Imaging and Pathology of Pancreatic Neoplasms

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2 Mirko D Onofrio Paola Capelli Paolo Pederzoli Editors Imaging and Pathology of Pancreatic Neoplasms A Pictorial Atlas Forewords by Claudio Bassi and Roberto Pozzi Mucelli With contribution by Alec J. Megibow 123

3 Imaging and Pathology of Pancreatic Neoplasms

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5 Mirko D'Onofrio Paola Capelli Paolo Pederzoli Editors Imaging and Pathology of Pancreatic Neoplasms A Pictorial Atlas Forewords by Claudio Bassi and Roberto Pozzi Mucelli With a contribution by Alec J. Megibow

6 Editors Mirko D'Onofrio Department of Radiology G.B. Rossi University Hospital Verona Italy Paolo Pederzoli Department of Surgery Casa di Cura Dott. Pederzoli Peschiera del Garda (Verona) Italy Paola Capelli Department of Pathology G.B. Rossi University Hospital Verona Italy ISBN ISBN (ebook) DOI / Springer Milan Heidelberg New York Dordrecht London Library of Congress Control Number: Springer-Verlag Italia 2015 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher's location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (

7 Professor Carlo Procacci had perceived the idea of creating an atlas on the imaging and pathology of pancreatic neoplasms around the year Carlo Procacci was born in Corato, Italy, in 1950 and died in Verona, Italy, in His idea was revived in 2012 by Paola Capelli, resulting in this book. Thanks Professor, the teachings last forever. Mirko D Onofrio Friend, you will forever be in our thoughts as your thoughts will always be part of us. Alec J. Megibow

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9 Foreword I The Verona Pancreas Centre, first of its kind in Italy and among only very few in the world, devotes itself in an interdisciplinary approach to the problems of this organ, focussing on the patient, on research, and on teaching. This dedicated center is based on 40 years of tradition. Many respected colleagues provided essential contributions in surgery, gastroenterology, oncology, pathology, and radiology. In this latter field, Prof. Carlo Procacci gave an essential impetus in going from mere descriptive radiology to a clinical approach emphasizing the integration with other disciplines. Carlo was a radiologist who worked by seeing, perceiving, and understanding: he often was encountered in the surgical operating rooms checking ex vivo what he had seen by reflex, as he usually said during those years. His weekly Thursday afternoon interdisciplinary meetings strengthened the diagnostic and strategic potential of the pancreas Team, and this format for clinical discussions is maintained here to the present days. I believe that Mirko D Onofrio, at that time one of the younger and favorite of Carlo s apprentices, has brilliantly compiled his teachings in this volume, reflecting how Prof. Procacci was able to share his knowledge with others. Apart from the professional perspectives, this book, for my brotherly friendship with Carlo, moves me deeply and makes me feel he is still alive, here next to me. Thanks Mirko and thanks to all your collaborating colleagues. Verona, Italy Claudio Bassi vii

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11 Foreword II Diagnostic imaging and pathology play a crucial role in the diagnosis of pancreatic diseases. Radiology and pathology are two distinct disciplines, but with common interests. Today, the amount of information provided by ultrasonography, computed tomography, and magnetic resonance images together reflects the macroscopic appearance of the pathological specimen, and in many cases, the images of these modalities contain data that correlate with the histological characteristics of the lesion. Therefore, for modern radiologists, comparing their data with the knowledge obtained by the pathologists has become an important part of education. In this perspective, this pictorial atlas focusses on the correlation between imaging and pathology based on an enormously large series of cases of pancreatic neoplasms including a large variety of uncommon types of tumors. This book draws on the long experience gathered in Verona, starting from many years ago at the Policlinico Borgo Roma, now Policlinico G. B. Rossi, with studies of pancreatic diseases, which has involved distinguished surgeons, pathologists, and radiologists well known in Italy and other countries. The book project is largely based on the enthusiasm of three colleagues: Paolo Pederzoli, with whom I have had the privilege to collaborate for 10 years; Paola Capelli, who has a deep knowledge of the pathology of the pancreas; and Mirko D Onofrio, who, besides being a respected radiologist at my department, has a broad knowledge of modern imaging modalities with a special emphasis on pancreatic diseases. The deep knowledge of these individuals and the extensive daily debates between surgeon, pathologist, and radiologist have promoted the reciprocal professional growth in this field. This pictorial atlas is organized into ten chapters, covering the entire spectrum of pancreatic neoplasms. Besides ductal adenocarcinoma, which is the most common pancreatic neoplasm, the reader will also find descriptions of rare and relatively rare neoplasms, such as neuroendocrine and cystic tumors. Although some of these lesions are rare and thus possibly of limited importance, the increased use of ultrasonography, computed tomography, and magnetic resonance imaging has led to an increased incidence, as in the case of some types of cystic tumors detected with greater frequency by magnetic resonance imaging. This broad collection of cases allows the reader to easily find in this pictorial atlas answers to the most difficult challenges in the diagnostic imaging of pancreatic neoplasms. Thanks to the excellent quality of the images, one can immediately understand the pathological features of the studied pancreatic diseases. Verona, Italy Roberto Pozzi Mucelli ix

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13 Acknowledgments The volume editors wish to express their most sincere thanks to the following colleagues, for their invaluable contribution and the precious exchange of constructive clinical and scientific experiences: Alec J. Megibow, Cristina Hajdu, Christoph Dietrich, Enrico Martone, Giancarlo Mansueto, Giovanni Carbognin, Carlo Biasiutti, Rossella Graziani, Alessandro Guarise, Elisabetta Buscarini, Paolo Arcidiacono, Arnaldo Fuini, Marco Ferdeghini, Franco Bonetti, Erminia Manfrin, Alice Parisi, Massimo Pregarz, Luigi Romano, Giuseppe Zamboni The volume editors are furthermore grateful to the following collaborators, for their effective technical support: Alma Olivieri, Renato Padovani, Flavio Rigo, Manola Crestani, Nicola Sperandio, Stefano Minutelli xi

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15 Contents Ductal Adenocarcinoma Mirko D Onofrio, Paola Capelli, Riccardo De Robertis, Paolo Tinazzi Martini, Emilo Barbi, Claudia Zampini, Stefano Crosara, Giovanni Morana, and Roberto Pozzi Mucelli Neuroendocrine Neoplasms Paola Capelli, Mirko D Onofrio, Stefano Crosara, Paolo Tinazzi Martini, Riccardo De Robertis, Matteo Fassan, Stefano Gobbo, Aldo Scarpa, and Roberto Pozzi Mucelli Intraductal Papillary Mucinous Neoplasm (IPMN) Giovanni Morana, Mirko D Onofrio, Paolo Tinazzi Martini, Riccardo De Robertis, Stefano Crosara, Claudio Luchini, Riccardo Manfredi, Riccardo Zanato, and Paola Capelli Serous Neoplasms Paola Capelli, Paolo Tinazzi Martini, Mirko D Onofrio, Giovanni Morana, Riccardo De Robertis, Claudio Luchini, Stefano Canestrini, Stefano Gobbo, and Roberto Pozzi Mucelli Mucinous Neoplasms Mirko D Onofrio, Paola Capelli, Riccardo De Robertis, Claudio Luchini, Paolo Tinazzi Martini, Stefano Crosara, Emilio Barbi, and Giovanni Morana Solid Pseudopapillary Neoplasms Giulia Anna Zamboni, Maria Chiara Ambrosetti, Sara Pecori, Riccardo Manfredi, and Paola Capelli Secondary Tumors and Lymphoma Paolo Tinazzi Martini, Roberto Malagò, Paola Capelli, Emanuele Demozzi, Valentina Ciaravino, Francesco Erdini, Miriam Ficial, and Roberto Pozzi Mucelli Rare Neoplasms Roberto Malagò, Paola Capelli, Riccardo De Robertis, Valentina Ciaravino, Federica Pedica, and Roberto Pozzi Mucelli Driving Questions and Flowcharts Riccardo De Robertis, Paolo Tinazzi Martini, Stefano Crosara, Stefano Canestrini, and Mirko D Onofrio Imaging Stigmata Review and Interpretation Anna Gallotti, Francesco Alessandrino, and Fabrizio Calliada Index xiii