Pancreatic Neoplasms Imaging Guide
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This document discusses pancreatic neoplasms and their imaging appearance. It provides details on the WHO classification and imaging protocols for evaluating pancreatic cancers. Key points include descriptions of pancreatic ductal adenocarcinoma and its appearance on CT/MRI, as well as other pancreatic masses like serous cystadenoma, mucinous cystic neoplasm, and intraductal papillary mucinous neoplasm. Differential diagnoses and imaging features that predict malignancy are also reviewed.
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Pancreatic Neoplasms Imaging Guide
- 1. Anu@StanleyRadiologyDept 1 PANCREATIC NEOPLASMS Dr Anushuya Junior resident Stanley radiology dept
- 4. PANCREAS-SPECIFIC PROTOCOL FOR PANCREATIC CANCER 4 Thin-section, multi-phase technique with Pre-contrast images and Early arterial phase (CT angiography phase) images of the aorta and the superior mesenteric artery (17-25 s after the start of contrast injection), Pancreatic phase (35-50 s after the start of contrast injection), and Portal venous phase images (55-70 s after the start of contrast injection). Pancreatic phase images show peak pancreatic parenchymal enhancement, and therefore provide the best lesion to pancreas contrast. Portal phase images are helpful to assess the extent of venous involvement and to identify possible liver metastases. Anu@StanleyRadiologyDept
- 5. POST PROCESSING ◈ Oblique coronal or sagittal MPR and CMPR along the pancreatic duct can clearly demonstrate the relationship between tumors and the pancreatic duct or adjacent major structures. ◈ MinIP images use the lowest density values along each ray and clearly show low-density structures such as pancreatic and bile ducts. The recommended MinIP slab thickness is 3 mm for the pancreatic duct. ◈ Maximum intensity projections are also often used to evaluate the relationship between tumors and adjacent, enhanced vessels 5 Anu@StanleyRadiologyDept
- 6. PANCREATIC DUCTAL ADENOCARCINOMA ◈ Malignancy arising from ductal epithelium of exocrine pancreas. ◈ > 95% of pancreatic malignancies ◈ Age: Median age at onset - 71 years, Almost always after age 45, Peak: 7th-8th decade ◈ M:F = 1.3 : 1 ◈ RISK FACTORS: Family history, Cigarette smoking, alcohol, obesity, diabetes mellitus, Chronic pancreatitis, high fat diet. ◈ ASSOCIATIONS: Hereditary pancreatitis, hereditary breast and ovarian cancer syndrome, Peutz-Jeghers, ataxia telangiectasia, familial colon cancer, Gardner syndrome, and familial aggregation of pancreatic cancer. 6 Anu@StanleyRadiologyDept
- 7. PANCREATIC DUCTAL ADENOCARCINOMA SYMPTOMS: ◈ Jaundice, severe weight loss, epigastric pain radiating to back, ◈ Asymptomatic – body and tail tumours ◈ Trosseau syndrome (migratory thrombophlebitis) due to tumour induced hypercoagulability ◈ Bleeding varices – result from SMV or splenic vein occlusion LAB: Elevated tumour markers – CA 19-9 (Most important), CEA, CA 242. CA 19-9: Normal range 0-37 U/ml, >37 U/ml is considered abnormal. 7 Anu@StanleyRadiologyDept
- 8. PANCREATIC DUCTAL ADENOCARCINOMA IMAGING FINDINGS ◈ Head (60%), body (20%), diffuse (15%), tail (5%) ◈ Average size 2-3 cm ◈ Poorly marginated, hypodense mass with tendency to infiltrate posteriorly into retroperitoneum ◈ Tumor enhance poorly most conspicuous in portal venous (~ 70 seconds) and pancreatic (~ 40 seconds) contrast phases ◈ Tumor virtually never calcifies in absence of treatment. 8 Anu@StanleyRadiologyDept
- 9. PANCREATIC DUCTAL ADENOCARCINOMA IMAGING FINDINGS 5% of tumors isodense to pancreas on all phases, requiring attention to secondary signs of tumor ◈ SECONDARY SIGNS -Strong tendency to obstruct pancreatic and common bile ducts with abrupt ductal cutoff at site of obstruction -Abnormal contour of pancreas with loss of normal fatty lobulation and texture -Pancreatic parenchymal atrophy upstream from mass -Soft tissue infiltration to involve adjacent vessels and organs e.g., duodenum, bowel, stomach, and adrenals 9 Anu@StanleyRadiologyDept
- 10. PANCREATIC DUCTAL ADENOCARCINOMA IMAGING FINDINGS - MRI ◈ Tumor conspicuous on T1WI, appearing low signal and juxtaposed against high signal pancreatic parenchyma. ◈ Atrophic pancreas upstream from tumor often abnormally low signal on T1WI ◈ Conspicuity on T1WI C+ ◈ T2WI generally not useful for tumor detection, as tumors often isointense to pancreas ◈ MRCP and T2WI can nicely demonstrate abrupt cutoff and obstruction of pancreatic and common bile ducts ◈ Tumors often demonstrate restricted diffusion with lower ADC values than adjacent normal pancreas. ◈ MR generally 2nd choice (behind CT) for evaluating vascular involvement. 10 Anu@StanleyRadiologyDept
- 14. PANCREATIC DUCTAL ADENOCARCINOMA IMAGING FINDINGS ◈ ULTRASOUND -Hypoechoic mass with only minimal internal color Doppler flow vascularity - Biliary dilatation and pancreatic ductal dilatation upstream from tumor ◈ BARIUM UPPER GI STUDY -Frostberg 3 sign: Inverted 3 contour to medial part of duodenal sweep -Widening of c-loop of duodenum -Antral padding: Extrinsic indentation by tumour of PI margin of antrum ◈ ERCP - “Double duct sign” Obstruction of MPD and CBD at same level - Abrupt cut off - Irregular, nodular, rat-tailed ducts 14 Anu@StanleyRadiologyDept
- 16. ROLE OF PET ◈ Not effective for diagnosis of primary tumour ◈ Not helpful to assess vascular invasion or locoregional staging ◈ Ductal ca vs benign lesions ◈ Ductal Ca vs AIP ◈ Judging response to treatment ◈ Post treatment fibrosis vs residual tumour ◈ Useful for Distant staging 16 Anu@StanleyRadiologyDept
- 17. TNM STAGING FOR PANCREATIC CA 17 Anu@StanleyRadiologyDept
- 18. MD ANDERSON CRITERIA FOR DETERMINATION OF LOCOREGIONAL RESECTABILITY 18 RESECTABLE Local LN immediately around tumour No distant LN/ Mets/ Vascular involvement BORDERLINE RESECTABLE < 180o encasement of SMA Short segment occlusion of SMV/PV UNRESECTABLE Distant mets / Bulky LN distant from mass Vascular involvement Anu@StanleyRadiologyDept
- 23. Only 15-20% of patients are candidates for surgery at time of presentation 5-year survival rate is ~ 20% after surgery Survival no better than chemoradiation alone if surgery performed for tumor found to be locally advanced. 5-year survival rate is < 5% without surgery with median survival of 3.5 months 23 Presentation Advanced local disease or metastases (65%) Tumour confined to pancreas (14%) Localized disease with spread to regional lymph nodes (21%) Anu@StanleyRadiologyDept
- 24. PANCREATIC ADENOCARCINOMA - Rx ◈ Only potentially curative treatment for resectable tumor is complete surgical resection with negative surgical margins (R0 resection) ◈ Pancreaticoduodenectomy (Whipple resection) for tumors of pancreatic head/uncinate, distal pancreatectomy for tumors of body/tail, and very rarely total pancreatectomy ◈ Chemotherapy and radiation (external beam) utilized for resectable, borderline, and unresectable cancers ◈ Gemcitabine and FOLFIRINOX are chemotherapy mainstays. ◈ Neoadjuvant chemoradiation often utilized prior to surgery in borderline resectable tumors ◈ Palliative procedures include endoscopic biliary stenting (for jaundice), enteric stents or diverting gastrojejunostomy (for gastric/duodenal obstruction), and chemical splanchnicectomy or celiac nerve block to palliate abdominal pain. 24 Anu@StanleyRadiologyDept
- 26. DIFFERENTIALS Autoimmune pancreatitis -Delayed enhancement -No upstream atrophy -MPD dilatation not more than 5 mm -Penetrating duct sign -sausage shaped with Halo sign -Extra pancreatic findings -Improvement after steroid therapy Chronic pancreatitis Beaded duct Ductal calculi Parenchymal calcifications Lymphoma Almost never causes ductal obstruction or atrophy Disseminated disease Lymphadenopathy 26 Anu@StanleyRadiologyDept
- 27. DIFFERENTIALS Groove pancreatitis -Sheet-like, curvilinear soft tissue mass between pancreatic head and duodenum Distal CBD CholangioCa -CBD duct wall thickening -Delayed enhancement -Intra-ductal mass -MPD may not be dilated Ampullary adenoma/Carcinoma - Detected when small - Extrahepatic ductal dilatation - Enhancement on both art and venous phases 27 Anu@StanleyRadiologyDept
- 28. SEROUS CYSTADENOMA ◈ 30% of pancreatic cystic neoplasms. ◈ Females, median age 65 yrs ”Grandmother lesion” ◈ Benign lesion ◈ More common in pancreatic head ◈ Growth rate = 4 mm /yr ◈ Imaging surveillance in asymptomatic patients. 28 1. Microcystic or honeycomb pattern 2. Macrocystic or Oligocystic variant (<10%) > 2 cm cysts. This variant is difficult to distinguish from mucinous cystic tumour. 3. “Solid” serous adenoma – enhancing septa predominate. Anu@StanleyRadiologyDept
- 29. SEROUS CYSTADENOMA ◈ MICROCYSTIC or HONEYCOMB PATTERN ◈ MACROCYSTIC PATTERN 29 Anu@StanleyRadiologyDept
- 30. SEROUS CYSTADENOMA - CT ◈ May appear solid on CT - compact arrangement of cysts ◈ Fine external lobulations + ◈ Enhancement of septa/ cyst wall. ◈ Fibrous central scar + a characteristic stellate calcification is seen in 30% of cases – pathognomonic ◈ Calcifications commonly peripheral 30 Anu@StanleyRadiologyDept
- 31. SEROUS CYSTADENOMA - MRI ◈ T1WI: Cystic components hypointense ◈ T2WI: Cystic components hyperintense and fibrous components/central scar hypointense ◈ T1WI C+: Enhancement of septations/lesion{periphery with delayed enhancement of central scar 31 Anu@StanleyRadiologyDept
- 32. SEROUS CYSTADENOMA ◈ Endoscopic US: Aspiration of the cyst contents revealed thin fluid with no cellular atypia or elevated tumor markers. 32 Anu@StanleyRadiologyDept
- 33. SEROUS CYSTADENOMA ◈ CECT: Hypertrophied feeding vessels from GDA 33 Anu@StanleyRadiologyDept
- 35. Unillocular or multilocular < 6 cysts Relatively large cysts > 2 cms Displacing MPD MUCINOUS CYSTIC NEOPLASM ◈ Premalignant/malignant ◈ Tendency to occur in tail of pancreas. ◈ Contains ovarian stroma ◈ “Mother” lesion – middle aged females ◈ Complete surgical resection with adjuvant chemotherapy 35 Anu@StanleyRadiologyDept
- 36. MUCINOUS CYSTIC NEOPLASM - IMAGING ◈ CT Multilocular encapsulated cyst Peripheral curvilinear Ca++ (16%) ◈ MRI Typically show high T2; low T1, but may be slightly less T2 hyperintense due to mucin content. 36 Anu@StanleyRadiologyDept
- 37. MCN WITH INVASIVE MALIGNANCY RISK FACTORS Older age Symptomatic pt – pain, pancreatitis etc Elevated CEA/CA 19-9 IMAGING FEATURES Larger lesions > 40 mm Thick enhancing septations, wall thickening Mural nodularity Upstream pancreatic duct dilatation / atrophy 37 Anu@StanleyRadiologyDept
- 38. MCN WITH INVASIVE MALIGNANCY 38 Anu@StanleyRadiologyDept
- 39. INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM (IPMN) ◈ Mucin-producing papillary tumor arising from epithelium of main pancreatic duct (MPD) or duct side branches. ◈ Incidental finding ◈ Age 50-70 yrs, Male ◈ More common in familial pancreatic cancer, PJ & FAP 39 Anu@StanleyRadiologyDept
- 40. IPMN – IMAGING FEATURES MAIN DUCT IPMN -Markedly dilated, tortuous MPD often with bulging ampulla filled with fluid (mucin) -Amorphous calcifications may be seen within duct -Pancreas often atrophic SIDE BRANCH IPMN -Multifocality, Multiple cystic lesions scattered throughout the pancreas -Comunication with adjacent MPD is the key to diagnosis COMBINED IPMN Cystic lesion in contiguity with dilated MPD 40 Anu@StanleyRadiologyDept
- 41. IPMN – IMAGING FEATURES MAIN DUCT IPMN SIDE BRANCH IPMN 41 Anu@StanleyRadiologyDept
- 42. IPMN - MRI ◈ MRCP Direct communication with main pancreatic duct easier to identify on thin-section 3D MRCP images ◈ Secretin MRCP Enlargement of cyst following administration of secretin may be secondary sign of communication with main duct. ◈ ADC Map Malignant IPMN may have lower ADC values on DWI compared to benign IPMN. 42 Anu@StanleyRadiologyDept
- 43. IPMN – ERCP FEATURES 1. Direct visualization of patulous, bulging, "fish- mouth” ampulla with mucin extruding through ampulla in main duct IPMN 2. Can demonstrate dilatation of MPD or communication of side branch IPMN with MPD 43 Anu@StanleyRadiologyDept
- 44. IPMN WITH INVASIVE CARCINOMA Worrisome features: EUS with cyst aspiration Cyst size ≥ 3 cm MPD dilatation 5-9 mm peripheral wall thickening mural nodularity abrupt change in MPD caliber with upstream pancreatic atrophy. High-risk features: warrants resection. MPD dilatation ≥ 1 cm Enhancing solid mural nodularity, or biliary obstruction 44 Anu@StanleyRadiologyDept
- 45. IPMN WITH INVASIVE CARCINOMA 45 Anu@StanleyRadiologyDept
- 46. NEUROENDOCRINE TUMOURS OF PANCREAS ◈ Arising from pancreatic endocrine cells – APUD cells ◈ Age: 4th – 6th decades, MEN1: <30 yrs ◈ 85% arise in the pancreas while 15% ectopic (Duodenum, stomach, lymph nodes & ovary) ◈ Functioning & Non functioning ◈ Now, Syndromic & Non syndromic ◈ Associations: MEN 1 (Gastrinomas), VHL, NF 1 & Tuberous sclerosis 46 Anu@StanleyRadiologyDept
- 47. SYNDROMIC NET ①Produce clinical syndrome ②Small < 3 cms ③Insulinoma, glucagonoma, gastrinoma, somatostatinoma, VIPoma (vasoactive intestinal polypeptide), carcinoid NON SYNDROMIC NET ①Symptoms due to mas effect, large at presentation /metastases ②Much larger (> 5 cms) with frequent cystic/necrotic degeneration. ③Strong tendency to be malignant (80-100%) ④Cystic NETs more likely to be non-insulin- producing /nonsyndromic 47 Anu@StanleyRadiologyDept
- 48. INSULINOMA ①M.c. NET (50%) ②Solitary ③Benign(90%) ④F>M ⑤Whipple’s triad -Hypoglycemia -Low fasting glucose -Relief by iv glucose ⑥Surgically resected ⑦Excellent prognosis GASTRINOMA ①2nd M.c (25%) ②Multiple ③Malignant(60%) ④M>F ⑤Ass. with MEN 1 ⑥“Passaro’s” Gastrinoma triangle ⑦Zollinger ellison syn. ⑧Poor prognosis 48 Anu@StanleyRadiologyDept
- 49. SYNDROMIC NET - GLUCAGONOMA ◈ Skin rash(Necrolytic erythema migrans) ◈ Diarrhoea ◈ Diabetes ◈ Weight loss ◈ Thromboembolism – DVT & PE 49 Anu@StanleyRadiologyDept
- 50. NET – IMAGING FEATURES CT ◈ Well circumscribed ◈ Non infiltrative margins ◈ Ca++ common ◈ Conspicuous on arterial phase ◈ Invasion of PV /SMV ◈ No biliary or pancreatic duct obstruction/atrophy 50 Anu@StanleyRadiologyDept
- 51. NET – IMAGING FEATURES MRI T1 Hypointense T2 Hyperintense Enhancement similar to CECT DWI help identify tiny occult lesions ULTRASOUND Endoscopic – Hypo to isoechoic Increased vascularity Intra-op: help identify small non- palpable lesions PET/CT Increased FDG uptake Novel tracers: Ga -68 DOTA F-18 DOPA Indium 111 DTPA octreotide (Octreoscan) 51 DSA Hepatic venous sampling after arterial stimulation – increased hormone levels in occult tumours Anu@StanleyRadiologyDept
- 52. 52 Guo, Chuangen et al. “Value of diffusion- weighted MRI in predicting WHO grade in G1/G2 pancreatic neuroendocrine tumors.” Oncolo gy letters vol. 13,6 Anu@StanleyRadiologyDept
- 53. 53 Barrio, Martin, and Eugene P Ceppa. “Diagnosing microscopic pancreatic neuroendocrine tumor using 68- Ga-DOTATATE PET/CT: case series.” Journal of surgical case reports vol. 2018,9 rjy237. 29 Sep. 2018. Anu@StanleyRadiologyDept
- 55. NET – METASTASES M.c Liver, lymph nodes & bones(sclerotic) Hypervascular T2 hyperintense Portal vein invasion often Fluid fluid levels- high specificity Perilesional staeatosis – metastatic insulinoma 55 Anu@StanleyRadiologyDept
- 56. PANCREATIC SOLID & PSEUDOPAPILLARY NEOPLASM ◈ Rare slow growing, low grade ◈ < 35 years, >90 % females ◈ M. c. Abd pain ◈ Tumor markers not typically elevated ◈ Anywhere in pancreas ◈ <10% metastasize or recur ◈ Excellent prognosis after complete surgical resection 56 Anu@StanleyRadiologyDept
- 57. SPEN IMAGING CT ◈ Well defined, encapsulated mass with thick enhancing capsule ◈ With cystic components and internal haemorrhage ◈ Frequent central or peripheral Ca++ (50%) ◈ No biliary or pancreatic ductal obstruction ◈ Metastases/ vascular invasion - rare 57 Anu@StanleyRadiologyDept
- 58. SPEN IMAGING MRI ◈ Large, well-demarcated mass with central areas of low and high T1 signal intensity (hemorrhage) ◈ Presence of internal hemorrhage highly characteristic feature, and may result in fluid- fluid or hematocrit levels ◈ Capsule appears as rim of low T2 signal intensity and enhances on post-gadolinium images 58 Anu@StanleyRadiologyDept
- 59. SPEN IMAGING US ◈ Echogenic rim of tumour capsule ◈ Echogenic mass with necrotic centre (or) ◈ Completely cystic with subcapsular rim of tumour ANGIO ◈ Hypo to avascular with peripheral displacement of vessels PET ◈ Variable, may show increased uptake 59 Anu@StanleyRadiologyDept
- 60. PANCREATIC LYMPHOMA ◈ Homogeneous soft tissue mass with little enhancement ◈ Diffuse enlargement of pancreas with infiltrating tumor (± peripancreatic fat involvement) may mimic acute pancreatitis ◈ Almost always associated lymphadenopathy or other sites of lymphomatous involvement ◈ Tumor classically encases peripancreatic vessels without narrowing or occlusion 60 Anu@StanleyRadiologyDept
- 61. PANCREATIC METASTASES May be solitary (73%), multiple (10%), or diffusely infiltrative (15%) Enhancement pattern is variable, but typically mimics primary tumor – Hypervascular: Most often renal cell cancer (RCC) – Hypovascular: Lung, breast, melanoma, colon Concomitant intraabdominal metastases in 60-95%, Dilatation of pancreatic duct or bile ducts less common than pancreatic adenocarcinoma (40%) Encasement or narrowing of peripancreatic vasculature is unusual 61 Anu@StanleyRadiologyDept
- 63. PANCREATO- BLASTOMA -Childhood tumour -Associated with Beckwith wiedemann and FAP -No obstruction -Poor prognosis --T2 high signal -Metastasis to liver + LN 63 Anu@StanleyRadiologyDept
- 64. ACINAR CELL CARCINOMA -Paediatric age group -Misdiagnosed as neuroendocrine tumour -Hypodense on both arterial and venous phases with Ca++ -Lipase hypersecretion syndrome 64 Anu@StanleyRadiologyDept
- 65. SMALL CELL CARCINOMA OF PANCREAS Paraneoplastic syndromes Homogenously enhancing mass conforming to the contours of adjacent structures Multiple haematologic and lymphatic metastases 65 Anu@StanleyRadiologyDept
- 66. ANAPLASTIC CARCINOMA Bulky mass with central necrosis Invasion of adjacent structures Unresectable at diagnosis 66 Anu@StanleyRadiologyDept
- 67. -PANCREATIC PLASMACYTOMA Patient with Multiple myeloma -very sensitive to chemoradiation -No pancreatic ductal obstruction or parenchymal atrophy, highly atypical for an adenocarcinoma - 67 Anu@StanleyRadiologyDept
- 68. GIANT CELL TUMOUR Multiseptate complex cystic masses Resection often impossible 68 Anu@StanleyRadiologyDept
- 69. NESIDIOBLASTOSIS -persistent hyperinsuinemic hypoglycemia of Infancy. -first few hrs – 1 yr -Enlarged hyperechoic pancreas -Galiium 68 Dotatate scan 69 Anu@StanleyRadiologyDept
- 70. PANCREATIC SCHWANNOMA Well circumscribed low density mass with internal cystic foci 70 Anu@StanleyRadiologyDept
- 71. PLEXIFORM NEUROFIBROMA In a patient with NF - 1 71 Anu@StanleyRadiologyDept
- 73. PAEDIATRIC NEOPLASMS 1. SPEN 2. PANCREATO- BLASTOMA 3. NESIDIO- BLASTOSIS 4. ACINAR CELL CA 5. BURKITT LYMPHOMA 6. LYMPHANGIOMA 7. PNET 8. NB (2O) 9. ISLET CELL TUMOURS HYPERVASCULAR NEOPLASMS 1. ISLET CELL 2. PAPILLARY NEOPLASM 3. METASTASES FROM Angiosarcoma, RCC, Thyroid, Adrenal, carcinoid & Melanoma MACROCYSTIC NEOPLASMS 1. MCN 2. Side br IPMN 3. Non syndromic NET 4. Congenital lymphangioma 73 Anu@StanleyRadiologyDept
- 74. CONGENITAL CYSTS OF PANCREAS 1. ADPKD 2. VHL 3. Beckwith – widemann 4. Meckel –Gruber syndrome 5. Cystic fibrosis 74 Anu@StanleyRadiologyDept
- 75. BULGING PAPILLA 1. IPMN 2. Papillitis 3. Ampullary adenoCa 4. Peri ampullary Ca 5. AIP 6. Choledochocele 75 Anu@StanleyRadiologyDept
- 76. PERI-AMPULLARY CA Tumor arising within 2 cm of the major papilla I. Pancreatic carcinoma (85%) 2. Cholangiocarcinoma of distal common bile duct (6%) 3. Ampullary tumor (4%): adenoma I carcinoma 4. Duodenal wall tumor adenocarcinoma, adenoma, carcinoid, smooth muscle tumor DOUBLE DUCT SIGN 1. Ampullary tumor (most common) 2. Pancreatic ductal adenocarcinoma 3. Stone impacted in ampulla of Vater 4. Papillary stenosis 76 Anu@StanleyRadiologyDept
- 77. PANCREATIC NEOPLASMS WITH CA++ (a) Microcystic adenoma (in 33%): "sunburst" appearance of calcifications (b) Macrocystic cystadenoma In 15%): amorphous peripheral calcifications (c) NET (d) Cavernous lymphangioma & hemangioma: multiple phleboliths (D) Metastases from colon cancer DIFFUSELY ENLARGED PANCREAS 1. Malignant Lymphoma 2. Plasmacytoma 3. Metastases 4. Diffuse infiltrative pancreatic Ca 5. Autoimmune pancreatitis 77 Anu@StanleyRadiologyDept
Editor's Notes
- 4th leading cause of mortality Incidence rate= mortality rate 5 yr survival rate < 5 %
- CT sensitivity for pancreatic cancer is excellent (~ 97%) Excellent modality for determining unresectability (positive predictive value for unresectability of 89-100%)/ Less effective in determining resectability, as only 60- 91% of tumors found to be resectable on CT are actually resectable at surgery
- Obstructive pseocycst/ CT sensitivity for pancreatic cancer is excellent (~ 97%) Excellent modality for determining unresectability (positive predictive value for unresectability of 89-100%)/ Less effective in determining resectability, as only 60- 91% of tumors found to be resectable on CT are actually resectable at surgery
- Normal pancreas - Diffusely high signal intensity on T1WI (≥ liver)/Parenchyma variable in signal on T2WI/Pancreas enhances avidly and homogeneously on T1WI C+ (hyperintense to liver on arterial phase and isointense on delayed phase){
- T1/T2
- T1C arterial and delayed
- MRCP / ADC
- change resectability status of ~ 20% of patients compared to CECT
- T1 limited to pancreas < 2 cms
- Most common sites are liver, peritoneum, and lungs
- Benign pancreatic tumor lined by glycogen-rich cells that arise from acinar cells. ~ 40%) are discovered incidentally in asymptomatic patients. Does not typically result in biliary or pancreatic ductal obstruction or pancreatic atrophy
- MR able to better characterize internal morphology than CT, with ↑ sensitivity for microcysts
- MR able to better characterize internal morphology than CT, with ↑ sensitivity for microcysts
- IPMN - Elevated cyst fluid CEA (> 192 ng/mL), positive mucin stain
- May show areas of T1 hyperintensity due to internal hemorrhage, proteinaceous content, or mucin. Internal septations (typically T2 hypointense) easier to perceive on MR compared to CT
- Axial CECT with curved planar reformation shows a diffusely dilated MPD ſt witha bulging ampulla st, a characteristic feature of main duct IPMN. (Right) Axial CECT demonstrates a markedly dilated MPD that contains intraductal solid tissue ſ characteristic of a malignant main duct IPMN.
- gaping ampulla with clear mucin pouring from the orifice, a classic finding in main duct IPMN due to mucin hypersecretion by the tumor
- surgery depends on cyst location and extent of MPd involvement: Whipple, distal pancreatectomy, or total pancreatectomy
- Main ductal ipmn
- amine precursor uptake and decarboxylation (APUD) cells Nonsyndromic tumors - Hypofunctioning or clinically silent large tumors
- Strong correlation between size of nonsyndromic tumors and malignancy, particularly when > 2 cm
- Gastrinoma triangle defined by cystic duct and common bile duct (CBD) superiorly,{2nd and 3rd parts of duodenum inferiorly, and pancreatic neck and body Medially. Most commonly arise in duodenal wall/-Severe peptic ulcer disease -Increased acidity -Diarrhoea
- Rarely can be most conspicuous on venous phase Rather than encasement. Some small tumors may rarely secrete serotonin that can cause fibrosis and obstruction of pancreatic duct
- marked fold thickening ſt and wall hyperenhancement in the proximal aspect of the stomach. The more distal stomach demonstrates normal wall thicknes
- Young woman
- Fevers, arthralgias, skin rash, and fat necrosis due to elevated lipase levels (often > 1000 U/L)