Radiological Analysis of Cystic Lesions of the Pancreas
Transcript of Radiological Analysis of Cystic Lesions of the Pancreas
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
Radiological Analysis of Cystic lesions of the Pancreas
Shruthi Mahalingaiah, Harvard Medical SchoolYear III, Gillian Lieberman, MD
September 2002
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
2
Agenda
• Background • Anatomy and histology• Radiological workup of a cyst in the
pancreas• Patient presentations • Summary
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
3
Background
2.2-2.4% of all cancers are pancreatic
4.7-5.5% deaths from pancreatic cancer
5-10% of all pancreatic neoplasms are of the cystic variety
Adapted from Landis, SH, et al: Cancer Studies. CA 48:6, 1998
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
4
The Pancreas: Anatomy
“Here lies the fickle romance of the
abdomen; the pancreas lies with her head in the
arms of the duodenum while her feet tickle the
spleen.”
–NJ Mizeres
Plate255 Netter’s Atlas of Human Anatomy
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
5
The Pancreas: Anatomy
•Retroperitoneal
• “Hidden”
•Virtually impossible to palpate
•Radiographic studies allow greater visualization and understanding of disease of the pancreas
Plate279 Netter’s Atlas of Human Anatomy
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
6
The Pancreas: Ductal Anatomy
• Pancreatic ductal system forms from dorsal and ventral buds
•Wirsung and Santorini named after fusion
•Failure of fusion results in Pancreas divisum, which increases susceptibility to pancreatitis
Plate279 Netter’s Atlas of Human Anatomy
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
7
The Pancreas: Ductal Anatomy
Plate279 Netter’s Atlas of Human Anatomy
•2.5- 3L of alkaline fluid daily
•Ave 15 cm in length
•Apposed to duodenum, stomach, spleen, great vessels
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
8
The Pancreas: Histology
Large reservoir of both endocrine and exocrine function.
Disease becomes symptomatic only when severe impairment occurs
85% exocrine
Gartner, LP, Hiat, JL, Color Atlas of Histology
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
9
Cystic lesions of the Pancreas
• Retention Cysts
• Pseudocysts• Cystic
Neoplasms
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
10
Cystic lesions of the Pancreas
• Retention Cysts: No clinical significanceSmall, developmental,
fluid filled, lined by normal duct or acinar cells.
• Pseudocysts• Cystic Neoplasms
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
11
Cystic lesions of the Pancreas
This fifteen minute presentation focuses on cystic pancreatic neoplasms with a brief discussion of pancreatic pseudocysts. For further discussion
of general cystic lesions and a more encompassing differential, please refer to the
reference section.
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
12
Pseudocysts• secondary to
inflammation and necrosis
• located within or outside the pancreas
• Lining contains fibrous and granulation tissue
• Lack of epithelial lining• Present >6wks
Cystic lesions of the Pancreas: Pseudocyst
from ACR teaching files
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
13
Pseudocysts• Pyloric Antrum• Remarkably
distended C-loop of duodenum
• Large Mass CT for further evaluation
Cystic lesions of the Pancreas: Pseudocyst
from ACR teaching files
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
14
Pseudocysts• Secondary to
pancreatitis • Variable size• located within or
outside the pancreas
• Present >6 wks
Cystic lesions of the Pancreas: Pseudocyst
John Kruskal, M.D, Ph.D, uptodate.com
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
15
• Serous: Microcystic• Cystadenoma/ cystadenocarcinoma
• Mucinous: Macrocystic• Cystadenoma/ cystadenocarcinoma• Intraductal papillary mucinous tumor (IPMT)
• Zebras
Cystic Neoplasms of the Pancreas
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
16
Survey of 9 Patients with Cystic Disease
• 7/9 cystic lesions were incidental findings
•4/9 MRI
•2/9 US
•1/9 CT
•
2/9 lesions in pancreas were suspected from patients’
history
CT is often initial modality in which neoplastic
cyst is found.
Silas, AM, Morrin, MM, Ratatopoulos, V, Keogan, MT, Intraductal
Papillary Mucinous Tumor, AJR. 176(1):179-85, 2001, Jan
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
17
Work-up of an incidental cyst
Cyst found incidentally• CT
• US
• ERCP
• MRI
Focused Radiological Study
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
18
Work-up of an incidental cystCyst found incidentally
• CT provides density of differentiation of intraductal and cystic spaces
•Septa may be appreciated with contrast enhancement
•Sensitive to Ca+ can detect pathognomonic stellate calcific lesion of serous cystadenoma
•Allows for non-invasive CT follow up
Focused Radiological Studies
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
19
Work-up of an incidental cystCyst found incidentally Ultra Sound
•Non-invasive
•More sensitive for finding septa than CT
•Often used for follow up of pseudocyst
•US guided biopsy
•Fast, cheap
•Operator dependent
Focused Radiological Study
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
20
Work-up of an incidental cystCyst found incidentally ERCP
•clarifies non-specific findings
•Visualize filling defects
•Observe mucinous extrusions from ampulla of Vater in cases of IPMT
•Allows sampling of ductal lining cells
•Risk of pancreatitis
Focused Radiological Study
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
21
Work-up of an incidental cystCyst found incidentally •MRI
•Non-invasive
•Better display of subtle abnormalities- of complex cystic masses, cavities, septae, and nodules
•MRCP may be able to replace ERCP in the future
Focused Radiological Study
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
22
Work-up of an incidental cyst
Enzyme richHx-recent pancreatits
fluid thin and wateryMultiple small or microcysts
•Mucinous aspirate
•One or macrocystic spaces
Cyst found incidentally
Focused Radiological Study
Fluid Aspiration/Tissue Biopsy
DDX
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
23
Serous Cystadenoma/ Cystadenocarcinoma
• Second most common cystic tumor of the pancreas•Middle aged women•Equal distribution throughout the pancreas•Mass may be quite large and produce symptoms from organ displacement.•Microcystic: Many small cysts lined by glycogen-rich cells •Lining is often denuded•Low malignant potential
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
24
Patient KS
65 y/o female with epigastric pain, nausea, and vomiting.
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
25
Abdominal Plain Film Patient KS
Courtesy: Dr. H. Gramm
• Stellate
calcification• Possibly renal• Possibly pancreatic• CT for further eval.
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
26
Computational Tomography (CT) of the Abdomen Patient KS
Courtesy: Dr. H. Gramm
•
Stellate
calcification in pancreas
• tiny cysts in a large
multilobulated
mass lesion
•Some cysts are confluent
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
27
Reconstruction CT of the Abdomen Patient KS
Courtesy: Dr. H. Gramm
• Symptoms from mass effect
impingement on stomach and
duodenum
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
28
Correlation of KUB to CT Patient KS
Courtesy: Dr. H. Gramm
Serous CystadenomaMicrocystic
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
29
Radiological Parameters of Serous Cystadenoma
Courtesy: Dr. H. Gramm
Serous CystadenomaMicrocystic
At least 4-6 cm
If multiloculated contains no more than 6 loculations each less than 2cm
Highly vascular on angio
Lined with evenly spaced, flat, cuboidal to polygonal cells
Cyst contains abundant glycogen
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
30
Correlation of KUB to CT Patient KS
Courtesy: Dr. H. Gramm
Serous CystadenomaMicrocystic
www.uptodate.com
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
31
Mucinous
Cystadenoma/ Cystadenocarcinoma
•Most common cystic neoplasm of the pancreas•Typically affects middle aged women•Occurs in in body or tail of pancreas•Presents with a mass lesion composed of one or more macrocytic
spaces
•Lined by mucous secreting cells•Lining is often denuded (hence difficult to make diagnosis even with pathology)•High malignant potential•Most are malignant at time of diagnosis
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
32
Patient MG
45 y/o woman with abdominal pain
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
33
Single Contrast Barium Study Patient MG
Courtesy: Dr. H. Gramm
•Impressive displacement of Small Bowel to RLQ
*
*
* Body of Stomach
* Antrum of stomach
CT for follow up Eval.
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
34
Abdominal CT Patient MG
Courtesy: Dr. H. Gramm
* unilocular
cystNo septa!
•Thin rim
•No fat strandingin surroundings
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
35
Correlation of Single-contrast Ba and CT Patient MG
Courtesy: Dr. H. Gramm
*
Mucinous
cystadenomaMacrocystic
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
36
Gross Pathology Patient MG
Courtesy: Dr. H. Gramm
*
Mucinous
cystadenomaMacrocysticFrom: www.uptodate.com
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
37
Intraductal
Papillary Mucinous
Tumor (IPMT)
• “mucinous duct ectasia”•Dilated ductal segments usually within the head of the pancreas•Hyperplasia and dysplasia of mucin producing columnar epithelium. •Formation of papillary projections may either protrude into pancreatic duct or remain in branch ducts•Duct obstruction from mucin plug or compression from cystic mass•High malignant potential•More common in elderly men •Can have thick mucous extruding from ampulla of Vater•Patients can present with repeat episodes of pancreatitis
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
38
Patient JT
45 y/o male with abdominal pain
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
39
Computational Tomography (CT) of the Abdomen Patient JT
Pancreas
Cyst
Courtesy: Dr. H. Gramm
Dilated ductof Wirsung
communicates with cystLumen of duodenum
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
40
Endoscopic Retrograde Cholangiopancreatography Patient JT
Reveals Cyst
Filling defects
Courtesy: Dr. H. Gramm
Typically can obs.Mucin extruding fromPapilla of Vater
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
41
Correlation of (ERCP) with CT Patient JT
Pancreas
Cyst
Courtesy: Dr. H. Gramm
IPMT-Main Type
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
42
Radiological Parameters for IPMT
Pancreas
Cyst
Courtesy: Dr. H. Gramm
IPMT-Main Type
Malignancy Highly Suspected:
Filling defects Diffuse main duct dil > 15mm
Side branch > 3 cm
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
43
IPMT Variants
Main Type
Main pancreatic duct +/- side branch involvement consider resection
Side Brianch Type
Side branch involvement onlyif lesion is less than 2.5 cm follow up with MRI
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
44
T1 W MRI Side Branch Variant
Courtesy: Dr. M. Morrin
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
45
T1 W MRI Side Branch Variant
* Liver
*IVC
*Aorta
*SMAPancreas
Courtesy: Dr. M. Morrin
*
* **
(fat bright; fluid dark)
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
46
Ultrasound Side Branch Variant
Cysts on side branches
Not communicating with main pancreatic duct
Courtesy: Dr. M. Morrin
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
47
Mucin
Producing Zebras of the Pancreas
Rare cystic neoplasms
also included in differential:• Papillary Cystic Tumor of the pancreas• Cystic Islet Cell tumor• Pancreatic Sarcoma• Pancreatic Cysts associated with
•Von Hippel-LindauVery Rare•Cystic teratoma (very rare)• Enteric cyst of the pancreas (very rare)•Lymphoepithelial cysts•Cystic lymphangioma
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
48
Pseudocysts
Cystic Neoplasms: • Serous cystadenoma• Mucinous Cystadenoma/ cystadenocarcinoma• Intraductal papillary mucinous tumor
Imaging Modalities
Cystic lesions of the Pancreas: Summary
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
49
References
•Feldman: Sleisenger & Fordtran’s Gastrointestinal and Liver Disease, 6th
ed., 1998: WB. Saunders, p.896-899.•Grogan JR, Saeian K, Taylor AJ, Quiroz F, Demeure MJ, Komorowski R. Making Sense of Mucin Producing Pancreatic Tumors. AJR 2001; 174(4): 921-9.•Gartner JP, Hiatt JL. Color Atlas of Histology, 2nd ed., 1994: Williams and Wilkins, p.280.•Silas AM, Morrin MM, Raptopoulos V, Keogan MT. Intraductal Papillary Mucinous Tumors of the Pancreas. AJR 2000; 176: 179-185.•Netter, FH. Atlas of Human Anatomy, 2nd ed., 1997:Novartis, plates: 255, 279.•Steer, MJ. Cystic Lesions of the Pancreas, June 11,2002 (last updated)•www.uptodate.com•Van Houten T, et al. Anatomy Dissector, 2002: Unpublished. Chapter 12: Biliary System, Pancreas, and Spleen.
Shruthi Mahalingaiah, HMS IIIGillian Lieberman, MD
50
Acknowledgements
Dr. Herbert Gramm, MD
Dr. Robert Ronan, MD
Dr. Martina Morrin, MD
Dr. Chad Brecher, MD
Dr. Gillian Lieberman, MD
Early morning gang-James, Eduardo, Jon
Pamela Lepkowski
Michael Larson
Larry Barbaras and Cara Lyn D’amour