KGMU PPT

1. CASE PRESENTATION
• MODERATOR
• Dr. AMIT VERMA
• MD,DNB
• PRESENTER
• RAHUL KM TIWARI
• JR III

2. Case
• 20 yr old female presented with abdominal lump & on and off
abdominal pain X 3 months.
No history of
Fever
Trauma
Significant weight loss
Diabetes or any other past medical or surgical history
 Routine blood investigations were normal.

3. USG

4. USG

5. NCCT

6. CECT

7. Differentials
• Pancreatic Pseudocyst
• Solid pseudopapillary tumour of pancreas
• Mucinous cystic neoplasm
• Serous cyst adenoma

8. Approach to pancreatic
lesions

9. Classification of cystic pancreatic
lesions
• Pancreatic cysts can be
classified into four
subtypes:
(a) Unilocular cysts
(b) Microcystic lesions
(c) Macrocystic lesions
(d) Cysts with a solid
component

11. Cystic pancreatic lesions
Benign:
Serous cystadenoma
Cystic teratoma
Inflammatory:
Pseudocyst, Abscess,
Echinococcus
Malignant/ Potentially malignant:
Mucinous cystic neoplasm
Intraductal papillary mucinous
neoplasm (IPMN)
Solid with cystic degeneration:
AdenoCa
Solid pseudopapillary tumour
Neuroendocrine tumours
Mets
Sarcoma
Cystic teratoma

12. Classification based on location
Head
• Serous cyst adenoma
• Intraductal papillary mucinous neoplasms (IPMN)
• Adenocarcinoma
Body and tail
• Mucinous cystic neoplasms
• Serous Pseudopapillary tumor of pancreas ( SPEN )
Intraductal
• Intraductal papillary mucinous neoplasm (IPMN)

13. Benign cystic lesions
SEROUS CYSTADENOMA
(MICROCYSTIC ADENOMA)
Glycogen containing hypervascular tumour
Female predominance (4.5:1), Mean age 60y
Usually micro-/polycystic pattern (from 2mm up to 2cm)
May appear solid (due to vascularity & honeycomb appearance)
with multiple surrounding cysts
Enhancing septa & cyst wall
30% show central scar, which may calcify

14. CECT
MR-T2 WI
Serous cystadenoma

15. Malignant & Potentially
malignant
MUCINOUS CYSTIC NEOPLASMS:
Includes Mucinous cystadenoma &
Cystadenocarcinoma
Female predominence, Average age 60y
70-90% occur in body & tail
Usually hypovascular thick-walled multilocular (occasionally
unilocular) with a few compartments (>2cm)
Septations usually very thin walled
Occasionally peripheral calcifications (↑ chance of malignancy)
Contain mucin, sometimes debris/ haemorrhage
CT show enhancement of wall & septations
MR show the content with variable signal intensity probably due to
proteinaceous fluid/ blood

16.  Serous cystadenoma  Mucinous cystadenoma
 Age- 6th – 7th decade  Age- 4th -5th decade
 Presence of multiple cyst > 6 in no.
& size < 2 cm.
 Thin walled
 No. of cysts < 6 & size > 2cm.
 Thick walled
 M/C location- Head
 Contour- lobulated
 M/C location- body & tail
 Contour- smooth
 Calcification- Central with stellate
fibrous scar.
 Calcification- Peripheral
 CECT- Septal enhancement  CECT- Enhancement of tumor
nodule is typical.

17. Characterized by papillary proliferation of
pancreatic ductal epithelium & production of mucin
3 Types:
Main duct (70% chance of malignancy)
Branch duct (20% chance of malignancy)
Mixed
More common in older men
CT:Cystic dilatation of a main or a side branch duct that contains thick
mucoid secretions
Mural nodules within a cyst/ duct is highly suggestive of malignancy
Intraductal papillary
mucinous neoplasms (IPMN)

18. FUKUOKA CONSEUNSUS GUIDELINES
Also referred as TANAKA CRITERIA used for diagnosing
malignant cystic pancreatic lesions :
• HIGH RISK STIGMATA
• Enhancing solid components more than 5mm .
• Main pancreatic duct more than or equal to 10 mm .
• Obstructive jaundice.
• WORRISOME FEATURES
• Cyst more than or equal to 3cm .
• Thickened and enhancing cyst .
• Enhancing mural nodule <5mm.
• Main pancreatic duct 5-9mm.
• Lymphadenopathy
• Abrupt change in caliber of PD with distal pancreatic atrophy.
• Cyst growth rate>5mm in 2 yrs .
• Elevated Ca 19-9 .

19. Features Mucinous cystic
neoplasms
Serous cystadenomas Intaductal papillary
mucinous neoplasms
Age ~50 yrs
(mother lesion)
>60yrs
(grandmother lesion)
60-80 yrs
Sex Female(>95%) Female Males
Incidence 2.5% of exocrine tumor 1-2% of exocrine tumor 1-2% of exocrine tumor
Complaints Incidental/ pain,
anorexia, palpable mass.
Pain, wt loss, palpable
mass rarely jaundice.
Incidental/ mass, diarrhoea
diabetes and wt loss.
Location Body or tail Head Head/ uncinate process
Imaging
Calcification
Multilocular, macrocystic
lobulated, well
encapsulated,
+/- internal nodularity
Septal / peripheral
Multilocular microcystic
with central stellate
scar( septa radiate from
centre)
Central
Thick walled cystic mass,
solid mural nodules,
dilated duct, intraductal
filling defects, bulging
duodenal papilla.
Usually absent

20. Serous cystadenoma
 Points in favour  Points against
 Well circumscribed cystic lesion
located in head .
 Young female
( Occurs in old age group 6th decade )
 Absence of multiple small cysts .
( usually > 6 small sized cysts )
 Absence of central calcification & fibrous
scar.

21. Mucinous cystic neoplasm
 Points in favour  Points against
 Large well defined cystic lesion with
enhancing solid component.
 Young female
(Common in 5th decade)
 Location of lesion – head
( M/C site – body & tail )
 Absence of multilocular cysts &
mural nodules.
 Absence of calcifications.
( peripheral )

22. Solid pseudo papillary tumour of pancreas
• Uncommon exocrine ( 1-2 % ) pancreatic
neoplasm.
• Commonly occurs in females ( F : M – 10 : 1 ).
• Age – 2nd -3rd decade of life.
• M/C site – Body & tail of pancreas.
• Presents with palpable mass & on and off pain.
• CT- Large solid cystic lesion with areas of haemorrhage & necrosis. Enhancing
solid component located peripherally while cystic component centrally.
• Atypical manifestations -metastases (to liver and peritoneum), main pancreatic
duct obstruction, capsular invasion or parenchymal infiltration may occur

23. Solid pseudo papillary tumour of
pancreas
 Points in favour  Points against
 Young female ( 2nd decade)  Pancreatic head is the location.
( Body & tail m/c location )
 Presents with abdominal lump &
on and off pain.
 Less solid component
 Large well encapsulated mixed
solid / cystic lesion with
peripherally located solid &
centrally located cystic
component.
 Absence of any infiltration of
adjacent organs.

24. Neuroendocrine tumor with cystic degeneration
• 1%-5% of all pancreatic tumors
• M/c aged 51-57 years.
• show no sex predilection
• Nonfunctioning endocrine neoplasm
• Also called islet cell tumor
• Hypervascular with avid enhancement in arterial phase .
This is unlike serous cystic neoplasms that enhance
from the center and more solid)
• Homogeneous enhancement is typical for small tumors
(<2cm)

25. • Risk of malignancy increases with tumor size
(especially in tumors > 5 cm). Because of this fact
90% of nonfunctioning tumors are malignant at
presentation
• Metastases to lymph nodes and solid organs such as
the liver may have an enhancement pattern similar
to that of the primary tumor

26. Solid pseudo papillary epithelial
neoplasms
Pancreatic neuroendocrine tumors
Age 2nd -3rd decade
(daughter lesion)
Middle age
Sex Females No sex predilection
Incidence 1-2% of exocrine tumor 1-5% of all tumours
Location Pancreatic tail Pancreatic body and tail.
Imaging Well encapsulated solid or solid-
cystic or mainly cystic with areas of
necrosis and haemorrhage.
Small tumors enhance
homogeneously and more than
normal pancreas. Larger -
heterogeneous with foci of cystic
change, hemorrhage, necrosis
Calcification Peripheral rare

27. Case
20 yr old female was presented with abdominal lump and pain.
On imaging-
• Well defined encapsulated predominantly cystic lesion with
enhancing peripheral solid component arising from head of
pancreas. No e/o communication with pancreatic duct.
• No e/o any calcification & loculations.
• No e/o infiltration of adjacent organs ,significant
lymphadenopathy or any distant metastasis.

28. DIAGNOSIS
• Solid Pseudopapillary epithelial neoplasm of
pancreas ( SPEN )

29. Resectible:
1. No mets
2. No abutment, distortion, tumour thrombus or
encasement of SMV/PV
3. 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 upto HA
(only short segment encasement/ abutment of
HA & no involvement of CA)
4. <180° Abutment of SMA circumference
Not resectable:
1. Mets
2. Lymphnode mets beyond the
field of resection
3. >180° Encasement of SMA
4. Unreconstructable occlusion
of SMV/PV
5. Aortic invasion/ encasement
National Comprehensive Cancer Network- Radiographics, July 2011
Criteria for defining the respectability of Pancreatic CA

30. QUESTIONS

31. Q 1- Cluster of grapes appearance is a feature of –
A- Mucinous cystadenoma
B- Solid papillary epithelial tumors
C- Serous cystadenoma
D- Cystic endocrine tumors
ANS 1- C
Ref- Diagnostic radiology -GI & hepatobiliary imaging , Arun
Kumar , 2009 ,3rd ed. ,P-344.

32. Q2- 60 year old female present with abdominal pain and lump
on CT shows multicystic lesion with enhancing septa and central
calcific scar . Most probable diagnosis is
A –Pseudocyst
B- Serous cystadenoma
C- Mucinous cystadenoma
D- Solid papillary epithelial tumors
ANS 2- B

33. Q3. True about Solid Pseudo papillary tumors is-
A. Hypervascular mass in pancreas.
B. Irregular, heterogeneous, poorly-enhancing mass with double
duct sign.
C. Well-demarcated large mass with solid and cystic areas in
pancreatic tail region in CT.
D. "Multicystic" lesion in uncinate process/head contiguous with
dilated MPD on CECT.
ANS 3 - C
Ref- Diagnostic imaging -Abdomen / Michael P. Federle , 2004 ,1st
ed, p II-3-35

34. Q 4- Match the following-
A).1-1,2-2,3-3
B).1-2,2-3,3-1
C).1-3,2-1,3-2
D)1-1,2-3,3-2
Ans 4- C
Ref- Radiographics,Cystic Pancreatic Lesions: A Simple Imaging-
based Classification System for Guiding Management , V. Sahni ,
Nov -Dec-2005,pg-3 to 6.
Tumors Features
1.Serous cystadenoma 1. Peripheral calcification
2.Mucinous cystadenoma 2. Cystic mass with peripheral
solid component
3.Solid Pseudopapillary epithelial
neoplasm
3. Central calcification with
fibrous scar

35. Q5- 16-year-old girl who presented with mid epigastric pain. On
CT axial image shows soild cystic lesion in pancreatic head
region, most probable diagnosis is
A-Serous cystadenoma
B- Mucinous cystadenoma
C-Solid Pseudopapillary tumour
D- Pseudocyst.
ANS 5- C

36. Q6. All are true about Solid Pseudopapillary Tumors ( SPEN ) except-
A. SPENs are rare pancreatic tumors.
B. Progesterone receptors are seen in > 90 % of tumors.
C. Pancreatic head is most common site in young females.
D. Termed as “daughter” lesion.
Ans 6- C
Ref-Diagnostic Radiology: Gastrointestinal and Hepatobiliary
Imaging, Arun Kumar, 2009, 3rd Ed. p 353

37. Q7. All are true about Mucinous cystadenoma of pancreas except –
A. Multiloculated cystic mass.
B. Predominantly avascular on Angiography.
C. Head is most common site.
D. Most consider as premalignant tumor.
ANS 7 - C
Diagnostic imaging. Abdomen / Michael P. Federle ,2004, 1st ed, pg-
II-3-35 to II-3-36

38. Q8-50 year female present with abdominal pain .On Axial
contrast-enhanced MDCT shows a large, smooth cystic lesion
with internal septations (arrow) and peripheral and septal
calcification.
A-Serous cystadenoma
B-Intra-ductal papillary mucinous neoplasm
C-Solid Pseudopapillary tumor of pancreas
D-Mucinous cystic neoplasm
Ans-8-D

39. Q9. False about Serous cystadenoma-
A. Central calcification is present.
B. Malignant pancreatic tumor.
C. Honeycomb or sponge-like mass in pancreatic head.
D. Head of pancreas is most common location.
ANS- 9-B
Diagnostic imaging. Abdomen / Michael P. Federle ,2004, 1st ed,
pg -II-3-35 to II-3-36

40. Q 10-False about intraductal Papillary Mucinous Neoplasms
(IPMN) –
A- More common in females
B- Age- 6th -7th decade
C-Bulging of major papillas into the duodenal lumen is considered
a pathognomonic sign on ERCP.
D-M/C location – head of pancreas
Ans 10- A
Ref- CT and MRI of the whole body, John .R.Haaga, 2009, 5th ed,
2nd vol, p- 2417

41. THANK YOU