Diagnostic Ultrasound - Abdomen and Pelvis
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Diagnostic Ultrasound - Abdomen and Pelvis

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09.07.2019 Views

Serous Cystadenoma of Pancreas (Left) Axial CECT shows a wellcircumscribed, lobulated pancreatic mass containing clusters of tiny cysts st resulting in the characteristic honeycomb appearance of a serous cystadenoma. (Right) Endoscopic ultrasound image in the same patient shows a predominantly echogenic mass due to the numerous acoustic interfaces between the innumerable tiny cysts st and intervening fibrous stroma ſt. Surgical resection confirmed this lesion to be a serous cystadenoma of the pancreas. Diagnoses: Pancreas (Left) Transverse intraoperative ultrasound of a pancreatic mass shows innumerable small cysts st with intervening linear septations ſt. (Courtesy A. Kamaya, MD.) (Right) Transverse color Doppler ultrasound of a pancreatic mass shows central echogenicity with peripherally-oriented small cysts st and color Doppler flow within intervening septa ſt. (Courtesy A. Kamaya, MD.) (Left) Transverse transabdominal ultrasound shows an ill-defined, heterogeneous hyperechoic mass in the tail of pancreas with highly reflective acoustic interfaces resulting from innumerable tiny cysts which are difficult to resolve. (Courtesy A. Kamaya, MD.) (Right) Axial contrast enhanced CT shows a large lobulated, low-attenuation mass in the body and tail of the pancreas with small cystic spaces st and dense stellate calcification ſt within the central scar of a serous cystadenoma. 373

Intraductal Papillary Mucinous Neoplasm (IPMN) Diagnoses: Pancreas TERMINOLOGY • Cystic neoplasm of pancreas arising from mucin-producing epithelium of main pancreatic duct (MPD) &/or side branch pancreatic ducts (SBD) with variable malignant potential IMAGING • Main pancreatic duct type: > 5 mm; no obstructive cause • Side branch duct type: Multicystic, grape-like cluster of cysts contiguous with the MPD • US: Not modality of choice: Difficult to evaluate entire pancreas due to bowel gas and limited characterization ○ Nonspecific anechoic or hypoechoic mass ± PD dilatation • Endoscopic ultrasound (EUS): Provides best morphologic evaluation and opportunity for cyst aspiration &/or biopsy • CT or MR: Important in identifying features associated with increased risk of malignancy • MRCP: Best noninvasive imaging modality for identification of ductal communication • Follow-up surveillance imaging with CEMR/MRCP KEY FACTS TOP DIFFERENTIAL DIAGNOSES • Mucinous cystic pancreatic neoplasm • Pancreatic serous cystadenoma • Chronic pancreatitis • Pancreatic pseudocyst • Pancreatic ductal adenocarcinoma CLINICAL ISSUES • If high-risk stigmata present based on Tanaka criteria → surgical resection • If worrisome features present → EUS for biopsy/aspiration • If no worrisome features present → follow-up interval determined by cyst size DIAGNOSTIC CHECKLIST • Look for communication between cystic lesion and pancreatic duct, which may be dilated (Left) Graphic demonstrates irregular, dilated main and branch pancreatic ducts within the head and uncinate process of the pancreas, typical of intraductal papillary mucinous neoplasm (IPMN). (Right) Transverse transabdominal ultrasound shows marked dilatation of the pancreatic duct st that measures > 10 mm in the body of the pancreas. Note the associated ill-defined hypoechoic mass posteriorly ſt. (Left) Color Doppler transabdominal ultrasound demonstrates an anechoic cystic lesion ſt communicating with a dilated main pancreatic duct st. (Right) Axial T2WI in the same patient better characterizes the presence of multiple cystic lesions ſt some of which show communication with the mildly dilated main pancreatic duct st. 374

Serous Cystadenoma of Pancreas<br />

(Left) Axial CECT shows a wellcircumscribed,<br />

lobulated<br />

pancreatic mass containing<br />

clusters of tiny cysts st<br />

resulting in the characteristic<br />

honeycomb appearance of a<br />

serous cystadenoma. (Right)<br />

Endoscopic ultrasound image<br />

in the same patient shows a<br />

predominantly echogenic mass<br />

due to the numerous acoustic<br />

interfaces between the<br />

innumerable tiny cysts st <strong>and</strong><br />

intervening fibrous stroma ſt.<br />

Surgical resection confirmed<br />

this lesion to be a serous<br />

cystadenoma of the pancreas.<br />

Diagnoses: Pancreas<br />

(Left) Transverse<br />

intraoperative ultrasound of a<br />

pancreatic mass shows<br />

innumerable small cysts st<br />

with intervening linear<br />

septations ſt. (Courtesy A.<br />

Kamaya, MD.) (Right)<br />

Transverse color Doppler<br />

ultrasound of a pancreatic<br />

mass shows central<br />

echogenicity with<br />

peripherally-oriented small<br />

cysts st <strong>and</strong> color Doppler<br />

flow within intervening septa<br />

ſt. (Courtesy A. Kamaya, MD.)<br />

(Left) Transverse<br />

transabdominal ultrasound<br />

shows an ill-defined,<br />

heterogeneous hyperechoic<br />

mass in the tail of pancreas<br />

with highly reflective acoustic<br />

interfaces resulting from<br />

innumerable tiny cysts which<br />

are difficult to resolve.<br />

(Courtesy A. Kamaya, MD.)<br />

(Right) Axial contrast<br />

enhanced CT shows a large<br />

lobulated, low-attenuation<br />

mass in the body <strong>and</strong> tail of<br />

the pancreas with small cystic<br />

spaces st <strong>and</strong> dense stellate<br />

calcification ſt within the<br />

central scar of a serous<br />

cystadenoma.<br />

373

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