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SOLID PANCREATIC MASSES: BENIGN OR MALIGNANT
D. Vanbeckevoort1 Solid masses in the pancreas mostly occur in the pancreatic head and may be related to inflammation due to chronic pancreatitis or may be caused by malignancy. Ductal pancreatic carcinoma is the most common malignant pancreatic neoplasm, accounting for more than 90% of malignant solid pancreatic tumours. Endocrine tumours represent only a minority of those tumours. While endocrine tumours tend to exhibit symptoms earlier in the course of the disease (due to tumour-related hormone production), adenocarcinomas present in nearly all cases in advanced stages when curative resection is not feasible.
Key-word: Pancreas, neoplasms.
Pancreatic adenocarcinoma: imaging techniques and evaluation. CT is now considered to be the imaging modality of choice for the detection and presurgical staging of pancreatic cancer. When compared to US, the performance of CT is less operator- and patient-dependent. A direct sign of tumour at contrast-enhanced CT is the presence of a hypoattenuating mass in the pancreas. However, in approximately 10% of cases, direct signs of tumour are absent because the mass is isoattenuating at contrast-enhanced CT. Indirect signs of pancreatic cancer must also be taken into account. These include presence of a stenosis of distal common bile duct in the pancreas with biliary dilatation, a stenosis of the pancreatic duct with upstream ductal dilatation – “double duct sign” –, loss of lobulated texture of the pancreatic parenchyma, and deformity of the pancreatic contours (1). Recently, the sensitivity of CT in the diagnosis of pancreatic neoplasms and accurate tumour staging has significantly improved by the use of multidetector row CT (2). In the published literature, overall accuracy of CT for the detection of pancreatic tumours ranges between 80 and 91%. Positive predictive values for surgical unresectability have been excellent, ranging from 89 to 95%. However, among patients with tumours judged potentially resectable based on CT criteria, surgical results show that only 60 to 91% of the tumours are truly resectable (3). One of the most common causes of unresectability not
detected by CT is vascular involvement by the tumour. Baum et al. have reported improvement in staging of pancreatic cancer with MDCT and the use of interactive multiplanar reconstructions (4). By adding the CT angiogram, the negative predictive value (NPV) of a resectable tumour was 96% compared to 70% for axial images alone. Features of vascular involvement are tumour involvement of one half circumference of the vessel, dilatation of peripancreatic veins and focal narrowing of vessel calibre. In addition to the assessment of vascular involvement, accurate staging implies evaluation of regional and distant metastases. A remaining problem is the identification and characterization of small hepatic lesions and detection of small metastatic peritoneal and omental metastases (2). If peritoneal metastatic disease is not accompanied by ascites, helical CT is often false negative. Furthermore CT does not allow accurate differentiation between benign and malignant causes of lymph node enlargement. Considering PET-CT, the exact role of this technique is unclear in most patients with pancreatic cancer. What it does allow is the detection of unsuspected metastases and it helps in the evaluation of masses with equivocal CT and MRI diagnosis. Finally, PET-CT helps in the evaluation of patients with suspected recurrent pancreatic carcinoma. Technical advances, such as highfield-strength MR imaging with phased array coils and ultra-fast imaging have provided excellent
results in terms of detection and staging of pancreatic cancer. MRI performed with a high gradient system using phased-array coils reaches a sensitivity of 95% in diagnosing the tumour. In the prediction of nonresectability MRI has a PPV of 90% and a NPV of 83%. MRI criteria of unresectability are similar to the established CT criteria. At most institutions, the involvement of the superior mesenteric artery, the celiac trunk or the superior mesenteric vein - portal vein confluence and peritoneal or hepatic metastases are considered as contraindications to curative resection (5). The primary role of MRI lies in the detection of small lesions that are potentially curable and to avoid “understaging” based on the CT examination. In addition, MRI is also helpful in the detection or exclusion of pancreatic cancer in patients showing a prominent pancreatic head or uncinate process on CT or ultrasound examinations. Schima et al found that mangafodipir trisodium-enhanced MR imaging and helical CT are equivocal for local staging of pancreatic cancer but that mangafodipir trisodium-enhanced MR imaging offers advantages in the detection of small pancreatic malignancies and liver metastases (6). Besides the wide range of MR applications in this field, some limitations remain in the detection of small peripancreatic lymph nodes and peritoneal implants. Endocrine tumours: imaging techniques and evaluation Insulinoma and gastrinoma are the most common endocrine tumours. Depending on their typical hypervascularity, insulinomas and gastrinomas characteristically show a nodular enhancement after intravenous contrast administration. On MR, they appear as hypointense lesions on T1-weighted images and
From: 1. Department of Radiology, University Hospitals Leuven, Leuven, Belgium. Address for correspondence: Dr D. Vanbeckevoort, M.D., Department of Radiology, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium. E-mail: firstname.lastname@example.org
For the detection of gastrinomas. Moreover. increasing the difficulty of differential diagnosis. variable intensity on T2 Peripancreatic ‘rim-sign’ Absence of or minimal presence of parenchymal atrophy Absence of peripancreatic extension Narrowing of Wirsung’s duct in the affected segments No marked prestenotic Wirsung dilatation Associated findings Absence of secondary findings of alcoholic pancreatitis (pseudocysts. the average success rate is only 20% (8). In most studies. Success rates of ultrasonography for the detection of insulinoma vary from 25% to 65% (7). the abdominal radiologist is often confronted with non-specific imaging signs. Palazzo et al. thus improving diagnostic confidence. Primary findings Presence of a hypoenhancing mass Mass is hypointense on T1-weighted MRI. Fat suppressed breathhold T1-weighted imaging usually increases the signal intensity difference between tumour and normal pancreatic tissue. Low enhancing endocrine pancreatic tumours at pancreatic-phase helical CT are correlated with poorly differentiated endocrine pancreatic tumours and with a decrease in overall survival. reported an overall diagnostic accuracy rate of 87. 1. and angiography in detecting endocrine pancreatic tumours. — Two representative arterial phase CT-images showing slightly hypovascular lesion in the body of the pancreas. mimicking presence of a pancreatic carcinoma and it is sometimes already difficult to distinguish between neoplasm and . Differentiating a chronic inflammatory mass from pancreatic cancer: a remaining challenge Once a mass lesion is detected in a patient known to suffer from chronic pancreatitis. calcifications) Absence of lymphadenopathy Findings of associated (autoimmune) disease: primary sclerosing cholangitis. inflammatory bowel disease Fig. calcifications are invisible and the Table I. Several studies suggest that state of the art MRI may be more sensitive than CT. replacement of normal pancreatic tissue by strands of fibrosis and decrease of vascularisation is characterized by loss of normal high signal on T1-weighted images and decreased enhancement on dynamic contrast-enhanced images. EUS has proved to be far superior to transabdominal ultrasonography. mimicking a tumour. CT. 90 (6) hyperintense lesions on T2-weighted images. the sensitivity of MRI largely depends on the technique used. Rodallec et al.488 JBR–BTR. recently demonstrated a statistically significant correlation between tumour vascularity evaluated by histological techniques and lesion enhancement evaluated by CT (10). These signs lack sensitivity and are highly non-specific. Therefore multiplanar reconstruction is helpful in separating the lesion from surrounding vessels. As in CT. On MRI however. — Summary of major and minor CT and MR imaging findings of autoimmune pancreatitis. On CT-exams. 2007. The reported sensitivity of CT in localizing functioning islet cell tumours varies from 71% to 82% due to the fact that small tumours are more frequently missed.5% for EUS in the detection of endocrine pancreatic tumours (9). the pancreas can occasionally even be focally enlarged. Small hyperattenuating islet tumours located in the pancreatic neck or body can be confused with adjacent vascular structures. the most pathognomonic features of chronic pancreatitis include presence of parenchymal calcifications and morphologic changes resulting in a shrinking and atrophy of the pancreatic body (11). Crucial requisites are fast and high resolution imaging.
we have demonstrated different major and associated findings of this disease (Table I). Bogomoletz W.. Knowledge of this clinical entity is important for a diagnostic imaging work-up of a patient presenting with a pancreatic mass. Specific signs such as a peripancreatic ‘rim-sign’ and associated findings of autoimmune disease may aid the diagnosis.S.D.: Pancreatic adenocarcinoma. 1998. Roseau G. 10. Endoscopy. 2005. Vanslembrouck. Unfortunately this specific sign is not found in all patients.A. Vilgrain V.D. histoprognostic factors and survival.: Using multidetector row computed tomography to diagnose and stage pancreatic carcinoma: the problems and the possibilities.and lymphocytic inflammatory tissue found on pathology. Van Hoe L. Prokesch R. 11. but 30% of patients with chronic pancreatitis have no definite cause and are classified as having idiopathic chronic pancreatitis.: Multiplanar spiral CT in the diagnosis 9.: Local staging of pancreatic carcinoma with multidetector row CT: use of curved planar reformations – initial experience. Kölbinger C. 17: 638649. Radiology.. the differential diagnosis in chronic pancreatic disease should include the entity of autoimmune or nonalcoholic duct destructive pancreatitis. 6: 77-85. Scaglione M.170: 643-647. et al. Finally.171: 353-357. The main cause of chronic pancreatitis is alcohol abuse.D. Pinto A.: Endocrine pancreatic tumours and helical CT: Contrast enhancement is correlated with microvascular density. 24 [Suppl 1]: 350-353. et al. In concordance with previously published reports (13). Ward E.M. Norton J. We are grateful to H.H. Radiology. K. M. 2006. 179: 717724. This is especially important since response to medical therapy is generally good and in the future unwarranted hemipancreatectomy may be avoided. Mammone J. D. Bielen. and I.and intra-operative ultrasound with CT and angiography.. M. Frucht H. angiography and US. Salmeron M. The peripancreatic rim-sign most likely represents the imaging analogue of the mono. Ba-Ssalamah A... 19: 35-52..K. 1992.. A new insight into the pathology of idiopathic nonalcoholic chronic pancreatitis.: Duct destructive chronic pancreatitis.: Endoscopic ultrasonography in the preoperative localization of pancreatic endocrine tumours.. 4. 225: 759-765.. Semin Ultrasound CT MRI. Charboneau J.: Gastrinomas: comparison of MR imaging with CT. Galiber A. J Pancreas. 1998.SOLID PANCREATIC MASSES: BENIGN OR MALIGNANT — VANBECKEVOORT 489 these changes. Schima W. 7. 1989. Doppman J. The diagnosis must be considered if a hypoenhancing mass in absence of or minimal presence of retroobstructive changes and lack of peripancreatic extension is found (Fig. Radiology.. Siegelman E. Eur.. clearly different from the more general form. M. 1998.13).W. associated with ‘classic’ chronic pancreatitis.: Nonalcoholic duct-destructive chronic pancreatitis: imaging findings.... chronic obstructive pancreatitis (e. Ph.K. Függer R. 1).F. 39: 958-964. et al. 8. 3....: Magnetic resonance of the pancreas and biliary tree. Furthermore. 13. Ectors N. Baum U.L.. et al. Chow L.. 2002. secondary to a mass) has distinct imaging features.. Outwater E. et al. Schima W. . We should however be aware that there are several subtypes of chronic pancreatitis.. AJR. Acknowledgements 5. Gryspeerdt S. 1999.W. Couvelard A. Suspicion should enlarge if the mass displays typical signal intensities (hypointense on T1-.. Dymarkowski. 166: 405-408. References 1.F .. 171: 713717. Reading C. of pancreatic. 6. The high nuclear-cytoplasmatic ratio might explain the low signal intensity on the MRI images.: Chronic pancreatitis: reassessment with current CT. Nomayr A.. et al. Radiology. Palazzo L. Gut..g. 2007.C. 1997.D. Lell M. 41: 272..D.: Diagnosis and staging of pancreatic cancer: comparison of mangafodipir trisodium – enhanced MR Imaging and contrast-enhanced helical hydro-CT.. M.. Hopefully analysis and application of the proper imaging criteria will increase the diagnostic specificity of this disease.. R. Rodallec M.. 12. Romane S. St. variable intensity on T2-weighted MRI) and if imaging features of chronic alcoholic pancreatitis are absent. Op de beeck.H. AJR.... 2002. et al. Fruyt for their assistance in preparing this article. which in turn possesses its own morphologic and histological features (12. et al. Luetmar P. 6: 1-5. et al. Radiol.. Schober E. Pancreatology.: Localisation of pancreatic insulinoma: comparison of pre. 2. Radiology. Stephens D. 1989.C.. Beaulieu C.. Vandenhout.
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