CYSTIC LESIONS OF

PANCREAS

Speaker : Dr. Deepthi

Moderator : Dr.M.Gayatri
 Citation: American Journal of Roentgenology
December 2002,Volume 179
DEVELOPMENT OF
PANCREAS
DEVELOPMENT OF
PANCREAS
 pancreas
 Coarsely lobulated gland meas15–20 cm in
length.

 Located in the anterior pararenal space of the

retroperitoneum.

 The gland can be divided into four parts:

Head - 0.6-2.8 cms
- Uncinate process
Neck
Body - 0.4- 2.3 cms
Tail - 0.5-2.8 cms
Relations of pancreas
 CYSTIC LESIONS OF
PANCREAS

Citation: American Journal of Roentgenology

December 2002,Volume 179
In this review, a gamut of pancreatic and
parapancreatic masses are illustrated .
 Pancreatic lesions are imaged with CT ,
sonography , MR imaging, endoscopic
retrograde cholangiopancreatography
(ERCP), and angiography.
 In this article we emphasize CT because
most lesions are either discovered or
evaluated on CT
 Congenital Pancreatic Lesions

 Most congenital pancreatic cysts are multiple,

and almost all are associated with underlying
congenital diseases that primarily affect other
organ systems.

 Solitary congenital cysts are rare.

 Multiple Pancreatic Cysts
 Autosomal dominant polycystic kidney
disease

 Von Hippel-Lindau disease

 Cystic fibrosis
Autosomal dominant polycystic kidney
disease
 Extrarenal cysts are most common in
liver(67%)
 In decreasing incidence, cysts also occur in
pancreas(5%), spleen, endometrium,
ovaries
 The incidence of cysts increases with aging.
 Pancreatic cysts vary from microscopic to
several cms in diameter
.
Autosomal dominant polycystic kidney
disease
 Von Hippel-Lindau disease
 Autosomal dominant condition characterized
by central nervous system and retinal
hemangioblastomas, visceral cysts,
pheochromocytomas, and renal cell carcinoma.

 Pancreatic cysts are found in up to 50% on

imaging studies .

 In families with this syndrome, pancreatic

lesions are the first or only manifestation of
the disease.
Von Hippel-Lindau disease
 Cystic fibrosis
 Most common pancreatic abnormality found
is fatty replacement of the pancreas, but
calcifications and cysts may also be found.
 True epithelium-lined cysts probably develop
as a result of inspissated mucin that obstructs
pancreatic ducts .
 Cysts can be single or multiple & most are
microscopic
 Rarely, cysts are so numerous and large that
most of the pancreas is replaced - “cystosis”
Cystic fibrosis
 Solitary Pancreatic Cysts

 True cyst : Most common in infants

 Anomalous development of pancreatic

ducts and range from microscopic to
several centimeters in diameter.

 unilocular or multilocular with epithelial

lining and contain serous fluid.
 Lymphoepithelial cyst

•Most occur in
middle-aged
to elderly men.
•Lesions have a
squamous lining,
and contain
keratinous
material
 Inflammatory and Infectious
Pancreatic Lesions

 Pseudocyst

 Abscess
 Pseudocyst
Panceatic and parapancreatic fluid collections
are most often complications of pancreatitis.
 Fluid collections can resolve spontaneously,
but those that do not are recognized as
pseudocysts ,on imaging studies when a well-
defined wall becomes visible .
 wall consists of fibrous tissue.
 No epithelial lining .
 Unilocular cyst without solid components,
central scar, or wall calcification.
 H/O Pancreatitis or abdominal trauma
 Found in any part of pancreas or
anywhere within the abdomen &
sometimes even in chest.
 When cysts are chronic, the cyst wall can
calcify .
 CT - uniform, low-attenuation fluid
collection with a thin uniform wall that
enhances after the administration of IV
contrast material
 Hemorrhagic and necrotic material can
increase the attenuation of fluid, whereas
fat decreases attenuation.
 Secondary infection can result in gas
formation.
Pseudocyst
Calcified pseudocyst
Traumatic pseudocyst
 USG : Uncomplicated pseudocysts are
hypoechoic but hemorrhage or necrotic
debris will produce internal echogenicity

 MR : uncomplicated, fluid-filled pseudocyst

on T1 - low signal intensity
on T2 – High signal intensity

 Protein content, necrotic debris, and

hemorrhage can alter these signal
characteristics
CONTRAST ENHANCED T1 CONTRAST ENHANCED T2
Pseudocyst with dependent debris
 On imaging studies, a pseudocyst may be
indistinguishable from a cystic neoplasm

 The amylase level of pseudocyst fluid is

almost always much higher than the fluid in
cystic neoplasms, but cystic neoplasms with
high levels of amylase have been reported .

 Extrapancreatic extension or location of a

pseudocyst on imaging studies is evidence
against a cystic neoplasm
 Pancreatic abscess
 Serious complication of pancreatitis.
 Abscesses may have poorly defined
margins & are often suspected when gas
is present in a fluid collection.
 In the absence of gas, differentiation of an
abscess from pancreatic necrosis or
simple fluid is not possible with imaging.
 Percutaneous aspiration is often used to
confirm infection or abscess before
percutaneous or surgical drainage .
 Pancreatic abscess
 Pancreatic gas is not pathognomonic of
abscess.

 A pancreatic—enteric fistula , a previous

internal pseudocyst drainage, or a previous
drainage of the pancreas by a pancreati-
cojejunostomy can all result in gas in
pancreatic bed.
Pancreatic abscess
Pancreatic gas caused by
pancreatic-enteric fistula
Common cystic neoplasms
Differentiation of pancreatic cysts
 Exocrine Pancreatic Lesions
Mucinous Adenocarcinoma -
(ColloidCarcinoma)
 Mucinous adenocarcinoma is an uncommon
variant .
 Produces a large volume of mucin that results in
a cystic appearance
 The prognosis is just as poor as for an
adenocarcinoma that has a typical appearance
and histology.
 Mucinous Adenocarcinoma -
(ColloidCarcinoma)
 Tumoral calcification, inspissated mucin or
tumor obstructing bile ducts, and
pseudomyxoma peritonei have all been
reported in association with mucinous
adenocarcinomas
Mucinous Adenocarcinoma
(ColloidCarcinoma)
 Microcystic Adenoma
(Cystadenoma,Serous Adenoma,
Glycogen-Rich Adenoma)
 Benign neoplasm

 Lobulated surface

 Cysts can be single or multiple and can

involve any part of the pancreas

 No communication between cysts and

pancreatic duct
 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
 Microcystic adenoma is one of the
pancreatic lesions found in von Hippel-
Lindau disease
 On CT - water, soft-tissue, or mixed
density & have a margin ranging from
poorly defined to a thin well-defined
capsule.

 Enhancement of cyst walls and septa ranges

from moderate to marked .

 The central stellate scar is well defined and

may be calcified
Microcystic Adenoma
Microcystic Adenoma
Microcystic Adenoma
 USG : Lesions may appear cystic, solid,
or even echogenic if the cysts are very
small. central scar is echogenic.

 MR : low signal intensity on T1 & high

signal intensity on T2 and also shows a
central scar and septa
Microcystic Adenoma
 A microcystic adenoma contains
intracellular glycogen but no mucin.

 This glycogen content is a feature that is

central in using percutaneous aspiration
biopsy to differentiate this from a mucinous
cystic tumour.
 Mucinous Cystic Tumor
(Cystadenoma, Cystadenocarcinoma,
Macrocystic Adenoma)

 Premalignant tumor - may transform into a

mucinous cystadenocarcinoma

 Exclusively seen in women

 Median age: 40-50 years

 MC Location : Tail and body of the pancreas

(95%).
 Cysts may be single or multiple.

 Macrocystic with thick wall septations and

peripheral calcifications (25%)

 Cyst walls can be irregular or contain

excrescences, both of which correlate
well with malignancy.
Mucinous Cystic Tumor
 .

Mucinous Cystadenocarcinoma
Mucinous Cystadenocarcinoma
 Most, but not all cysts, are larger than 2
cm in diameter.
 Microcystic adenomas are characterized
by cysts < 2 cm, but some of them also
contain cysts that are > 2 cm.
 In these cases, a microcystic adenoma
cannot be differentiated from a mucinous
cystic tumor
CT shows a near-water-density unilocular
or multilocular cystic lesion with
enhancing walls and septa that range from
thin and regular to thick and irregular with
excrescences and nodules .
 Peripheral or curvilinear calcifications in
the lesion are located in cyst walls which is
different from the central calcification of
microcystic adenomas
 USG :shows the features of cyst walls
well & may show echogenicity caused by
cyst wall calcification .
 MR imaging shows variable,
heterogeneous signal on both T1-
weighted and T2-weighted images and
provides good depiction of cyst wall and
septa features
 Calcification is easier to see on CT than
on MR imaging
 Intraductal Papillary Mucinous Tumor
(Ductectatic Cystadenoma, Cystadenocarcinoma,
Ductectatic Mucinous Tumor)
 Mucine producing tumor in main pancreatic
duct or branch-duct.
 Dilatation of the main pancreatic duct and
side ducts in the pancreatic head and uncinate
process. The ducts may be so dilated that they
resemble cysts.
 More common in males .
 Median age :60 - 80 yrs
 S/S :abdominal mass,diarrhea, diabetes &
weight loss
 IPMTs are classified into :
 Main duct type : segmental or diffuse,
 Branch duct type : macrocystic or
microcystic
 The branch duct type most commonly
occurs in the uncinate process or
pancreatic head, but can involve the body
or tail.
 IPMTs can also present as a combination
of the branch and main duct types
Main duct IPMT
 ERCP & MRCP
 ERCP is the imaging modality of choice for branch type
and main duct IPMTs.
 Demonstrates :
- The communication of the lesion with the pancreatic
duct,
- Intraductal filling defects, and
- Bulging of the duodenal papilla and mucin protrudin into
the duodenal lumen through a patulous orifice.

 MR with MRCP can replace ERCP as the gold standard of

imaging especially when copious mucin production inhibits
adequate opacification of the ductal system on ERCP.
ERCP
Intraductal Papillary Mucinous
Tumor
ERCP
Branch-duct IPMN
IPMN with malignant transformation
 Endocrine Pancreatic Neoplasms

 Insulinomas

 Glucagonomas

 Gastrinomas

 Nonfunctioning endocrine tumors

 Endocrine Pancreatic Neoplasms

 These tumors can be isolated or associated

with the multiple endocrine neoplasia
syndrome type 1 (MEN 1)

 All types of pancreatic islet cell neoplasms

have been reported in patients with this
syndrome.
 Insulinoma
 Most common functioning islet cell tumor.

 The clinical triad leading to the diagnosis is

fasting hypoglycemia, symptoms of
hypoglycemia, and immediate relief of
symptoms after the administration of IV
glucose.

 Fasting hypoglycemia with no decrease in

insulin level is confirmatory.
 Insulinoma
Approximately 10% of insulinomas are
multiple, 10% are malignant, and 10% of
patients have hyperplasia rather than
neoplasia
 Most insulinomas are small and
hypervascular. Some contain calcification.
 Malignant tumors tend to be large. Cystic
lesions are rare
CYSTIC INSULINOMA
 Gastrinoma
 Second most common functioning islet
cell tumor.
 Most are sporadic and associated with the
Zollinger-Ellison syndrome.
 Diagnosis is confirmed by increased
serum gastrin concentrations .
 Gastinomas are frequently multiple,
extrapancreatic, difficult to locate, and
malignant.
 Gastrinoma
 Hepatic metastases are associated with a
poor prognosis, whereas patients with
metastases isolated to lymph nodes often
have long-term survival.
 The tumor size is variable, but pancreatic
lesions average 3-4 cm.
 The lesions are often hypervascular, so
they may be visible on arterial phase CT
and angiography. Rare cystic lesions have
been reported
 Glucagonoma
 Most lesions are malignant
M=F
 Present with a necrolytic migratory rash
and various other elements of the
“glucagonoma syndrome” including diabetes
mellitus, stomatitis, diarrhea, anemia, and
weight loss.
 An elevated plasma glucagon level
establishes the diagnosis.
 Glucagonoma
 Tumor size is variable, but most are large
and have metastasized at the time of
diagnosis.
 Most are located in the distal pancreas
and are vascular.
 Tumors may be solid or contain central
low-attenuation areas on CT. Cystic
lesions are rare .
CYSTIC GLUCAGONOMA
Nonfunctioning Endocrine Tumors

 Non-functioning
endocrine tumors
occur throughout
pancreas, can be
calcified, and may be
cystic
Nonfunctioning Endocrine Tumors
 Even though termed “nonfunctioning” and
clinically silent, most produce some
hormone detectable by sensitive assays.
 These tumors are usually low-grade
malignancies, but most are large and have
metastasized to the liver by the time of
diagnosis.
 Symptoms occur late when the bile ducts,
pancreatic duct, or nerves become
involved
Rare Exocrine Neoplasms of the
Pancreas
Solid Papillary Epithelial Neoplasm
(Solid Pseudopapillary Tumor, Papillary
Cystic Tumor)

 Giant Cell Tumor

 Solid Papillary Epithelial Neoplasm
(Solid Pseudopapillary Tumor, Papillary Cystic
Tumor)

 Low-grade malignancy & approximately 1%

of pancreatic neoplasms.
 young women
 Eosinophilia and polyarthralgia.
 Solid and cystic neoplasm with capsule &
with early 'hemangioma-like' enhancement.
Sometimes intratumoral hemorrhage
Solid Pseudopapillary Tumor
 Giant Cell Tumor
Two histologic types:
 The pleomorphic type : Highly malignant
& has a poor prognosis.
 The osteoclastic type : Has a better
prognosis.
- Most lesions are large and highly vascular
- Cystic appearance is the result of central
necrosis
Giant Cell Tumor
Nonepithelial Neoplasms of the
Pancreas
 Sarcoma

 Metastases to the Pancreas

 Sarcoma
 Most sarcomas originate in the parapancreatic
tissues and secondarily invade the pancreas.
 Primary origin in the pancreas is rare.
 Leiomyosarcoma is the most common.
 Poorly differentiated
 The gross morphology ranges from solid to
cystic when central necrosis is present.
 The solid lesions have an appearance similar to
that of adenocarcinoma, whereas necrotic
lesions can stimulate mucinous cystic tumors
Leiomyosarcoma
 Metastases to the Pancreas
 When lymphoma was excluded, breast,
lung, melanoma, and gastrointestinal tract
were the most common primary sites
 The incidence is much lower in patients
who present with solitary pancreatic
lesions
 several series of metastases identified by
imaging studies have reported renal cell
carcinoma to be the most common
primary neoplasm .
 Metastases to the Pancreas
 Cystic metastases can be the result of
central necrosis or cystic degeneration .

 A cystic lesion in a patient presented here

proved to be multiple myeloma .

 The imaging characteristics of pancreatic

metastases tend to mirror the
characteristics of the primary neoplasm
Multiple myeloma
Metastatic colon carcinoma
Metastatic renal cell carcinoma
 Parapancreatic Neoplasms
 Most common – Lymphomas
 USG - Homogeneous lymphomatous lymph
nodes can appear to be cystic
 CT - Tumor necrosis can result in a cystic
appearance
 Retro-peritoneal neoplasms, some of which
can be cystic, occur in the in the area of the
pancreas.
 Lymphangiomas , paragangliomas , cystic
teratomas, and metastases .
 Lymphangiomas are most often
homogeneous, thin-walled, fluid-filled
cysts, but they may have septa, thick walls,
calcification, and internal debris.
 These lesions have an epithelial lining but
do not contain keratin, which
differentiates them from lymphoepithelial
cysts
Parapancreatic lymphangioma
Parapancreatic metastasis
Parapancreatic retroperitoneal
cystic teratoma
Parapancreatic metastases can appear cystic
if they become necrotic or if they are from
a primary neoplasm that has a cystic
appearance.
THANK U