SOLID AND CYSTIC LESION OF

PANCREAS
Rabina panta
1701938
 Anatomy
• Pancreas is a soft, finely lobulated, elongated
exocrine and endocrine gland.
• Exocrine part secretes the pancreatic juice and
endocrine part secretes the hormones, insulin, etc.
• Pancreatic juice helps in the digestion of lipids,
carbohydrates and proteins whereas the pancreatic
hormones maintain glucose homeostasis.
 Imaging
• MRI
• CT, US and MR provide high quality images if the
pancreatic parenchyma and are used as the primary
imaging modalities for the pancreas.
• Endoscopic ultrasonography(EUS)
• Position emission tomography(PET)
• CECT: Hypodense, irregular border, peripancreatic
vessel involvement, double duct sign
• MRCP: non invasive method for pancreatic duct and
biliary system. Establish the relationshio of the
pseudocyst to pancreatic ducts.
• MDCT optimises contrast enhancement for detection of
small tumors and provides capability of CT angiography to
detect vascular involvement by pancreatic tumor.
• US and CT guided biospy and drainage procedures play
major role in the diagnosis and treatment of pancreatic
disease.
• Endoscopic US is an important adjunct to characterize
pancreatic tumors by imaging and endoscopic US guided
fine needle aspiration.
Conventional
• Signs of acute pancreatitis
1. Duodenal ileus; the duodenal
folds may be thickened
2. Gasless abdomen
3. Sentinel loop
4. Absent left psoas shadow
5. Colon cut off sign; where the
dilated transverse colon becomes
abruptly gasless in the region of
the splenic flexure.
• Signs of chronic
pancreatitis
1. Calcification
 Solid lesions of the pancreas

Autoimmune
pancreatitis: It is a
chronic
inflammation that
is thought to be
caused by the
body's immune
system attacking
the pancreas.
While approaching a solid lesions we need to know:

1. Epidemiology

2. Imaging

3. Serology

4. Histology
 Clinical features

• Nonspecific in majority
• Abdominal pain, weight loss, progressive obstructive
jaundice-PDA
• Recurrent pain
• H/o RCC, Sarcoidosis, TB, Immuno deficiency
• Symptoms of lymphoma( Fever, chills, night sweats)
 Solid lesions of the pancreas

Neoplastic
1. Pancreatic
adenocarcinoma
(Ductal
carcinoma): It is
highly lethal
tumor and a
common
gastrointestinal
malignancy and
is often
associated with
poor prognosis.
 Solid lesions of the pancreas

2. Neuroendocrine
tumor: They are
neoplasms tht arise from
cells of the
endocrine(hormonal) and
nervous systems. They
most commonly occur in
intestine.
• Hypervascular tumor
• Calcification 20% Vs
2% in PDA
• Vscular infiltration vs
encasement in PDA
 Solid lesions of the pancreas
Solid pseudopapillary tumor: It is a
rare neoplasm usually characterised
by well encapsulated mass with low
malignant potential.
• MC in tail region
• Tendency to displace rather than
invade surrounding structures
• Rarely causes obstruction of the
bile duct or pancreatic duct
• Pseudocapsule has low attenuation
at CT
• Internal hemorragic and cystic
degeneration
 Solid lesions of the pancreas

Lymphoma: It is a group of
blood cancers that develop
from lymphocytes.
• More CBD dilation than
MPD
• Enlarged lymph nodes
below renal vein
• Invasive; No respect of
anatomic boundaries
• Vscular invasion less
common
 Solid lesions of the pancreas

Metastasis: It is a
pathogenic agent's spread
from an initial or primary
site to a different or
secondary site of the body.
• Most common from
Renal cell carcinoma, Ca
lung, Ca breast, CRC
• Hypervascular Mets-
Renal cell carcinoma
• Hypovascular Mets-
Lung, breast, colon
• Equivocal cases requires
 Solid lesions of the pancreas

Neoplastic
• Focal pancreatitis: It
is a confined
inflammation that
mimics a pancreatic
mass.
 Solid lesions of the pancreas

Lipomatous
pseudohypertrophy(F
atty infiltration) : It is a
rare benign entity
characterised by focal
or diffuse
enlargement of the
pancreas due to the
replacement of
exocrine parenchyma
with adipose tissue.
While approaching a cystic lesions we need to know:

1. Histology

2. Broad differential diagnosis

3. Epidemiology of common lesions

4. Clinical presentation

5. Imaging

6. Blood tests
 Clinical features
• Majority of pancreatic cysts are incidentally detected i.e.
they are asymptomatic.
• Symptomatic cysts are most likely to manifest with
abdominal pain.
• Jaundice or recurrent pancreatitis often indicates that the
lesion is either in communication with the pancreatic
ductal system or obstructing the pancreatic or biliary
duct.
• Pseudocysts typically occur with acute pancreatitis or
may develop insidiously in the setting of chronic
pancreatitis.
 Unilocular cysts
Pseudocyst
• Sharply marginated unilocular or multilocular fluid-filled
pancreatic or peripancreatic collections that are
encapsulated by fibrous tissue and usually form after
inflammation, necrosis or hemorrhage related to acute
• IPMN occasionally
pancreatic or trauma.
• Unilocular serous cystadenoma
• Lymphoepithelial cyst
• Multiple
1. von Hippel-Lindau
2. Pseudocysts
Ultrasound
• Real time
• Usually solitary unilocular cyst(body or tail), Multilocular in 6% of cases
• Fluid-debris level and internal echoes due to autolysis(blood clot/cellular debris)
• Septations (rare;sign of infection or hemorrhage)
• Dilated pancreatic duct and CBD may be seen
• Calcification of pancreas (chronic pancreatitis)
CT-PLAIN AND CONTRAST
NECT
• Round or oval, homogenous, hypodense lesion(Mature pseudocyst)
• Hemorrhagic/Infected pseudocyst: Lobulated, heterogenous, mixed density lesion
• May or may not be present pancreatic calcification; MPD and common bile duct (CBD) dilation
CECT
• Enhancement of thin rim of fibrous capsule
• No enhancement of pseudocyst contents
• Gas within pseudocyst suggests superimposed infection, decompression of pseudocyst into
pancreatic duct, stomach or bowel.
• Pseudo aneurysms can be caused by or simulate pseudocyst. CECT shows enhancement like
adjacent blood vessels.
Serous cystadenomas
• They are benign tumors
that do not need treatment.
• Tumors occurs most
commonly in women esp.
>60yrs. and are distributed
uniformly throughout head,
body and tail of pancreas
• Lesions is associated with
von Hippel-Lindau
symdrome.
Mucinous cystic neoplasms
• Most common
• Typically involves the body
and tail of the pancreas
• Never multifocal, occuring
only in one location within
the pancreas.
• Asymptomatic; If symptoms-
abdominal pain, palpable
mass.
 Intraductal papullary mucinous
neoplasms(IPMN)

• They are mucinous

tumors with
malignant potential
deserving surgical
resection.
Reference
• Appliedradiology.com
• www.ncbi.nlm.nih.gov
• www.ajronline.org
• www.karger.com
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