Computed tomography of pancreatic carcinoma

The ductal adenocarcinoma is the most frequent tumour of the pancreas. So far, imaging methods did not enable early diagnosis of the tumour, since in most cases it cannot be detected before it has grown to a size of 2-3 cm diameter. CT findings of the carcinoma of the pancreas as well as problems connected with the diagnosis and with staging of the tumour are presented in a concise review.     

Selective phlebography in pancreatic and peripancreatic disease

Pancreatic phlebography was performed in 67 patients with proven inflammatory or tumour disease in the region of the pancreas. The findings are described and the diagnostic value of the method is discussed.     

Ultrasonic and computed tomographic appearances of paraganglioma simulating pancreatic mass.

We report two cases of paraganglioma in which the tumour was situated adjacent to the head of the pancreas simulating a pancreatic mass lesion. The absence of biliary or pancreatic duct dilatation on ultrasound in the presence of a large mass suggested a retroperitoneal tumour rather than a pancreatic adenocarcinoma. Functional activity in these tumours is common and should be excluded before biopsy.     

Metastatic acinar cell carcinoma of the liver from a benign-appearing pancreatic lesion: a mimic of hepatocellular carcinoma

Acinar cell carcinoma (ACC) is a rare pancreatic tumour with a favourable prognosis compared with the more common ductal adenocarcinoma. The radiological findings of this tumour have been described in the literature; however, only limited data are available regarding the metastatic features of ACC of the liver, the most common metastatic site. We report a case of ACC of the pancreas with a hepatic metastasis from a benign-appearing malignant pancreatic lesion.     

Angiographic evaluation of gastrointestinal haemorrhage complicating pancreatic disease.

Seven patients with gastro-oesophageal varices due to splenic or portal vein obstruction from a diseased pancreas have been seen at the Mater Hospital during the past three years. Four of these patients had episodes of acute and massive gastrointestinal bleeding and this paper emphasises the role of angiography in the management of this complication. In three instances the bleeding was the result of the varices, but in one patient with carcinoma of the head of the pancreas the bleeding was shown to result from invasion of the tumour into the duodenum.     

Magnetic resonance imaging of pancreatic carcinoma

The authors have used MRI for investigation of 41 patients with pancreatic tumours. MR examinations were performed with 0.5 T superconductive equipment. Short TR, short TE spin echo (SE) sequences were obtained with 8 averages and 256×256 matrix. T2-weighted sequences were also acquired. T1-weighted SE sequences provided more detail, with high intrinsic contrast between the tumour and the normal pancreas; small lesions (19 smaller than 3 cm in diameter) were always detected on these images. T2-weighted SE sequences were not useful for lesion detection, due to the lower intrinsic contrast and the number of artefacts. T2-weighted sequences proved helpful for lesion characterisation in two cases of cystoadenocarcinoma only. Staging of the tumour was possible with MRI, with good assessment of local spread, lymphoadenopathy, vascular involvement and hepatic metastases. MRI of the pancreas at medium field strength can be an alternative to CT in selected cases. Offprints requests to: P.Pavone     

Ultrasonography and computed tomography in pancreatic malignancy

Previous reports have shown that ultrasonography (US) is inferior to computed tomography (CT) in detecting pancreatic carcinoma. Since our recent observations suggested the opposite we re-evaluated the accuracy of these two methods. Among 36 patients with malignant tumours the US was normal in one, in 4 it showed only secondary signs of tumour, and in 31 it revealed the tumour. The corresponding figures for CT were 2, 9 and 25, respectively. The conclusion is that US should be considered the primary method for imaging the pancreas.     

Quantitative tissue characterisation in pancreatic disease using magnetic resonance imaging

Twenty-nine patients, 27 of whom had either inflammatory disease of the pancreas or pancreatic tumour, were studied by magnetic resonance imaging (MRI) and computed tomography (CT). Six healthy volunteers were studied by MRI alone. The pancreatic T1 and T2 relaxation times were calculated using a multipoint iterative method with data from seven total saturation recovery and six spin echo sequences. Magnetic resonance imaging can demonstrate the normal pancreas and a variety of pathological processes greater than 1-2 cm in size, but with less spatial resolution than CT. The relaxation-time results indicated no significant discrimination between chronic pancreatitis and pancreatic tumour. A significant elevation in the relaxation times was observed, however, in those patients with calcific chronic pancreatitis compared with the non-calcific chronic pancreatitic group and normal controls, suggesting a different pathophysiology for the two subgroups of chronic pancreatitis. The active phase of acute pancreatitis was associated with significantly elevated relaxation times, which returned to normal levels during the resolved phase of the disease. Associated extrapancreatic fluid collections were characterised by their very long relaxation times. The problems associated with spatial resolution, respiratory motion and lack of quantitative tissue characterisation suggest that MRI of the pancreas, using present methods, is unlikely to contribute to the overall management of patients with exocrine pancreatic disease.     

Sonographic diagnosis of liver and pancreatic tumors

From an overall point of view sonographic diagnostics of tumours of the liver is characterised by a high degree of sensitivity. Although an approximate differentiation between benign and malignant tumours is possible, it is not sufficiently reliable. Compared with the often monotonous CT imaging of liver tumours, the extremely "colourful" sonographic image (which seems to be full of "variety of species") of lesions of the liver supplies decisive pointers, so that the range of tumours to be considered in differential diagnosis becomes more limited. Such preselection is important especially for the choice of further measures to confirm the diagnosis. Sonographic differentiation between primary and secondary liver tumours is uncertain, and hence histological verification is mandatory. In what way sonography can help to determine whether a tumour is operable or not, has not yet been studied and is therefore by no means clear. Sonography is highly sensitive in the detection of tumours of the pancreas, especially with minor lesions of less than 2 cm diameter. The sonographic image of the adenocarcinoma is non-specific, so that it must be considered imperative to clarify by histological examination even extensive findings that appear totally inoperable, so that a distinction can be made against tumours of the pancreas which have a better prognosis. Sonographic assessment of whether or not a tumour can be resected can only be effected in a negative sense if there are unequivocal sonographic criteria proving that the tumour is inoperable.     

Intravascular ultrasound for evaluation of portal venous involvement in pancreatic cancer

The aim of this study was to evaluate the accuracy of intravascular ultrasound (IVUS) in diagnosing tumour involvement of the portal vein in patients with exocrine cancer of the head of the pancreas. Seven consecutive patients with a preoperative diagnosis of carcinoma, preoperatively deemed to be resectable, were examined with IVUS of the portal vein during surgery. The IVUS catheters were 6.2 F (2.0 mm) in diameter with a 20-MHz transducer and were introduced into the portal vasculature through the mesenteric superior vein. All patients had tumour extending to the portal vein as demonstrated at histopathological examinations in six cases and at surgical dissection in one case. The IVUS technique correctly identified all these patients, whereas five patients were incorrectly deemed at surgery not to have tumour involvement of the portal vein. These results indicate that IVUS is a very sensitive method for the evaluation of tumour involvement of the portal vein. Received 4 October 1995; Revision received 12 February 1996; Accepted 14 February 1996     

Imaging of early pancreatic cancer on multidetector row helical computed tomography

Early pancreatic cancer is small and limited to the pancreas. In contrast, small pancreatic cancer may include peripancreatic vasculature or metastasis involvement. This study evaluates images of early pancreatic cancer on multidetector CT (MDCT) using contrast-enhanced multiphasic imaging, and post-processed pancreatic duct images. CT findings and pathological features were analysed in eight patients with early pancreatic cancer. Pathological evaluation included location, size and histological grading of the tumour. MDCT evaluation covered the maximum diameter of the main pancreatic duct (MPD), stenosis or obstruction of the MPD, loss of normal lobar texture and associated pancreatitis. Attenuation differences between normal pancreatic parenchyma and the tumour (AD–PT) were also measured. Focal stenosis or obstruction of the MPD with dilatation of the distal MPD was demonstrated in all patients. Associated pancreatitis occurred in six patients with tumours measuring 12 mm or greater. Loss of normal lobar texture was recognised in four cases with the tumour measuring 14 mm or greater. Statistically, low-attenuated lesions and high-attenuated lesions differed with respect to the tumour size (p<0.01), and a positive relationship was demonstrated between the tumour size and AD–PT (r = 0.84). In seven cases, AD–PT is higher during the arterial phase than the pancreatic phase. Early pancreatic cancer appears as low attenuation on early phase, and as high- to iso-attenuation during the pancreatic and delayed phases in respect to the tumour size. Focal stenosis or obstruction of the MPD with dilatation of the distal MPD observed on curved reformation imaging seems important in the diagnosis of early pancreatic cancer.It is well known that pancreatic cancer is rarely cured and often fatal. Surgical resection is currently the only potentially curative treatment for pancreatic carcinoma, and detection of pancreatic cancer at an early stage is very important for increasing the resectability of the tumour and improving prognosis. Stage I pancreatic cancer, or early pancreatic cancer, is defined as a tumour smaller than 2 cm by histological measurement, limited to the pancreas without invasion to the peripancreatic vasculature, lymph node metastasis or distant metastasis [1]. It is generally known that the smaller the tumour size and the earlier the clinical stage, the better the prognosis. Small pancreatic cancer is defined as a tumour smaller than 2 cm with or without invasion to the peripancreatic vasculature or metastasis.Contrast-enhanced helical CT has facilitated the detection and staging of pancreatic cancer and is accepted as one of the most effective imaging techniques for the diagnosis of pancreatic cancer [2–10]. Current multidetector row helical CT (MDCT) can provide imaging details of pancreatic lesions, and some studies have reported on the imaging of small pancreatic cancer [4], but limited data are available comparing small and early pancreatic cancer.In the present retrospective study, we evaluated images of small and early pancreatic cancer on MDCT using contrast-enhanced multiphasic imaging and post-processed pancreatic duct images and compared them with the pathological findings of surgical specimens.     

Case report: solid-pseudopapillary tumour of the pancreas associated with dorsal agenesis

Solid-pseudopapillary tumour of the pancreas is a rare benign or low-grade malignant epithelial tumour; its association with pancreatic dorsal agenesis has been reported only once before. We present the radiological and histological findings of a case of pancreatic solid-pseudopapillary tumour associated with total pancreatic dorsal agenesis. A 49-year-old woman presented with abdominal pain radiating to the back for several months. Radiological findings showed absence of the dorsal pancreas and an 8 cm x 6 cm diameter tumour arising from the head of the pancreas. She underwent successful complete resection of the tumour. Histopathology revealed a diagnosis of solid-pseudopapillary tumour.     

Reliability of ultrasound-guided fine-needle biopsy of pancreatic masses

Fine-needle aspiration biopsy (FNB) was performed with ultrasound guidance in 79 patients in whom sonography had revealed a mass suggesting pancreatic malignancy. The final diagnosis (surgery, autopsy and clinical course) in 69 of these 79 patients was a malignancy closely related to the pancreas while in the remaining 10 patients benign disease was confirmed. A correct diagnosis of malignancy was attained by FNB in 59 of the 69 patients with a malignant tumour while in 10 it failed to confirm the diagnosis. FNB yielded a true negative result in 10 patients with benign disease. The accuracy of sonographically guided FNB in the present investigation was 87 per cent. Ultrasound-guided fine-needle biopsy is considered the method of choice for further evaluation of pancreatic masses.     

Therapeutic concepts and demands on radiology from the surgical viewpoint in liver and pancreatic tumors

The aim of modern diagnostic procedures in hepato-biliary and pancreatic tumours is the characterization of origin, type and resectability of a lesion and the staging of the tumour. Furthermore, preoperative diagnostic methods should reduce the operative risk by demonstration of anatomical variations i.e. hepatic blood supply. In addition alternative therapeutic concepts like chemoembolization should be kept in mind. A diagnostic procedure in liver and pancreas tumours is demonstrated following aspects of economical and surgical requirements.     

Ectopic Cushing's syndrome caused by a functioning pancreatic neuroendocrine tumour in a patient with von Hippel-Lindau disease

We present a 36-year-old woman diagnosed with von Hippel-Lindau disease. A haemangioblastoma of the central nervous system was successfully excised ten years ago and a left nephrectomy had been performed because of clear cell carcinoma. For the last six months, the patient has suffered from amenorrhoea, asthenia, muscular debility and capillary fragility. Physical examination showed hirsutism and bruising. Laboratory findings supported ectopic Cushing's syndrome. A solid pancreatic mass was identified on computed tomography. 111-In-DPTA-pentetreotide scintigraphy demonstrated marked uptake at this location, suggesting a neuroendocrine tumour. Duodenopancreatectomy was performed. After surgery, the cortisol levels returned to normal with complete resolution of the syndrome. This is the first case of Cushing's syndrome caused by an ectopic ACTH-secreting neuroendocrine tumour of the pancreas associated with von Hippel-Lindau disease.     

Mesenteric venous collateral vessels mimicking cystic pancreatic neoplasm

We report an unusual case of intrapancreatic mesenteric venous collateral vessels following partial pancreatic surgical resection resembling pancreatic neoplasm upon greyscale sonographic and unenhanced CT examinations.Cystic lesions of the pancreas can be divided into three broad categories: lesions without an epithelial lining (pseudocyst), lesions with an epithelial lining (mucinous and serous cystadenoma and cystadenocarcinoma) and degenerative or necrotic change within a solid neoplasm (solid pseudopapillary neoplasm and cystic degeneration of ductal adenocarcinoma or neuroendocrine tumour). Here we report an unusual aetiology for a cyst-like pancreatic lesion: intrapancreatic mesenteric venous collateral vessels developing after a previous partial pancreatic resection. Failure to recognise this condition, particularly during image-guided intervention such as biopsy, endoscopic retrograde cholangiopancreatography (ERCP) or during surgery, could result in a disastrous outcome.     

Sensitivity of pancreatic ultrasonography in the detection of pancreatic disease

Pancreatic ultrasonography was correct 87% of the time separating patients with a normal pancreas from those with an abnormality. Of those patients felt to have a normal pancreas by ultrasonography, only 81% wre ultimately found normal. In this group, errors occurred primarily in patients with chronic pancreatitis. An abnormal pancreatic ultrasonogram is significant and usually indicates disease; ultrasonography correctly identified 94% of those patients ultimately found to have an abnormal pancreas.     

MR imaging of pancreatic diseases

This article presents current MR imaging techniques for the pancreas, and review a spectrum of MR imaging features of various pancreatic diseases. These include: 1) congenital anomalies such as anomalous union of pancreatobiliary ducts, divisum, and annular pancreas, 2) inflammatory diseases, including acute or chronic pancreatitis with complications, groove pancreatitis, and autoimmune pancreatitis, tumor-forming pancreatitis, 3) pancreatic neoplasms, including adenocarcinoma, islet cell tumors, and cystic neoplasms (microcystic adenoma, mucinous cystic neoplasms, and intraductal mucin-producing pancreatic tumor). Particular attention is paid to technical advances in MR imaging of the pancreas such as fat-suppression, MR pancreatography (single- or multi-slice HASTE), and thin-section 3D multiphasic contrast-enhanced dynamic sequences. Imaging characteristics that may lead to a specific diagnosis or narrow the differential diagnosis are also discussed.     

Angiectatic pseudocyst of the pancreatic head

BACKGROUND: Arteriovenous malformations of the pancreas are very rare, most frequently congenital ones, but tending to increase frequency, predominantly due to the introduction and use of new diagnostic modalities. They usually present with gastrointestinal bleeding and abdominal pain. CASE REPORT: The autors presented a 52-year-old woman in whom, during the investigation for the abdominal pain and gastrointestinal bleeding, an ultrasonography showed a hypoechogenic lesion within the head of the pancreas 3 cm in diameter. Endoscopic ultrasound showed an irregular hypoechogenic lesion. Computed tomography showed a low density area within the lesion (< 10HU). At endoscopic retrograde cholangiopancreatography, a cystic lesion within the head of the pancreas was filled with contrast from the normal pancreatic duct. Angiography showed an arteriovenous malformation within the head of the pancreas. The patient underwent pylorus preserving cephalic duodenopancreatectomy. The diagnosis of arteriovenous malformation, probably of congenital origin, was confirmed on histology. CONCLUSION: Arteriovenous malformations should be considered in patients with gastrointestinal bleeding of unknown etiology. In this case, the lesion was taken into account preoperatively, based on color Doppler ultrasonography and angiography. The best results of treatment can be achieved with resection, but it has to be performed before an eventual portal hypertension takes place.     

Intraductal papillary mucinous tumour of the pancreas: imaging features

Intraductal papillary mucinous tumour of the pancreas is an uncommon distinctive pancreatic tumour characterized by dilatation of the main pancreatic duct or branch ducts as a result of excessive production and disturbance in the draining of mucin. The imaging characteristics of a case in an 82-year-old woman are compared.