Non-invasive quantitative evaluation of the exocrine pancreas in physiologic and pathologic conditions using functional magnetic resonance imaging (2011)

The proposal of this work was to determine the contribution of functional MR imaging techniques, i.e. secretin-enhanced MRCP (S-MRCP) and dynamic contrast-enhanced magnetic resonance (DCE-MR) imaging in the quantitative assessment of exocrine pancreatic function and perfusion. The pancreas is both an exocrine and endocrine organ, though the exocrine tissue accounts for more than 90%. The exocrine pancreas is specialized in the synthesis and storage of digestive enzymes and in bicarbonate and water secretion in response respectively to various secretagogues (CCK, ach, GRP, VIP,…) and to secretin. The arterial supply of the pancreas derives from branches of the celiac trunk and of the superior mesenteric artery. The microvascularity of the exocrine and the endocrine parts of the gland are anatomically and functionally separated, with differentially regulated blood perfusion. Based on the knowledge of a close relationship between the activity of the gland and its blood supply, in normal conditions pancreatic perfusion responds to the functional state of the exocrine parenchyma: increased demands for exocrine secretions are associated with increased pancreatic blood flow. The pancreatic gland can be involved at different degrees of severity in acute and chronic inflammatory processes due to various causes. In both processes microcirculatory changes occur and the pancreatic exocrine function can be impaired. Moreover, an exiguous microvascular component characterizes pancreatic ductal adenocarcinoma (PDA) related to a prominent stroma. In the first section of this thesis, quantitative assessment of the pancreatic exocrine secretions was performed with S-MRCP in physiologic and non-physiologic conditions. The stimulating effect of secretin as well as the inhibitory effect of somatostatin on normal pancreas, both administered at different dose-regimens, were tested. The results of these investigations showed that quantitative S-MRCP is able to detect changes in pancreatic exocrine secretions correlated to the degree of stimulation or inhibition. In pathologic settings, pancreatic exocrine secretions were assessed in chronic pancreatitis patients showing different degrees of severity, before and after endoscopic pancreatic duct drainage procedures (PDDP). In the group of patients presenting a reduced pancreatic exocrine reserve before treatment, quantitative S-MRCP showed a short-term improvement after PDDP. In the second section, the feasibility and the reproducibility of DCE-MR imaging to quantify regional pancreatic perfusion was firstly investigated. DCE-MR imaging was performed in normal volunteers. Reference values for regional pancreatic perfusion were achieved with an intra-individual variability of 21%. DCE-MR investigations were repeated during secretin stimulation and disclosed a significant increase of regional pancreatic perfusion in all individuals. Secondly, DCE-MR imaging investigated benign and malignant focal pancreatic solid lesions and non tumoral tissue in patients undergoing pancreatic surgical resection. The purpose was to correlate DCE-MR quantitative parameters, (reflecting perfusion and/or permeability and the distribution volume fraction) with histologic features such as the degree of fibrosis and the microvascular density (MVD) in the corresponding tissues. A significant correlation was found between DCE-MR and histologic parameters: Ktrans was negatively correlated with the degree of fibrosis (high fibrosis was correlated with low perfusion), while the distribution volume fraction was positively correlated with the degree of fibrosis and with MVD (larger EES was correlated with high fibrosis and higher MVD).