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Hx- Renal Cell Carcinoma Do you see a pancreatic mass?

Hx- Renal Cell CarcinomaDo you see a pancreatic mass?

 

Metastatic RCC to Pancreas only Seen on Arterial Phase

Metastatic RCC to Pancreas only Seen on Arterial Phase

 

Missed Diagnosis on CT

 

Right Nephrectomy for Clear Cell RCC: Routine Follow-up

Right Nephrectomy for Clear Cell RCC: Routine Follow-up

 

Missed Diagnosis on CT

 

Missed Diagnosis on CT

 

Missed Diagnosis on CT

 

Challenging Cases: Pancreatitis vs Pancreatic Neoplams

  • Autoimmune pancreatitis
  • Groove pancreatitis
  • Concurrent pancreatitis and pancreatic cancer in the same patient (up to 5%)

 

Autoimmune Pancreatitis

  • Type of chronic pancreatitis that is characterized by an autoimmune inflammatory process with lymphoplasmacytic infiltration associated with fibrosis of the pancreas
  • Key findings absence of classic hx of prior pancreatitis, elevated immunoglobulin G4, dramatic response to steroid therapy, and difficulty distinguishing from pancreatic cancer

 

Autoimmune Pancreatitis: Facts

  • Age range 14-77 but most patients over 50
  • Male affected 2x compared to woman
  • Signs and symptoms at presentation include jaundice (63%), abdominal pain (35%), weight loss (35%), and diabetes mellitus (42-76%)
  • Extra-pancreatic processes include sclerosing cholangitis and PBC (68-88%) of cases, IBD (usually ulcerative colitis), Sjogren syndrome, renal involvement, retroperitoneal fibrosis

 

Autoimmune Pancreatitis can be confused with Pancreatic Cancer

  • Hx of weight loss
  • No good hx of pancreatitis
  • CEA 19-9 may be elevated
  • CT appearance often mass like and looks like pancreatic cancer

 

Autoimmune Pancreatitis: CT Findings

  • Diffuse glandular enlargement with loss of lobular texture (“featureless gland)
  • Homogeneously iso- or hypoattenuating parenchyma with a nondilated or diffusely narrowed pancreatic duct
  • “halo” around gland is not uncommon

 

Missed Diagnosis on CT

 

Autoimmune Pancreatitis

Autoimmune Pancreatitis

 

Pre and Post Treatment

Pre and Post Treatment

 

Autoimmune Pancreatitis and Renal Involvement

Autoimmune Pancreatitis and Renal Involvement

 

Missed Diagnosis on CT

 

Missed Diagnosis on CT

 

“ Radiology departments are encouraged to develop reliable means of identifying challenging and missed diagnoses and using these cases as an education resource in an ongoing effort to mitigate misdiagnosis. A monthly CME conference with pathology and/or surgical correlation and clinical follow-up is an excellent means of providing meaningful peer review to improve practice of the entire division and reduce interpretative errors.”
Mitigating Misdiagnosis in Radiology: Educational CT CME Case Conference for Peer Review and Interpretative Improvement
Pamela T. Johnson, MD, , David Badger, MD, Karen M. Horton, MD, Elliot K. Fishman, MD
JACR: Volume 13, Issue 10, October 2016, Pages 1244–1246

 

“As opposed to standard peer review, where the reviewing radiologist informs the primary reader that he or she believes a diagnosis was missed or an interpretation provided the wrong information, a CT case conference that includes correlation with other diagnostic information (pathology, surgical findings, clinical follow-up) provides accurate peer review based on gold standards, from which everyone in the division can learn to improve their interpretative skills.”
Mitigating Misdiagnosis in Radiology: Educational CT CME Case Conference for Peer Review and Interpretative Improvement
Pamela T. Johnson, MD, , David Badger, MD, Karen M. Horton, MD, Elliot K. Fishman, MD
JACR: Volume 13, Issue 10, October 2016, Pages 1244–1246

 

CT Reading and Checklists

  • Should you use checklists for specific clinical applications?
  • Will checklists help decrease errors especially “missed CT findings”?
  • Are checklists only for the resident and fellow?

 

“We advocate the use of checklists for different types of radiologic examinations, depending on the body part imaged, to facilitate active search patterns to decrease the incidence of this type of error.”
Fool Me Twice: Delayed Diagnoses in Radiology With Emphasis on Perpetuated Errors
Kim YW, Mansfield LT
AJR 2014;202:465-470

 

Missed Diagnosis on CT

 

Missed Diagnosis on CT

 

Missed Diagnosis on CT

 

Training the Computer with Organ Segmentation for the Pancreas

Training the Computer with Organ Segmentation for the Pancreas

 

Example of Pancreas Segmentation

Example of Pancreas Segmentation

 

Missed Diagnosis on CT

 

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