CT 101 :Pancreas and Spleen Shikha Khullar,, MD, MPH Division of Radiology University of South Alabama
The Pancreas
Normal Pancreas
3 Phase Pancreatic CT Non contrast Arterial phase : 30-35 35 second delay Venous phase : 70 second delay
Arterial Phase Portal vein Celiac Portal vein Spleno-portal confluence SMA CBD SMA SMV
Venous Phase Portal vein Celiac Portal vein Spleno-portal confluence SMA CBD SMV SMA
Non Contrast Portal vein Celiac Portal vein Spleno-portal confluence SMA CBD SMA
Diffuse Pancreatic Disease
Pancreatic Atrophy
Fatty Infiltration
Complete Fatty Replacement
Benign inflammatory Diseases Acute pancreatitis Chronic pancreatitis
Acute Pancreatitis CT may show normal appearing gland Edematous pancreas Stranding in peripancreatic fat, peritoneal planes Irregular decreased attenuation (edema, focal necrosis) Extension of inflammatory process to anterior pararenel space, colon
Acute Pancreatitis
Pancreatic Necrosis
Chronic Pancreatitis Strong association with alcohol abuse CT appearance Irregular dilatation of pancreatic duct Duct width/ Gland width ratio> 0.5, calcifications May present as focal mass
Chronic Pancreatitis
Focal Pancreatic Disease
Focal Pancreatic Abnormality Solid Mass Adenocarcinoma Islet Cell Tumor Others Cystic Mass Pseudocyst Non Pseudocyst IPMT Cystic Neoplasm Serous cystadenoma Mucinous Adenoma Cystic Adenocarcinoma Things that Simulate Masses Focal Pancreatitis Pancreatic Necrosis Pancreatic Laceration
Solid Pancreatic Neoplasms Adenocarcinoma Islet cell tumors
Adenocarcinoma Majority (65%) occur in head, present early CT findings Hypo-enhancing mass relative to normal parenchyma Dilated common bile duct Dilated pancreatic duct in body and tail Atrophy or pancreatitis distal to mass Convex uncinate process CT useful for staging, determining resectability
Adenocarcinoma
Adenocarcinoma
Adenocarcinoma
Adenocarcinoma Encasing SMA
Focal Pancreatic Abnormality Solid Mass Adenocarcinoma Islet Cell Tumor Others Cystic Mass Pseudocyst Non Pseudocyst IPMT Cystic Neoplasm Serous cystadenoma Mucinous Adenoma Cystic Adenocarcinoma Things that Simulate Masses Focal Pancreatitis Pancreatic Necrosis Pancreatic Laceration
Islet Cell Tumors Uncommon tumors Most common Insulinomas, gastrinomas Differentiating from adenocarcinoma arterial phase hyperenhancement presence of calcification lack of vascular ecasement absence of central necrosis, cystic change
Islet Cell Tumor
Glucagonoma
Islet Cell Tumor
Focal Pancreatic Abnormality Solid Mass Adenocarcinoma Islet Cell Tumor Others Cystic Mass Pseudocyst Non Pseudocyst IPMT Cystic Neoplasm Serous cystadenoma Mucinous Adenoma Cystic Adenocarcinoma Things that Simulate Masses Focal Pancreatitis Pancreatic Necrosis Pancreatic Laceration
Cystic Masses: A pseudocyst or not a pseudocyst?? Pseudocyst Non Pseudocyst Intraductal papillary mucinous tumor (IPMT) Cystic neoplasms (Serous cystadenoma, mucinous adenomas) Cystic adenocarcinoma
Pseudocyst Collection of pancreatic fluid Lacks septations,, mural nodules Result of acute or chronic pancreatitis or pancreatic trauma If managed non-operatively, operatively, will either spontaneously resolve or remain stable
Pseudocyst
Chronic Pancreatitis with Pseudocyst
Focal Pancreatic Abnormality Solid Mass Adenocarcinoma Islet Cell Tumor Others Cystic Mass Pseudocyst Non Pseudocyst IPMT Cystic Neoplasm Serous cystadenoma Mucinous Adenoma Cystic Adenocarcinoma Things that Simulate Masses Focal Pancreatitis Pancreatic Necrosis Pancreatic Laceration
Non Pseudocyst : IPMT Communication with pancreatic duct is diagnostic
Non Pseudocyst : IPMT
Non Pseudocyst : Cystic Neoplasms 10% of cystic pancreatic masses Two groups Microcystic adenoma (serous cystadenoma) Macrocystic adenoma (mucinous( adenoma)
Macrocystic Adenoma
The Spleen
Is the Spleen Normal?
Splenomegaly
Accessory Spleens 10-20% of population Usually near hilum Same pattern of enhancement as the spleen Same vascular supply
Accessory Spleen
Multiple Splenules
Autosplenectomy
Cystic Splenic Mass Posttraumatic pseudocyst - 80% Final stage in evolution of splenic hematoma Congenital epithelial cysts Hydatid cysts Other cystic masses: Pancreatic pseudocyst Lymphangioma, hemangioma Abscess Hematoma
Splenic Cyst
Multiple Cysts
Solid Splenic Masses Lymphoma Splenic involvement in up to 30% patients Several forms: Homogenous enlargement Miliary nodules Multi focal Single solitary mass
Other Solid Splenic Tumors Hemangioendothelioma Angiosarcoma Mesenchymal tumors teratoma) Benign Tumors (hemangioma, lymphangioma) Metastasis tumors (fibrosarcoma,leiomyosarcoma,
Splenic Metastasis
Splenic Infarcts Embolic disease- cardiac or atherosclerotic origin Sickle cell anemia Wedge shaped, base at capsule and apex towards the hilum
Splenic Infarct
Traumatic Iaceration
Take Home Message. Pathology arising from peripancreatic organs (Common Bile Duct, duodenum, lymph nodes) can be confusing Solid Pancreas Mass : Adenocarcinoma does not enhance on arterial phase while Islet cell tumors show hyperenhancement Cystic pancreas mass : Pseudocyst vs Others Pseudocyst lacks internal septations and nodules
Acknowledgements Heidi Umphrey, MD Radiology Resident, University of Alabama at Birmingham Janis O Malley, MD Head, Division of Nuclear Medicine, Department of Radiology, UAB HG Liu Research Associate, Division of Nuclear Medicine, Department of Radiology, UAB