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Preoperative Detection of Pancreatic Insulinomas on Multiphasic Helical CT

J. L. Fidler1, J. G. Fletcher1, C. C. Reading1, J. C. Andrews1, G. B. Thompson2, C. S. Grant2 and F. J. Service3

1 Department of Radiology, Mayo Clinic and Mayo Foundation, 200 First St. S.W., Rochester, MN 55905.
2 Departmemt of Surgery, Mayo Clinic and Mayo Foundation, Rochester, MN 55905.
3 Department of Endocrinology, Mayo Clinic and Mayo Foundation, Rochester, MN 55905.



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  		Fig. 1. —Atypical appearance of pancreatic insulinoma in 29-year-old woman. Multiphase helical CT scan obtained during pancreatic phase shows low-density cystic-appearing tumor (arrow) in pancreatic tail. Note surrounding decreased enhancement of pancreatic parenchyma. This patient previously underwent intraoperative exploration that did not detect insulinoma. Lack of enhancement may be caused by devascularization that occurred at time of surgery.

 


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  		Fig. 2A. —Atypical hypoenhancing appearance of pancreatic insulinoma in 37-year-old woman. Multiphase helical CT scan obtained during pancreatic phase shows hypodense insulinoma (arrow) located in pancreatic head.

 


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  		Fig. 2B. —Atypical hypoenhancing appearance of pancreatic insulinoma in 37-year-old woman. Multiphase helical CT scan obtained during portal venous phase shows hypodense insulinoma (arrow) located in pancreatic head.

 


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  		Fig. 3A. —Atypical appearance of pancreatic insulinoma in 45-year-old man. Multiphase helical CT scan obtained superiorly during arterial phase shows isodense pedunculated insulinoma (arrow) arising from superior aspect of pancreatic tail.

 


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  		Fig. 3B. —Atypical appearance of pancreatic insulinoma in 45-year-old man. Multiphase helical CT scan obtained inferiorly during arterial phase shows isodense pedunculated insulinoma (arrow) arising from superior aspect of pancreatic tail.

 


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  		Fig. 4A. —Pancreatic insulinoma in 69-year-old man. (Reprinted with permission from [23]) Arterial phase helical CT scan fails to conclusively show tumor. Only minimal nodularity is seen at location of tumor (arrow).

 


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  		Fig. 4B. —Pancreatic insulinoma in 69-year-old man. (Reprinted with permission from [23]) Pancreatic phase CT scan shows hyperenhancing insulinoma (arrow) that is more conspicuous than on arterial phase.

 


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  		Fig. 5A. —Pancreatic insulinoma in 79-year-old woman. Arterial phase CT scan (obtained superiorly) shows vessel (arrows) that obscured insulinoma. When viewing scan from superior to inferior, note that vessels diverge and insulinoma comes into view.

 


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  		Fig. 5B. —Pancreatic insulinoma in 79-year-old woman. Arterial phase CT scan (mid) shows hyperenhancing insulinoma (solid arrow) that was not detected prospectively, located next to vessel (open arrow). When observing image from superior to inferior, note that vessels diverge and insulinoma comes into view.

 


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  		Fig. 5C. —Pancreatic insulinoma in 79-year-old woman. Arterial phase CT scan (obtained inferiorly) shows hyperenhancing insulinoma (arrow) that was not detected prospectively.

 


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  		Fig. 6A. —Pancreatic insulinoma in 60-year-old woman. Pancreatic phase CT scan shows hyperenhancing insulinoma (straight arrow) in uncinate process of pancreas immediately posterior to superior mesenteric vein (curved arrow), which is minimally enhanced. Tumor was not detected prospectively.

 


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  		Fig. 6B. —Pancreatic insulinoma in 60-year-old woman. Portal venous phase CT scan shows reversal in enhancement, with insulinoma (straight arrow) more isodense to normal pancreas after washout and increased enhancement of superior mesenteric vein (curved arrow).

 

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