have been simultaneously published in Radiology and Gastroenterology.In summary, the article by Tirkes et al is an excellent example of how collaboration between knowledgeable radiologists and experienced clinicians can identify key features within correctly performed imaging studies that can inform the radiologist’s report. This collaboration yields an evaluation with actionable information for the patient and can further be used for longitudinal follow-up or multi-institutional trials. Individual radiologists may choose to present this information in a format that is suitable to their reporting style and the needs of their referring physicians. The article is yet another example of how this type of collaboration strengthens the diagnostic radiology value chain by providing integration of imaging and clinical data to produce a “robust and information-rich report” (13).Disclosures of Conflicts of Interest: A.J.M. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: is a consultant for Bracco Diagnostics. Other relationships: disclosed no relevant relationships.References1. Conwell DL, Lee LS, Yadav D, et al. American Pancreatic Association practice guidelines in chronic pancreatitis: evidence-based report on diagnostic guidelines. Pancreas 2014;43(8):1143–1162. Crossref, Medline, Google Scholar2. Stevens T, Conwell DL, Zuccaro G. Pathogenesis of chronic pancreatitis: an evidence-based review of past theories and recent developments. Am J Gastroenterol 2004;99(11):2256–2270. Crossref, Medline, Google Scholar3. Yadav D, Timmons L, Benson JT, Dierkhising RA, Chari ST. Incidence, prevalence, and survival of chronic pancreatitis: a population-based study. Am J Gastroenterol 2011;106(12):2192–2199 [Published correction appears in Am J Gastroenterol 2011;106(12):2209.]. Crossref, Medline, Google Scholar4. Lew D, Afghani E, Pandol S. Chronic pancreatitis: current status and challenges for prevention and treatment. Dig Dis Sci 2017;62(7):1702–1712. Crossref, Medline, Google Scholar5. Layer P, Yamamoto H, Kalthoff L, Clain JE, Bakken LJ, DiMagno EP. The different courses of early- and late-onset idiopathic and alcoholic chronic pancreatitis. Gastroenterology 1994;107(5):1481–1487. Crossref, Medline, Google Scholar6. Tirkes T, Shah ZK, Takahashi N, et al. Reporting standards for chronic pancreatitis by using CT, MRI, and MR cholangiopancreatography: the Consortium for the Study of Chronic Pancreatitis, Diabetes, and Pancreatic Cancer. Radiology 2019;290:216–217. Link, Google Scholar7. Ip IK, Mortele KJ, Prevedello LM, Khorasani R. Focal cystic pancreatic lesions: assessing variation in radiologists’ management recommendations. Radiology 2011;259(1):136–141. Link, Google Scholar8. Silverman SG, Megibow AJ, Fletcher JG. Society of Abdominal Radiology disease-focused panel program: rationale for its genesis and status report. Abdom Radiol (NY) 2017;42(8):2033–2036. Crossref, Medline, Google Scholar9. Al-Hawary MM, Francis IR, Chari ST, et al. Pancreatic ductal adenocarcinoma radiology reporting template: consensus statement of the Society of Abdominal Radiology and the American Pancreatic Association. Gastroenterology. Jan 2014;146(1):291-304 e291. Crossref, Medline, Google Scholar10. Al-Hawary MM, Francis IR, Chari ST, et al. Pancreatic ductal adenocarcinoma radiology reporting template: consensus statement of the Society of Abdominal Radiology and the American Pancreatic Association. Radiology. Jan 2014;270(1):248-260. Link, Google Scholar11. Bruining DH, Zimmermann EM, Loftus EV, Jr., Sandborn WJ, Sauer CG, Strong SA. Consensus recommendations for evaluation, interpretation, and utilization of computed tomography and magnetic resonance enterography in patients with small bowel Crohn's disease. Gastroenterology. Mar 2018;154(4):1172-1194. Crossref, Medline, Google Scholar12. Bruining DH, Zimmermann EM, Loftus EV, Jr., Sandborn WJ, Sauer CG, Strong SA. Consensus recommendations for evaluation, interpretation, and utilization of computed tomography and magnetic resonance enterography in patients with small bowel Crohn's disease. Radiology. Mar 2018;286(3):776-799. Link, Google Scholar13. Enzmann DR. Radiology’s value chain. Radiology 2012;263(1):243–252. Link, Google ScholarArticle HistoryReceived: Sept 18 2018Revision requested: Sept 20 2018Revision received: Sept 24 2018Accepted: Sept 26 2018Published online: Oct 16 2018Published in print: Jan 2019 FiguresReferencesRelatedDetailsAccompanying This ArticleReporting Standards for Chronic Pancreatitis by Using CT, MRI, and MR Cholangiopancreatography: The Consortium for the Study of Chronic Pancreatitis, Diabetes, and Pancreatic CancerOct 16 2018RadiologyRecommended Articles Secretin-enhanced MR Imaging of the PancreasRadiology2016Volume: 279Issue: 1pp. 29-43Chronic Pancreatitis or Pancreatic Tumor? 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