Making Sense of Mucin-Producing Pancreatic Tumors
John R. Grogan1,
Kia Saeian2,
Andrew J. Taylor1,3,
Francisco Quiroz1,
Michael J. Demeure4 and
Richard A. Komorowski5
1
Department of Radiology, Medical College of Wisconsin, 8701 Watertown Plank
Rd., Milwaukee, WI 53226.
2
Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
53226.
3
Present address: Department of Radiology, Box 3252, University of Wisconsin
Medical School, E3/311 Clinical Science Center, 600 Highland Ave., Madison, WI
53792-3252.
4
Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
53226.
5
Department of Pathology, Medical College of Wisconsin, Milwaukee, WI
53226.
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Fig. 1. —Side branch intraductal papillary mucinous neoplasm. Drawing
shows abnormal cells in uncinate side branches that produce large enough
quantity of mucus (yellow) to distend side branch system. Mucus can
spill over to enlarge adjacent main pancreatic duct. Note that papillary
orifice gapes with extruding mucus. Abnormal cells that are not visible may be
hyperplastic lining (blue). Subtle elevated area or polypoid
projection (purple) can occasionally be seen separate from mobile
mucus.
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Fig. 2. —34-year-old man with pancreatitis who presented for
endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic image shows
patulous papillary orifice (arrow) with mucus bulging into lumen.
Note ERCP cannula (asterisk).
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Fig. 3. —Main duct intraductal papillary mucinous neoplasm. This
schematic illustrates marked main pancreatic duct distention from mucus
(yellow). Pancreatic parenchyma atrophies. As in side branch
intraductal papillary mucinous neoplasm, abnormal mucus-producing cells are
usually subtle in appearance if seen at all. Blue = hyperplastic cells, purple
= intraluminal excrescences.
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Fig. 4. —Mucinous cystic neoplasm. Schematic shows mass emanating from
pancreas without connection to duct system. Capsule is formed from outer
fibrous sheath (stippled) and inner ovarian stroma (pink).
Lining may be hyperplastic (blue) or develop intraluminal projections
such as polyps (purple) or septa (white). There may be areas
of normal columnar epithelia, which can result in false-negative findings at
biopsy if more aggressive epithelia present are not sampled. Yellow =
mucus.
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Fig. 5A. —Side branch intraductal papillary mucinous neoplasm in
46-year-old man with abdominal pain and pancreatitis. CT scan obtained through
pancreatic head shows numerous small "cysts"
(arrows).
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Fig. 5B. —Side branch intraductal papillary mucinous neoplasm in
46-year-old man with abdominal pain and pancreatitis. CT scan obtained 10 mm
caudad to A shows cyst is actually composed of dilated main pancreatic
duct (d) and enlarged uncinate side branch (b), which forms curvilinear
tube.
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Fig. 6. —Main duct intraductal papillary mucinous neoplasm in
66-year-old male renal transplant patient with abdominal pain and recent onset
of diabetes. Unenhanced CT scan through pancreatic body shows diffusely
dilated main pancreatic duct (arrows) with severe parenchymal
atrophy.
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Fig. 7. —Mucinous cystic neoplasm in 63-year-old woman with pancreatic
mass found at workup for vague left upper quadrant fullness. CT scan shows
complex, multilocular mass involves body and tail. At surgery, this mucinous
cystic neoplasm was found to be malignant with metastatic disease to
liver.
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Fig. 8A. —Endoscopic retrograde pancreatograms show side branch
intraductal papillary mucinous neoplasm in this 38-year-old man presenting
with recurrent bouts of epigastric pain. Early during injection of contrast
material, filling defects are seen in main pancreatic duct (straight
arrows). Dilated uncinate side branch is partially filled with mucus
(curved arrow), making it difficult to see.
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Fig. 8B. —Endoscopic retrograde pancreatograms show side branch
intraductal papillary mucinous neoplasm in this 38-year-old man presenting
with recurrent bouts of epigastric pain. After most of mucus has been removed
using retrieval balloon, abnormal side branch (arrowhead) can be
readily seen.
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Fig. 9A. —Endoscopic retrograde pancreatogram shows main duct
pancreatic intraductal papillary mucinous neoplasm in this 66-year-old renal
transplant patient with abdominal pain and diabetes (same patient as in
Fig. 6). Early during injection
of contrast material, there is massively dilated main pancreatic duct with
diffuse filling defects.
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Fig. 9B. —Endoscopic retrograde pancreatogram shows main duct
pancreatic intraductal papillary mucinous neoplasm in this 66-year-old renal
transplant patient with abdominal pain and diabetes (same patient as in
Fig. 6). With removal of mucus,
large polypoid mass (arrow) is revealed. Brushings were obtained at
this time.
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Fig. 10. —56-year-old woman with pancreatitis is shown to have
calcification associated with an intraductal papillary mucinous neoplasm.
Endoscopic retrograde pancreatogram shows calcification (arrowhead)
in main pancreatic duct just above sphincteric segment. This large
calcification straddles junction of main duct and uncinate side branch, which
was later filled.
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Fig. 11. —34-year-old woman with recurrent bouts of pancreatitis.
Endoscopic retrograde pancreatogram shows dilated side branch
(arrowhead), but throughout this and subsequent examinations, no
filling defects were discovered. No mucin was returned on balloon sweeps.
However, because of side branch ectasia, diagnosis of intraductal papillary
mucinous neoplasm was made and subsequently proved at surgery.
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Fig. 12A. —54-year-old man with recurrent pancreatitis who underwent
both CT and MR imaging for what was eventually found at surgery to be side
branch intraductal papillary mucinous neoplasm. CT scan shows complex cystic
mass (arrow) in pancreatic head.
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Fig. 12B. —54-year-old man with recurrent pancreatitis who underwent
both CT and MR imaging for what was eventually found at surgery to be side
branch intraductal papillary mucinous neoplasm. Gadolinium-enhanced MR image
shows better than CT scan individual ectatic side branches
(arrowhead) forming tubes within uncinate process.
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Fig. 13A —Incidental mass found on lumbar spine MR image in this
80-year-old woman with lower back pain. Diagnosis of mucinous cystic neoplasm
was made on basis of imaging characteristics in association with patient's
sex, age, and lack of presenting complaints. Large mass in pancreatic tail can
be seen on CT scan. Contrast material could not be given because of renal
failure. Mass appears to be unilocular. Notice calcification in wall
(arrow).
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Fig. 13B. —Incidental mass found on lumbar spine MR image in this
80-year-old woman with lower back pain. Diagnosis of mucinous cystic neoplasm
was made on basis of imaging characteristics in association with patient's
sex, age, and lack of presenting complaints. T2-weighted MR image better shows
complex septa not seen on CT scan.
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Fig. 14. —71-year-old man who presented for endoscopic sonography after
detection of incidental pancreatic mass found during CT workup (not shown) for
biopsy-proven hepatocellular carcinoma. Endoscopic sonogram shows pancreatic
mass (arrows) to be complex with thick septa and nodules. Biopsy
sample was obtained at this time. Malignant mucinous tumor, intraductal
papillary mucinous neoplasm, was diagnosed at pathologic examination. Asterisk
= needle.
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Fig. 15A. —Chronic calcific pancreatitis simulates intraductal papillary
mucinous neoplasm at CT in this 57-year-old man with recurrent bouts of
pancreatitis. Pancreatic CT performed in 1991 (not shown) showed only subtle
main pancreatic duct dilatation. Six years later, CT shows marked change. CT
scan obtained through body and tail of pancreas shows diffuse dilatation of
main pancreatic duct (arrow) with calcifications
(arrowheads).
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Fig. 15B. —Chronic calcific pancreatitis simulates intraductal papillary
mucinous neoplasm at CT in this 57-year-old man with recurrent bouts of
pancreatitis. Pancreatic CT performed in 1991 (not shown) showed only subtle
main pancreatic duct dilatation. Six years later, CT shows marked change. CT
scan obtained just caudad to A shows complex cystic mass related to
uncinate is present (arrow). Patient had only changes of chronic
calcific pancreatitis at surgical resection without abnormal epithelial
cells.
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Fig. 16. —Pancreatic carcinoma simulates mucinous cystic neoplasm in
63-year-old woman who presented with left upper quadrant pain and no history
of alcohol abuse. Contrast-enhanced CT scan revealed complex mass
(straight arrows) in pancreatic tail. There is extension of this mass
(arrowhead) into spleen, with splenic infarction and thrombosed
splenic vein. Adjacent pancreas (curved arrow) is abnormally low in
attenuation. At surgery, pancreatic ductal carcinoma was found with extensive
local spread and associated pseudocyst.
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Fig. 17. —Pancreatic ductal carcinoma simulates intraductal papillary
mucinous neoplasm in this 57-year-old man with abdominal distention and
jaundice. CT scan reveals marked dilatation of main pancreatic duct
(arrow). This dilatation with parenchymal atrophy could simulate main
duct intraductal papillary mucinous neoplasm. However, there is dilatation of
biliary tree as well. Biopsy of low-attenuation area within uncinate process
(not shown) revealed pancreatic ductal carcinoma.
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Fig. 18. —Intraductal pancreatic ductal adenocarcinoma simulates main
duct intraductal papillary mucinous neoplasm in this 71-year-old man
presenting with steatorrhea. Endoscopic retrograde pancreatogram shows nodular
filling defect on initial injection of contrast material. On subsequent
injection, this filling defect did not move. There is ductal dilatation
upstream. At surgery, this was ductal pancreatic carcinoma with primarily
intraductal growth.
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Fig. 19A. —Islet cell tumor simulating mucinous cystic neoplasm.
38-year-old woman with pancreatic mass found during pregnancy. CT scan shows
cystic mass (arrow) in pancreatic head. At surgery, this mass proved
to be cystic islet cell tumor.
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Fig. 19B. —Islet cell tumor simulating mucinous cystic neoplasm.
63-year-old man who presented with diarrhea. CT scan shows complex mass
(arrow) involving tail of pancreas. At surgery, this mass was
necrotic islet cell tumor of pancreas.
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Fig. 20. —Necrotic pancreatic sarcoma mimics mucinous cystic neoplasm
in this 58-year-old man with left upper quadrant pain. CT scan reveals large
complex mass that could be interpreted as mucinous cystic neoplasm, but at
surgery mass was shown to be sarcoma. Note metastasis to liver
(arrows).
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Fig. 21. —16-year-old girl who presented with mid epigastric pain was
found to have solid and pseudopapillary epithelial neoplasm, which could be
confused with mucinous cystic neoplasm. CT scan shows complex mass
(arrow) in pancreatic head. Even though this mass could simulate
mucinous cystic neoplasm, age and sex of this patient would more likely
indicate solid and pseudopapillary epithelial neoplasm, which was removed at
surgery.
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Fig. 22. —Multiloculated mass, incidentally found on this CT scan, in
51-year-old woman has appearance of a mucinous cystic neoplasm; however, at
surgery, it proved to be serous cystadenoma.
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Fig. 23. —45-year-old woman who presented with epigastric pain. On CT
scan, pancreatic head mass appears fairly well circumscribed and of water
attenuation with small nodule in its wall (arrow). This mass proved
to be lymphoepithelial cyst at surgery.
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Fig. 24A. —28-year-old woman with von Recklinghausen's disease who
presented with complaints of abdominal pain related to pancreatitis. CT scan
obtained through pancreatic body and tail reveals moderate dilatation of main
pancreatic duct (arrow).
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Fig. 24B. —28-year-old woman with von Recklinghausen's disease who
presented with complaints of abdominal pain related to pancreatitis. CT scan
obtained slightly caudad to A shows pancreatic duct dilatation coursing
toward papilla (arrowhead). At surgery, periampullary adenoma was
selectively obstructing pancreatic duct at ampulla.
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Copyright © 2001 by the American Roentgen Ray Society.
