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

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09.07.2019 Views

Intraductal Papillary Mucinous Neoplasm (IPMN) (Left) Axial CT demonstrates marked diffuse dilation of the main pancreatic duct st with intraluminal soft tissue nodularity ſt. (Right) Curved planar reconstruction in the same patient demonstrates the diffusely dilated main pancreatic duct st communicating with a cystic mass in the head of the pancreas. Note the irregular peripheral soft tissue thickening and nodularity . Diagnoses: Pancreas (Left) Endoscopic ultrasound in the same patient better demonstrates mural nodularity associated with the cystic lesion ſt in the pancreatic head, contiguous with a dilated main pancreatic duct (not shown). (Right) Endoscopic ultrasound in a different patient demonstrates a diffusely dilated pancreatic duct (labeled PD) communicating with a focal cystic lesion (labeled cyst), consistent with a main duct IPMN. (Left) Axial CECT shows very marked dilatation of the pancreatic duct ſt and a large infiltrative soft tissue mass st compatible with malignant transformation of a main duct IPMN. Note the cavernous transformation of the portal vein due to venous occlusion from the mass. (Right) Corresponding endoscopic ultrasound shows the very dilated, mucin-filled duct ſt with low-level echoes and the large soft tissue mass st arising posteriorly. 379

Pancreatic Ductal Carcinoma Diagnoses: Pancreas TERMINOLOGY • Solid epithelial neoplasm from ductal epithelium of exocrine pancreas IMAGING • Ill-defined pancreatic mass obstructing pancreatic and possibly common bile duct (producing "double duct" sign) • Best imaging tool: CECT for demonstrating mass and evaluating resectability • Without metastatic disease, resectability determined by vascular involvement ○ Best assessed on CTA using NCCN criteria • US often first-line imaging to evaluate obstructive jaundice ○ Often shows level of obstruction ○ Not as sensitive as CT or MR for demonstrating mass or assessing resectability TOP DIFFERENTIAL DIAGNOSES • Chronic pancreatitis KEY FACTS • Mucinous cystic pancreatic neoplasm • Lymphoma • Neuroendocrine tumor of pancreas • Metastases CLINICAL ISSUES • Poor overall prognosis;5-year survival rate of ~ 5% • Usually presents late with unresectable disease • Better long-term survival through complete resection DIAGNOSTIC CHECKLIST • Heterogeneous pancreatic head mass with ductal dilatation, upstream atrophy, and often extensive local extension around vessels, &/or regional metastases (Left) Graphic shows an infiltrative mass in the pancreatic head partially obstructing the common bile duct and pancreatic duct. Superior mesenteric vessels are encased . Celiac nodes are present. (Right) Longitudinal oblique color Doppler ultrasound shows an ill-defined, solid, hypoechoic mass in the pancreatic head obstructing the terminal portion of the common bile duct with proximal dilatation ſt. (Left) Longitudinal oblique color Doppler ultrasound shows dilatation of the common bile duct in the porta hepatis ſt and a solid, hypoechoic hepatic metastasis . Note the sludge-filled gallbladder . (Right) Transverse transabdominal ultrasound in the same patient shows a large, ill-defined, solid, hypoechoic mass in the pancreatic head, with pancreatic duct dilatation ſt in the atrophic pancreatic body and tail. 380

Intraductal Papillary Mucinous Neoplasm (IPMN)<br />

(Left) Axial CT demonstrates<br />

marked diffuse dilation of the<br />

main pancreatic duct st with<br />

intraluminal soft tissue<br />

nodularity ſt. (Right) Curved<br />

planar reconstruction in the<br />

same patient demonstrates<br />

the diffusely dilated main<br />

pancreatic duct st<br />

communicating with a cystic<br />

mass in the head of the<br />

pancreas. Note the irregular<br />

peripheral soft tissue<br />

thickening <strong>and</strong> nodularity .<br />

Diagnoses: Pancreas<br />

(Left) Endoscopic ultrasound in<br />

the same patient better<br />

demonstrates mural<br />

nodularity associated with<br />

the cystic lesion ſt in the<br />

pancreatic head, contiguous<br />

with a dilated main pancreatic<br />

duct (not shown). (Right)<br />

Endoscopic ultrasound in a<br />

different patient<br />

demonstrates a diffusely<br />

dilated pancreatic duct<br />

(labeled PD) communicating<br />

with a focal cystic lesion<br />

(labeled cyst), consistent with<br />

a main duct IPMN.<br />

(Left) Axial CECT shows very<br />

marked dilatation of the<br />

pancreatic duct ſt <strong>and</strong> a large<br />

infiltrative soft tissue mass st<br />

compatible with malignant<br />

transformation of a main duct<br />

IPMN. Note the cavernous<br />

transformation of the portal<br />

vein due to venous<br />

occlusion from the mass.<br />

(Right) Corresponding<br />

endoscopic ultrasound shows<br />

the very dilated, mucin-filled<br />

duct ſt with low-level echoes<br />

<strong>and</strong> the large soft tissue mass<br />

st arising posteriorly.<br />

379

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