IMAGING IN CYSTIC
LESIONS OF PANCREAS
(agnyayshay / pachak granthi)
Majority of pancreatic cysts are incidentally
detected i.e. they are asymptomatic.
Symptomatic cysts are most likely to manifest
with abdominal pain.
Jaundice or recurrent pancreatitis often
indicates that the lesion is either in
communication with the pancreatic ductal
system or obstructing the pancreatic or biliary
Pseudocysts typically occur with acute
pancreatitis or may develop insidiously in the
setting of chronic pancreatitis.
Sharply marginated Unilocular or multilocular fluid-filled
pancreatic or peripancreatic collections that are
encapsulated by fibrous tissue and usually form after
inflammation, necrosis, or hemorrhage related to acute
pancreatitis or trauma.
In acute pancreatitis, there is mesenteric edema and
In chronic pancreatitis, there may be associated pancreatic
Older cysts tend to have thicker walls that may contain
These cysts can be located anywhere within the pancreas
but predominantly involve the body or tail of the organ.
CONVENTIONAL( OLD IS GOLD !!)
A) SIGNS OF ACUTE PANCREATITITS
1.) Duodenal ileus ; the duodenal folds may be thickened.
2.) Gasless abdomen
3.) Sentinel loop
4.)Absent left psoas shadow .
5.)Colon cut-off sign', where the dilated transverse colon
becomes abruptly gasless in the region of the splenic flexure.
B.) SIGNS OF CHRONIC PANCREATITITS
Colon cut off sign and ileus
Usually solitary unilocular cyst (body or tail),
multilocular in 6% of cases
Fluid-debris level & internal echoes due to
autolysis(blood clot/cellular debris)
Septations (rare; sign of infection or
Dilated pancreatic duct & CBD may be seen
Calcification of pancreas (chronic pancreatitis)
CT-PLAIN AND CONTRAST….
Round or oval, homogeneous, hypodense lesion ("mature"
Hemorrhagic/ Infected pseudocyst: Lobulated , heterogeneous,
mixed density lesion
± Pancreatic calcification;(MPD) & common bile duct (CBD)
Enhancement of thin rim of fibrous capsule
No enhancement of pseudocyst contents
Gas within pseudocyst suggests superimposed infection,
decompression of pseudocyst into pancreatic duct, stomach or
Pseudo aneurysms can be caused by or simulate a pseudocyst.
CECT shows enhancement like adjacent blood vessels
Mixed intensity (fluid + debris)
T1 C+: May show enhancement of fibrous
Hyperintense cyst contiguous with dilated
Axial T2-weighted MR image complex cyst
with a fluid-debris level in head.
Side-branch IPMN manifesting as a
•The diagnosis of a cystic neoplasm should be considered
when there is no history of pancreatitis or trauma.
•Morphological characteristics of a cystic neoplasm are:
- thick irregular rim,
- solid components
- dilated pancreatic duct > 3mm and calcifications.
•Fluid aspirated from a cyst with an HIGH amylase level
•It is important to make the diagnosis of a serous cystic
neoplasm, since this is the only tumor that has no
•Benign tumor, but large tumors have a tendency to
increase in size and cause symptoms.
• Typically seen in 'Grandma' .
•Microcystic or honey-combed cyst with central scar
(30%) and calcifications (18%)
•Macrocystic in 10% and difficult to differentiate from
pseudocyst and mucinous cystic neoplasm .
•Lobulated surface .
•No communication between cysts and pancreatic duct.
•Hypervascular enhancement is sometimes seen and can
look like cystic neuroendocrine tumor
Hypodense lesion with central
calcification&enhancement of septae
T2WI fatsat shows a lobuated hyperintense
lesion with central scar,characteristic of SCN.
Premalignant tumor - may transform into a
Exclusively seen in women - Typically in 'Mother' median age: 40-50 years
Macrocystic with thick wall septations and
Peripheral calcifications seen in 25%. This
finding allows you to make a specific diagnosis
Location in the tail and body of the pancreas
Most are symptomatic, presenting with
nondescript abdominal pain
•Mucinous cystadenocarcinoma manifest
at MR imaging as large complex cystic
• They may be distinguished from Mucinous
cystadenoma by the presence of
intracystic enhancing soft tissue.
•Hence, any enhancing soft tissue within a
cystic neoplasm depicted on MR images is
considered an indication for resection
Axial T2-weighted MR image shows a large,
complex cystic lesion in head
Contrast-enhanced MR images show
enhancing mural soft-tissue elements
projecting toward the cyst center.
•Mucin producing tumor in main pancreatic duct or
•Location: pancreatic head >> tail and corpus.
•Must have communication with pancreatic duct.
•Best seen with MRCP.
•Can be multifocal.
•Main-duct IPMN has imaging features distinct
•Branch-duct type can look like other cystic
duct (red arrow).
•"Multicystic" lesion in uncinate process/head
contiguous with dilated MPD("grape-like"
clusters or tubes & arcs)
SOMETIMES THERE IS A
THE MRCP SHOWS BOTH A
MAIN-DUCT AS WELL AS A
Signs of malignancy are:
•Pancreatic duct > 8 mm
•Solid node in duct.
•Mass around the
Unilocular or multilocular
True cystic tumors or solid pancreatic neoplasms with cystic
Mucinous cystic neoplasms
Islet cell tumor
Solid pseudopapillary tumor (SPEN)
All malignant or have a high malignant potential
neoplasm seen in
women 20-30 years
Solid and cystic
neoplasm with capsule
and with early
Also called islet cell
This is unlike serous
that enhance from
the center and more
Can provide detailed morphologic evaluation of cystic
For detecting malignant tumors:
▪ Sensitivity: 40%
▪ Specificity: 100%
▪ Accuracy: 50%
Advantage of aspiration of contents, sampling of cyst wall,
septa or mural nodule
Less potential for tumor seeding than percutaneous
Highly viscous contents (mucin) consistent with mucinous
Tumor markers, cytologic analysis, biochemical markers,
Advantage of CT over MRI
Better depicts a central calcification in
SCN or peripheral calcification in a mucinous
cystic neoplasm (MCN).
AdvantageS of MRI over CT..
1. MR with heavily weighted T2WI and MRCP will
better demonstrate the cystic nature and the
internal structure of the cyst and has the advantage
of demonstrating the relationship of the cyst to the
pancreatic duct as is seen in IPMN.
2. MRI better shows the central scar in SCN.
3. Presence of internal dependent debris appears to
be a highly specific MR finding for the diagnosis of
Age & Gender
“Daughter Lesion”: SPEN
“Mother Lesion”: Mucinous cystic
“Grandmother Lesion”: Serous cystadenoma
Head/neck for serous & side branch IMPN
Body/tail for mucinous cystic neoplasm
Peripheral in mucinous cystic
Central in serous cystadenoma
Mural Nodularity (enhancement = neoplasm)
Duct communication (narrow neck) favors IPMN