imaging of pancreatic neoplasms solid tumours pancreatic ductal adenocarcinoma staging endocrine tumours imaging pancreatic mesenchymal tumours solid pseudopapillary tumours functional and non functional pancreatic neoplasms imaging CT MRI and USG apperances of various solid pancreatic lesions TNM staging of pancreatic ductal adenocarcinoma associations of endocrine tumours pancreatic PEComa gatrinoma pancreatoblastoma pancreatic lipoma differntial diagnosis for pancreatic ductal adenocarcinoma-RAGUBHARATHI RADIOLOGY RESIDENT

1. Pancreatic neoplasms
(Solid)
R.RAGUBHARATHI,
RADIOLOGY RESIDENT,
TIRUNELVELI MEDICAL COLLEGE.

3. Classification based on function
1. Exocrine tumors
2. Endocrine tumours
3. Mesenchymal tumours

4. Exocrine tumors
• Ductal adenocarcinoma
• Cystic neoplasms
• Solid pseudopapillary tumour of pancreas

5. Endocrine tumors of the pancreas
• Functional
• Non functional

6. Pancreatic mesenchymal neoplasms
• Pancreatic mesenchymal neoplasms (or pancreatic
nonepithelial neoplasms) are a group of rare pancreatic
neoplasms that arise from the structural elements of the
pancreas (nerves, fat, lymph), rather than from the exocrine or
endocrine cells of the pancreas.

7. Pancreatic ductal adenocarcinoma
• Most common pancreatic neoplasm
• Risk factors
• Cigerrte smoking
• Obesity
• Familial predisposition

8. HNPCC
familial breast cancer
familial atypical multiple mole melanoma (FAMMM)
hereditary pancreatitis
ataxia-telangiectasia
Peutz-Jeghers syndrome

9. Clinical presentation
• Pain (most common)
• Courvoisier’s gallbladder: painless jaundice and enlarged gallbladder
• Trousseau’s syndrome: migratory thrombophlebitis
• new onset diabetes mellitus
• lipase hypersecretion syndrome

10. Pathology
• Three precursor lesions for pancreatic adenocarcinoma have been
identified
• pancreatic intraepithelial neoplasia (PanIN)
• intraductal papillary mucinous neoplasm (IPMN)
• mucinous cystic neoplasm

11. Location and classification
• Head and uncinate process: two-thirds of cases
• body and tail: one-third of cases

12. Fluoroscopy
• Barium meal/small bowel follow through
• may demonstrate a reverse impression on the duodenum: Frostburg
inverted 3 sign or a wide duodenal sweep

14. Ultrasound
Findings are non-specific and include:
hypoechoic mass
double duct sign may be seen

17. CT
• Ductal adenocarcinomas appear as poorly defined masses with
extensive surrounding desmoplastic reaction
• . They enhance poorly compared to adjacent normal pancreatic tissue
• appear hypodense on arterial phase scans in 75-90% of cases, but
may become isodense on delayed scan
• The most important feature to assess locally is the relationship
of the tumor to surrounding vessels (SMA and celiac axis). If the
tumor surrounds a vessel by more than 180 degrees, then it is
deemed T4 disease and is unresectable

23. MRI
• T1: hypointense .
• T1 FS: hypointense .
• T1 + C (Gd): slower enhancement than normal pancreas, therefore
dynamic injection with fat saturation with arterial phase imaging is
ideal
• T2/FLAIR: variable , depending on the amount of reactive
desmoplastic reaction
• MRCP: double duct sign may be seen

27. Differential diagnosis
acute pancreatitis
chronic pancreatitis
other pancreatic neoplasms
lymphoma
fatty infiltration of the pancreatic head
cholangiocarcinoma
periampullary tumors
pancreatic metastases

29. Solid pseudopapillary tumor of the
pancreas
• Solid pseudopapillary tumors (SPT) of the pancreas are rare (usually
benign) pancreatic tumors.

30. Other names
• Solid pseudopapillary tumor (SPT) of the pancreas
• solid pseudopapillary neoplasm (SPN)
• solid pseudopapillary epithelial neoplasm (SPEN)
• papillary cystic neoplasm of the pancreas
• Hamoudi tumor
• Gruber-Frantz tumor (or just Frantz tumor)

31. Location
• There is a greater predilection to occur at pancreatic tail.

32. Associations
• Pancreatic dorsal agenesis

33. Ultrasound
• Large well-defined mass with heterogeneous apperances, due
to its solid and cystic composition.

35. CT
• Usually seen as a well-encapsulated lesion with varying solid and
cystic components owing to hemorrhagic degeneration.
• Following IV contrast administration, enhancing solid areas are
typically noted peripherally, whereas cystic spaces are usually more
centrally located.
• Calcifications and enhancing solid areas may be present at the
periphery of the mass.

38. MRI
• T1: low to heterogeneous signal intensity
• T2: heterogeneous to high signal intensity
• C+ (Gd): can show heterogeneous and slowly progressive
enhancement

40. •Endocrine tumors of the
pancreas

41. Endocrine tumors of the
pancreas

42. • Endocrine tumors of the pancreas arise from the pancreatic
islet cells

43. Associations
• von Hippel-Lindau disease and
• Men 1

44. • Syndromic tumors tend to present earlier, with clinical signs and
symptoms related to their cell type and biological activity.
• insulinoma: Whipple triad
• gastrinoma: Zollinger-Ellison syndrome
• glucagonoma: 4D syndrome
• non-functioning tumors: tend to present late, similar
to pancreatic adenocarcinomas
• Non-syndromic tumors tend to present later and are often larger
in size.

45. • syndromic tumors
• insulinoma: most common
• gastrinoma: second most common
• glucagonoma
• VIPoma
• somatostatinoma (some of these can be non-functional)
• non-syndromic tumors: third most common

46. Ultrasound
• well-circumscribed with smooth margins
• round or oval
• hypoechoic
• Liver metastases may be hyperechoic or targetoid.

48. CT
Smaller tumors:
• hypervascular
• tend to be homogenous and well-circumscribed
• Larger tumors:
• may appear heterogeneous and contain areas of cystic or
necrotic change

49. MRI
• T1: hypointense relative to pancreas
• T2: typically hyperintense relative to pancreas, but there is a
range of signal intensities
• T1 C+ (Gd): hyperintense/hypervascular relative to pancreas

50. Insulinoma
• Insulinomas are the most common sporadic endocrine tumor
of the pancreas

51. Clinical presentation
• Typically insulinomas present with Whipple's triad consisting of:
• fasting hypoglycemia (<50 mg/dL)
• symptoms of hypoglycemia (due to subsequent catecholamine
release)
• immediate relief of symptoms after the administration of IV
glucose

52. Nuclear medicine
• 68Ga-DOTATATE PET/CT
• About 80% of insulinomas express the somatostatin receptors
2, and the 68Ga-DOTATATE scans have a high affinity for thee
receptors and, therefore, have high sensitivity in the detection of
these tumors

53. • 18F-FDG PET/CT
• Neuroendocrine tumors are slow-growing tumors that usually
have slow metabolic activity in their initial stages and, therefore,
are not notably avid on 18F-FDG PET/CT

57. Gastrinoma
• Gastrinomas are the second most common pancreatic
endocrine tumor and the most common type in the setting
of multiple endocrine neoplasia type I (MEN I)

58. • Markers
• chromogranin A levels may be elevated
• Nuclear medicine
• Because gastrinomas often have abundant somatostatin
receptors, In-111 octreotidestudies have a higher sensitivity for
these pancreatic endocrine tumors

59. Pancreatic mesenchymal neoplasms
• Benign
• pancreatic neurofibroma
• pancreatic schwannoma
• pancreatic ganglioneuroma
• pancreatic desmoid tumor
• pancreatic lipoma
• pancreatic perivascular epithelioid cell tumor (pancreatic
PEComa)
• pancreatic mature cystic teratoma (pancreatic dermoid)
• pancreatic lymphangioma

60. • Malignant
• pancreatoblastoma
• pancreatic lymphoma
• pancreatic sarcoma

61. • Radiographic features
• CT
• well-circumscribed
• hypoattenuating
• mildly enhancing
• MRI
• T1: hypointense
• T2: hyperintense

63. Pancreatic lipoma
• CT
• well-circumscribed, lobulated lesion in the pancreas
• generally fat attenuation (≤ -30 HU)
• non-enhancing
• MRI
• well-circumscribed, lobulated lesion in the pancreas
• T1 and T2 hyperintense
• saturates on a fat-saturated sequence
• may not be hypointense on an out-of-phase sequence (edge may
show "india-ink" artefact)

66. Pancreatic PEComa
• Radiographic features
• CT
• tend to occur in the head and body of the pancreas
• well-demarcated
• hypoenhancing mass with a hypervascular capsule
• may demonstrate hemorrhage or cystic degeneration
• fat attenuation may be present
• MRI
• Signal characteristics include
• T1: hypointense
• T2: hyperintense
• T1 C+: heterogeneous enhancement

69. Pancreatoblastoma
• Pancreatoblastomas are rare pediatric tumors of
the pancreas. However, they are the most common pancreatic
neoplasm of childhood and are often associated with a raised
alpha-fetoprotein.

70. Associations
• Beckwith-Wiedemann syndrome

71. Ultrasound
• They are usually large, well defined, heterogeneous mass with
solid and multilocular cystic areas that contain hyperechoic
septae.

73. CT
• usually relatively well defined and heterogeneous due to solid
and multilocular cystic components with enhancing septae
• may demonstrate fine calcifications, similar to those seen
in neuroblastoma
• most often occurs in the head of the pancreas and tend to be
large and solitary

76. Differential diagnosis
• Wilms tumour
• Neuroblastoma