Download Cystic lesions of the pancreato-duodenal confluence. Who is who?

Cystic lesions of the pancreato-duodenal confluence. Who is
who?
Poster No.:
C-0183
Congress:
ECR 2014
Type:
Educational Exhibit
Authors:
L. Goiburu Gonzalez , M. Paraira Beser , A. Pedrerol Perez ,
1
3 1
2
2
2
J. A. de Marcos ; Terrassa, Barcelona/ES, Barcelona/ES,
3
TERRASSA/ES
Keywords:
Neoplasia, Inflammation, Cysts, Diagnostic procedure, Ultrasound,
MR, CT, Pancreas, Gastrointestinal tract, Abdomen
DOI:
10.1594/ecr2014/C-0183
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Page 1 of 22
Learning objectives
Our purposes are to illustrate the anatomy of the pancreato-duodenal region, and to
describe the key radiological features of the different entities with a true cystic or a cysticlike component that can be found in this area.
Background
A wide spectrum of anomalies can be encountered at radiologic evaluation of the
pancreato-duodenal junction. The hystology of the anatomic structures and pathology of
different anomalies favor a true cystic or a cystic-like component at radiologic evaluation.
From January 2009 through May 2012 we have retrospectively reviewed the radiological
files of patients with cystic pancreatic lesions focusing on those located in the pancreatoduodenal confluence.
We have revised the radiological signs on contrast enhanced-CT (CECT) and magnetic
resonance imaging (MRI) with MR-cholangiopancreatography (MRCP) of each entity
to characterize the lesions, to address the differential diagnosis and make a definite
diagnosis whenever it has been possible.
Normal anatomy Fig. 1 on page 3 Fig. 2 on page 3
- The pancreato-duodenal confluence is the region in which the duodenum, pancreatic
head and distal common bile duct converge. It is located in the anterior pararenal space
of the retroperitoneum.
- In the pancreatic head we find the distal end of the common bile duct, the main
pancreatic duct and accessory pancreatic ducts.
- The major and minor papilla are located in the medial wall of the 2nd portion of the
duodenum.
- In the pancreaticoduodenal groove, we find the superior duodenopancreatic
artery (gastroduodenal artery branch), which anastomoses with the inferior
pancreaticoduodenal artery (branch of the superior mesenteric artery). The
pancreaticoduodenal arteries establish the anatomical boundary between the head of the
pancreas and duodenum.
Page 2 of 22
We classified the findings as:
1.-Congenital and other entities: Duodenal diverticulum, choledochocele, santorinocele
and duodenal duplication cyst.
2.-Inflammatory conditions: groove pancreatitis, focal pancreatitis and pancreatic
pseudocyst.
3.-Tumoral pathology: Simple cyst, Cystoadenocarcinoma, Intraductal papillary
mucinous neoplasm (IPMN), serous cystadenoma and mucinous cystic neoplasm.
In all cases the final diagnosis was confirmed either pathologically or by stabilization of
radiological findings for more than five years.
Images for this section:
Fig. 1: Axial CECT slices which show the superior mesenteric artery (red arrow) the
gastroduodenal artery (yellow arrow) and the superior pancreatic duodenal artery (black
arrow).
Page 3 of 22
Fig. 2: Coronal CECT scans of the previous patient where we can observe the superior
mesenteric artery (red arrow) the gastroduodenal artery (yellow arrow) and the superior
pancreatic duodenal artery (black arrow).
Page 4 of 22
Findings and procedure details
Congenital and other entities:
- Duodenal diverticulum Fig. 3 on page 11
• Most frequent location: periampullary region within a radius of 2 cm.
• In 3% the major papilla is located inside
• Communicates with the duodenal lumen
• Radiological image: sacculation of the duodenal wall containing fluid and/or air.
- Duodenal duplication cyst Fig. 4 on page 11
• It can be localized in any part of gastrointestinal tract. The medial wall of the second
portion of the duodenum is a frequent site.
• Generally it does not communicate with the duodenal lumen
• Radiologic appearance: as a cystic lesion on ultrasound, CT and MRI.
- Choledochocele
• Type III biliary cyst Todani's classification.
• Focal dilation of distal common bile duct.
- Santorinocele
• Cystic dilation of the distal dorsal pancreatic duct, proximal to the minor papilla.
Inflammatory conditions:
- Groove pancreatitis
Page 5 of 22
• It is an uncommon form of focal chronic pancreatitis
• Young males, alcohol abuse
• Controversial pathogenesis: biliary disease, peptic ulcer, pancreatic heterotopia in the
duodenal wall, anatomical or functional alteration in the minor papilla.
• Two presentations:
- Pure: affects only the groove
- Segmental: affects also the pancreatic head
PURE FORM image appearance Fig. 5 on page 11
CT
MRI
Flattened, hypodense lesion
T1-WI hypointense lesion
Generally does not produce dilation of the T2-WI varies depending on the evolution
pancreatic duct
Duodenal wall thickening with cystic
lesions that are intramural or in the
groove
T2-WI hyperintense nodules in the
duodenal wall
Enhanced in delayed phases with iv
contrast
Enhanced in delayed phases with iv
contrast
SEGMENTAL FORM: Image appearance Fig. 6 on page 12 Fig. 7 on page 12 Fig.
8 on page 13 Fig. 9 on page 13
CT
MRI/CPMRI
Hypodense lesion in the pancreatic head
Hypodense lesion in the pancreatic head
on T1-WI
Discrete dilated pancreatic and bile ducts
Smooth and long segmental stenosis of
the distal pancreatic duct and common bile
duct
Preservation of vascular structures
Widening of the space between the distal
pancreatic duct, common bile duct and
duodenum lumen
- Pseudocyst Fig. 10 on page 14 Fig. 11 on page 15
Page 6 of 22
• Most common pancreatic cystic lesion.
• 4-6 weeks after onset of acute pancreatitis
• Rounded, well-defined, hypodense lesion on CT.
• The wall enhances after iv contrast administration WITHOUT intralesional
enhancement.
• MR imaging: hypointense on T1-WI, hyperintense on T2-WI, with areas of intermediate
signal if it contains debris.
• Look for pancreatic gland calcification.
Tumoral pathology:
- Ductal adenocarcinoma with cystic features Fig. 12 on page 15 Fig. 13 on page
16 Fig. 14 on page 17
• The cystic component has been described in 8% of ductal adenocarcinomas.
• They can be associated with pseudocysts, dilated side branches or tumoral necrosis.
-Intraductal papillary mucinous neoplasm (IPMN) Fig. 15 on page 18 Fig. 16 on
page 18 Fig. 17 on page 19
• No sex predilection. 60-70 years old
• Overproduction of mucin with progressive dilation of the ducts
• Types:
- Involving the main duct:
• Diffuse or segmental dilation
• 70% of malignancy
- Involving secondary branches:
• uni-or multifocal
Page 7 of 22
• It can communicate with main pancreatic duct
• Frequently in head / uncinate process
• 20% of malignancy
• NO calcified scar
- Combined Form:
• Dilation of the main duct and its branches.
• Signs that suggest malignancy:
- Involvement of the main duct
- Diffuse (> 50%) or multifocal involvement of the main duct
- Main duct dilation (> 6mm)
- Solid component that enhances with iv contrast
- Cyst size> 3.5cm
- Intraluminal calcium
- Serous cystic neoplasm
• Benign neoplasm
• 75% in women aged 60-70 years.
• Formed by multiple microcysts (<1 cm), separated by thin septa forming a central scar
that may be calcified.
• Association with von Hippel-Lindau (multifocal)
• It may displace / compress adjacent organs
• It does not communicate with the main pancreatic duct
• Variants:
-Hypervascular or solid: (very rare)
Page 8 of 22
• Very small cysts that can be demonstrated with MRI
• Differential diagnosis: Neuroendocrine tumor
-Macrocystic or oligocystic: (10%)
• Differential Diagnosis: mucinous cystic neoplasm
Radiologic image
CT: hypodense lesion with thin septa, well-defined, multi-lobulated Fig. 18 on page 19
- Multiple small cysts (1-5mm of diameter)
- Larger cysts (10-20 mm) in the periphery
- 30% Calcified central scar
- Central scar enhances in delayed post-contrast phase.
- Highly vascularized septa with honeycomb appearance (20%)
- No vascular involvement
MRI: polilobulated nodule, formed by multiple microcysts, with high signal intensity on
T2-WI Fig. 19 on page 19
- thin septa with low signal intensity
- Hypointense central scar
- Calcification produces a signal void in every sequence.
- Post-Gd: Septa enhancement.
- Delayed enhancement of the scar
- Mucinous cystic neoplasm Fig. 20 on page 19
• Uncommon (2.5 %) among exocrine tumors
• It has a high potential for malignancy (mucinous cystadenocarcinoma)
• >95% females; 40-50 years of age.
Page 9 of 22
• Mucin-producing cystic lesion immersed in ovarian-type stroma
• Typically found in pancreatic body and tail
• No communication with pancreatic duct.
Radiologic image
MRI: mutilocular(more frequently) or unilocular cystic lesion
- Simple fluid signal: low signal on T1-WI and hyperintense on T2-WI
- Cysts > 2cm separated by septa
- Cyst walls and thick septa with delayed enhancement
CT: well circumscribed hypodense lesion.
- Multilocular (more frequently) or unilocular cystic lesion
- Cysts > 2cm separated by septa
- Walls and thick septa that enhances in with intravenous contrast.
- Chronic pancreatitis changes distal to the tumor
- 25% calcifications, typically peripheral
•Signs that suggest malignancy
- Enhancing mural nodules or papillary projections.
- Calcifications
- Cystic neuroendocrine tumor
• Uncommon manifestation of a rare tumor.
• Gastrinoma is the most common neuroendocrine tumor in this area, called the
"gastrinoma triangle"
• Caused by cystic degeneration.
• Adults, 50 years, with no sex predilection
Page 10 of 22
• Most frequently associated with MEN syndrome
• Radiological image: well-defined nodule with a rim of highly vascularized tissue that
shows avid enhancement in the early arterial phase.
Images for this section:
Fig. 3: Coronal and axial MRI T2 WI and CPMRI shows a structure with a fluid air level that
appears to originate from the second portion of the duodenum consistent with duodenal
diverticulum.
Fig. 4: Axial and coronal MRI T2 WI. Cystic lesion in the medial wall of the descending
duodenum.
Page 11 of 22
Fig. 5: Groove pancreatitis pure form. Axial and coronal MRI T2-WI. Multiple cystic
lesions in the duodenal wall with discrete duodenal narrowing. Pancreas is unaffected.
The common bile duct and pancreatic duct are of normal caliber.
Fig. 6: Acute segmental groove pancreatitis. Axial CECT images (A, B), coronal (D,
E) and with oral contrast (C, F): There is a multilocular cystic lesion that affects the
duodenum and pancreatic head. Note the adjacent fat stranding, without deforming or
encompassing vascular structures. There is no biliary duct dilation. Minimal pancreatic
duct dilation.
Page 12 of 22
Fig. 7: Chronic phase of segmental groove pancreatitis. Axial CECT images in arterial
phase: Thickening and hypodensity of the medial wall of the second portion of the
duodenum is noted. Calcifications in the uncinate process of the pancreas. Intrahepatic
biliary tract dilation. Vascular structures are unaffected. Retroaortic left renal vein.
Fig. 8: Coronal CECT venous phase of the previous patient. Note the dilation of the
common bile duct. The black arrow indicates the dilation of the Wirsung duct. The red
arrow indicates a pseudocyst. Calcifications in the distal portion of the pancreatic duct.
Hypodense nodules can be perceived in the thickened duodenal wall (yellow arrow).
Page 13 of 22
Fig. 9: MR images in T2 WI (A, C, D and E) and T1 WI (B) of the previous patient,
confirming cystic lesions in the duodenal wall.
Page 14 of 22
Fig. 10: Pseudocyst. CECT images in axial and coronal sections. Rounded, hypodense,
homogeneous, well-defined lesion in the pancreatic head with wall enhancement but
without intralesional enhancement. It displaces vascular structures and compresses the
duodenum and the bile duct. Multiple calcifications in the uncinate process indicating
chronic pancreatitis
Fig. 11: Coronal CECT image that shows another pseudocyst case with more severe
chronic pancreatitis changes. Calcification in a dilated main pancreatic duct and marked
pancreatic atrophy.
Page 15 of 22
Fig. 12: 45 year old male A)Doppler ultrasound reveals an anechogenic lesion with
internal echoes and focal thickening of the wall, located in the pancreatic head. B),C)
and D)Ultrasound with intravenous contrast, clearly identifying a polypoid mass with early
enhancement and early wash out of the contrast, consistent with a malignant process.
Page 16 of 22
Fig. 13: MRI axial T2 WI (A, B) and coronal (C, D) of the same patient. We can observe a
hyperintense mass (*) in the pancreato-duodenal junction region with focal wall thickening
that causes dilation of the pancreatic and biliary ducts (double duct sign). Note in C the
regular contour of the dilated pancreatic duct (black arrow).
Page 17 of 22
Fig. 14: Axial CECT scans (A, B and C), coronal CECT scans (D, E) and sagittal MIP
(F) of the prior patient, choledochal stent carrier, showing a hypodense mass (*) at the
pancreato-duodenal confluence, which includes the common bile duct (yellow arrow)
causing retrograde dilation of the bile duct (black arrow). There is not fat plane between
the mass and the duodenum. The mass is encompassing the pancreato-duodenal artery
(red arrow).
Fig. 15: IPMN. Axial and coronal CECT scan images (A, B) and MR HASTE sequences
(C, D, E). Observe the marked dilation of the pancreatic duct at uncinated process. There
is also multifocal dilation of secondary branches in the pancreatic body and tail.
Fig. 16: IPMN. CECT images in axial (A, B) and coronal (C) showing a hypodense
lesion in the uncinate process, with a cystic appearance, well circumscribed, without
calcifications or adjacent vessel involvement. No pancreatic duct dilatation. The arrow
indicates the pancreaticoduodenal artery that helps us to locate the lesion in the
pancreas.
Page 18 of 22
Fig. 17: IPMN. Coronal MRI T2 weighted images of the prior patient shows that the
uncinate process cystic-like lesion communicates with the pancreatic duct (arrow). The
main pancreatic duct is not dilated. Minimum bile duct ectasia.
Fig. 18: Serous cystic neoplasm. Axial (A) and coronal (B and C) CECT images. Mass
in head/uncinate process, multicystic, well defined, with thin septa, which enhance
after contrast administration (honeycomb appearance). Note displacement of adjacent
structures. Cysts are small; the largest are seen in the periphery of the lesion.
Fig. 19: Serous cystic neoplasm. MR images in T2-WI: Polylobulated nodule in the
uncinate process formed by multiple hyperintense microcysts. Discrete dilation of the bile
duct in a cholecystectomized patient. Main pancreatic duct not dilated.
Page 19 of 22
Fig. 20: Mucinous cystic neoplasm. Axial and coronal CECT images which shows a lesion
in the uncinate process. It is hypodense, well-defined, with septa, oligocystic and with
peripheral calcifications.
Page 20 of 22
Conclusion
MRI and CECT are the imaging modalities of choice in the study of the pancreatoduodenal confluence.
Knowledge of the normal anatomy and the typical radiological signs of the different
entities involving this area is crucial to reach the proper diagnosis.
Personal information
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