Helical CT of Islet Cell Tumors of the Pancreas: Typical and Atypical Manifestations
Sheila Sheth1,
Ralph K. Hruban2 and
Elliot K. Fishman1
1 Russell H. Morgan Department of Radiology and Radiological Science, Johns
Hopkins University, 600 N. Wolfe St., Nelson B176D, Baltimore, MD 21287.
2 Department of Pathology, Johns Hopkins University, 401 N. Broadway St.,
Weinberg 2242, Baltimore, MD 21231.
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Fig. 1A. —Malignant stomatinoma in 61-year-old woman with history of
recurrent abdominal pain. Findings illustrate benefit of using water as oral
contrast agent. This subtle mass would have been obscured if positive oral
contrast material had been administered. Patient was treated with
pylorus-preserving pancreaticoduodenectomy. Axial CT image of periampullar
region obtained in arterial phase of enhancement shows 8-mm hyperattenuating
mass (arrow) obstructing pancreatic duct.
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Fig. 1B. —Malignant stomatinoma in 61-year-old woman with history of
recurrent abdominal pain. Findings illustrate benefit of using water as oral
contrast agent. This subtle mass would have been obscured if positive oral
contrast material had been administered. Patient was treated with
pylorus-preserving pancreaticoduodenectomy. Axial CT image obtained at same
level as A in venous phase shows mass (arrow) exhibiting more
intense enhancement.
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Fig. 2A. —83-year-old man with life-threatening hypoglycemia and 1.2-cm
insulinoma. Patient underwent distal pancreatectomy because enucleation of
this lesion was not possible as a result of lack of sufficient bridging
pancreatic tissue. Axial CT image of pancreas obtained in arterial phase of
enhancement shows small homogeneous hyperattenuating mass (arrow) in
neck of pancreas.
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Fig. 2B. —83-year-old man with life-threatening hypoglycemia and 1.2-cm
insulinoma. Patient underwent distal pancreatectomy because enucleation of
this lesion was not possible as a result of lack of sufficient bridging
pancreatic tissue. Axial CT image obtained at same level as A in venous
phase of enhancement shows mass (arrow) to be less conspicuous than
in arterial phase.
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Fig. 3A. —61-year-old woman with severe hypoglycemia and 1-cm
insulinoma. Axial CT image of pancreas obtained in arterial phase of
enhancement shows 1-cm homogeneous hyperattenuating mass (arrow) in
neck of pancreas.
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Fig. 3B. —61-year-old woman with severe hypoglycemia and 1-cm
insulinoma. Axial CT image of pancreas obtained in arterial phase of
enhancement at narrow window settings shows lesion (arrow) better
than A.
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Fig. 3C. —61-year-old woman with severe hypoglycemia and 1-cm
insulinoma. Axial CT image obtained at same level as A in venous phase
of enhancement shows that lesion (arrow) has become almost
inconspicuous.
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Fig. 4A. —56-year-old woman with history of pancreatic mass
incidentally detected on MR imaging at outside institution. Middle segment
pancreatectomy confirmed presence of nonfunctioning islet cell tumor and
unusual atrophy of body and tail of pancreas. Axial CT image of pancreas
obtained in arterial phase of enhancement shows subtle 2-cm hyperattenuating
mass (arrow) in body of pancreas.
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Fig. 4B. —56-year-old woman with history of pancreatic mass
incidentally detected on MR imaging at outside institution. Middle segment
pancreatectomy confirmed presence of nonfunctioning islet cell tumor and
unusual atrophy of body and tail of pancreas. Axial CT image obtained at same
level as A in venous phase of enhancement shows mass (arrow)
is nearly isoattenuating to superior mesenteric vein.
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Fig. 4C. —56-year-old woman with history of pancreatic mass
incidentally detected on MR imaging at outside institution. Middle segment
pancreatectomy confirmed presence of nonfunctioning islet cell tumor and
unusual atrophy of body and tail of pancreas. Axial CT image obtained 15 mm
below level of A shows gland distal to lesion is completely replaced
with fatty tissue (arrowheads).
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Fig. 5A. —43-year-old man with history of multiple endocrine neoplasia
type 1 and 3-cm nonfunctioning islet cell tumor. Surgical enucleation of mass
confirmed diagnosis. Axial CT image of pancreas obtained in arterial phase of
enhancement shows 3-cm exophytic and partially cystic mass (arrow)
arising from tail of pancreas.
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Fig. 5B. —43-year-old man with history of multiple endocrine neoplasia
type 1 and 3-cm nonfunctioning islet cell tumor. Surgical enucleation of mass
confirmed diagnosis. Axial CT image obtained at same level as A in
venous phase of enhancement shows heterogeneous bright enhancement in lesion
(arrow).
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Fig. 6A. —Nonfunctioning islet cell tumor in 45-year-old woman with
history of abdominal pain. Diagnosis of benign nonfunctioning islet cell tumor
was established at pancreaticoduodenectomy. Axial CT image of pancreas
obtained in arterial phase of enhancement shows 2-cm mass (arrow) in
uncinate process of pancreas. Lesion is hypoattenuating compared with normal
parenchyma. Note unopacified inferior vena cava (arrowhead) posterior
to mass.
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Fig. 6B. —Nonfunctioning islet cell tumor in 45-year-old woman with
history of abdominal pain. Diagnosis of benign nonfunctioning islet cell tumor
was established at pancreaticoduodenectomy. Axial CT image obtained at same
level as A in venous phase of enhancement shows that mass
(arrow) has become nearly isoattenuating relative to pancreas and is
nearly inconspicuous except for subtle ring enhancement. This enhancement
pattern is unusual for adenocarcinoma and islet cell tumors.
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Fig. 7A. —Malignant nonfunctioning islet cell tumors in 39-year-old
woman with history of von Hippel-Lindau syndrome. Patient underwent
pancreaticoduodenectomy. Axial CT image of pancreas obtained in arterial phase
of enhancement shows 3.5-cm hypervascular mass (arrow) with
hypoattenuating center and ring enhancement in uncinate process of pancreas.
Note small left renal cyst (arrowhead).
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Fig. 7B. —Malignant nonfunctioning islet cell tumors in 39-year-old
woman with history of von Hippel-Lindau syndrome. Patient underwent
pancreaticoduodenectomy. Axial CT image obtained at same level as A in
venous phase of enhancement shows that enhancement in lesion (arrow)
is more evident in this phase.
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Fig. 8A. —Malignant nonfunctioning islet cell tumor in 46-year-old man
with abdominal pain. No vascular invasion was noted at time of
pancreaticoduodenectomy. Axial CT image of pancreas obtained in arterial phase
of enhancement shows 6-cm hypervascular mass (arrow) in head of
pancreas. Note central low-attenuation area of necrosis
(arrowhead).
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Fig. 8B. —Malignant nonfunctioning islet cell tumor in 46-year-old man
with abdominal pain. No vascular invasion was noted at time of
pancreaticoduodenectomy. Axial CT image obtained at same level as A in
venous phase of enhancement shows that superior mesenteric vein (curved
arrow) is well opacified and does not appear invaded. Straight arrow
shows hypervascular mass.
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Fig. 9A. —Malignant nonfunctioning islet cell tumor in 45-year-old man
with abdominal pain. Extended pancreaticoduodenectomy was required to remove
entire tumor, and peripancreatic spread was confirmed at pathology. Axial CT
image of pancreas obtained in arterial phase shows 6-cm heterogeneously
enhancing hypervascular mass (arrow) in head of pancreas. Tumor
appears to extend into peripancreatic fat.
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Fig. 9B. —Malignant nonfunctioning islet cell tumor in 45-year-old man
with abdominal pain. Extended pancreaticoduodenectomy was required to remove
entire tumor, and peripancreatic spread was confirmed at pathology. Axial CT
image obtained at same level as A in venous phase of enhancement shows
portal confluence (arrow) to be markedly narrowed.
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Fig. 9C. —Malignant nonfunctioning islet cell tumor in 45-year-old man
with abdominal pain. Extended pancreaticoduodenectomy was required to remove
entire tumor, and peripancreatic spread was confirmed at pathology. Coronal
reconstruction image obtained in arterial phase of enhancement shows tumor
abutting gastroduodenal artery (arrow).
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Fig. 9D. —Malignant nonfunctioning islet cell tumor in 45-year-old man
with abdominal pain. Extended pancreaticoduodenectomy was required to remove
entire tumor, and peripancreatic spread was confirmed at pathology. Coronal
reconstruction image obtained in venous phase of enhancement confirms severe
narrowing of portal confluence (arrow).
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Fig. 10A. —Malignant nonfunctioning islet cell tumors with liver
metastases in 58-year-old woman referred from outside institution for therapy.
Patient underwent distal pancreatectomy and splenectomy as well as wedge
resection and ablation of hepatic metastases. Axial CT image of pancreas
obtained in arterial phase of enhancement shows 5-cm heterogeneously enhancing
mass (arrow) in body and tail of pancreas. Portions of mass are
hyperattenuating. Note at least two small enhancing liver metastases
(arrowheads).
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Fig. 10B. —Malignant nonfunctioning islet cell tumors with liver
metastases in 58-year-old woman referred from outside institution for therapy.
Patient underwent distal pancreatectomy and splenectomy as well as wedge
resection and ablation of hepatic metastases. Axial CT image obtained at same
level as A in venous phase of enhancement shows that liver lesions have
become isoattenuating compared with normal liver parenchyma and are
inconspicuous. Splenic vein is invaded by mass (arrow).
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Fig. 10C. —Malignant nonfunctioning islet cell tumors with liver
metastases in 58-year-old woman referred from outside institution for therapy.
Patient underwent distal pancreatectomy and splenectomy as well as wedge
resection and ablation of hepatic metastases. Axial CT image obtained at level
of gastric fundus shows collateral veins (arrow) nicely outlined by
water-filled stomach.
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Fig. 11A. —Small insulinoma in 87-year-old man with history of severe
hypoglycemia. Tumor was easily enucleated from pancreas at surgery. Axial CT
image of pancreas obtained in arterial phase of enhancement shows 2-cm
pseudocyst (arrow) in head of pancreas. One-centimeter adjacent mass
is difficult to see.
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Fig. 11B. —Small insulinoma in 87-year-old man with history of severe
hypoglycemia. Tumor was easily enucleated from pancreas at surgery. Axial CT
image obtained at same level as A in venous phase shows lesion
(arrow) enhanced almost to same degree as adjacent portal vein.
Lesion was mistaken for vessel on preliminary review.
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Fig. 11C. —Small insulinoma in 87-year-old man with history of severe
hypoglycemia. Tumor was easily enucleated from pancreas at surgery. Sagittal
reconstruction image obtained in venous phase of enhancement clearly shows
lesion (arrow) anterior to superior mesenteric vein.
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Fig. 12A. —Hypervascular pancreatic metastasis in 69-year-old man with
history of left nephrectomy for renal cell carcinoma 10 years earlier. Axial
CT image of pancreas obtained in arterial phase of enhancement shows
hyperattenuating mass (arrow) in body and tail of pancreas. Note
small hypervascular hepatic metastasis (arrowhead).
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Fig. 12B. —Hypervascular pancreatic metastasis in 69-year-old man with
history of left nephrectomy for renal cell carcinoma 10 years earlier. Axial
CT image obtained at same level as A in venous phase of enhancement
shows that enhancement in pancreatic mass (arrow) is not as
pronounced as in A. Note that liver metastasis has become
inconspicuous, collateral veins (arrowhead) are present, and splenic
vein is occluded.
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Copyright © 2002 by the American Roentgen Ray Society.
