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Acute Pancreatic Transplant Rejection: Evaluation with Dynamic Contrast-enh...red with Histopathologic Analysis -- Krebs et al. 210 (2): 437 -- Radiolog

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PubMed Citation

Articles by Krebs, T. L.

Articles by Bartlett, S. T.

(Radiology.1999;210:437-442.)

RSNA, 1999

Gastrointestinal Imaging

Acute Pancreatic Transplant Rejection:Evaluation with Dynamic Contrast-enhanced MR Imaging Compared with

Histopathologic Analysis

Thorsten L. Krebs, MD1, Barry Daly, MD1, Jade J. Wong-You-Cheong,

MD1, Kieran Carroll, MB1and Stephen T. Bartlett, MD2

1Departments of Diagnostic Radiology (T.L.K., B.D., J.J.W.Y.C., K.C.)2Surgery (S.T.B.), University of Maryland School of Medicine, 22 S Greene St, Baltimore,

MD 21201.

Abstract

TOP

Abstract

Introduction

MATERIALS AND METHODS

RESULTS

DISCUSSIONReferences

PURPOSE:To evaluate the use of dynamic contrast materialenhancedgradient-

recalled-echo MR imaging for the diagnosis of acutepancreatic transplant rejection,

as confirmed at histopathologicanalysis.

MATERIALS AND METHODS:Thirty MR imaging studies were performedin 25patients within 3 days of percutaneous biopsy or pancreatectomy.The mean

percentage of parenchymal enhancement (MPPE) at dynamiccontrast-enhanced MR

imaging was calculated.

RESULTS:Biopsy findings were no evidence of rejection (n=7 [23%]), mild rejection (n= 10 [33%]), moderate (n= 6

[20%])and severe (n= 2 [7%]) acute rejection, and infarction (n=5 [17%]). The corresponding MPPEs at 1 minute were

106%, 66%,62%, 57%, and 3%, respectively. Overlap of cases in the normaland rejection groups occurred; however,

using an MPPE cutoffof 100% resulted in a sensitivity of 96%. An MPPE over 120%was seen in the normal group only.

The MPPE was significantlygreater in the normal group than in the rejection or infarctiongroup (P< .05).

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CONCLUSION:Dynamic contrast-enhanced MR imaging is highly sensitivefor the detection of acute pancreatic

transplant rejection.Because of overlap of cases in the normal and rejection groups,percutaneous biopsy may be needed in

some cases. Pancreaticallografts with infarction can be clearly identified.

Index terms:Magnetic resonance (MR), contrast enhancement, 77.121412, 77.12143 Magnetic resonance (MR), tissue

characterization, 77.121412, 77.12143 Pancreas, MR, 77.121412, 77.12143, 77.12144, 77.12146 Pancreas,

transplantation, 77.458

Introduction

TOP

Abstract

Introduction


RESULTS

DISCUSSION

References

Pancreatic transplantation is performed in selected patientswho have major

complications of type 1 diabetes mellitus. Advancesin surgical technique and

postoperative management have improvedgraft survival; however, up to 60% of

pancreatic transplantshave rejection episodes (1). Early detection of acute rejectionis

required to institute antirejection therapy promptly andavert graft loss. Clinical and

biochemical indicators of rejectionhave proved to be relatively insensitive and

nonspecific in

determining acute rejection (2,3). Similarly, computed tomography

(CT) and ultrasonography (US) have been demonstrated to be unreliablefor the detection of acute rejection (46).

Spin-echo MR imaging and gadopentetate dimeglumineenhancedMR imaging have been inconsistent in the evaluation o

pancreatictransplant dysfunction (79). In these series, only a fewcases were correlated with histopathologic results; most

ofthe acute rejection cases were diagnosed by using clinical orbiochemical evaluation. Few pancreatic biopsy procedures

wereperformed in prior studies because of the perceived risk ofcomplications and the need for general anesthesia and ope

biopsy(10). Recent developments in percutaneous technique now enablesafe and consistent biopsy of pancreatic

transplants (5,1114)and thereby enable standard-of-reference correlation with imagingfindings. We analyzed the

usefulness of dynamic contrast materialenhancedMR imaging in the diagnosis of acute rejection by correlatingMR

imaging enhancement patterns with histopathologic findings

obtained at imaging-guided percutaneous core biopsy orsurgicalexplantation.


TOP

Abstract

Introduction


RESULTS

DISCUSSION

References

Patient Population

A computerized database of patients who had undergone pancreatictransplant MR

imaging during 37 months, for a total of 158 MRimaging examinations, was created.

The results of 32 studieswere correlated with histopathologic findings within 3 days

of the MR imaging examination. Two MR imaging studies were eliminatedbecause

of severe physiologic motion artifact, technical problems,or both; this resulted in a

final study group of 30 images obtainedin 25 patients (15 men, 10 women; mean age,

37 years; range2861 years). Fifteen patients had simultaneously transplantedpancreas and kidney allografts from the

same donor (simultaneouspancreatic/kidney), and eight had unrelated donor pancreaticimplants after a previously

successful kidney transplant (pancreasafter kidney). Two patients had a pancreatic transplant alone.Four studies were

performed within 2 weeks after transplantation,with a mean time of study after surgery of 3.8 months (range,5 days to 1.7

years). Patients were referred for MR imagingbecause of abnormal laboratory assay results that suggestedallograft

dysfunction in 24 cases and abdominal pain in sixcases. No asymptomatic patients were studied.



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The surgical technique used for transplantation in all caseswas intraperitoneal placement of a cadaveric whole-organ

allograftand a portion of the duodenal C loop into the iliac fossa. Exocrinesecretions were drained by either creating a

pancreaticoduodenocystostomywhereby the donor duodenum was connected to the superior aspectof the recipient's

bladder ("bladder drained") or draining thesmall intestine where the donor duodenum was anastomosed toa loop of

recipient jejunum ("enteric drained"). All but fourstudies (in three patients) involved bladder-drained allografts.

Histopathologic Correlation

Correlation was made with the results of imaging-guided percutaneouspancreatic biopsy, which was performed in 24 case

(22 US guided,two CT guided) within 3 days after the MR imaging studies (mean,1.4 days) by using a previously

described technique (5,1114).Three patients underwent biopsy within 2 weeks after transplantation,and most biopsy

procedures were performed within 4 months aftersurgery (range, 10 days to 44.3 months; mean, 3.9 months). Indications

for percutaneous pancreatic biopsy were a twofold increase inthe serum amylase or lipase level, a sustained (ie, 40% or

greater)decrease in the urinary amylase level, or clinical featuressuggestive of acute rejection such as fever, graft

tenderness,or abdominal distention.

Patients with biochemical abnormalities that improved afterurinary catheterization of bladder-drained allografts were

consideredto have reflux pancreatitis and thus did not undergo biopsyand were not included in this series. The MR

imaging findingswere correlated with the results of analyses of pancreatic specimensremoved at surgery in six cases, with

a mean time from imagingto surgery of 2.2 days. One patient underwent explantation withina week after transplantation.

Most of the remainder of the explantedallografts were older than 1 year (range, 5 days to 50.6 months;mean, 18.3months). Pancreatic explantation was performed becauseof unremitting abdominal pain, severe hyperglycemia that

requiredinsulin, imaging findings suggestive of infarction, or all threeof these indications.

Biopsy results were evaluated by experienced histopathologists.The severity of acute rejection, if present, was graded as

mild,moderate, or severe by using a qualitative analysis system thathas been demonstrated to correlate with graft survival

(15).This grading scale was based on the degree of vascular, septal,and acinar inflammatory changes (15). In addition, the

presenceof infarction or vascular thrombosis was noted. Biopsy specimensthat did not have pancreatic parenchyma were

not included inthe study.

MR Imaging and AnalysisAll MR imaging studies were acquired on a 1.5-T system (Signa,GE Medical Systems, Milwaukee, Wis) with a phased-

array coil.Initially, a fast multiplanar spoiled gradient-recalled-echo(GRE) MR image in the sagittal plane (20/1.2 [TR

msec/TE msec],60 flip angle, 256 x128 matrix, two signals averaged,10-mm section thickness without gap) was

obtained to determinethe area of coverage. Before and immediately after injectionof the contrast material, a coronal 23-

second, breath-hold T1-weightedfast multiplanar spoiled GRE image (150/4.2, 60 flip angle,256 x128 matrix, 5-mm

section thickness without gap, 24-cmfield of view) was acquired, and imaging was repeated everyminute for 5 minutes.

Thirteen sections per breath hold wereobtained; this permitted coverage of the entire pancreatic allograft.After written

informed consent was obtained, an intravenousbolus injection (0.1 mmol per kilogram of body weight injectedfor 510

seconds) of gadopentetate dimeglumine (Magnevist;Berlex Laboratories, Wayne, NJ) followed by a saline flush was

administered through a 21-gauge needle. These two sequencesrequired approximately 15 minutes of imaging time. In

addition,axial T2-weighted chemical fat-suppressed fast spin-echo MRimaging and flow-sensitive MR angiography wereperformed, butthese images were not evaluated for the purposes of this study.

During the unenhanced breath-hold study, a mean glandular signalintensity for each pancreatic transplant was derived by

averagingtwo 1-cm-diameter regions of interest from a representativeimage section that encompassed the middle portion

of the tailand head of the transplanted pancreas. The representative areaswere selected by one investigator (K.C.) without

knowledge ofthe results of histopathologic analysis. Pancreatic allograftenhancement may be heterogeneous, and focal

areas of signalintensity abnormality (eg, intraparenchymal fluid collection)were excluded from sampling. The same

regions of interest weremeasured during the subsequent contrast enhancement portionof the study. In most cases, a single

section was adequate foranalyzing both the head and tail of the transplanted pancreas.These measurements were used to



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calculate a mean percentageof parenchymal enhancement (MPPE) for each breath-hold gadolinium-enhancedGRE study

by using the following formula: MPPE = (contrast-enhancedMGSI - unenhanced MGSI) x100%/unenhanced MGSI,

where MGSI isthe mean glandular signal intensity. A time-enhancement curvewas created by using these values plotted

against the histopathologicfindings.

Statistical Analyses

An unpaired Student ttest was performed with the MPPE measurementsduring the 1-minute breath-hold (90 seconds after

the bolusinjection) portion of the gadolinium-enhanced MR imaging study,which was stratified by using histopathologic

subgroups andExcel version 7 (Microsoft, Redmond, Wash). A statisticallysignificant difference in means was considered

to be presentwhen Pwas less than .05. Sensitivity, specificity, and accuracywere calculated with standardized formulas.

RESULTS

TOP

Abstract

Introduction


RESULTS

DISCUSSION

References

Acute graft rejection was diagnosed in 18 (75%) percutaneousbiopsy specimens, 10

of which were graded as mild; six, moderate;and two, severe. In seven (23%) biopsy

specimens, there wasno evidence of glandular rejection. Five of six explanted

allograftsshowed histopathologic evidence of severe infarction. In fourof five cases,

underlying severe acute rejection was also detected;the one case without acute

rejection occurred within a weekof transplantation and demonstrated vascular

thrombosis. Oneof the six explanted allografts had severe acute rejection without

infarction. No biopsy specimens showed evidence of acute pancreatitisor chronic rejection.

Comparison of the time-MR enhancement curves with the histopathologicfindings revealed three basic patterns (Fig 1).

The averageMPPE in the normal group was greater for each time measurement than in all other histopathologic groups. A

peak mean enhancementof 106% occurred at 1 minute, with a subsequent minimal decreaseover time. For each period, th

average MPPE in the rejectionsubgroups was similar between these groups; it remained wellbelow the average MPPE in

the normal group and never exceeded67%. Enhancement in mild and moderate grades of rejection peakedat 1 minute and

subsequently diminished. The MPPE in the severerejection group rose slightly over time. Transplanted organsthatdemonstrated infarction had an average MPPE that was wellbelow that in the rejection and normal subgroups and

remainedless than 6% for all periods.

View larger version(16K):

[in this window]

[in a new window]

Figure 1. Average of MPPEs measured over 5 minutes plotted according

to histopathologic diagnoses of normal, mild, moderate, and severe acute

rejection and of infarction.

The optimal period for data separation occurred at the 1-minutebreath-hold portion of the study (90 seconds after contrast

injection), where the greatest difference in MPPE occurred; MPPE measurements were 106% in the normal group and

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66%, 62%,57%, and 3% in the transplanted organs with mild, moderate,and severe grades of rejection and with infarction

respectively(Fig 2). The MPPE in the normal group was significantly greaterthan that in the rejection subgroups (P< .05)

however,there was an overlap of cases between these groups. Clear separationof the normal group and group with

infarction (P< .01) waspresent without overlap. Pairwise analyses revealed no significantdifference in MPPE between th

different grades of rejection(P> .05), but there was significantly greater enhancementon the images in the rejection group

than on those in the infarctiongroup, without overlap (P< .005).


[in this window]

[in a new window]

Figure 2. Scatter diagram shows the range of MPPEs at 1 minute with

histopathologic diagnoses of normal, mild, moderate, and severe acute

rejection and of infarction.

If an MPPE cutoff value of 100% were used to predict rejection, a sensitivity, specificity, and accuracy of 96%, 67% and

87%,respectively, would result. The one false-negative case demonstratedmild acute rejection at histopathologic analysis

and had anMPPE of 116% at MR imaging. Two of the three false-positivecases were in the normal group; the other was a

case of infarctionwithout rejection. If an MPPE cutoff of 20% were used to evaluatefor transplant infarction, the resultant

sensitivity and specificityeach would be 100%.

DISCUSSIONTOP

Abstract

Introduction


RESULTS

DISCUSSION

References

Several MR imaging techniques have been evaluated for the noninvasive

determination of acute pancreatic transplant rejection. Priorstudies (79,16,17) in

which the use of unenhanced MR imagingfor assessment of pancreatic rejection was

evaluated have hadvariable results and limited histopathologic correlation. Yuhet al

(16) found spin-echo MR imaging to be 100% sensitive and76% specific for acute

pancreatic graft rejection in a seriesof 44 studies, as determined by using clinical

assessment only.The allograft edema that occurs with acute rejection was

qualitativelyidentified when the glandular signal intensity was either lessthan the signal intensity of muscle on T1-

weighted images or

greater than or equal to the signal intensity of the bladder

urine on T2-weighted images. Vahey et al(17) quantitativelyevaluated pancreatic transplant signal intensity on 13 MR imagingstudies in nine patients. They found

that the mean calculatedT2 of the seven transplants with rejection was substantiallyelevated compared with that of the

allografts without rejection.However, seven studiesfive with pancreatic tissue andtwo with renal tissuehad histologic

correlation. In comparison,by using clinical assessment, Kelcz et al (8) and Fernandezet al (9) evaluated the quantitative

measurement of pancreatictransplant signal intensity with spin-echo sequences and werenot able to demonstrate signal

intensity differences in pancreaticallograft dysfunction.

Experience with contrast-enhanced MR imaging for assessmentof pancreatic allograft rejection has been limited.

Fernandezet al (9) obtained dynamic, single-section contrast-enhancedMR images through the pancreatic transplant



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during breath holding.They demonstrated that the percentage of enhancement in normallyfunctioning pancreatic

transplants was greater than that indysfunctional allografts (with either rejection or infarction).In six cases of normally

functioning allografts, they recordeda mean percentage of enhancement at 1 minute of 98% comparedwith 42% in six

cases with acute dysfunction. In their series,the findings of five MR imaging studies were correlated withpancreatic

transplant biopsy results.

Although many transplantation centers now use percutaneous pancreatictransplant biopsy to reliably diagnose acute

rejection (11,13,18),this previously was not the case. Acute pancreatic rejectionwas thought to occur synchronously with

acute renal rejection

in simultaneously transplanted pancreas and kidney allografts

from the same donor, and pancreaticrejection was not thoughtto occur in isolation (19). Because renal rejection could easilybe diagnosed by using serum

creatinine levels and percutaneousrenal biopsy, the accepted practice was to use renal rejectionto determine pancreatic

rejection (1922). However, ithas been demonstrated that episodes of acute rejection aftersimultaneous renal and

pancreatic transplantation may be discordantthatis, may occur in one organ but not in the otherin 22%47%of cases

(23,24). A sensitive noninvasive imaging study wouldbe preferable because it would enable the small but substantial(ie,

up to 3%) risk of major complications after percutaneouspancreatic biopsy to be avoided (5,14).

In our study, we compared the results of dynamic breath-holdcontrast-enhanced pancreatic allograft MR imaging with

thoseof standard-of-reference histopathologic analysis. Normallyfunctioning transplanted organs tended to enhance avidly

with

contrast material administration, whereas the transplanted organs

with rejection enhanced less actively. At 1 minute,the percentageof enhancement in the normal group was substantially greater,106%, compared with 50% in the

dysfunctional group (ie, transplantswith rejection and infarction); these results are similar tothose of the study by

Fernandez et al (9). However, in theirstudy, dysfunctional transplanted organs were not separatedinto rejection versus

infarction groups, presumably becauseof the limited number of cases. In our study, the MPPE in thetransplanted organs

with rejection at 1 minute (63%) was markedlydifferent from that in the transplanted organs with infarction(3%).

One of the mechanisms of dysfunction that occurs with acutepancreatic rejection is an alloimmune vasculitis (25).

Decreasedcontrast enhancement in the transplanted organ, as occurredin the allografts with acute rejection in our study,

may bedue to narrowed or occluded small vessels, which result in adecreased rate and degree of accumulation of

extracellular contrastmaterial. For this purpose, gadolinium-based extracellular contrastmaterials for MR imaging have an

advantage over the iodinatedcontrast materials that are used for CT, because most recipientshave a coexistent renal

transplant, and there is a reduced riskof nephrotoxicity.

The difference in enhancement between normal transplanted organsand dysfunctional allografts on gadolinium-enhanced

GRE MR imagesmay be useful in the clinical assessment and treatment of allograftrecipients and in helping to guide the

selective use of biopsy.In our study, despite the overlap of MPPE data points in thenormal and rejection groups, the

MPPE in the normal group wassignificantly different from that in the rejection group (P< .05). Gadolinium-enhanced

GRE MR imaging appears to behighly sensitive for the detection of rejection; an MPPE cutoffof 100% resulted in a

sensitivity of 96% (Figs 3, 4). In ourseries, the one false-negative case was due to infarction ina transplanted organ

without acute rejection. Failure to diagnosethis case by using MR imaging was not clinically relevant, becausethe allogra

needed to be removed regardless of whether acuterejection was present. The two histopathologically normal false-positivecases, which occurred in transplanted organs that had diminishedenhancement, were more problematic. If MR imaging ha

been usedas the sole guide for antirejection treatment instead of biopsy,unnecessary therapy may have been instituted.

These allograftsmay have had areas of acute rejection that were not detectedbecause of biopsy sampling error. An MPPE

of greater than 120%was demonstrated in normally functioning allografts only; thisindicates that this group may not

require biopsy. There wasa very small number of such cases in our series. The conversemay also be useful; allografts with

an MPPE of less than 60%were dysfunctional owing to either acute rejection or infarction.



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[in this window]

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Figure 3a. Coronal fast multiplanar spoiled GRE MR images (150/4.2, 60

flip angle) obtained in a patient with a normal pancreas allograft, as

confirmed at percutaneous biopsy. (a)Unenhanced image and (b)image

obtained 1 minute after the administration of gadolinium-based contrast

material demonstrate avid enhancement throughout a normal-sized

pancreatic allograft (straight arrows). Note the adjacent enteric anastomosis

(curved arrow) and renal allograft (arrowheads). The measured MPPE was

122%.

View larger version(195K):[in this window]

[in a new window]

Figure 3b. Coronal fast multiplanar spoiled GRE MR images (150/4.2, 60

flip angle) obtained in a patient with a normal pancreas allograft, asconfirmed at percutaneous biopsy. (a)Unenhanced image and (b)image

obtained 1 minute after the administration of gadolinium-based contrast

material demonstrate avid enhancement throughout a normal-sized

pancreatic allograft (straight arrows). Note the adjacent enteric

anastomosis (curved arrow) and renal allograft (arrowheads). The

measured MPPE was 122%.


[in this window]

[in a new window]

Figure 4. Coronal fast multiplanar spoiled GRE MR image (150/4.2, 60

flip angle) obtained 1 minute after the administration of gadolinium-based

contrast material in a patient with moderate acute rejection of pancreatic

allograft, as confirmed at percutaneous biopsy. Image demonstrates

diminished enhancement (straight arrows) compared with the

enhancement in the pancreas in Figure 3b. Mild hydronephrosis of therenal transplant (curved arrow) is noted. The measured MPPE was 72%.

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Another reason to develop a clinically useful imaging techniquefor the diagnosis of acute rejection in pancreatic allografts

is that pancreatic allografts are no longer routinely placedin the pelvis (26). Instead, the pancreatic allograft is placedin th

mesentery of the middle part of the abdomen, with portalvenous drainage of endocrine secretions. Portal venousdrained

pancreatic transplants have the theoretic advantage of normalizedinsulin physiology (26). Unfortunately, these

transplanted organsare more difficult to monitor with imaging because they areoften located deeply within the abdomen

and may have surroundinginterposed bowel; therefore, they are also more difficult toperform biopsy on percutaneously.

Hence, a sensitive, noninvasivealternative for predicting rejection episodes has greater importance.

Graft thrombosis that leads to allograft infarction is anothermajor cause of graft loss. This event can occur early (ie, inles

than 1 month) or late after surgery. Early graft thrombosis,as occurred in one patient in this series, is usually the resultof

vascular graft anastomotic error or microvascular damagefrom preservation injury. Late thrombosis (ie, that which occurs

more than a month after surgery), as occurred in four casesin this series, usually results from severe acute rejectionwith

alloimmune arteritis and causes occlusion of small vessels,which leads to complete major vessel occlusion. Regardless of

the causes, all cases with an MPPE of less than 10% in our studyhad infarction and were identified by using gadolinium-

enhancedGRE MR imaging (Fig 5). Identification of total graft thrombosisand infarction is important, because the

transplanted organshould be removed immediately to avoid the severe systemic effectsof graft autolysis (21). Acute

rejection, regardless of itsseverity, is usually treated medically, and the allograft usuallydoes not need to be removed;

however, it may be difficult todifferentiate severe rejection from graft infarction in theclinical setting. In our study, there

was no overlap of casesbetween the rejection subgroups and the infarction group. Therefore,the described technique

appears to be useful in separating thesetwo diagnoses. This supports the findings in previous MR imagingliterature (27),

which have demonstrated a lack of enhancementin pancreatic allografts with infarction in a small number ofcases.


[in this window]

[in a new window]

Figure 5. Coronal fast multiplanar spoiled GRE MR image (150/4.2, 60

flip angle) obtained 1 minute after the administration of gadolinium-based

contrast material in a patient with pancreatic allograft infarction that was

proved at surgical explantation. There is no enhancement in the enlargedpancreatic allograft (white arrows) or in the duodenal cuff (black arrow).

The measured MPPE was 1%. A normal enhancing renal transplant

(arrowheads) is noted.

Limitations of this study include a relatively small patientpopulation. At our institution, MR imaging is used for

problematiccases that could not be adequately assessed by using US or CT.The study group was further diminished

because of our requirementthat a maximum of 3 days intervene between the histopathologicand MR imaging

examinations (mean interval, 1.4 days). Increasingthis interval would have increased the number of cases in theseries, but

it would have diminished the quality of the histopathologiccorrelation. A further limitation of our study is that

percutaneousbiopsy was performed on only one site in the pancreas allograft.We could have potentially underdiagnosed

the prevalence of acuterejection. In addition, because the study was performed retrospectively,the use of the described



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modality should be evaluated furtherin a prospective manner.

In summary, we correlated dynamic contrast-enhanced GRE MR imagingfindings in pancreas allografts with

histopathologic results,as determined by using pancreatic biopsy specimens, and foundsignificant differences in the

enhancement patterns. The meanpercentage of enhancement in normal pancreatic transplants ondynamic MR imaging

studies at 1 minute was 104%, which was significantlygreater than the 67% and 3% in the pancreatic transplants thathad

acute rejection and infarction, respectively. Transplantedorgans with infarction can be clearly differentiated from viable

allografts for prompt surgical intervention. Despite the overlapof acute rejection and normal cases, decreased enhancemen

on

MR images appears to be highly sensitive for rejection. Such

imaging findings in the appropriate clinical setting and/or

with associated biochemical abnormalities may allow greaterconfidence in clinical decision making. By using an MPPE

cutoffof 100%, gadolinium-enhanced GRE MR imaging was 96% sensitivefor the detection of acute rejection. Biopsy

may not be requiredin transplanted organs with an MPPE of greater than 120%. Forclinically indeterminate cases, in

particular those with anMPPE of 100%120%, biopsy may be required. Sensitive detectionof acute rejection is likely to

be important in portal venousdrainedpancreatic transplants, in which percutaneous biopsy cannotbe readily performed.

Acknowledgments

We thank Jeffrey M. Silverman, MD, for his helpful comments.In addition, we thank Linda Clarke for manuscript

preparationand David Crandall for photographic assistance.

Footnotes

Address reprint requests toT.L.K.

From the 1997 RSNA scientific assembly.

Abbreviations: GRE = gradient-recalled echo MPPE = mean percentage of parenchymal enhancement

Author contributions: Guarantor of integrity of entire study,T.L.K.; study concepts and design, T.L.K., B.D., J.J.W.Y.C.;

definition of intellectual content, T.L.K., B.D., J.J.W.Y.C.;literature research, T.L.K.; clinical studies, T.L.K., B.D.,

J.J.W.Y.C., K.C., S.T.B.; data acquisition, K.C.; data analysis,T.L.K., B.D., J.J.W.Y.C., K.C.; statistical analysis, T.L.K.,

B.D., J.J.W.Y.C.; manuscript preparation, T.L.K.; manuscriptediting, B.D., J.J.W.Y.C., S.T.B.; manuscript review, T.L.K

B.D., J.J.W.Y.C., S.T.B.

Received March 30, 1998; revision requested June 17, 1998; revision received July 24, 1998; accepted September 28,

1998.

References

TOP

Abstract

Introduction


RESULTS

DISCUSSION

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http://www.ajronline.org/cgi/content/abstract/175/2/381http://www.ajronline.org/cgi/content/full/175/2/381http://radiology.rsnajnls.org/cgi/content/abstract/210/2/437http://radiology.rsnajnls.org/cgi/content/figsonly/210/2/437http://radiology.rsnajnls.org/cgi/reprint/210/2/437http://radiology.rsnajnls.org/cgi/eletter-submit/210/2/437http://radiology.rsnajnls.org/cgi/alerts/ctalert?alertType=citedby&addAlert=cited_by&saveAlert=no&cited_by_criteria_resid=radiology;210/2/437&return_type=article&return_url=http%3A%2F%2Fradiology.rsnajnls.org%2Fcgi%2Fcontent%2Ffull%2F210%2F2%2F437http://radiology.rsnajnls.org/cgi/alerts/ctalert?alertType=eletter&addAlert=eletter&saveAlert=no&eletter_criteria_value=210/2/437&return_type=article&return_url=http%3A%2F%2Fradiology.rsnajnls.org%2Fcgi%2Fcontent%2Ffull%2F210%2F2%2F437http://radiology.rsnajnls.org/cgi/alerts/ctalert?alertType=correction&addAlert=correction&saveAlert=no&correction_criteria_value=210/2/437&return_type=article&return_url=http%3A%2F%2Fradiology.rsnajnls.org%2Fcgi%2Fcontent%2Ffull%2F210%2F2%2F437http://radiology.rsnajnls.org/cgi/citemap?id=radiology;210/2/437http://radiology.rsnajnls.org/cgi/mailafriend?url=http%3A%2F%2Fradiology.rsnajnls.org%2Fcgi%2Fcontent%2Ffull%2F210%2F2%2F437&title=Acute+Pancreatic+Transplant+Rejection%3A+Evaluation+with+Dynamic+Contrast-enhanced+MR+Imaging+Compared+with+Histopathologic+Analysishttp://radiology.rsnajnls.org/cgi/search?qbe=radiology;210/2/437&journalcode=radiology&minscore=5000http://radiology.rsnajnls.org/cgi/external_ref?access_num=10207427&link_type=MED_NBRShttp://radiology.rsnajnls.org/cgi/alerts/etochttp://radiology.rsnajnls.org/cgi/citmgr?gca=radiology;210/2/437http://radiology.rsnajnls.org/cgi/external_ref?access_num=10207427&link_type=PUBMEDhttp://radiology.rsnajnls.org/cgi/external_ref?access_num=Krebs+TL&link_type=AUTHORSEARCHhttp://radiology.rsnajnls.org/cgi/external_ref?access_num=Bartlett+ST&link_type=AUTHORSEARCHhttp://radiology.rsnajnls.org/http://radiology.rsnajnls.org/help/http://radiology.rsnajnls.org/cgi/feedbackhttp://radiology.rsnajnls.org/subscriptions/http://radiology.rsnajnls.org/contents-by-date.0.shtmlhttp://radiology.rsnajnls.org/search.dtlhttp://radiology.rsnajnls.org/content/vol210/issue2/http://radiographics.rsnajnls.org/http://www.rsnajnls.org/http://www.rsnajnls.org/http://radiographics.rsnajnls.org/http://radiology.rsnajnls.org/content/vol210/issue2/http://radiology.rsnajnls.org/search.dtlhttp://radiology.rsnajnls.org/contents-by-date.0.shtmlhttp://radiology.rsnajnls.org/subscriptions/http://radiology.rsnajnls.org/cgi/feedbackhttp://radiology.rsnajnls.org/help/http://radiology.rsnajnls.org/http://radiology.rsnajnls.org/cgi/external_ref?access_num=Bartlett+ST&link_type=AUTHORSEARCHhttp://radiology.rsnajnls.org/cgi/external_ref?access_num=Krebs+TL&link_type=AUTHORSEARCHhttp://radiology.rsnajnls.org/cgi/external_ref?access_num=10207427&link_type=PUBMEDhttp://radiology.rsnajnls.org/cgi/citmgr?gca=radiology;210/2/437http://radiology.rsnajnls.org/cgi/alerts/etochttp://radiology.rsnajnls.org/cgi/external_ref?access_num=10207427&link_type=MED_NBRShttp://radiology.rsnajnls.org/cgi/search?qbe=radiology;210/2/437&journalcode=radiology&minscore=5000http://radiology.rsnajnls.org/cgi/mailafriend?url=http%3A%2F%2Fradiology.rsnajnls.org%2Fcgi%2Fcontent%2Ffull%2F210%2F2%2F437&title=Acute+Pancreatic+Transplant+Rejection%3A+Evaluation+with+Dynamic+Contrast-enhanced+MR+Imaging+Compared+with+Histopathologic+Analysishttp://radiology.rsnajnls.org/cgi/citemap?id=radiology;210/2/437http://radiology.rsnajnls.org/cgi/alerts/ctalert?alertType=correction&addAlert=correction&saveAlert=no&correction_criteria_value=210/2/437&return_type=article&return_url=http%3A%2F%2Fradiology.rsnajnls.org%2Fcgi%2Fcontent%2Ffull%2F210%2F2%2F437http://radiology.rsnajnls.org/cgi/alerts/ctalert?alertType=eletter&addAlert=eletter&saveAlert=no&eletter_criteria_value=210/2/437&return_type=article&return_url=http%3A%2F%2Fradiology.rsnajnls.org%2Fcgi%2Fcontent%2Ffull%2F210%2F2%2F437http://radiology.rsnajnls.org/cgi/alerts/ctalert?alertType=citedby&addAlert=cited_by&saveAlert=no&cited_by_criteria_resid=radiology;210/2/437&return_type=article&return_url=http%3A%2F%2Fradiology.rsnajnls.org%2Fcgi%2Fcontent%2Ffull%2F210%2F2%2F437http://radiology.rsnajnls.org/cgi/eletter-submit/210/2/437http://radiology.rsnajnls.org/cgi/reprint/210/2/437http://radiology.rsnajnls.org/cgi/content/figsonly/210/2/437http://radiology.rsnajnls.org/cgi/content/abstract/210/2/437http://www.ajronline.org/cgi/content/full/175/2/381http://www.ajronline.org/cgi/content/abstract/175/2/381http://www.ajronline.org/http://www.ajronline.org/http://www.ajronline.org/

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