imaging approach to pancreas tumours
DESCRIPTION
Imaging Approach to Pancreas tumours. Ryno vd Berg Dept Radiology Kimberley hospital 13/4/2012. Retroperiteal organ, except for tail in splenorenal lig at L1 level Head(uncinate process), neck, body & tail. - PowerPoint PPT PresentationTRANSCRIPT
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Imaging Approach to Imaging Approach to Pancreas tumoursPancreas tumours
Ryno vd BergDept Radiology
Kimberley hospital13/4/2012
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Pancreas:Pancreas: Retroperiteal organ, except for tail
in splenorenal lig at L1 level Head(uncinate process), neck,
body & tail. Size decreases with age; rough
guide: Head≤3.5cm & Rest ≤2.5cm. Pancreatic duct 1-3mm.
Bloodsupply from splenic, R gastro-omental & Sup mesenteric aa.
Drainage to portal system.
Endocrine part (2%):Langerhans islets: α-,β-,δ- & PP-cellsIslets clustered together crossed by network of capillaries
Exocrine part:Acinar cells producing & secreting digestive enzymesAlkaline juice secreted by ductal cellsSecreted into duodenum for digestion with bile
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Imaging classification:Imaging classification:Solid lesions
MalignantBenign
Cystic lesionsUnilocular simpleSmall cysticSeptated
Solid with cystic components
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Solid Pancreas lesions:Solid Pancreas lesions:
Malignant:1.AdenoCA*2.Neuroendocrine*3.Solid Pseudopapillary*4.Panceaticoblastoma5.Lymphoma6.Mets to Pancreas*7.Very rare:
Epthelial: Acinar cell, Giant cell & Colloid CAMesenchymal: Granular cell CA, Fibrous histiocytoma, Juvenile hemangioendothelioma, Fibroma, Inflam Myoblastic tumor & Sarcoma*Mixed: Squamous cell & Mixed endo-exocrine tumors
Benign:1.Focal Pancreatitis2.Fatty infiltration/replacement3.Intrapancreatic accessory spleen4.Pancreas lobulation/Cong anomalies5.Miscellaneous:
Pancreatic SarcoidosisCastleman’s Disease
*May have cystic degeneration
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Malignant & Potentially Malignant Malignant & Potentially Malignant Solid Pancreas tumoursSolid Pancreas tumours
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Pancreatic AdenocarcinomaPancreatic Adenocarcinoma
85-95% of all Pancreatic malignancies Age 60-80y, Males(2:1) Head – 60-70%, Body – 10-20%, Tail- 5-10% Poor prognosis (5-y survival < 5%) Non-resectable in 75% on presentation Surgery only cure (5-y survival 20%) Need appropriate pt selection to prevent
unnecessary surgery
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CT:Hypovascular with low attenuation best seen in arterial phasePorto-venous phase to detect mets & evaluate surrounding veins10% Isodense, look for secondary signs (Abn pancreas shape, ductal obstruction, vascular
invasion)Mets commonly to liver, lymphnodes, peritoneum & lung
Isodense mass in head causing abrupt distal narrowing & dilatation of CBD
Double duct sign
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MRI:Fibrotic nature – Low on T1 & T2Often thin peritumour ring of increased enhancementSuperior to CT for detecting small tumours & MetsAccuracy for detecting & staging of AdenoCA 90-100%
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Endoscopic US:Role in detecting small tumours (2-3mm) and help clarify equivocal CT & MR findingsIll-defined, heterogenous hypoechoic mass98% sensitivity in detecting adenoCA However operator dependent & narrow field of view for assessing local invasion
PET:Increased uptake & retention of FDGSensitivity 85-100%, Specificity 84-93%Biggest impact ability to detect small metastasesFalse negatives: Mucinous tumours, Necrotic tumours, Peritoneal mets < 1cm & hyperglyceamiaFalse positives: Inflammatory tissue
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Resectible:1. No mets2. No abutment, distortion, tumour
thrombus or encasement of SMV/PV3. Clear fat planes around CA, SMA & HA
Borderline resectable:1. Abutment or encasement of SMV/PV
(No impingement/ narrowing of lumen)2. Short segment occlusion from tumour
thrombus/ encasement, but allowing safe resection & reconstruction
3. Encasement of Gastroduodenal a up to HA (only short segment encasement/ abutment of HA & no involvement of CA)
4. <180° Abutment of SMA circumference
Not resectable:1.Mets2.Lymphnode mets beyond the field of resection3.>180° Encasement of SMA4.Unreconstructable occlusion of SMV/PV5.Aortic invasion/ encasement
National Comprehensive Cancer Network- Radiographics, July 2011
Criteria for defining the respectability of Pancreatic AdenoCA
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Pancreatic Neuroendocrine tumours Pancreatic Neuroendocrine tumours Previously Islet cell tumours1-5% of all Pancreas tumours, Age 51-57y, Equal both gendersMostly sporadic, but may be associated with MEN type 1, Von Hippel-Lindau,
Neurofibromatosis type 1 & Tuberous SclerosisClassified into Functioning & Non-functioningFurther histologically:- Well differentiated benign features- Well differentiated uncertain- Well differentiated carcinoma- Poorly differentiated carcinoma
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Insulinoma:• Most common NET (60-75%)• 10% Malignant• M:F = 2:3 Age: 40-60 yr• Associated with MEN I in 10%• No predilection for any part of the pancreas• Mostly <2cm• Classically hypervascular • Surgical resection is curative• Localization of tumour prior to surgery:
– Endoscopic US / intra-operative US– Angiography – Intra-Arterial Calcium Stimulation with Hepatic Venous Sampling
• Catheterize – Superior mesenteric artery (SMA)– Gastroduodenal artery (GDA)– Splenic artery (SpA)
• Twofold rise in insulin levels following calcium gluconate injection in SMA or GDA = tumour is located in the pancreatic head or uncinate process
• Twofold rise after injection into the SpA suggests caudal location
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Gastrinoma:• 2nd most common NET• 80% in patients < 20yr M>F• Associated with MEN I in 50-60%• 50-60% malignant • Tumour size does not appear to be associated with biological behaviour or clinical
course• Lymph node or liver metasteses present in 70-80% of cases at diagnosis• Zollinger –Ellison syndrome: Hypersecretion of gastrin leading to Acid secretion with
peptic ulceration & diarrhoea• Average tumour size 3,5cm (up to 15cm)• Tend to be less vascular than insulinoma• More often multiple compared to insulinoma• Associated metasteses• Associated gastric wall thickening, indicating peptic ulcer disease and gastric
hyperplasia due to effects of gastrin can be helpful in diagnosis
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Non-Functioning NET:• 3rd most common• Histological from alpha or beta cells• Mean age 57 yrs• Symptoms due to mass effect (present like adenocarcinoma)• Predominantly in pancreatic head• 90% malignant at presentation• Imaging
– Large in size 3- 25cm– Large, well-defined masses with moderate to strong enhancement– No invasion of adjacent vessel– Associated with cystic degeneration and calcifications– More easily detected by mass effect compared to functioning tumors
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Glucagonoma:• Uncommon tumour• Middle age M<F• Associated with MEN• Secrete excessive amounts of glucagon and cause a syndrome characterized by
dermatitis, stomatitis, weight loss, and anaemia(fatigue) • ( 4D syndrome = dermatosis, diarrhoea, depression, dvt )• Increased glucagon leads to glucose intolerance (DM) and cachexia (catabolic
effects)• Third of patients with glucagonoma syndrome have secondary thromboembolic
phenomena– This feature is unique among the different NET
Predominantly in pancreas body & tail Large tumour (>5cm in 70%) with solid and necrotic elements Hypervascular in 90 % 60-80% malignant transformation 60% liver metasteses at presentation
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VIPoma:• Excretes Vasoactive Intestinal Peptide
– Acting directly on cyclic AMP within epithelial cells in bowel– Relaxes vascular smooth muscle + causes electrolyte secretion
• WDDH syndrome:– Watery diarrhoea + hypokalaemia + hypochlorhydria – “pancreatic cholera” / Verner-Morrison syndrome
• >50% malignant transformation
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Somatostatinoma:• May be associated with NF1• symptoms reflect the general inhibitory action of somatostatin on global
gastroenteropancreatic function– often have history findings consistent with diabetes mellitus, which is probably
secondary to the inhibitory action of somatostatin on insulin and glucagon release– Inhibition of the action of cholecystokinin by somatostatin causes relative biliary
stasis and the formation of gallbladder calculi– diarrhea and/or steatorrhea, both of which are likely to be caused by the inhibition
of pancreatic enzyme and bicarbonate secretion Predominantly in
◦ Pancreas head◦ Duodenum at ampulla of Vater
Tumour size 0,6-20cm ( avg >4cm ) >50% chance of malignant transformation 60% liver/lymph node metasteses at presentation
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Imaging approach to NETImaging approach to NETCT:Most distinctive feature: rich blood supply – enhancing more rapid + intense than
surrounding tissue in arterial phaseHomogenous enhancement of tumours < 2cm & more heterogenous for larger tumours
which can be ring-likePorto-venous phase show no typical patternMetastases often follow same enhancement pattern as primarySensitivity 94%
MR:Generally have longer T1&T2 relaxation than other tumours and normal pancreasLow on T1 and intermediate to high on T2Sensitivity 85-94%
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Endoscopic US:Sensitivity 94%, but combined with CT up to 100%Also useful in detecting duodenal gastrinomas & used in u/s guided FNA
SPECT/CT:Radiolabeled Octreotide (Somatostatin analog) taken up by most NET, except insulinomasSensitivity 90% Specificity 80%, however helpful in detecting mets
PET:Role in detecting poorly differentiated NET, which have a high proliferative rate (High FDG
uptake), compared to well differentiated NET with low proliferation rates
Differentiating NET from AdenoCA:
AdenoCA NET
Enhancement Hypovascular Hypervascular
Calcifications Only 2% 20%
Vascular involvement Encasement Infiltration & tumour thrombus
Ductal involvement Often Uncommon
Central necrosis/Cystic deg Less More often
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Insulinoma:
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Insulinoma: Solid mass with hypervascular periphery
Splenic arteriogram showing tumour in pancreatic tail
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Gastrinoma: heterogeneous mass in the head of the pancreas with cystic degeneration and shell-like dense calcification. (b) Wall of the gastric antrum is hypertrophied
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Solid Pseudopapillary tumourSolid Pseudopapillary tumourSolid cystic papillary epithelial-, Papillary cystic-, Solid and cystic-/ Franz tumour1-2% of Pancreas tumoursAge range 10-74y (mostly young adults), female predominance (9:1), African & AsianLow malignant potential with excellent prognosis post resectionMets uncommon (7-9%): Liver, omentum, peritoneumTypically large (mean 9cm), slow-growing, well encapsulated massCommon in pancreas tail & tend to displace rather than invade
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CT:Hypodense pseudocapsule (compressed
pancreas tissue & fibrosis)Peripheral heterogenous enhancement
during arterial phase followed by progressive non-uniform enhancement (generally less than surrounding pancreas)
10-20% fluid-fluid or fluid-debris level30% Peripheral calcifications
MR:Capsule low T1&T2Internal haemorrhage & cystic
degeneration due to fragile vascular network of tumour
Subacute bleeding (high on T1), Chronic bleed (Low on T1+T2)
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Main differential to consider:Solid Pseudopapillary Cystic NET
Age of presentation Young adults Rarely <30y
MR T1 Haemorrhage may show as high Low
Enhancement Heterogeneous & less enhancement than surrounding tissue
More vascular with diffuse / rimlike hyperenhancement
Well encapsulated solid tumour, low on T1 & interm-high on T2
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PancreatoblastomaPancreatoblastoma0.2% of all pancreas tumours, but the most common in children (mean age 5y)Male predominance (1.3:2.7), Asian (>50% of all cases)Raised α-FP in 25-33%Slow growing & usually manifest as asymptomatic large mass (mean 10cm)Adrenocorticotropic hormone secretion have been documented (Cushing’s / Inapp ADH)Due to large size often not possible to identify organ of origin and generally require biopsy to
diagnoseRarely cause bile/ duodenal obstruction due to soft gelatinous consistencyMetastases: Liver, lymphnodes, lung, bone, mediastinum, peritoneum & omentum
US:Heterogeneous mass with hypoechoic cystic spaces (necrosis) and hyperechoic internal
septaeOccasionally only hypoechoic solid massCT:Generally multiloculated heterogeneous mass with enhancing septaeCalcifications if present rimlike or clusteredMild contrast enhancementMR:Low-interm T1 & High T2
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US: Large heterogenous mass with cystic spaces encasing CA & displacing the Portal vein
CT: Solid mass with cystic components displacing the Portal confluence & stomach anteriorly
Pancreatoblastoma in 5y old:
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Pancreatic LymphomaPancreatic LymphomaMost commonly B-cell type of Non-Hodgkin lymphomaPrimary: <2% of Extranodal lymphomas & 0.5% of Pancreatic tumoursSecondary: In 30% of widespread NH LymphomasAge 35-75y, ImmunocompramisedTwo morphological patterns:
1.Focal well circimscribed: 80% in headMean size 8cmCT: Uniform hypodenseMR: Low T1, Interm T2 Faint contrast enhancement
2.Diffuse form: CT: Infiltrative with enlargement & poorly defined of pancreas
MR: Low T1 + T2Homogeneous contrast enhancement
Important to distinguish from AdenoCa, because better prognosis & Chemo as 1st line treatment:
Mild pancreatic duct dilatation & CBD dilatation more common Enlarged lymphnodes below the level of the renal vein Invasive – infiltrates retroperitoneum, surrounding organs & GIT Vascular invasion less common Calcifications & necrosis not feature
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Primary Pancreas Lymphoma:Pt 10y post renal transplantFocal hypodense tumour in head
Secondary Pancreas Lymphoma:Local invasion of pancreas tail from lymphomatous infiltration of the spleenAlso extensive retroperitoneal lymphadenopathy
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Metastases to the PancreasMetastases to the Pancreas2-5% of Pancreatic neoplasmsMostly from: Renal cell CA, Lung CA, Breast CA, Colorectal CA & MelanomaUS:Hyper- / hypoechoicCT:Hypo-/IsodenseMR:Low T1 & high on T2Follow enhancement pattern of primary>1.5cm mostly peripheral enhancement with central necrotic area & smaller lesions mostly
homogeneous enhancementRenal cell CA hypervascular, need to differentiate from NETRest mostly hypovascular, need to diff from AdenCAPast medical history very important
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Mets from Renal cell CAAsymptomatic pt had nephrectomy 20y agoHypervascular tumour with cystic-necrotic degeneration & intratumour vessels
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Benign solid Pancreatic massesBenign solid Pancreatic masses
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Focal PancreatitisFocal PancreatitisChronic pancreatitis:Focal inflammatory mass, often in headAccount for 5-10% of pancreatectomies for presumed malignancyDifficault to distinguish from AdenoCA, even histologically
Shared features Favour focal Pancreatitis
Favour AdenoCA
US: Hypoechoic Duct penetrating sign: Non dilated/ smooth tapering duct through mass
Abrupt interruption of dilated pancreas duct
CT: Hypodense Non-abrupt gradual narrowing of ducts
Upstream pancreas atrophy
MR: Low T1&T2 Calcifications High ratio of duct diameter to gland diameter
Double duct sign Modest atrophyDuctal stricturesInfiltration of adjacent fatArterial encasementPeripancreatic venous obstruction
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Focal chronic pancreatitisFocally enlarged head with irregular contour & internal calcificationsRemained stable over 3y after follow up imaging
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Autoimmune Pancreatitis: (AIP)
25% of focal pancreatitsMay occur alone or with other autoimmune disorders; most patients have increased IgG
and antinuclear antibody levelsUS: focal hypoechoic, diffuse enlargement (“sausage”)/ normalCT: diffuse enlargement , loss of normal surface indentations, tail retracted from splenic
hilum, capsule-like rim enhancement, peripancreatic adenopathy, no calcification or vascular encasement
MRCP/ERCP: diffuse irregular narrowing of pancreatic duct(often >3cm long), CBD stricture
Diffusely enlarged pancreas with hypodense capsule-like rim
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Groove pancreatitis:Uncommon form of focal pancreatitis
involving pancreaticoduodenal grooveTwo forms: 1. Segmental – Involves head
with scar tissue in the groove
2. Pure – Affects the groove, but spares the head
May manifest as duodenal or biliary obstruction
CT: Sheetlike hypodense fibrotic scar tissue in groove, delayed contrast enhancement
MR: Low on T1, Interm-high on T2Associated with smooth stricture of
pancreatic part of CBD & Wall thickening + cystic dysplasia of duodenum
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Fatty infiltration-replacementFatty infiltration-replacementCommon finding in elderly & obese, but usually diffuseAlso associated with chronic pancreatitis & Cystic fibrosisHas predilection for anterior part of head, sparing posterior part & uncinate processUS:Fat – Hyperechoic & spared areas hypoechoicCT:If macroscopic will show negative HU on uncontrasted scan (contrast spread between fat increasing
attenuation)Absence of mass effectMR:Modality of choiceMacroscopic fat easily detected on fat-sat sequencesMicroscopic fat detected with chemical shift imaging
Dual phase T1 weighted GRE series: Areas show high on the in-phase & signal loss on opposed-phase sequence
Hypoechoic area of fatty sparing in hyperechoic fatty pancreas
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Intrapancreatic accesory spleenIntrapancreatic accesory spleenFailed fusion of splenic anlage in dorsal mesogastriumTypically 1-3cm, well-defined ovoid mass in tailUS:Homogeneous, mildly echogenic.May show posterior acoustic enhancementVascular hilum sometimes seen with dopplerCT:Greater enhancement similar to spleen with same tigroid patternMR:Lower on T1, Higher on T2Need to diff from other vascular lesions:
Superparamagnetic iron-oxide MR: Phagocytosed by reticuloendothelial cells, leading to decreased signal on post-contrast series
Scintography:Splenic tissue traps 90% 99m-Tc Heat damaged RBC
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Well-defined oval mass with same intensity as spleen
Same enhancement pattern
SPECT/CT with 99m-TC HDRBC
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Congenital anomaliesCongenital anomaliesPancreatic lobulation:
Bifid pancreas tail:Tuber omentale:Focal prominence of anterior pancreatic surface left of sup mesenteric vessels
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Very rare solid massesVery rare solid massesSarcoidosis:Idiopathic systemic granulomatous disorderPancreatic involvement very rare, only 19 biopsy-proven cases in literatureSolitary/ multiple masses, may reach 6-7cmPeripancreatic lymphnode enlargentUS: HypoechoicCT: Hypodense & non-enhancingMR: Low T1, High T2 & HypoenhancingHistory & other findings
Castleman Disease:Rare angiofollicular lymphnode hyperplasiaOnly 10 cases of pancreatic involvement documentedCT: Solid, well-encapsulated mass with strong enhancement (may be ringlike)May have calcifications & cystic changes
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Cystic pancreatic lesionsCystic pancreatic lesionsBenign:
Serous cystadenomaCystic teratoma
Inflammatory:Pseudocyst, Abscess, Echinococcus
True epithelial cysts:Von Hippel-LindauAdult PCKDCystic fibrosis
Rare:LymphangiomaHemangiomaParaganglioma
Malignant/ Potentially malignant:Mucinous cystic neoplasmIntraductal papillary mucinous
neoplasm (IPMN)Solid with cystic degeneration:
AdenoCaSolid pseudopapillary tumourNeuroendocrine tumoursMetsSarcomaCystic teratoma
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Morphological classificationMorphological classification
Pseudocyst, IPMN, Serous cystadenoma, Epithelial cysts
Serous Cystadenoma
Mucinous cyst adenoma,IPMN
Mucinous cystic neoplasmIPMNAdenoCaSolid pseudopapillary tumourNeuroendocrine tumoursMetsSarcomaCystic teratoma
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Inflammatory cystsInflammatory cystsPseudocyst:No epithelial lining, but fibrous wall surrounding pancreatic fluid, cellular debris & bloodMost common cystic massComplication of acute or chronic pancreatitis or pancreatic traumaUS:Usually well defined, smooth-walled anechoic cystMay be multilocular with internal septations with internal echoes or fluid-fluid levels if
heamorrhage or infectedCT:Usually well defined round thin/thick walled fluid collection with mild rim enhancement
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Pancreas abscess
Haemorrhagic pseudocyst
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Echinococcus cyst:Rare, liver & lung involvement much more commonUni-/multilocularPeripheral enhancement Peripheral calcifications my be present
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True epithelial cystsTrue epithelial cystsUssually multiple small simple cysts
PCKD with cyst in pancreas Von Hippel-Lindau disease
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Benign cystic lesionsBenign cystic lesionsSerous cystadenoma (Microcystic adenoma)Glycogen containing hypervascular tumourFemale predominance (4.5:1), Mean age 60yUsually micro-/polycystic pattern (from 2mm up to 2cm) May appear solid (due to vascularity & honeycomb appearance) with multiple
surrounding cystsEnhancing septa & cyst wall30% show central scar, which may calcify
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Serous cystadenoma:Echogenicity due to interaction between multiple tiny cysts
T2 weighted image sowing multiple cysts with fibrous central scar
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Macrocystic serous cystadenoma:RareDifficult to distinguish from Mucinous cystic neoplasmUsually more lobular outline & less peripheral enhancement
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Cystic teratoma:Very rareWell defined mostly cystic & solid components
Well defined cystic mass with thick walls & septations. Areas of fat
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Malignant & Potentially malignantMalignant & Potentially malignantMucinous cystic neoplasms:Includes Mucinous cystadenoma & CystadenocarcinomaFemale predominence, Average age 60y70-90% occur in body & tailUsually hypovascular thick-walled multilocular (occasionally unilocular) with a few
compartments (>2cm)Septations usually very thin walledOccasionally peripheral calcifications (↑ chance of malignancy)Contain mucin, sometimes debris/ haemorrhageCT show enhancement of wall & septationsMR show the content with variable signal intensity probably due to proteinaceous fluid/
blood
VS
Multilocular serous cystadenoma
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Endoscopic US: Septated cyst
Peripheral calcifications
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Intraductal papillary mucinous neoplasms (IPMN):Potentially malignantCharacterized by papillary proliferation of pancreatic ductal epithelium & production of
mucin3 Types:
Main duct (70% chance of malignancy)Branch duct (20% chance of malignancy)Mixed
More common in older menCT:Cystic dilatation of a main or a side branch duct that contains thick mucoid secretionsMural nodules within a cyst/ duct is highly suggestive of malignancy
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ERCP: Diffusely or segmentally dilated pancreatic duct without stricturing Side branches may also be dilated Filing defects may be seen due to mucus or mural nodules The papilla resembles a "fish-mouth," frequently with mucus extruding from the orifice Able to do cytology by aspiration of the duct contents or brushings & therapeutic drainagePancreatoscopy also possibleMRCP:Less invasiveMore sensitive than ERCP for differentiating mural nodules from mucin (mucin has same signal intensity as pancreatic fluid)
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Cysts with solid componentsCysts with solid componentsAdenoCaSolid pseudopapillary tumourNeuroendocrine tumoursMetsSarcoma
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Hypoattenuating AdenoCA with cystic degeneration
Necrotic NET (63 y old pt presenting with diarrhoea)
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Necrotic pancreatic sarcoma mimics mucinous cystic neoplasm in this 58-year-old man with left upper quadrant pain. Liver mets.
Solid Pseudopapillary tumour: 16-year-old girl who presented with mid epigastric pain.
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Summerize:Summerize:Solid lesions: Malignant:
◦ AdenoCA: Hypovasc, Encasement, Ductal involvement◦ NET: Assoc sympt, Hypervasc, Calcif, Infiltrative, Often cystic changes◦ Solid pseudopapil: Young adult, Fibrous pseudocapsule, Cystic◦ Pancreatoblastoma: Child, Large heterogenous◦ Lymphoma: Immunity, Other LN, Invasive, Not calcify/necrosis◦ Mets
Benign:◦ Pancreatitis◦ Fatty changes◦ Acces spleen◦ Congenital
Cystic lesions Unilocular: Inflamm (Pseudo/Abscess), Epithelial (assoc syndromes) Small cystic: Serous cystadenoma (Vascular, Central calcif) Septated: Mucinous cystic (Body+tail, Few compartments, Periph calcif,
Content variable)IPMN (Duct dilat with mucin, Mural nodules)
Mixed solid & Cystic:AdenoCa, Solid pseudopapillary tumour, Neuroendocrine tumours, Mets, Sarcoma
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Final points:Final points:
Important to distinguish between benign /malignant lesions & respectability Multimodality imaging approach often helpful Proper clinical history & associated findings Helpful to divide lesions into:
◦ Solid◦ Cystic◦ Solid with cystic component
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References:References: Multimodality imaging of neoplastic and non-neoplastic solid lesions of the
pancreas, Low G, et al, Radiographics, July 2011 Cystic pancreatic lesions: A simple imaging-based classification sytem for
guiding management, Dushyant VS, et al, Radiographics, Nov 2005 Cystic masses of the pancreas, Pablo RR, et al, Radiographics, July 1992 Imaging diagnosis of cystic pancreatic lesions: Pseudocyst vs Non-
pseudocyst, Young HK, et al, Radiographics, May 2005 Solid pseudopapillary tumour of the pancreas, Coleman KM,
Radiographics, Nov 2003 Clinical manifestations, diagnosis, and staging of exocrine pancreatic
cancer, Castillo CF, et al, Review Feb 2012, Uptodate New Diagnostic Imaging Modalities for Pancreatic Disease, Piraka C,
Scheiman JM, Current Opinion Gastroenterology, 2011;27(5):475-480 Primer of Diagnostic Imaging, Weissleder, et al, 4th ed, 2007