Abstract
For the radiological investigation of the various pancreatic masses, there is a wide variety of available imaging modalities, such as computed tomography (CT), magnetic resonance imaging (MRI), ultrasonography (US), and nuclear medicine. In this chapter, a short overview of these techniques with an emphasis on recent advances will be presented, followed by a practical diagnostic imaging algorithm. Finally, the imaging features of the most common solid, such as pancreatic ductal adenocarcinoma (PDAC) and pancreatic neuroendocrine tumor (PNET), and cystic pancreatic lesions [such as serous cystic adenoma (SCA), mucinous cystic neoplasm (MCN), and intraductal papillary mucinous neoplasm (IPMN)] will be illustrated.
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References
Tempero MA, Arnoletti JP, Behrman SW, Ben-Josef E, Benson 3rd AB, Casper ES, et al. National Comprehensive Cancer Networks. Pancreatic Adenocarcinoma, version 2.2012: featured updates to the NCCN guidelines. J Natl Compr Canc Netw. 2012;10:703–13.
Schueller G, Schima W, Schueller-Weidekamm C, Weber M, Stift A, Gnant M, et al. Multidetector CT of pancreas: effects of contrast material flow rate and individualized scan delay on enhancement of pancreas and tumor contrast. Radiology. 2006;241:441–8.
Prokesch RW, Chow LC, Beaulieu CF, Nino-Murcia M, Mindelzun RE, Bammer R, et al. Local staging of pancreatic carcinoma with multi-detector row CT: use of curved planar reformations initial experience. Radiology. 2002;225:759–65.
Horton KM, Fishman EK. Volume-rendered 3D CT of the mesenteric vasculature: normal anatomy, anatomic variants, and pathologic conditions. Radiographics. 2002;22:161–72.
Horton KM. Multidetector CT, and three-dimensional imaging of the pancreas: state of the art. J Gastrointest Surg. 2002;6:126–8.
Horton KM, Fishman EK. Multidetector CT angiography of pancreatic carcinoma: part 2, evaluation of venous involvement. AJR Am J Roentgenol. 2002;178:833–6.
Horton KM, Fishman EK. Multidetector CT angiography of pancreatic carcinoma: part I, evaluation of arterial involvement. AJR Am J Roentgenol. 2002;178:827–31.
Kambadakone AR, Sahani DV. Body perfusion CT: technique, clinical applications, and advances. Radiol Clin North Am. 2009;47:161–78. doi:10.1016/j.rcl.2008.11.003.
Tirkes T, Menias CO, Sandrasegaran K. MR imaging techniques for pancreas. Radiol Clin North Am. 2012;50:379–93. doi:10.1016/j.rcl.2012.03.003.
Le Bihan D. Molecular diffusion, tissue microdynamics and microstructure. NMR Biomed. 1995;8:375–86.
Koh DM, Collins DJ, Orton MR. Intravoxel incoherent motion in body diffusion-weighted MRI: reality and challenges. AJR Am J Roentgenol. 2011;196:1351–61. doi:10.2214/AJR.10.5515.
Song HK, Dougherty L. Dynamic MRI with projection reconstruction and KWIC processing for simultaneous high spatial and temporal resolution. Magn Reson Med. 2004;52:815–24.
Tofts PS, Brix G, Buckley DL, Evelhoch JL, Henderson E, Knopp MV, et al. Estimating kinetic parameters from dynamic contrast-enhanced T(1)-weighted MRI of a diffusable tracer: standardized quantities and symbols. J Magn Reson Imaging. 1999;10:223–32.
Sandrasegaran K. Functional MR, imaging of the abdomen. Radiol Clin North Am. 2014;52:883–903. doi:10.1016/j.rcl.2014.02.018.
Badea R, Seicean A, Diaconu B, Stan-Iuga R, Sparchez Z, Tantau M, et al. Contrast-enhanced ultrasound of the pancreas—a method beyond its potential or a new diagnostic standard? J Gastrointestin Liver Dis. 2009;18:237–42.
Kitano M, Kudo M, Sakamoto H, Komaki T. Endoscopic ultrasonography and contrast-enhanced endoscopic ultrasonography. Pancreatology. 2011;11 Suppl 2:28–33. doi:10.1159/000323493.
van Essen M, Sundin A, Krenning EP, Kwekkeboom DJ. Neuroendocrine tumours: the role of imaging for diagnosis and therapy. Nat Rev Endocrinol. 2014;10:102–14. doi:10.1038/nrendo.2013.246.
Rufini V, Baum RP, Castaldi P, Treglia G, De Gaetano AM, Carreras C, et al. Role of PET/CT in the functional imaging of endocrine pancreatic tumors. Abdom Imaging. 2012;37:1004–20. doi:10.1007/s00261-012-9871-9.
Nensa F, Beiderwellen K, Heusch P, Wetter A. Clinical applications of PET/MR: current status and future perspectives. Diagn Interv Radiol. 2014;20(5):438–47. doi:10.5152/dir.14008.
Schima W, Függer R, Schober E, Oettl C, Wamser P, Grabenwöger F, et al. Diagnosis and staging of pancreatic cancer: comparison of mangafodipir trisodium-enhanced MR imaging and contrast-enhanced helical hydro-CT. AJR Am J Roentgenol. 2002;179:717–24.
Schima W, Ba-Ssalamah A, Goetzinger P, Scharitzer M, Koelblinger C. State-of-the-art magnetic resonance imaging of pancreatic cancer. Top Magn Reson Imaging. 2007;18:421–9. doi:10.1097/rmr.0b013e31816459e0.
Sahani DV, Kambadakone A, Macari M, Takahashi N, Chari S, Fernandez-del Castillo C. Diagnosis and management of cystic pancreatic lesions. AJR Am J Roentgenol. 2013;200:343–54. doi:10.2214/AJR.12.8862.
Berland LL, Silverman SG, Gore RM, Mayo-Smith WW, Megibow AJ, Yee J, et al. Managing incidental findings on abdominal CT: white paper of the ACR Incidental Findings Committee. J Am Coll Radiol. 2010;7:754–73. doi:10.1016/j.jacr.2010.06.013.
Tanaka M, Fernández-del Castillo C, Adsay V, Chari S, Falconi M, Jang JY, et al. International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology. 2012;12:183–97. doi:10.1016/j.pan.2012.04.004.
Del Chiaro M, Verbeke C, Salvia R, Klöppel G, Werner J, McKay C, et al. European experts’ consensus statement on cystic tumours of the pancreas. Dig Liver Dis. 2013;45:703–11. doi:10.1016/j.dld.2013.01.010.
Macari M, Lee T, Kim S, Jacobs S, Megibow AJ, Hajdu C, et al. Is gadolinium necessary for MRI follow-up evaluation of cystic lesions in the pancreas? Preliminary results. AJR Am J Roentgenol. 2009;192:159–64. doi:10.2214/AJR.08.1068.
Nougaret S, Reinhold C, Chong J, Escal L, Mercier G, Fabre JM, et al. Incidental pancreatic cysts: natural history and diagnostic accuracy of a limited serial pancreatic cyst MRI protocol. Eur Radiol. 2014;24:1020–9. doi:10.1007/s00330-014-3112-2.
Saif MW. Pancreatic neoplasm in 2011: an update. JOP. 2011;12:316–21.
Oberg K. Pancreatic endocrine tumors. Semin Oncol. 2010;37:594–618. doi:10.1053/j.seminoncol.2010.10.014.
Horton KM, Fishman EK. Adenocarcinoma of the pancreas: CT imaging. Radiol Clin North Am. 2002;40:1263–72.
Miller FH, Rini NJ, Keppke AL. MRI of adenocarcinoma of the pancreas. AJR Am J Roentgenol. 2006;187:W365–74.
Kim JH, Park SH, Yu ES, Kim MH, Kim J, Byun JH, et al. Visually isoattenuating pancreatic adenocarcinoma at dynamic-enhanced CT: frequency, clinical and pathologic characteristics, and diagnosis at imaging examinations. Radiology. 2010;257:87–96. doi:10.1148/radiol.10100015.
Prokesch RW, Schima W, Chow LC, Jeffrey RB. Multidetector CT of pancreatic adenocarcinoma: diagnostic advances and therapeutic relevance. Eur Radiol. 2003;13:2147–54.
Valls C, Andía E, Sanchez A, Fabregat J, Pozuelo O, Quintero JC, et al. Dual-phase helical CT of pancreatic adenocarcinoma: assessment of resectability before surgery. AJR Am J Roentgenol. 2002;178:821–6.
Coakley FV, Hanley-Knutson K, Mongan J, Barajas R, Bucknor M, Qayyum A. Pancreatic imaging mimics: part 1, imaging mimics of pancreatic adenocarcinoma. AJR Am J Roentgenol. 2012;199:301–8. doi:10.2214/AJR.11.7907.
Ichikawa T, Sou H, Araki T, Arbab AS, Yoshikawa T, Ishigame K, et al. Duct-penetrating sign at MRCP: usefulness for differentiating inflammatory pancreatic mass from pancreatic carcinomas. Radiology. 2001;221:107–16.
Sahani DV, Sainani NI, Deshpande V, Shaikh MS, Frinkelberg DL, Fernandez-del Castillo C. Autoimmune pancreatitis: disease evolution, staging, response assessment, and CT features that predict response to corticosteroid therapy. Radiology. 2009;250:118–29. doi:10.1148/radiol.2493080279.
Lu N, Feng XY, Hao SJ, Liang ZH, Jin C, Qiang JW, et al. 64-slice CT perfusion imaging of pancreatic adenocarcinoma and mass-forming chronic pancreatitis. Acad Radiol. 2011;18:81–8. doi:10.1016/j.acra.2010.07.012.
Kim JH, Lee JM, Park JH, Kim SC, Joo I, Han JK, et al. Solid pancreatic lesions: characterization by using timing bolus dynamic contrast-enhanced MR imaging assessment—a preliminary study. Radiology. 2013;266:185–96. doi:10.1148/radiol.12120111.
Fattahi R, Balci NC, Perman WH, Hsueh EC, Alkaade S, Havlioglu N, et al. Pancreatic diffusion-weighted imaging (DWI): comparison between mass-forming focal pancreatitis (FP), pancreatic cancer (PC), and normal pancreas. J Magn Reson Imaging. 2009;29:350–6. doi:10.1002/jmri.21651.
Lee SS, Byun JH, Park BJ, Park SH, Kim N, Park B, et al. Quantitative analysis of diffusion-weighted magnetic resonance imaging of the pancreas: usefulness in characterizing solid pancreatic masses. J Magn Reson Imaging. 2008;28:928–36. doi:10.1002/jmri.21508.
Klauss M, Lemke A, Grünberg K, Simon D, Re TJ, Wente MN, et al. Intravoxel incoherent motion MRI for the differentiation between mass forming chronic pancreatitis and pancreatic carcinoma. Invest Radiol. 2011;46:57–63. doi:10.1097/RLI.0b013e3181fb3bf2.
Kang KM, Lee JM, Yoon JH, Kiefer B, Han JK, Choi BI. Intravoxel incoherent motion diffusion-weighted MR imaging for characterization of focal pancreatic lesions. Radiology. 2014;270:444–53. doi:10.1148/radiol.13122712.
Imdahl A, Nitzsche E, Krautmann F, Högerle S, Boos S, Einert A, et al. Evaluation of positron emission tomography with 2-[18F]fluoro-2-deoxy-D-glucose for the differentiation of chronic pancreatitis and pancreatic cancer. Br J Surg. 1999;86:194–9.
Lee TY, Kim MH, do Park H, Seo DW, Lee SK, Kim JS, et al. Utility of 18F-FDG PET/CT for differentiation of autoimmune pancreatitis with atypical pancreatic imaging findings from pancreatic cancer. AJR Am J Roentgenol. 2009;193:343–8. doi:10.2214/AJR.08.2297.
Ozaki Y, Oguchi K, Hamano H, Arakura N, Muraki T, Kiyosawa K, et al. Differentiation of autoimmune pancreatitis from suspected pancreatic cancer by fluorine-18 fluorodeoxyglucose positron emission tomography. J Gastroenterol. 2008;43:144–51. doi:10.1007/s00535-007-2132-y.
Herwick S, Miller FH, Keppke AL. MRI of islet cell tumors of the pancreas. AJR Am J Roentgenol. 2006;187:W472–80.
Gallotti A, Johnston RP, Bonaffini PA, Ingkakul T, Deshpande V, Fernández-del Castillo C, et al. Incidental neuroendocrine tumors of the pancreas: MDCT findings and features of malignancy. AJR Am J Roentgenol. 2013;200:355–62. doi:10.2214/AJR.11.8037.
Poultsides GA, Huang LC, Chen Y, Visser BC, Pai RK, Jeffrey RB, et al. Pancreatic neuroendocrine tumors: radiographic calcifications correlate with grade and metastasis. Ann Surg Oncol. 2012;19:2295–303. doi:10.1245/s10434-012-2305-7.
Sheth S, Hruban RK, Fishman EK. Helical CT of islet cell tumors of the pancreas: typical and atypical manifestations. AJR Am J Roentgenol. 2002;179:725–30.
Kawamoto S, Shi C, Hruban RH, Choti MA, Schulick RD, Fishman EK, et al. Small serotonin-producing neuroendocrine tumor of the pancreas associated with pancreatic duct obstruction. AJR Am J Roentgenol. 2011;197:W482–8. doi:10.2214/AJR.10.5428.
Schmid-Tannwald C, Schmid-Tannwald CM, Morelli JN, Neumann R, Haug AR, Jansen N, et al. Comparison of abdominal MRI with diffusion-weighted imaging to 68Ga-DOTATATE PET/CT in detection of neuroendocrine tumors of the pancreas. Eur J Nucl Med Mol Imaging. 2013;40:897–907. doi:10.1007/s00259-013-2371-5.
de Herder WW, Kwekkeboom DJ, Valkema R, Feelders RA, van Aken MO, Lamberts SW, et al. Neuroendocrine tumors and somatostatin: imaging techniques. J Endocrinol Invest. 2005;28(11 Suppl International):132–6.
Christ E, Wild D, Forrer F, Brändle M, Sahli R, Clerici T, et al. Glucagon-like peptide-1 receptor imaging for localization of insulinomas. J Clin Endocrinol Metab. 2009;94:4398–405. doi:10.1210/jc.2009-1082.
d’Assignies G, Couvelard A, Bahrami S, Vullierme MP, Hammel P, Hentic O, et al. Pancreatic endocrine tumors: tumor blood flow assessed with perfusion CT reflects angiogenesis and correlates with prognostic factors. Radiology. 2009;250:407–16. doi:10.1148/radiol.2501080291.
Wang Y, Chen ZE, Yaghmai V, Nikolaidis P, McCarthy RJ, Merrick L, et al. Diffusion-weighted MR imaging in pancreatic endocrine tumors correlated with histopathologic characteristics. J Magn Reson Imaging. 2011;33(5):1071–9. doi:10.1002/jmri.22541.
Jang KM, Kim SH, Lee SJ, Choi D. The value of gadoxetic acid-enhanced and diffusion-weighted MRI for prediction of grading of pancreatic neuroendocrine tumors. Acta Radiol. 2014;55:140–8. doi:10.1177/0284185113494982.
Bhosale PR, Menias CO, Balachandran A, Tamm EP, Charnsangavej C, Francis IR, et al. Vascular pancreatic lesions: spectrum of imaging findings of malignant masses and mimics with pathologic correlation. Abdom Imaging. 2013;38:802–17. doi:10.1007/s00261-012-9954-7.
Fernández-del Castillo C, Warshaw AL. Cystic tumors of the pancreas. Surg Clin North Am. 1995;75:1001–16.
Sarr MG, Murr M, Smyrk TC, Yeo CJ, Fernandez-del-Castillo C, Hawes RH, et al. Primary cystic neoplasms of the pancreas. Neoplastic disorders of emerging importance—current state-of-the-art and unanswered questions. J Gastrointest Surg. 2003;7:417–28.
Choi JY, Kim MJ, Lee JY, Lim JS, Chung JJ, Kim KW, et al. Typical and atypical manifestations of serous cystadenoma of the pancreas: imaging findings with pathologic correlation. AJR Am J Roentgenol. 2009;193:136–42. doi:10.2214/AJR.08.1309.
Barral M, Soyer P, Dohan A, Laurent V, Hoeffel C, Fishman EK, et al. Magnetic resonance imaging of cystic pancreatic lesions in adults: an update in current diagnostic features and management. Abdom Imaging. 2014;39:48–65. doi:10.1007/s00261-013-0048-y.
Chu LC, Singhi AD, Hruban RH, Fishman EK. Characterization of pancreatic serous cystadenoma on dual-phase multidetector computed tomography. J Comput Assist Tomogr. 2014;38:258–63. doi:10.1097/RCT.10.1097/RCT.0b013e3182ab1556.
Takeshita K, Kutomi K, Takada K, Kohtake H, Furui S, Takada T, et al. Unusual imaging appearances of pancreatic serous cystadenoma: correlation with surgery and pathologic analysis. Abdom Imaging. 2005;30:610–5.
Mottola JC, Sahni VA, Erturk SM, Swanson R, Banks PA, Mortele KJ. Diffusion-weighted MRI of focal cystic pancreatic lesions at 3.0-Tesla: preliminary results. Abdom Imaging. 2012;37:110–7. doi:10.1007/s00261-011-9737-6.
Khurana B, Mortelé KJ, Glickman J, Silverman SG, Ros PR. Macrocystic serous adenoma of the pancreas: radiologic-pathologic correlation. AJR Am J Roentgenol. 2003;181:119–23.
Dewhurst CE, Mortele KJ. Cystic tumors of the pancreas: imaging and management. Radiol Clin North Am. 2012;50:467–86. doi:10.1016/j.rcl.2012.03.001.
Visser BC, Yeh BM, Qayyum A, Way LW, McCulloch CE, Coakley FV. Characterization of cystic pancreatic masses: relative accuracy of CT and MRI. AJR Am J Roentgenol. 2007;189:648–56.
Procacci C, Carbognin G, Accordini S, Biasiutti C, Guarise A, Lombardo F, et al. CT features of malignant mucinous cystic tumors of the pancreas. Eur Radiol. 2001;11:1626–30.
Crippa S, Salvia R, Warshaw AL, Domínguez I, Bassi C, Falconi M, et al. Mucinous cystic neoplasm of the pancreas is not an aggressive entity: lessons from 163 resected patients. Ann Surg. 2008;247:571–9. doi:10.1097/SLA.0b013e31811f4449.
Goh BK, Tan YM, Chung YF, Chow PK, Cheow PC, Wong WK, et al. A review of mucinous cystic neoplasms of the pancreas defined by ovarian-type stroma: clinicopathological features of 344 patients. World J Surg. 2006;30:2236–45.
Nadig SN, Pedrosa I, Goldsmith JD, Callery MP, Vollmer CM. Clinical implications of mucinous nonneoplastic cysts of the pancreas. Pancreas. 2012;41:441–6. doi:10.1097/MPA.0b013e318229b9b8.
Sarr MG, Kendrick ML, Nagorney DM, Thompson GB, Farley DR, Farnell MB. Cystic neoplasms of the pancreas: benign to malignant epithelial neoplasms. Surg Clin North Am. 2001;81:497–509.
Balci NC, Semelka RC. Radiologic features of cystic, endocrine and other pancreatic neoplasms. Eur J Radiol. 2001;38:113–9.
Chalian H, Töre HG, Miller FH, Yaghmai V. CT attenuation of unilocular pancreatic cystic lesions to differentiate pseudocysts from mucin-containing cysts. JOP. 2011;12:384–8.
Procacci C, Megibow AJ, Carbognin G, Guarise A, Spoto E, Biasiutti C, et al. Intraductal papillary mucinous tumor of the pancreas: a pictorial essay. Radiographics. 1999;19:1447–63.
Pedrosa I, Boparai D. Imaging considerations in intraductal papillary mucinous neoplasms of the pancreas. World J Gastrointest Surg. 2010;2:324–30. doi:10.4240/wjgs.v2.i10.324.
Arakawa A, Yamashita Y, Namimoto T, Tang Y, Tsuruta J, Kanemitsu K, et al. Intraductal papillary tumors of the pancreas. Histopathologic correlation of MR cholangiopancreatography findings. Acta Radiol. 2000;41:343–7.
Irie H, Honda H, Aibe H, Kuroiwa T, Yoshimitsu K, Shinozaki K, et al. MR cholangiopancreatographic differentiation of benign and malignant intraductal mucin-producing tumors of the pancreas. AJR Am J Roentgenol. 2000;174:1403–8.
Choi BS, Kim TK, Kim AY, Kim KW, Park SW, Kim PN, et al. Differential diagnosis of benign and malignant intraductal papillary mucinous tumors of the pancreas: MR cholangiopancreatography and MR angiography. Korean J Radiol. 2003;4:157–62.
Maire F, Voitot H, Aubert A, Palazzo L, O’Toole D, Couvelard A, et al. Intraductal papillary mucinous neoplasms of the pancreas: performance of pancreatic fluid analysis for positive diagnosis and the prediction of malignancy. Am J Gastroenterol. 2008;103:2871–7. doi:10.1111/j.1572-0241.2008.02114.x.
Werner JB, Bartosch-Härlid A, Andersson R. Cystic pancreatic lesions: current evidence for diagnosis and treatment. Scand J Gastroenterol. 2011;46:773–88. doi:10.3109/00365521.2011.551892.
Manfredi R, Graziani R, Motton M, Mantovani W, Baltieri S, Tognolini A, et al. Main pancreatic duct intraductal papillary mucinous neoplasms: accuracy of MR imaging in differentiation between benign and malignant tumors compared with histopathologic analysis. Radiology. 2009;253:106–15. doi:10.1148/radiol.2531080604.
Waters JA, Schmidt CM, Pinchot JW, White PB, Cummings OW, Pitt HA, et al. CT vs MRCP: optimal classification of IPMN type and extent. J Gastrointest Surg. 2008;12:101–9.
Akisik MF, Sandrasegaran K, Aisen AA, Maglinte DD, Sherman S, Lehman GA. Dynamic secretin-enhanced MR cholangiopancreatography. Radiographics. 2006;26:665–77.
Sperti C, Bissoli S, Pasquali C, Frison L, Liessi G, Chierichetti F, et al. 18-fluorodeoxyglucose positron emission tomography enhances computed tomography diagnosis of malignant intraductal papillary mucinous neoplasms of the pancreas. Ann Surg. 2007;246:932–7; discussion 937–9.
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Kartalis, N., Löhr, J.M. (2016). Radiographic Imaging. In: Wagh, M., Draganov, P. (eds) Pancreatic Masses. Springer, Cham. https://doi.org/10.1007/978-3-319-19677-0_7
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