Cystic lesions of pancreas

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  • 1. IMAGING IN CYSTIC LESIONS OF PANCREAS (agnyayshay / pachak granthi)
  • 2. 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 duct.  Pseudocysts typically occur with acute pancreatitis or may develop insidiously in the setting of chronic pancreatitis. 
  • 3.  Pseudocyst Common cystic pancreatic neoplasms  Rare cystic pancreatic neoplasms   Serous cystadenoma  Mucinous cystic neoplasm  IPMN      Solid pseudo papillary tumor Acinar cell cystadenocarcinoma Lymphangioma Hemangioma Paraganglioma
  • 4. Solid pancreatic lesions with cystic degeneration  Pancreatic adenocarcinoma  Cystic islet cell tumor (insulinoma, glucagonoma, gastrinoma)  Metastasis  Cystic teratoma  Sarcoma  True epithelial cysts  Associated with von Hippel–Lindau disease, autosomal dominant polycystic kidney disease, and cystic fibrosis
  • 5. Epithelial Neoplasms Exocrine tumors  Duct cell origin -Adenocarcinoma -Adenocarcinoma variants( Mucinous adenocarcinoma)a Micro cystic adenoma Mucinous cystic tumora IPMT    Acinar cell origin - Acinar cell carcinoma - Acinar cell cystadenocarcinomaa Solid papillary epithelial neoplasma Giant cell tumora
  • 6. Endocrine tumors Insulinomaa Gastrinomaa Glucagonoma VIPoma Somatostatinoma Polypeptidoma Carcinoid tumor Pheochromocytoma  Nonepithelial Neoplasms Sarcomaa Metastasesa Lymphoma
  • 7.      Pseudocyst IPMN occasionally Unilocular serous cystadenoma Lymphoepithelial cyst Multiple  von Hippel-Lindau  Pseudocysts
  • 8.      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 peripancreatic stranding. In chronic pancreatitis, there may be associated pancreatic parenchymal calcifications. Older cysts tend to have thicker walls that may contain calcium. These cysts can be located anywhere within the pancreas but predominantly involve the body or tail of the organ.
  • 9. 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 1.) Calcification.
  • 10. Colon cut off sign and ileus
  • 11. ULTRASOUND Real Time 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 hemorrhage)  Dilated pancreatic duct & CBD may be seen  Calcification of pancreas (chronic pancreatitis)  
  • 12. CT-PLAIN AND CONTRAST…. NECT  Round or oval, homogeneous, hypodense lesion ("mature" pseudocyst)  Hemorrhagic/ Infected pseudocyst: Lobulated , heterogeneous, mixed density lesion  ± Pancreatic calcification;(MPD) & common bile duct (CBD) dilatation CECT  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 bowel.  Pseudo aneurysms can be caused by or simulate a pseudocyst. CECT shows enhancement like adjacent blood vessels
  • 13. MR Findings T1WI: Hypointense T2WI Hyperintense (fluid) Mixed intensity (fluid + debris) T1 C+: May show enhancement of fibrous capsule MRCP: Hyperintense cyst contiguous with dilated pancreatic duct 
  • 14. Axial T2-weighted MR image complex cyst with a fluid-debris level in head.
  • 15.  Side-branch IPMN manifesting as a Unilocular cyst.
  • 16. •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, - septations - 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 malignant potential.
  • 17. •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
  • 18. Hypodense lesion with central calcification&enhancement of septae T2WI fatsat shows a lobuated hyperintense lesion with central scar,characteristic of SCN.
  • 19.   Mucinous cystic neoplasms Intraductal Papillary Mucinous Neoplasm (IPMN)
  • 20.       Premalignant tumor - may transform into a mucinous cystadenocarcinoma Exclusively seen in women - Typically in 'Mother' median age: 40-50 years Macrocystic with thick wall septations and peripheral calcifications Peripheral calcifications seen in 25%. This finding allows you to make a specific diagnosis Location in the tail and body of the pancreas (95%). Most are symptomatic, presenting with nondescript abdominal pain
  • 21. •Mucinous cystadenocarcinoma manifest at MR imaging as large complex cystic pancreatic lesions. • 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
  • 22. 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.
  • 23. •Mucin producing tumor in main pancreatic duct or branch-duct. •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 from branch-type. •Branch-duct type can look like other cystic neoplasms
  • 24. Extremely widened main pancreatic duct (red arrow).
  • 25. •"Multicystic" lesion in uncinate process/head contiguous with dilated MPD("grape-like" clusters or tubes & arcs)
  • 26. SOMETIMES THERE IS A MIXED TYPE. THE MRCP SHOWS BOTH A MAIN-DUCT AS WELL AS A BRANCH-DUCT IPMN (ARROW). .
  • 27. Signs of malignancy are: •Pancreatic duct > 8 mm •Solid node in duct. •Mass around the pancreatic duct. •Enlarged choledochal duct.
  • 28.    Unilocular or multilocular True cystic tumors or solid pancreatic neoplasms with cystic component/degeneration Wide DDx         Mucinous cystic neoplasms IPMNs Islet cell tumor Solid pseudopapillary tumor (SPEN) Adenocarcinoma Metastasis All malignant or have a high malignant potential Surgical management
  • 29. •Very uncommon neoplasm seen in women 20-30 years (Daughter). Solid and cystic neoplasm with capsule and with early 'hemangioma-like' enhancement. Sometimes intratumoral hemorrhage
  • 30. •Non-functioning endocrine neoplasm Also called islet cell tumor. •Hypervascular with ring-enhancement. This is unlike serous cystic neoplasms that enhance from the center and more solid
  • 31.   Can provide detailed morphologic evaluation of cystic lesions  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 sampling  Highly viscous contents (mucin) consistent with mucinous neoplasm  Tumor markers, cytologic analysis, biochemical markers, fluid amylase
  • 32.  Advantage of CT over MRI  Better depicts a central calcification in SCN or peripheral calcification in a mucinous cystic neoplasm (MCN).
  • 33. 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 pancreatic pseudocyst.
  • 34.  Age & Gender  “Daughter Lesion”: SPEN  “Mother Lesion”: Mucinous cystic  “Grandmother Lesion”: Serous cystadenoma  Location  Head/neck for serous & side branch IMPN  Body/tail for mucinous cystic neoplasm  Calcification  Peripheral in mucinous cystic  Central in serous cystadenoma  Mural Nodularity (enhancement = neoplasm)  Duct communication (narrow neck) favors IPMN