evaluation of common pancreatic condition

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The single-slice thick-slab acquisition method is

attractive because a snapshot of the pancreaticobiliary

system is obtained while respiratory and bowel

motion is virtually eliminated, and no postprocessing

of the images is required (Fig. 1). Typically, 30-mm

to 50-mm thick slabs are prescribed in several oblique

planes to depict the extrahepatic biliary and pancre-

atic ducts, each requiring less than a 2-second breath

hold. Alternatively, images may be acquired at endexpiration during relaxed natural breathing. Regard-

less, it is important to wait at least 10 seconds

between acquisitions, to allow for recovery from the

previous overlapping radial excitation. An imaging

plane parallel to the pancreatic duct in the body and

tail of the pancreas is employed and prescribed from

an axial image (Fig. 2). Because fat is bright on

SSFSE images, chemically selective fat saturation is

utilized to increase duct-to-background contrast. A

significant advantage of the single-slice method is its

short acquisition time, which allows for the perform-ance of a dynamic MRCP. Repeated sequential

imaging of the same slab demonstrating the pancre-

atic duct and extrahepatic biliary tree, performed over

several minutes, will resolve the possibility of sphinc-

ter of Oddi dysfunction. It may also demonstrate

changes in the pancreatic duct following secretin

administration [2931].

The main drawback of the single-section acquisi-

tion is that ductal visibility may be degraded by

overlap with other fluid-containing structures or asci-

tes included in the field of view (Fig. 3). To overcome

overlap by fluid in the stomach, ideally, patientsshould fast 4 hours before the examination or be

given a T2-negative oral contrast agent such as high-

concentrate ferric ammonium citrate [32]. Negative

oral contrast may interfere with identification of the

duodenum and ampulla of Vater, however. Overlap

also can be overcome by tailoring the orientation and

positioning of the thick slab to the patients ductal

anatomy. Alternatively, a multislice thin-section

acquisition can be performed.

A multislice acquisition is typically performed

with 4-mm or 5-mm thick slices with a shorter echotime (TE) than is used for single-section thick-slab

acquisition (see Fig. 2). With intermediate TE, (100

300 milliseconds), fluid is bright and periductal

structures are well seen, a feature particularly useful

when malignant obstruction is suspected or an over-

lap artifact is noted on single-section acquisition.

Fig. 1. Thick-section MRCP. (A) Coronal, oblique, thick-section SSFSE image showing a normal pancreatic duct ( P) with a loop

configuration (L). Also shown are the common bile duct (B), common hepatic duct (H), and the cystic duct (C). (B) Coronal,

oblique, thick-section SSFSE image of the patient in Fig. 1, acquired at a different obliquity, showing unfolding of the pancreaticduct loop configuration (L).

Fig. 2. Thin-section MRCP. Axial, thin-section SSFSE

image showing a dilated pancreatic duct (arrow). A thick-

section coronal oblique image may be prescribed parallel to

the main pancreatic duct, as defined by the white rectangle.

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Image quality is unaffected by motion because each

slice is acquired in less than 1 second, but motion will

cause slice-to-slice misregistration. Even thinner sec-

tions of the pancreaticobiliary tree (as thin as 2 mm),

can be performed and used for reconstructing a 3D

data set in any plane via maximum-intensity projec-tion, although the quality of projection images is

usually superior with a fast thick-slab acquisition.

Secretin-enhanced dynamic MRCP (s-MRCP) is a

technique for functional imaging and improved ana-

tomic depiction of the pancreatic ductal system.

Secretin stimulates the secretion of fluid and bicar-

bonate by the exocrine pancreas, with a consequent

increase in the volume of fluids inside the pancreatic

ducts [33]. In the first 5 minutes, secretin also causes

the sphincter of Oddi to contract, resulting in tem-

porary increased pancreatic ductal pressure in healthysubjects [34]. A thick-slab acquisition, showing the

full length of the pancreatic duct, extrahepatic biliary

tree, and duodenum in one projection, can be per-

formed dynamically with good temporal resolution to

evaluate flow of pancreatic fluid from the pancreatic

ducts into the duodenum. Secretin improves visu-

alization of the pancreatic duct and reduces the

false-positive depiction of strictures [29,31,35,36].

Administration of secretin also provides an estimate

of pancreatic exocrine function [31,37 39] and better

evaluation of sphincter and ductal anatomy, including

pancreas divisum. The main limitation to the perform-ance of s-MRCP is the additional cost and limited

availability of secretin.

Evaluation of pancreatic disease:

MRCP or ERCP?

Several studies have found MRCP comparable

with ERCP for diagnosing extrahepatic biliary and

pancreatic ductal abnormalities [2,9,15,20,29,40 43]. At many institutions, MRCP has replaced ERCP

for some indications. MRCP is noninvasive, whereas

ERCP-related morbidity and mortality is not trivial,

with potential complications including pancreatitis

(3.9%), hemorrhage (1%), perforation (1%), sepsis

(0.5%), and even death in up to 0.5% of cases

[44,45]. In addition, the risk of sedation-related

complications looms. MRCP is also less expensive

than is ERCP, uses no ionizing radiation, and is less

dependent on the operators skill. No preparation is

required for MRCP (other than brief fasting at somecenters), and no exogenous contrast is needed. Fur-

thermore, MRCP shows the ductal diameter more

accurately than does ERCP, because contrast injec-

tion during ERCP may increase biliary duct caliber

by as much as 6 mm [46,47], falsely giving the

impression of ductal dilation.

MRCP has a high success rate, whereas ERCP

failure rates range between 3% and 10% [44,48].

Failure of ERCP may be due to limited operator skill.

In the case of duodenal and gastric obstruction,

periampullary diverticula, and in patients who have

had an operative choledochoenteric or pancreaticoen-teric anastomosis, however, ERCP may be techni-

cally impossible and fail in up to 20% of cases (Fig. 4)

Fig. 3. MRCP with overlap of fluid-containing structures. (A) Coronal, oblique, thick-section SSFSE image in a patient with

autosomal-dominant polycystic kidney disease and multiple small liver cysts (small arrows) and renal cysts (R) depicted on the

thick-section MRCP. These fluid-containing structures obscure view of the pancreatic duct (P) in the pancreatic tail. (B) Axial,

thin-section SSFSE image of the same patient shows delineation of the pancreatic duct ( P) in the pancreatic tail. Enlarged

kidneys containing multiple cysts (R) are noted bilaterally.

L.M. Fayad et al / Radiol Clin N Am 41 (2003) 97114 99


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[18,49]. With MRCP, a duct can be visualized beyond

an obstructing lesion. Combined with traditional

T1-weighted and T2-weighted sequences, MRCP

also allows for complementary imaging of extraduc-

tal disease. Thus, in most patients, and especially in

the 40% to 70% of patients who undergo ERCP whohave normal studies [50,51], MRCP appears to be an

excellent first choice in the workup of patients with

pancreatic disease and should be considered the test

of choice in all patients with failed or incomplete

ERCP [49,52,53].

There are two main limitations of MRCP. First,

unlike ERCP, MRCP offers no therapeutic options at

the time of diagnosis. Such options include sphinc-

terotomy, endoscopic lithotomy, brush cytology, col-

lection of pancreatic juice, stricture dilation, stent

placement, and biopsy. Proponents of MRCP, how-ever, argue that MRCP provides guidance for these

therapeutic alternatives. Second, the higher level of

spatial resolution achievable by ERCP may be of

critical importance in situations in which precise

delineation of the pancreatic side branches is needed.

Such situations include the recently advocated less-

invasive pancreatic surgeries, segmental pancreatic

resection, and cyst enucleation, in which management

of the pancreatic duct and its ductules is vital to

prevent postoperative pancreatic leaks leading to

fistula formation, abscess, and hemorrhage. Usually,

more precise definition of the pancreatic sidebranches can be attained by ERCP than by MRCP

[54]. The development of s-MRCP may offset the

lack of spatial resolution of conventional MRCP [30],

but further technical developments are needed to

adequately rival the spatial resolution of ERCP.

Pancreatic ductal anatomy and the significance ofanatomic variants

The normal pancreatic duct, less than 3 mm in

caliber, is challenging to visualize completely by

MRCP. The caliber of the duct increases slightly

from the pancreatic tail to the head. The main duct

receives 20 to 35 short tributaries that enter perpen-

dicularly, but are not usually seen in the normal

pancreas by MRCP. The pancreatic duct course varies

greatly, but it most commonly descends. It can have a

loop configuration, particularly at the point of fusionof the ducts of Santorini and Wirsung in the pancre-

atic neck (see Fig. 1) [28].

Patterns of drainage of the pancreas also vary. In

90% of cases, the pancreas drains primarily through

the duct of Wirsung, which joins the bile duct at the

major papilla [28]. An accessory duct of Santorini

that drains through the minor papilla is present in

44% of individuals, and is not always visualized by

MRCP, due to its limited spatial resolution. The

normal main pancreatic duct, however, is visualized

in more than 80% of patients, depending on the

Fig. 4. Duodenal diverticulum. Coronal, oblique, thick-section SSFSE image showing a duodenal diverticulum with

an air-fluid level (long arrow) lateral to a normal common bile

duct (B). The pancreatic duct (P) also appears normal. A

duodenal diverticulum is a common cause for ERCP failure.

Fig. 5. Choledochal cyst and anomalous pancreaticobiliary

junction. Coronal, oblique, thick-section SSFSE image

showing an anomalous union of the common bile duct with

the pancreatic duct (P) and a long common channel (long

arrow), in a patient with a choledochal cyst (C).



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MRCP sequence used [28,55]. Fulcher and Turner

[28] depicted the main pancreatic duct in the head

and body in 97% of cases and in the tail in 83% of

cases. Fortunately, an abnormally dilated duct can be

seen in 100% of cases [40].

In 1.5% to 3% of individuals, there is an anom-alous union of the pancreatic and bile ducts, which

results in an unusually long common channel prox-

imal to the duodenum. This channel is present in 33%

to 83% of patients with choledochal cysts and is

important to identify, because its presence may alter

the operative approach undertaken at surgical resec-

tion (Fig. 5) [56,57]. Gallbladder carcinoma is also

more frequent in patients with an anomalous union

than in those without such a union. Elnemr et al [58]

reported that 18.3% of patients with gallbladder

cancer had an anomalous union.The most common anatomic abnormality of the

pancreaspancreas divisumoccurs in 5% to 14%

of the population [59,60], when the dorsal (Santorini)

and ventral (Wirsung) pancreatic ducts fail to fuse

(Fig. 6). When standard cannulation of the major

papilla is performed on ERCP, only the ventral duct is

opacified, resulting in incomplete ductography. The

termination of the ventral duct can be mistaken for

occlusion of the main duct, potentially mimicking

pancreatic cancer. An astute endoscopist will recog-

nize this pattern, but MRCP can easily demonstrate

the anomaly and is an accurate method for diagnosing

pancreas divisum, because it shows a continuous

dominant dorsal pancreatic duct. The accuracy of

MRCP in the diagnosis of pancreas divisum has been

demonstrated to be 100% [41].

In a patient with pancreas divisum, the minorpapilla may provide a functional obstruction, resulting

in elevated pancreatic duct pressure that may precipi-

tate pancreatitis, because no communication with the

major papilla exists for adequate decompression. Pan-

creas divisum is commonly detected incidentally in

asymptomatic patients, but it occurs more frequently

in patients who present with acute recurrent pancre-

atitis than in the general population [6165].

There is no consensus regarding the appropriate

endoscopic treatment for recurrent pancreatitis asso-

ciated with pancreas divisum. Papillotomy of theminor papilla appears to yield improvement in most

cases, and placement of a transpapillary pancreatic

stent has been touted as a safe and effective endo-

scopic treatment [66]. A potential role of MRCP in

the diagnosis of pancreas divisum is to identify a

subset of patients with pancreas divisum and pancre-

atitis who may benefit from these invasive treat-

ments. Such a subset includes patients with a true

functional obstruction at the level of the minor

papilla with or without a santorinicelea cystic

dilation of the distal dorsal duct just proximal to the

minor papilla. A santorinicele is believed to resultfrom relative obstruction and weakness of the distal

ductal wall and has been suggested as a possible

cause of relative stenosis of the accessory papilla

[67,68]. Manfredi et al [30] showed that a santorini-

cele is associated with a partial functional obstruction

at the level of the minor papilla. Following secretin

administration, the onset of duodenal filling was

delayed significantly in patients with pancreas divi-

sum and a santorinicele compared with patients with

pancreas divisum alone. Furthermore, after sphincter-

otomy of the minor papilla, the size of the mainpancreatic duct and of the santorinicele was signifi-

cantly reduced, and patients had symptomatic

improvement. In this study [30], conventional MRCP

detected fewer cases of pancreas divisum with or

without santorinicele compared with s-MRCP (50%

and 57%, respectively).

The role of MRCP in pancreatitis

What is the state of the pancreaticobiliary tree in

patients with acute and chronic pancreatitis? Thisfrequent indication for ERCP may now be answered

by MRCP. Sica et al [69] showed sensitive detection

Fig. 6. Pancreas divisum. Coronal, oblique, thick-section

SSFSE image showing pancreas divisum with the dorsal (D)

and ventral (V) ducts. Cannulation of the major papilla (long

arrow) during ERCP results in opacification of the small

ventral duct only.



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and accurate characterization of duct segments with

MRCP that were comparable with ERCP.

In the setting of a single episode of acute pancre-

atitis, MRCP is focused on the noninvasive detection

or exclusion of choledocholithiasis, noting that only

30% to 52% of suspected calculi are present in

patients referred for ERCP (Fig. 7) [50]. The high

incidence of negative results using ERCP suggests

that a noninvasive test such as MRCP should be usedto screen these patients to avoid unnecessary morbid-

ity and mortality.

In the setting of recurrent acute pancreatitis,

MRCP may be used to suggest its cause and to

detect complications of pancreatitis. Possible causes

of recurrent acute pancreatitis include choledocho-

lithiasis, pancreatic cancer, or an anatomic abnor-

mality such as pancreas divisum. Sphincter of Oddi

dysfunction is also a cause of recurrent pancreatitis

that, in some instances, may be suggested by

MRCP [70].

In patients with chronic pancreatitis, MRCP can

be used to support a clinical diagnosis, especially in

the early stages of chronic pancreatitis. Chronic

pancreatitis is a chronic inflammatory process that

results in pancreatic parenchymal atrophy and fib-

rosis. Alcoholism is the cause of at least 70% of

cases. Approximately 10% of cases are attributed tochronic ductal obstruction, autoimmune disorders,

inflammatory disease, and inherited diseases causing

abnormal pancreatic enzymes or ductal secretion.

Remaining cases are idiopathic. Alcoholic pancre-

atitis is usually heterogeneous and characterized by

side-branch dilation and ductal calcifications (Fig. 8),

whereas obstructive pancreatitis is more homogen-

eous, lacks calcifications, and is associated more

often with main duct dilation. Nonalcoholic duct-

Fig. 7. Acute pancreatitis secondary to stones. (A) Coronal, oblique, thick-section SSFSE image showing gallstones (short

arrows) and common bile duct stones (long arrows) in the setting of acute pancreatitis. (B) Axial, thin-section SSFSE image

showing gallstones (short arrow) and common bile duct stones (long arrow). The pancreas (P) is enlarged and heterogeneous in

this patient with acute pancreatitis.

Fig. 8. Chronic pancreatitis. (A) Coronal, oblique, thick-section SSFSE image showing a markedly dilated pancreatic duct (large

arrow) with markedly dilated side-branches (small arrows) in a patient with chronic alcoholic pancreatitis. (B) Axial, thin-

section, fat-suppressed, 2D FSE image showing small hypointense filling defects in the pancreatic duct and its side branches,

representing pancreatic duct stones (arrows) in a patient with chronic alcoholic calcific pancreatitis.



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destructive pancreatitisor autoimmune pancre-

atitisis characterized by a narrow pancreatic duct

and diffuse parenchymal abnormality, typically involv-

ing the pancreatic body and tail, without ductal calci-

fications [71,72].

Early alcoholic chronic pancreatitis manifests asirregularities and dilation of the ductal side branches.

These side branches may be below the limits of

resolution of MRCP, so ERCP is generally more

sensitive to early side-branch changes. Side-branch

ectasia is the most specific and prominent feature of

alcoholic chronic pancreatitis. At a later stage, the

main pancreatic duct is dilated with loss of the normal

tapering of the duct in the tail. Areas of focal

narrowing produce a characteristic beaded chain of

lakes appearance. Even the biliary tract may become

dilated as a result of fibrosis in the head of the

pancreas. MRCP has demonstrated the pancreatic

duct, after stimulation with secretin, loses distensi-

bility and has decreased exocrine function [31,37].

In addition, MRCP may be used in conjunction

with other MR sequences, especially nonenhancedT1-weighted images, which show low pancreatic

signal intensity in patients with chronic pancreatitis.

MRCP is not only important for detecting chronic

pancreatitis, but is also valuable for the identification

of a surgically or endoscopically correctable lesion

(Fig. 9). The location of strictures, degree of ductal

dilation, presence of ductal filling defects, and asso-

ciated complications such as pseudocysts all influ-

ence the therapy of patients with chronic pancreatitis.

MRCP agrees with ERCP in 83% to 100% of ductal

Fig. 9. Chronic pancreatitis. (A) Coronal, oblique, thick-section SSFSE image showing changes of chronic pancreatitis, including

a dilated pancreatic duct (large arrow) with filling defects representing mucus (small arrows), and two pseudocysts (C). (B)

Coronal, thin-section SSFSE image showing the findings in Fig. 9A in greater detail. (C) Coronal, thin-section SSFSE image

acquired more anteriorly. C, pseudocysts. (D) Axial, nonenhanced, T1-weighted, gradient echo image showing decreased signal

in the pancreas (P) from fibrosis. The dilated pancreatic duct (arrow) and two pseudocysts (C) are again noted.



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dilation cases, in 70% to 92% of ductal narrowing

cases, and in 92% to 100% of filling defect cases

[36,43]. On MRCP, filling defectsrepresenting

mucus, calculi and debriscan be reliably identified

with a diameter as small as 2 mm [40]. MRCP is,however, superior for detecting pseudocysts, which

are missed approximately 50% of the time by ERCP

[73], although ERCP can consistently determine the

presence or site of communication of a pseudocyst

with the main pancreatic duct.

Therapeutic options for chronic pancreatitis

include surgical decompression, partial pancreatec-

tomy, total pancreatectomy, and endoscopic decom-

pression, which relieve pain in 75% to 90% of

patients. Ductal decompression is the main principle

of therapy, because early decompression delays theonset of exocrine dysfunction, as well as endocrine

dysfunction that occurs in 33% of patients with

chronic pancreatitis [74]. Filling defects such as

calculi, mucus, and debris may be removed endo-

scopically through a pancreatic duct sphincterotomy,

and strictures can be dilated with short-term stent

placement to improve pain [75]. Duct decompression

by surgery depends, in part, on the size of the main

pancreatic duct. For example, duct-destructive chron-

ic pancreatitis, with a main duct diameter of less than

3 mm, requires a drainage procedure different from

that required for a duct diameter over 7 mm [75,76].Hence, when using MRCP it is important to fully

describe the state of the pancreatic duct in the

setting of chronic pancreatitis to adequately guide

treatment options.

Chronic pancreatitis or carcinoma?

When findings of chronic pancreatitis are iden-

tified in a patient without a prior history of chronic

pancreatitis or of ethanol abuse, an obstructing lesion

should be suspected (Fig. 10). Pancreatic ductal

adenocarcinoma is the usual cause of chronic

obstructive pancreatitis and comprises 75% to 90%

of all pancreatic carcinomas [77]. Differentiating

adenocarcinoma from mass-forming chronic pancre-

atitis with MR imaging is sometimes difficult. Typ-

ically, the chronically inflamed pancreas will enhancemore than will pancreatic tumors on immediate post-

gadolinium images, particularly those tumors arising

in the head. Unfortunately, the degree of enhance-

ment cannot be used to reliably distinguish these

entities because abundant fibrosis is seen in both

chronic pancreatitis and carcinoma, accounting for

their similar appearances [78].

MRCP may be helpful to aid in this differenti-

ation, because chronic alcoholic pancreatitis, com-

pared with chronic obstructive pancreatitis due to

adenocarcinoma, is more frequently associated with

an irregularly dilated duct with intraductal calcifica-tion [79]. The ratio of duct caliber to pancreatic gland

width is higher in patients with carcinoma [80]. Also,

Fig. 10. Focal obstructive pancreatitis due to adenocarcinoma of the pancreas. (A) Coronal, thick-section SSFSE image showing

a dilated pancreatic duct (thick arrows) in the body and tail of the pancreas with termination ( thin arrow) of the duct in the body.

(B) Axial, T1-weighted, 3D, gradient echo image of the pancreas obtained in the arterial phase following the administration of

intravenous gadolinium shows a hypoenhancing mass (arrow) that is responsible for obstruction of the pancreatic duct with

resultant obstructive pancreatitis distally.



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the duct-penetrating sign, seen in 85% of chronic

pancreatitis and in only 4% of patients with cancer,

helps to distinguish an inflammatory pancreatic mass

from pancreatic carcinoma. The duct-penetrating

sign refers to a nonobstructed main pancreatic duct

penetrating an inflammatory pancreatic mass, unlikeits usual obstruction by pancreatic carcinoma. [81].

Furthermore, MRCP can depict the classic double

duct sign of pancreatic carcinoma (enlargement and

noncommunication of the pancreatic and common

bile ducts) and the imaging counterpart of Cour-

voisiers sign (an enlarged, nontender gallbladder

caused by an obstructing tumor) (Fig. 11) [82]. A

normal-sized pancreatic duct is present in up to 20%

of patients with adenocarcinoma, however, and

should not dissuade its diagnosis in the setting of

common bile duct dilation.These latter signs are useful when present, but

MRCP (like ERCP) is thought to be a poor way to

differentiate benign from malignant strictures.

Because morphologic features of benign and malig-

nant strictures overlap, ERCP may be the imaging

modality of choice because of its ability to obtain a

diagnostic sample with brush cytologic biopsy

[75,83]; however, MRCP, including MR imaging

pulse sequences, has a sensitivity of 84% for diag-

nosing pancreatic carcinoma, whereas the corres-

ponding sensitivity for ERCP with brush cytology

varies between 33% and 85% [42,83]. Adding MRCPto conventional T1-weighted and T2-weighted

sequences improves specificity by depicting extra-

ductal structures not seen with ERCP [84]. Compre-

hensive MR imaging is also useful to accurately

determine resectability [85].

Cystic pancreatic masses

The incidence of detected cystic pancreatic

masses is increasing because of the widespread use

of cross-sectional imaging. Cystic pancreatic lesions

include benign entities such as pseudocysts and

epithelial pancreatic cysts, as well as malignant

lesions. Epithelial cysts are usually associated with

entities such as polycystic kidney disease and von

Hippel-Lindau disease. Other cystic lesions are dis-

cussed below.

Pancreatic pseudocysts occur as a complication ofacute or chronic pancreatitis and represent 90% of

cystic pancreatic masses [86]. They are encapsulated

collections of pancreatic fluid, caused by pancreatic

duct disruption and tissue dissolution in acute pancre-

atitis, and microperforation of the pancreatic duct in

chronic pancreatitis. The surgical definition of a

pseudocyst requires that it be present for at least

6 weeks. These lesions may communicate with the

main pancreatic duct and may be identified on ERCP

(Fig. 12). Less than 50% of pseudocysts are detected

at ERCP [73], however, giving MR imaging a large

advantage for their diagnosis. Pseudocysts are usuallyaccompanied by a clinical history of pancreatitis and

are associated with pancreatic parenchymal and ductal

Fig. 11. Pancreatic adenocarcinoma. (A) Coronal, thick-section SSFSE image showing the classic double-duct sign of

pancreatic carcinoma; both the pancreatic duct (P) and common bile duct (C) are dilated and abruptly terminate (large arrow) inthe head of the pancreas. In this case, the intrahepatic biliary ducts are also dilated. (B) Axial, nonenhanced, T1-weighted,

gradient echo image showing an ill-defined hypointense mass (arrow) in the head of the pancreas. A biopsy of this mass revealed

pancreatic adenocarcinoma.



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changes that suggest pancreatitis, making their differ-

entiation from pancreatic neoplasms possible in most

cases. Pseudocysts resolve spontaneously in 60% of

cases [87].

Treatment options for persistent pseudocysts

include endoscopic, radiologic, and surgical drainage.

These must be considered cautiously, in the event that

a cystic neoplasm is misdiagnosed as a pseudocyst

[88]. Misdiagnosis, usually by CT, has been reported

as high as one third of the time [8991]. The tra-

ditional approach for treating pseudocysts that require

drainage has been surgical. Treatment is considered

when the patient is symptomatic, if the pseudocyst

demonstrates enlargement or complications including

hemorrhage, or if there is suspicion of a malignancy

[88]. Enlargement and hemorrhage are two factors that

can be determined with MR imaging (Fig. 13).

Cystic neoplasms of the pancreas are uncommon,

representing 10% of cystic lesions [86]. Classification

of cystic neoplasms is based on the location of the

lesion, the size of the cysts, the serous or mucinous

nature of the contents, and the most dedifferentiated

epithelial change recognizable at pathology [92,93].

Additionally, almost any pancreatic neoplasm can

present as a cystic mass, including adenocarcinoma,

which is the most common pancreatic neoplasm.

Fig. 12. Communicating pseudocyst. Axial, thin-section SSFSE image showing an uncomplicated pseudocyst (C) with

communication to the pancreatic duct (arrow) in a patient with pancreatitis.

Fig. 13. Hemorrhage pseudocyst. (A) Axial, thin-section SSFSE image showing a large complex cystic collection with a fluid

fluid level (arrow) representing a hemorrhagic pseudocyst in a patient with pancreatitis. The head of the pancreas (P) is denoted.

(B) Axial, T1-weighted, gradient echo image showing hyperintensity (arrows) at the posterior aspect of the pseudocyst,

representing hemorrhage. The head of the pancreas (P) is again denoted.



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Parenchymal cystic lesions include serous and muci-

nous cystic neoplasms. Intraductal neoplasms are

referred to as intraductal papillary mucinous tumors

(IPMTs). Cystic neoplasms can easily be detected on

MRCP because of their high fluid content, but full

examination requires T1-weighted, T2-weighted, andpostgadolinium sequences.

Serous microcystic adenomas are benign pancre-

atic parenchymal lesions with a relatively equal

distribution throughout the pancreas. Although typi-

cally appearing solid on CT or US, a serous adenoma

is cystic with more than six internal cysts, each

measuring less than 2 cm in diameter. Approximately

40% of these tumors have calcifications and 15%

have a central stellate scar (Fig. 14). Their soft tissue

component is typically hypervascular and aspirated

contents contain glycogen [94]. A small seroustumor adjacent to the main pancreatic duct or a

branch duct may be difficult to distinguish from an

intraductal neoplasm.

Mucinous cystic neoplasms are also parenchymal

lesions. In the past, this neoplasm was subcategorized

into macrocystic adenomas and adenocarcinomas,

which are indistinguishable on the basis of imaging.

In fact, all mucinous cystic neoplasms should be

considered malignant or potentially malignant; thus,

this subcategorization is not appropriate. Mucinous

neoplasms, with strict histologic criteria, probablyoccur only in women and are usually located in the

pancreatic body and tail. Most mucinous cystic neo-

plasms have fewer than six cysts, each greater than

2 cm in diameter. Twenty-five percent of these lesions

have calcification, and the soft tissue component is

hypovascular. Aspiration of these lesions yields

mucin [92]. Because these lesions are frequently

unilocular, they may be confused with pseudocysts.

In such cases, changes of pancreatitis should be

sought to confirm the possibility of a pseudocyst

(Fig. 15).Intraductal tumors, previously described in the

literature under different names such as ductectatic

mucinous cystadenocarcinomas, predominate in men

and older individuals. These tumors, now referred to

as IPMTs, usually grow slowly, with a good prog-

Fig. 14. Serous tumor. (A) Coronal, thick-section SSFSE image showing a round, well-defined, cystic mass ( large arrow) in the

head of the pancreas with a conglomerate of small cysts measuring less than 2 cm each. The common bile duct (B), pancreatic

duct (P), and cystic duct (C) are denoted on this image. (B) Axial, thin-section SSFSE image showing the cystic mass ( thick

arrow) with a suggestion of a central scar (thin arrow), characteristic of a serous tumor.



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nosis. IPMTs arise from the epithelial lining of the

pancreatic ductal system and include lesions repre-

senting the histologic progression of epithelial hyper-

plasia, dysplasia, adenoma, carcinoma-in-situ, and

invasive carcinoma [9598]. Hyperplasia, dysplasia,

and adenoma may undergo malignant transformation

over many years [98]. Multiple IPMTs can be present

in an individualapproximately 23% of the timeas

described in a series by Megibow et al [99]. IPMT is

associated with excessive mucin secretion, resulting

in progressive ductal dilation or cyst formation

(Fig. 16). IPMT may involve the main duct or branch

ducts of the pancreas. Imaging patterns include seg-

mental or diffuse involvement of the main pancreatic

duct, and microcystic or macrocystic masslike lesions

involving the branch ducts [95,97,98].

Fig. 15. Mucinous tumor. (A) Coronal, thick-section SSFSE image depicting a cystic mass ( thick arrow) in the tail of the

pancreas, without associated dilation of the pancreatic duct (thin arrow). (B) Axial, thin-section SSFSE image showing the cystic

mass (thick arrow) with internal complex signal. The pancreatic duct (thin arrows) is not dilated. Resection of this mass yielded a

benign mucinous cystic tumor.

Fig. 16. IPMT. (A) Coronal, thick-section SSFSE image showing a cystic mass ( large arrow) associated with a dilated pancreatic

duct (P) with dilated side branches. Incidental note is made of a cystic duct remnant ( C). (B) Coronal, thin-section SSFSE image

showing the cystic mass (large arrow) in communication with a dilated draining pancreatic duct ( P), a finding that is highly

suggestive of an intraductal papillary mucinous tumor.



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When an IPMT involves the full length of the

main pancreatic duct without a localized cystic mass,

differentiation from chronic pancreatitis may be dif-

ficult [100,101]. A finding virtually pathognomonic

of IPMTs is dilation of the major papilla, minor

papilla, or both, with bulging into the duodenallumen. This finding, which can be seen on MR

imaging and is well appreciated by ERCP, is demon-

strated with CT imaging approximately 25% of the

time (Fig. 17) [97].

With segmental involvement of the main pancre-

atic duct, the adjacent pancreatic parenchyma is

normal or thin. IPMTs such as this can be difficult

to differentiate from localized chronic obstructive

pancreatitis. In such cases, hypointense filling defects

representing mucin facilitate the diagnosis of IPMT.

When the IPMT is located in the head, it may be

difficult to differentiate between diffuse invasion of

the main pancreatic duct and simple ductal dilationfrom mechanical obstruction. In difficult cases, ERCP

is valuable to demonstrate intraluminal mucinous

filling defects with jellylike mucin leaking from the

papilla, another pathognomonic finding for IPMT. On

occasion, mucin can be viscous enough to obstruct

the pancreatic duct, preventing successful ERCP.

Nevertheless, the endoscopist can confirm the pres-

Fig. 17. IPMT. (A) Coronal, thick-section SSFSE image showing an IPMT ( thick arrow) with a dilated draining pancreatic duct

(P) and bulging papilla (thin arrow). The latter finding is pathognomonic of IPMTs. (B) Coronal, thick-section SSFSE image

obtained in a different projection showing the dilated main pancreatic duct ( thin arrows) in association with this IPMT (thick

arrow). (C) Coronal, thin-section SSFSE image again demonstrating a cystic mass representing an IPMT ( thick arrow) with a

dilated draining pancreatic duct and bulging papilla (thin arrow). On thin-section MRCP images, a bulging papilla is seen as a

filling defect in the duodenum. In this case, possible papillary projections are noted within the cystic mass.



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ence of an IPMT by observing copious drainage of

mucin from the papilla [97,102].

Branch-duct IPMT is most frequently located in

the uncinate process and can have a macrocystic or

microcystic appearance [97,98]. Communication withthe main pancreatic duct is a valuable finding that is

often demonstrated best on ERCP [103] and s-MRCP.

A branch-duct IPMT may be differentiated from a

communicating pseudocyst if the IPMT contains

papillary proliferations. If an IPMT manifests as a

more cystic masslike lesion, it can resemble a muci-

nous cystic tumor or necrotic adenocarcinoma

(Fig. 18). With the latter entities, however, the main

pancreatic duct central to the tumor should not be

dilated as it is in the presence of an IPMT.

A number of researchers have concluded thatMRCP is more sensitive and effective than is ERCP

in evaluating IPMT [54,104107]. MRCP, however,

does not offer definitive pathologic information to

decide whether a lesion is malignant, but features

have been described that suggest malignancy. Gen-

erally, a less-favorable histology is noted with the

main-duct type of IPMT [99,108,109]. The obser-

vation of thick walls and mural nodules aids the

diagnosis of malignancy [104,108,110]; the detection

of nodules in the cystic lesion is better accomplished

with MRCP than with ERCP [104,105]. The size of

the lesion is also important: in one series, Obara et al[111] found that 83% of tumors larger than 4 cm were

malignant. The size of the main pancreatic duct is

valuablemain pancreatic ductal dilation greater

than 15 mm [109], as well as diffuse main pancreatic

duct dilation with the branch-duct type of IPMT [95],

is associated with malignancy.

The features described above are influential in

deciding whether an IPMT is benign or malignant,but at this time, imaging cannot reliably distinguish

benign from malignant tumors [111 113]. Surgical

management is usually recommended when these

lesions are encountered [99,114,115]. A review of

cystic pancreatic masses by Megibow et al [99],

however, concluded that surveillance might be pos-

sible if lesions are smaller than 2.5 cm, spare the main

pancreatic duct, and demonstrate no solid compo-

nents. Because many of these patients are asympto-

matic elderly individuals and growth may be slow or

negligible over several years, surgical removal maynot be the only appropriate management.

Summary

In the evaluation of common pancreatic diseases,

MRCP is a noninvasive alternative to ERCP. Ductal

anatomy can be ascertained without risk of compli-

cations. MRCP is valuable in defining common

anatomic variants, determining the state of the pan-

creatic duct in pancreatitis, and characterizing neo-plasms, especially combined with other MR imaging

sequences. With the advent of MRCP, techniques

requiring endoscopy and percutaneous access are

largely reserved for histologic diagnosis and treat-

ment, or for cases in which MRCP fails to establish

a diagnosis.

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evaluation of common pancreatic condition

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