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

8. 




Pseudocyst
IPMN occasionally
Unilocular serous cystadenoma
Lymphoepithelial cyst
Multiple
 von Hippel-Lindau
 Pseudocysts

9. 




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.

10. 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.

11. Colon cut off sign and ileus

12. 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)



14. 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

18. 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


19. Axial T2-weighted MR image complex cyst
with a fluid-debris level in head.

21. 
Side-branch IPMN manifesting as a
Unilocular cyst.

23. •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.

24. •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

26. Hypodense lesion with central
calcification&enhancement of septae
T2WI fatsat shows a lobuated hyperintense
lesion with central scar,characteristic of SCN.

28. 

Mucinous cystic neoplasms
Intraductal Papillary Mucinous Neoplasm
(IPMN)

29. 





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

33. •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

34. 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.

35. •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

36. Extremely widened
main pancreatic
duct (red arrow).

37. •"Multicystic" lesion in uncinate process/head
contiguous with dilated MPD("grape-like"
clusters or tubes & arcs)

38. SOMETIMES THERE IS A
MIXED TYPE.
THE MRCP SHOWS BOTH A
MAIN-DUCT AS WELL AS A
BRANCH-DUCT IPMN
(ARROW).
.

39. Signs of malignancy are:
•Pancreatic duct > 8 mm
•Solid node in duct.
•Mass around the
pancreatic duct.
•Enlarged choledochal
duct.

40. 


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

41. •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

43. •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

49. 

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

50. 
Advantage of CT over MRI
 Better depicts a central calcification in
SCN or peripheral calcification in a mucinous
cystic neoplasm (MCN).

51. 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.

52. 
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