imaging pancreas tumor adenocarcinoma non endocrine

1. Imaging of non endocrine
tumours of pancreas
DR. DEV LAKHERA

2. Anatomy
L1 vertebral body

3. Pancreatic malignancy
2nd most common in GI malignancy
5 year - Survival rate <5%
Most are ductal in origin- pancreatic adenocarcinoma
Cystic pancreatic tumours and endocrine tumours rare.
Curative - surgical resection // partial pancreaticoduodenectomy - 'pylorus-
preserving’ Whipple

4. Classification of tumours
Pancreatic malignancies
Duct Cell Origin
• Solid neoplasms
1. Adenocarcinoma
2. Variant carcinomas
• Cystic neoplasms
1. Congenital cysts
2. Pseudocysts
3. Serous cystadenoma
4. Mucinous cystic neoplasm
5. Mucinous ductal ectasia
Acinar origin (1%)
1. Acinar cell carcinoma
2. Acinar cell cystadenocarcinoma
3. Pancreaticoblastoma
Rest are endocrine
Indeterminate Origin
1. Osteoclast-type giant cell carcinoma
2. Solid and papillary epithelial neoplasm
3. Mixed endocrine-exocrine neoplasm
4. Microadenocarcinoma.
Pancreatic cancers (85%) are
adenocarcinoma of ductal origin.

5. Pancreatic adenocarcinoma
 (M:F – 1.5:1)  60 - 70 years (60-70 male with painless jaundice)
Advanced local tumor extension (40%) / distant metastatic disease (40%)
Head - Painless jaundice
Body and tail - Pain and weight loss

6. Pancreatic tumor - Site
Mainly - Head of the pancreas (75%).
Minority - in the body (15%) and tail (10%).
At the time of diagnosis head malignancies - 2-3
cm - present earlier
Periampullary tumors (0.1%)
intense desmoplastic response
Tumors originating in the distal common bile duct or ampulla
may also grow into the pancreatic head and together with
pancreatic head carcinoma these tumors are often grouped
together under the name.

7. Imaging work up
Ultrasound – First line imaging test - Better detects masses >3 cm and mets >2 cm
CT
Higher diagnostic accuracy
Local and distant staging
Signs of unresectability
MRCP - sensitive for detecting a periampullary mass, but offers no significant additional staging
information
Clinical feature
painless obstructive jaundice

8. Ultrasonography (US)
 Hypoechoic
Necrotic tumors may show heterogenous
echopattern
Ductal obstruction and dilatation may also be
visualized.
Vascular involvement -thickening of
periarterial tissues
large, hypoechoic mass (M) obstructing the extrahepatic
common bile duct (CBD).
normally echogenic fat immediately adjacent to the artery is
replaced by tissue of lower echogenicity

9. hypoechoic mass in the pancreatic
head (A). On CDFI peritumoral
vascularity and absence of internal
vascularity seen. No vascular
invasion was seen in this case // A,
Transverse sonogram
reveals a subtle cancer in the body
of the pancreas (yellow arrows) with
a pseudocyst peripheral to the mass
(white arrow). B, CT image at a
similar level shows identical findings.

10. Endoscopic US
Second part of duodenum - pancreatic head, portal vein and papilla
Duodenal bulb - for head, neck and distal CBD
Stomach - for imaging of body, tail and the pancreatic duct
Sensitive for small (< 2 cm) solid tumors

11. Barium – head of pancreas
Widening of C loop of duodenum
Antral pad sign
effacement and distortion of the
mucosal pattern on the medial wall
Inverted 3 sign
Double contour of duodenal loop // Enlarged
duodenal loop with 'reversed 3' sign of Frostberg.
Earlier percutaneous transhepatic cholangiogram
shows characteristic ' gloved finger' obstruction of
intrapancreatic common bile duct pathognomonic
of carcinoma of the pancreatic head

12. first image is a prone view from UGI series showing mass effect on 2nd and 3rd portions of the duodenal sweep.
The second image is an RAO view from UGI series showing mass effect on 3rd portions of the duodenal sweep with
mild dilatation of proximal duodenum.

13. CT
Imaging modality of choice for the detection and presurgical staging.
High density oral contrast should be avoided and water should be used
Optimal imaging - early-portal phase 40-50 sec - pancreatic phase.
Late portal phase
Overall assessment of the abdomen to look for liver metastases, lymph nodes and peritoneal
implants.
Plain scan for pancreatic calcifications
When performing CT evaluation of pancreatic tumors, as oral
contrast.

14. Characteristic imaging features
Solid schirrous type
Reduced vascular perfusion
Ill defined margins
Not encapsulated
Desmoplastic reactionFibrous tissue, hard
slow growing / Rather than heterogenous
enhamcnet – soild hypoenehancing
masss with illdefined margins /
Fibrous tissue, hard slow growing / Rather than heterogenous enhancment – solid hypoenhancing masss
with illdefined margins /

15. .
During the early portal phase,
ill defined nonenhancing
hypodense area in tail of the
pancreas. B.. During the
venous phase, the mass is
almost isodense with the
remainder of the pancreas
(arrow)..
Adenocarcinoma, head of
pancreas and same patient as
C. The mass is unrecognizable
20 seconds later during the
portal phase. Both cases
illustrate the critical
importance of pancreatic
phase imaging

16. Strong tendency to obstruct ducts – with dilatation
Parenchymal thinning
Side branches may undergo cystic dilatation with
obstruction rupture causing pancreatitis and
extrapancreatic effusion / pseudocyst formation
CBD obstruction –compression by mass /
lymphadenopathy
CECT image showing an ill defined hypodense lesion in the pancreatic head which appears bulky.
There is also upstream dilatation of the main pancreatic duct// Metastatic lymphadenopathy
adjacent to suprapancreatic part of the bile duct can also cause ductal obstruction.

17. subtle hypodense hypoenhancing
area in uncinate process of
pancreas with dilatation of
pancreatic duct.

18. Double duct sign -
Concurrent dilatation of pancreatic duct and CBD
CECT images showing the “double duct sign”, dilated CBD and
MPD due to mass within the pancreatic head

19. Extension into adjacent structures
Portal, splenic and superior mesenteric vein (SMV) lying
adjacent to the pancreas and confluence .
Duodenum by head masses, stomach by body masses and
hilum of spleen by tail masses.
subcentimetric lymphnodes have to mentioned.
Perivascular and perineural tissues are particularly susceptible
to involvement

20. Metastatic dissemination
◦ regional lymph nodes, i.e. coeliac, common hepatic, superior mesenteric and para-aortic.
◦ hepatic via portal venous drainage,
◦ omental and peritoneal via intraperitoneal shedding of tumor cells.

21. Unresectability
Vascular ingrowth
Ingrowth into the celiac axis, hepatic artery or
superior mesenteric artery also preclude resection.

22. Vascular encasement
◦ obliteration of the normal fat between the pancreatic margin and the adjacent vessel
◦ more than 180-degree contact between the tumor and the vessel
◦ morphologic changes in the artery, including narrowing or encasement of the affected artery.
MDCT – more accurate description of local spread
Venous invasion – Criteria - > 180 o

23. Ill defined hypodense lesion in uncinate
process appearing to contact the
superior mesenteric artery over a greater
than 180-degree circumference (arrow).
B. coronal // mass (asterisk) in the body
of the pancreas that contacts but does
not surround the splenic artery. Note the
upstream atrophy and main pancreatic
duct dilation in the body and tail of the
pancreas (arrow). // The hepatic
metastasis is seen on the portal
acquisition; on the pancreatic phase,
there is only a vague region of low
attenuation. This case illustrates the
differing times of peak enhancement of
the pancreas and liver. The presence of
the hepatic metastasis makes this case
unresectable despite the fact that the
tumor is locally resectable.

24. Axial pancreatic-phase contrast-enhanced CT in a 78-yearold man with an adenocarcinoma of the midpancreatic
body (large arrow) with upstream pancreatic duct dilatation (small arrow) and peripancreatic extension of
tumor. The tumor has extended to encase the celiac axis (thin arrows), rendering the patient inoperable.// Axial
pancreatic-phase contrast-enhanced CT in a 73-yearold
woman with soft tissue encasement by pancreatic adenocarcinoma of the superior mesenteric artery (arrows),
but the superior mesenteric vein is unaffected (small arrow). This patient was inoperable.

27. Differential diagnosis
focal pancreatitis
lymphoma
metastasic disease.

28. MRI
Axial and coronal T1 weighted postcontrast images show ll defined hypointense non enhancing mass in uncinate

29. coronal image in a case of carcinoma pancreatic head showing an isointense mass causing obstructive
biliopathy. MRCP image in the case showing dilatation of the common duct proximal to the lesion and the
dilated main pancreatic duct (B)

30. Cystic tumours of pancreas
Most common cystic lesion benign – pseudocyst
Masses
◦ Mucinous cystic neoplasm
◦ Serous adenomas

31. Mucinous Cystic Neoplasms (MCNs)
Collective
◦ mucinous cystadenoma of pancreas
◦ mucinous cystadenocarcinoma of pancreas
◦ intraductal papillary neoplasms (IPMN) of the pancreas
Rare – body and tail
95% females

32. CT- Cystadenoma
Rounded or ovoid
Calcification when present more peripheral
Contents of the lesion may be heterogenous is
attenuation
Internal septations may be present and tend to
be linear or curvilinear

33. CECT - thin walled
multiloculated
hypodense mass arising
from pancreatic body
and tail

34. multilocular
MR image revealing a multilocular cyst in
the pancreatic head. The fluid component shows high signal
and
mural nodules show isointense signal –

35. Differential diagnosis
mucinous cystadenocarcinoma of the pancreas:
at times impossible to differentiate on ultrasound or CT from a mucinous cystadenoma
pancreatic pseudocyst (unilocular)
variant of serous cystadenoma of the pancreas

36. Intraductal papillary mucinous neoplasm (10-
15%)
Older patients
Difficult to differentiate from chronic pancreatitis
main duct branch duct type
chronic pancreatitis head and uncinate process
segmental or diffuse
distribution
more localised and mass-like
Highest malignant potential may be multifocal
indolent

37. CT - main duct IPMN
Segmental or entire duct dilatation >5mm
Thinning of overlying pancreatic parenchyma
solid mural nodules are concerning for malignant
transformation- hyperdense nodules protruding into
the mucin-filled dilated ducts
enhancing nodules

38. branch duct IPMN
single or multiple side branches demonstrating marked dilatation
cystic mass-like appearance which often mimicks cystic tumours of
the pancreas
bunch of grapes appearance
microcystic variety has appearances similar to serous
cystadenomas, but again communication with the main pancreatic
duct is the key to correct diagnosis

39. Axial MR image (A) and coronal TRUFISP MR image (B) showing grossly dilated pancreatic duct with
intraluminal filling defects and a non dilated biliary system

40. Serous cystadenoma
Imaging appearance
Multicystic, lobulated mass in the pancreatic head - 'bunch of grapes’
Individual cysts are typically <20 mm in size and greater than six in number (except for the
oligocystic variety
Characteristic enhancing central scar - which can show associated stellate calcification (~20%)

41. CECT images showing a bulky, multiloculated hypodense predominantly cystic mass of the
pancreatic head with a central calcified stellate scar – serous cystadenoma

42. Corronal t2 fat sat large
multiloculated
hyperitnersne cystic
lesion I tail of [pancreas
with multiple septation

43. Pancreatic cysts
1. Von Hippel Lindau syndrome
2. Autosomal dominant polycystic kidney disease (ADPKD)
3. Cystic fibrosis

44. Pancreatic metastases
Uncommon - patients with widespread metastasis
PRIMARIES
◦ renal cell carcinoma (RCC): one of commonest of tumours that metastatise to the pancreas
◦ melanoma
◦ breast cancer
◦ lung cancer
◦ gastric cancer
Imaging findings are non specific
Well circumscribed mass – iso to hypodense, heterogenous enhancement

46. Lymphoma
Involvement : -Direct extension from
peripancreatic B-cell type lymphadenopathy
due to non-Hodgkin’s lymphoma.
Presentation
◦ Focal mass
Diffuse enlargement
bulky lobulated centrally necrotic hypodense mass replacing
entire pancreas except uncinate process
(A) with extensive liver metastases (B)—Pancreatic lymphoma

47. THANK YOU