Preoperative Computerized Tomography and Magnetic Resonance Imaging of the Pancreas Predicts Pancreatic Mass and Functional Outcomes After Total Pancreatectomy and Islet Autotransplant

Abstract

Objectives About two-thirds of patients will remain on insulin therapy after total pancreatectomy with islet autotransplant (TPIAT) for chronic pancreatitis. We investigated the relationship between measured pancreas volume on computerized tomography (CT) or magnetic resonance imaging (MRI), and features of chronic pancreatiits on imaging, with subsequent islet isolation and diabetes outcomes. Methods CT or MRI was reviewed for pancreas volume (Vitrea software), and presence or absence of calcifications, atrophy, and dilated pancreatic duct in 97 patients undergoing TPIAT. Relationship between these features and: (1) islet mass isolated and (2) diabetes status at 1 year post-TPAIT were evaluated. Results Pancreas volume correlated with islet mass measured as total islet equivalents (r=0.50, p<0.0001). Mean islet equivalents was reduced by more than half if any one of calcifications, atrophy, or ductal dilatation were observed. Pancreatic calcifications increased the odds of insulin dependence 4.0 fold (1.1, 15). Collectively, the pancreas volume and 3 imaging features strongly associated with 1 year insulin use (p=0.07), islet graft failure (p=0.003), Hemoglobin A1c (p=0.0004), fasting glucose (p=0.027), and fasting C-peptide level (p=0.008). Conclusions Measures of pancreatic parenchymal destruction on imaging, including smaller pancreas volume and calcifications associate strongly with impaired islet mass and 1 year diabetes outcomes.

Pancreatic Cancer–Related Mutational Burden Is Not Increased in a Patient Cohort With Clinically Severe Chronic Pancreatitis

“…Samples were labeled such that identical numbers denote samples from the same patient, and distinct tissue regions were denoted by letters. Severity of pancreatic fibrosis was assessed using a standardized approach by the islet laboratory facility on a scale of 0–10, as previously described ( 35 , 39 ). In brief, resected pancreases were assessed for firmness and texture and assigned an initial score of 1 (minimal change), 3 (mildly fibrotic), 5 (moderately fibrotic), 7 (very fibrotic), or 9 (severely fibrotic) to estimate the extent of fibrosis.…”

“…Pain is frequently the most debilitating symptom and is the primary indicator for surgical intervention ( 32 ), although it is poorly predicted by imaging analyses ( 33 ). Severe fibrosis is a feature of advanced disease and is correlated with progressive pancreatic dysfunction ( 34 , 35 ). Calcification, resulting from recurrent inflammation, is also considered a classical hallmark of severe chronic pancreatitis ( 36 ).…”

Patient Demographics, Perioperative Testing, and Symptom Management in Total Pancreatectomy with Islet Autotransplantation: A Brief Review

“…Large series have reported significantly higher islet yields in pediatric patients, possibly related to a decreased number of prior surgical interventions which are independently associated with higher rates of islet graft failure 1 year post-operatively [6]. The etiology of CP is variably predictive, and patients with alcoholism or hereditary pancreatitis may have lower pancreas volumes, increased pancreatic structural changes, lower islet yields, and increased risk of islet graft failure, while those with idiopathic pancreatitis may have lower risks of islet graft failure [6,9,10]. Multiple studies have also demonstrated the relationship between longer disease duration and duration of narcotic use with low islet yield and graft failure (Table 2) [6,11].…”

“…MRI and computerized tomography (CT) scanning can generate 3-dimensional images of the pancreas and accurately calculate the volume of the pancreas, as well as assess for the presence of structural changes including: parenchymal calcifications, atrophy, and dilation of the main pancreatic duct. Islet yield has been understandably correlated with increased pancreatic mass, and mean islet yield has been reported to be decreased by 50% if any structural changes are demonstrated on imaging [9]. Calcifications in particular increase the odds of insulin dependence greatly, with only 15% of those with calcifications being insulin independent 1-year postoperatively [9].…”

“…Islet yield has been understandably correlated with increased pancreatic mass, and mean islet yield has been reported to be decreased by 50% if any structural changes are demonstrated on imaging [9]. Calcifications in particular increase the odds of insulin dependence greatly, with only 15% of those with calcifications being insulin independent 1-year postoperatively [9]. Additionally, utilizing magnetic resonance imaging (MRI) and secretin-enhanced magnetic resonance cholangiopancreatography (SMRCP), features such as T1 signal-intensity ratio between the pancreas and paraspinal muscles and duodenal filling after secretin injection can accurately predict pancreatic fibrosis, islet mass, and subsequent islet yield [10,16].…”