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Imaging Spectrum of Cystic Pancreatic Lesions: Learn from Atypical Cases  Hiroyuki Irie, MD, Kengo Yoshimitsu, MD, Tsuyoshi Tajima, MD, Yoshiki Asayama,

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Presentation on theme: "Imaging Spectrum of Cystic Pancreatic Lesions: Learn from Atypical Cases  Hiroyuki Irie, MD, Kengo Yoshimitsu, MD, Tsuyoshi Tajima, MD, Yoshiki Asayama,"— Presentation transcript:

1 Imaging Spectrum of Cystic Pancreatic Lesions: Learn from Atypical Cases 
Hiroyuki Irie, MD, Kengo Yoshimitsu, MD, Tsuyoshi Tajima, MD, Yoshiki Asayama, MD, Masakazu Hirakawa, MD, Kousei Ishigami, MD, Yasuhiro Ushijima, MD, Hiroshi Honda, MD  Current Problems in Diagnostic Radiology  Volume 36, Issue 5, Pages (September 2007) DOI: /j.cpradiol Copyright © 2007 Mosby, Inc. Terms and Conditions

2 FIG 1 38-year-old female. Classic appearance of pseudocyst. Diminished signal intensity of pancreatic parenchyma on T1-weighted MRI (A) and slightly dilated main pancreatic duct (MPD) (arrow) on T2-weighted MRI (B) suggest chronic pancreatitis and may lead to diagnosis of pseudocyst. However, in female patients, MCT should also be considered. Current Problems in Diagnostic Radiology  , DOI: ( /j.cpradiol ) Copyright © 2007 Mosby, Inc. Terms and Conditions

3 FIG 2 33-year-old male. Lobulated multilocular retention cyst. The MR cholangiopancreatography (MRCP) (A) demonstrates a lobulated multilocular cyst, and contrast-enhanced MRI (B) shows the irregular thick wall of the cyst. Preoperative diagnosis included a pseudocyst, retention cyst, and MCT. Current Problems in Diagnostic Radiology  , DOI: ( /j.cpradiol ) Copyright © 2007 Mosby, Inc. Terms and Conditions

4 FIG 3 37-year-old male. Suspected mural nodule. The MRCP (A) shows an oval-shaped large cyst with a defect (arrow) in it. The defect (arrow) was considered to have contrast enhancement on CT (B), and MCT was therefore suspected, although the patient was male. The surgical specimen revealed the defect to be sludge aggregates within the pseudocyst. Current Problems in Diagnostic Radiology  , DOI: ( /j.cpradiol ) Copyright © 2007 Mosby, Inc. Terms and Conditions

5 FIG 4 70-year-old male. Suspected mural nodule. A unilocular thick-walled cyst was found in the pancreatic tail on T2-weighted MRI (A). A small nodule (arrow) was demonstrated in the ventral portion of the cyst wall, which the MRI showed as an apparent contrast enhancement (B). The surgical specimen revealed that the nodule was fibrous granulation tissue. Current Problems in Diagnostic Radiology  , DOI: ( /j.cpradiol ) Copyright © 2007 Mosby, Inc. Terms and Conditions

6 FIG 5 47-year-old male. Irregularly shaped retention cyst communicating with MPD. The MRCP (A) showed an irregularly shaped cystic mass with a filling defect (arrow) in the pancreatic head, and ERCP (B) reveals communication between the cyst and MPD. The preoperative diagnosis was IPMT, but the pathologic diagnosis was a retention cyst with sludge aggregates. Current Problems in Diagnostic Radiology  , DOI: ( /j.cpradiol ) Copyright © 2007 Mosby, Inc. Terms and Conditions

7 FIG 6 78-year-old female. Pseudocyst with calcification and communication with MPD. A thin-walled cyst with small calcification (arrow) is seen in the body of the pancreas on CT (A). ERCP (B) shows communication between the cyst and MPD. The preoperative diagnosis was MCT. Current Problems in Diagnostic Radiology  , DOI: ( /j.cpradiol ) Copyright © 2007 Mosby, Inc. Terms and Conditions

8 FIG 7 9-year-old female. Multilocular congenital cyst. The MRCP (A) shows a lobulated multilocular cyst in the pancreatic head. Contrast-enhanced MRI (B) shows that the cyst has a thin wall. The preoperative diagnosis was MCT. Current Problems in Diagnostic Radiology  , DOI: ( /j.cpradiol ) Copyright © 2007 Mosby, Inc. Terms and Conditions

9 FIG 8 66-year-old female. Unilocular congenital cyst in adult patient. Unilocular cyst with small calcification (arrow) is seen in the pancreatic body on plain CT (A). Delayed phase dynamic CT (B) shows the thick wall of the cyst and upstream MPD dilation. Differentiation from MCT is considered impossible in this female patient. Current Problems in Diagnostic Radiology  , DOI: ( /j.cpradiol ) Copyright © 2007 Mosby, Inc. Terms and Conditions

10 FIG 9 58-year-old male. Classic lymphoepithelial cyst. Unilocular lobulated cyst in the pancreatic neck shows exophytic growth on CT. This finding is reported to be relatively characteristic for a lymphoepithelial cyst, but not specific. Current Problems in Diagnostic Radiology  , DOI: ( /j.cpradiol ) Copyright © 2007 Mosby, Inc. Terms and Conditions

11 FIG 10 66-year-old male. Bilocular lymphoepithelial cyst containing lipid fluids. The MRCP (A) shows a bilocular cyst with different signal intensity in the pancreatic tail. CT (B) shows fatty attenuation of the ventral cyst (arrow). Current Problems in Diagnostic Radiology  , DOI: ( /j.cpradiol ) Copyright © 2007 Mosby, Inc. Terms and Conditions

12 FIG 11 26-year-old female. Pseudocyst-like epidermoid cyst. CT shows thin-walled unilocular cyst in the pancreatic tail. The finding is nonspecific, but an epidermoid cyst should be included in the differential diagnosis when it is located in the pancreatic tail. Current Problems in Diagnostic Radiology  , DOI: ( /j.cpradiol ) Copyright © 2007 Mosby, Inc. Terms and Conditions

13 FIG 12 49-year-old female. Epidermoid cyst showing high signal on high b-value diffusion-weighted MRI. Small unilocular cyst (arrow) is identified in the pancreatic tail on MRI. The signal intensity is nonspecific on T1-weighted image (A) and T2-weighted image (B). However, the high signal intensity of the cyst (arrow) on high b-value diffusion-weighted image (C), almost the same as the spleen, may indicate an epidermoid cyst. Current Problems in Diagnostic Radiology  , DOI: ( /j.cpradiol ) Copyright © 2007 Mosby, Inc. Terms and Conditions

14 FIG 13 74-year-old female. Microcystic SCT. CT (A) shows solid-like tumor with central small calcification surrounded by relatively larger cysts. The cystic nature of the mass is apparent on T2-weighted MRI (B). This type of SCT should be diagnosed correctly. Current Problems in Diagnostic Radiology  , DOI: ( /j.cpradiol ) Copyright © 2007 Mosby, Inc. Terms and Conditions

15 FIG 14 61-year-old female. Macrocystic SCT. The MRCP (A) reveals a multilocular cyst in the pancreatic head. The shape of the cyst is lobulated and called a “cyst-on-cyst appearance” (see Fig 18: “cyst-in-cyst appearance” on MCT). CT (B) shows the cyst wall is very thin, which may indicate macrocystic SCT, although MCT cannot be excluded. Current Problems in Diagnostic Radiology  , DOI: ( /j.cpradiol ) Copyright © 2007 Mosby, Inc. Terms and Conditions

16 FIG 15 44-year-old female. Solid variant SCT. T2-weighted MRI (A) shows a high signal intensity, but not cystic mass (arrow) in the pancreatic head. Early phase dynamic MRI (B) reveals hypervascularity of the tumor (arrow). Preoperative diagnosis was nonfunctioning endocrine tumor. The pathologic specimen showed that the tumor is solid and composed of numerous small tubules. Current Problems in Diagnostic Radiology  , DOI: ( /j.cpradiol ) Copyright © 2007 Mosby, Inc. Terms and Conditions

17 FIG 16 48-year-old male. Chronic pancreatitis mimicking SCT. The CT (A) and MRCP (B) showed that the tumor was composed of numerous tiny cysts, and the diagnosis was microcystic SCT. On ERCP (C), contrast medium flowed in the cysts, indicating the tumor could not be SCT. The surgical specimen clarified tiny cysts to be minimally dilated, many branch ducts, and a diagnosis of chronic pancreatitis was obtained. Current Problems in Diagnostic Radiology  , DOI: ( /j.cpradiol ) Copyright © 2007 Mosby, Inc. Terms and Conditions

18 FIG 17 63-year-old female. Mucinous noncystic carcinoma. CT (A) and T2-weighted MRI (B) show an irregularly shaped cystic mass with a central scar-like (arrow) appearance, mimicking SCT. Irregular shape of the mass may be unusual for SCT. The pathologic specimen shows that the tumor is not cystic but solid and has abundant extracellular mucin production, compatible with mucinous noncystic carcinoma. Current Problems in Diagnostic Radiology  , DOI: ( /j.cpradiol ) Copyright © 2007 Mosby, Inc. Terms and Conditions

19 FIG 18 47-year-old female. MCT communicating with MPD. Delayed phase CT (A) demonstrates round, thick-walled multilocular cystic mass (“cyst-in-cyst” appearance), characteristic to MCT, in the pancreatic body. ERCP (B), however, shows communication between the cyst and MPD, a rare finding of MCT. The filling defect within the cyst (arrow) is a loculus without communication with the main large loculus. Current Problems in Diagnostic Radiology  , DOI: ( /j.cpradiol ) Copyright © 2007 Mosby, Inc. Terms and Conditions

20 FIG 19 60-year-old female. MCT communicating with MPD. The MRCP (A) shows a lobulated multilocular cystic mass, which may be interpreted as a “cyst-on-cyst appearance” and resembles macrocystic SCT (see Fig 14). ERCP (B) demonstrates communication between the cyst and MPD, mimicking IPMT. Current Problems in Diagnostic Radiology  , DOI: ( /j.cpradiol ) Copyright © 2007 Mosby, Inc. Terms and Conditions

21 FIG 20 60-year-old female. IPMT mimicking malignant MCT. Round, thin-walled unilocular cystic mass with calcification (arrow) was found in the pancreatic tail on CT (A) and T2-weighted MRI (B). A large solid component filled the cystic cavity. Communication between the MPD and cyst (*) and calcification (arrow) were demonstrated on ERCP (C). Malignant MCT was suspected. A detailed pathologic analysis revealed a diagnosis of IPMT. Current Problems in Diagnostic Radiology  , DOI: ( /j.cpradiol ) Copyright © 2007 Mosby, Inc. Terms and Conditions

22 FIG 21 70-year-old male. IPMT mimicking MCT or macrocystic SCT. The CT (A) and MRCP (B) reveal a multilocular cystic mass in the pancreatic head composed of a large loculus (*) in the cranial aspect of the mass and multiple small loculi in the caudal portion (arrow). ERCP (C) reveals small loculi (arrow) communicating with MPD, but the large loculus (*) has no communication with MPD. Current Problems in Diagnostic Radiology  , DOI: ( /j.cpradiol ) Copyright © 2007 Mosby, Inc. Terms and Conditions

23 FIG 22 30-year-old male. Multilocular SPT. CT (A) and T2-weighted MRI (B) show large cyst with multiple small cysts (arrows) and thick solid component (*) in the pancreatic tail. Cyst fluid shows high signal intensity on T1-weighted image with fat-suppression (C), suggesting hemorrhagic fluid. Current Problems in Diagnostic Radiology  , DOI: ( /j.cpradiol ) Copyright © 2007 Mosby, Inc. Terms and Conditions

24 FIG 23 12-year-old female. MCT-like SPT. Thick-walled unilocular cystic mass with solid mural nodule (arrow) is demonstrated in the pancreatic tail on T2-weighted (A) and contrast-enhanced T1-weighted MRI (B). Cyst fluid is considered to be hemorrhagic since it shows high signal intensity onT1-weighted image with fat suppression (C). Current Problems in Diagnostic Radiology  , DOI: ( /j.cpradiol ) Copyright © 2007 Mosby, Inc. Terms and Conditions

25 FIG 24 75-year-old male. Multilocular cystic insulinoma. T2-weighted MRI (A) demonstrates lobulated multilocular cystic mass (arrow) in the pancreatic tail. The thick wall and thin septum show early enhancement (arrow) on dynamic CT (B). Current Problems in Diagnostic Radiology  , DOI: ( /j.cpradiol ) Copyright © 2007 Mosby, Inc. Terms and Conditions

26 FIG 25 57-year-old male. Small cystic nonfunctioning endocrine tumor. Small unilocular cyst (arrow) is depicted on T2-weighted MRI (A). The mass (arrow) is somewhat unclear on early phase dynamic MRI (B), suggesting weak enhancement of the mass, but no rim enhancement is identified. Current Problems in Diagnostic Radiology  , DOI: ( /j.cpradiol ) Copyright © 2007 Mosby, Inc. Terms and Conditions

27 FIG 26 57-year-old male. Adenosquamous carcinoma. Large cyst surrounded by thick solid mass is demonstrated in the pancreatic body. Peripheral rim shows early enhancement on dynamic CT. Current Problems in Diagnostic Radiology  , DOI: ( /j.cpradiol ) Copyright © 2007 Mosby, Inc. Terms and Conditions

28 FIG 27 73-year-old male. Adenosquamous carcinoma. T2-weighted MRI (A) shows irregularly shaped cystic pancreatic head mass with irregular thick solid wall, which shows enhancement on contrast-enhanced T1-weighted image (B). Current Problems in Diagnostic Radiology  , DOI: ( /j.cpradiol ) Copyright © 2007 Mosby, Inc. Terms and Conditions

29 FIG 28 70-year-old male. Anaplastic carcinoma. T1-weighted (A) and T2-weighted (B) MRI show large cystic mass partially surrounded by a thick solid tumor (*). Current Problems in Diagnostic Radiology  , DOI: ( /j.cpradiol ) Copyright © 2007 Mosby, Inc. Terms and Conditions

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