Pancreas Flashcards
Which is the most typical finding of serous cystadenoma of the pancreas?
A. Numerous sub centimetre cysts forming a homogenous pattern
B. Multiple cysts < 2cm separated by a fibrous septa coalescing into a central scar
C. A few large cysts > 2cm with septae in the head of the pancreas
D. Multicystictumour larger than 10cm
E. Hypervascular solid tumour
B. Multiple cysts < 2cm separated by a fibrous septa coalescing into a central scar
In serous cystadenoma of the pancreas, the polycystic pattern with cysts < 2cm represents 70% of cases.
The honeycomb pattern occurs in 20% and macro/oligocytic type in 10%.
Giant subcutaneous serous cystic change with intraluminal haemorrhage and solid serous cystadenoma are atypical manifestations.
A 40-year-old with a Multiple Endocrine Neoplasia (MEN) syndrome has parathyroid hyperplasia with hyperparathyroidism recently diagnosed. Which of the following is a feature of MEN II rather than MEN I?
A. Pancreatic islet cell tumour
B. Pituitary gland tumour
C. Adenocortical adenoma
D. Carcinoid tumour
E. Phaeochromocytoma
E. Phaeochromocytoma
Features of MEN2A include parathyroid hyperplasia, medullary T cell carcinoma of the thyroid, and phaeochromocytoma. MEN2A may also be associated with carcinoid and Cushing’s.
@# Which is the most likely source of a metastatic deposit to the pancreas?
A. Bronchogenic carcinoma
B. Breast cancer
C. Renal Cell Carcinoma (RCC)
D. Soft tissue sarcoma
E. Colon carcinoma
C. Renal Cell Carcinoma (RCC)
The most likely primary tumor leading to a metastatic deposit to the pancreas is renal cell carcinoma. These metastases are usually solitary and heterogeneously enhancing masses with increased attenuation relative to the pancreas.
Which of the following favour a diagnosis of glucagonoma rather than somatostatinoma?
A. Arrange size > 4cm
B. Hypervascular
C. Duodenal obstruction
D. Predilection for body/tail of pancreas
E. Association with Neurofibromatosis Type 1 (NFI)
D. Predilection for body/tail of pancreas
Glucagonomas are predominantly in pancreatic body/tail, mean size 6.4 cm and hypervascular. Somatostatinomas are predominantly in pancreatic head/duodenum of ampulla of Vater.
A 35-year-old woman presents with severe watery diarrhoea. She is hypokalaemic. A neuroendocrine tumour is diagnosed in the pancreatic body measuring 5cm. This is mildly hypervascular. Which of the following is the most likely diagnosis?
A. Somatostatinoma
B. Non functional islet cell tumour
C. Glucagonoma
D. VIPoma (Verner Morrison Syndrome)
E. Gastrinoma
D. VIPoma (Verner Morrison Syndrome)
VIPOMA are usually in the pancreatic body/tail (75%).
Extrapancreatic locations include retroperitoneal ganglioblastoma, phaeochromocytoma, lung, neuroblastoma (in children).
50-80% of VIPOMAs undergo malignant transformation.
Which of the following most favours a diagnosis of an infected rather than a sterile post-necrotic fluid collection, following acute pancreatitis?
A. Presence of gas bubbles
B. Size of collection > 5cm
C. Association with extrapancreatic necrosis
D. Association with organised pancreatic necrosis
E. Association with central gland necrosis
A. Presence of gas bubbles
The only reliable feature on imaging indicating an infected collection is the presence of gas bubbles.
All three types of pancreatic necrosis, organised central gland and extrapancreatic are associated with post-necrotic fluid collection.
Necrotic pancreatitis becomes infected in 40-70%, most often with gram negative enteric bacteria.
Regarding intraductal papillary mucinous tumours (IPMT):
A. Is more common in females than mucinous cystic tumours
B. Has a higher incidence of malignancy in branch than main ducts
C. Focal wall thickening indicates malignancy with very high sensitivity and specificity
D. Parietal nodules indicate malignancy with very high sensitivity and specificity
E. Can range from hypoplasia to invasive carcinoma
E. Can range from hypoplasia to invasive carcinoma
Parietal nodules and focal wall thickening are useful indicators in detecting malignant branch IPMT but there is a high incidence of false positive errors. IPMT has a slightly higher incidence in males.
- A 65-year-old woman undergoes CT of the abdomen. An incidental finding of a well-defined 5 cm mass in the head of the pancreas is noted. It has a mean attenuation value of 5 HU, and contains multiple tiny cysts with a central nidus of calcification. There is no pancreatic duct dilatation. What is the most likely diagnosis?
A. mucinous cystadenoma
B. main duct intraductal papillary mucinous tumour
C. serous cystadenoma
D. pancreatic pseudocyst
E. pancreatic insulinoma
C. serous cystadenoma
Serous cystadenomas are benign neoplasia of the pancreas most commonly seen in older women and are frequently asymptomatic.
Typical appearances are of a cystic lesion measuring up to 20 cm in size, containing innumerable small cysts, though these may be difficult to discriminate, giving the appearance of a solid mass.
They may occur in any part of the pancreas but are slightly more common in the pancreatic head and neck.
Characteristic features include a central stellate scar containing dystrophic calcification.
Mucinous cystadenomas usually occur in the pancreatic tail (90%) and, when multilocular, contain larger cysts of >2 cm in diameter.
Pancreatic pseudocysts are usually unilocular and occur following a history of pancreatitis.
Intraductal papillary mucinous tumours of the main duct are typically associated with dilatation of the main pancreatic duct.
Insulinomas are usually small (<2 cm) solid tumours that produce symptoms early due to recurrent hypoglycaemia.
- A 50-year-old woman presents with recurrent episodes of hypoglycaemia. Biochemistry confirms endogenous insulin hypersecretion, and she undergoes multiphasic CT of the abdomen. Which of the following is the most likely finding in the pancreas?
A. 1.5 cm arterially enhancing, solid mass in the head
B. 5 cm arterially enhancing, cystic mass in the tail
C. 1.5 cm arterially enhancing, cystic mass in the body
D. 1.5 cm non-enhancing, solid mass in the tail
E. 5 cm non-enhancing, cystic mass in the body
A. 1.5 cm arterially enhancing, solid mass in the head
Insulinomas are rare tumours of the islet cells of the pancreas, which present at an early stage with hypoglycaemic episodes.
Diagnosis is made biochemically, by demonstrating fasting hyperinsulinaemia, and the main purpose of imaging is to detect and localize accurately the tumours, which tend to be small (<2 cm) at presentation.
Tumours may occur anywhere in the pancreas, with 2–5% in an ectopic location.
CT is considered the first-line investigation, but newer techniques such as MR and functional imaging are being increasingly used.
On CT, insulinomas are typically solid and highly vascular, and are best visualized on arterial-phase imaging, when they demonstrate marked enhancement.
@# 3. A 64-year-old woman presents to the dermatologist with erythematous maculopapular lesions on her legs, buttocks and face, and is diagnosed with necrolytic migratory erythema. Which initial imaging investigation is most appropriate?
A. no imaging
B. mammography
C. CT of the brain
D. chest radiograph
E. CT of the abdomen
E. CT of the abdomen
Necrolytic migratory erythema is a rare dermatological condition with a strong association with glucagonoma, an islet-cell tumour of the pancreas derived from alpha cells. Over 70% of patients with glucagonoma demonstrate the condition, and they may also complain of weight loss, diarrhoea and diabetes. The association is considered strong enough to warrant thorough investigation for pancreatic malignancy. Glucagonomas typically occur in the pancreatic body or tail, and are large (2.5– 25 cm) Hypervascular tumours with solid and necrotic components. They have a high rate of malignant transformation, and around 50% of patients have liver metastases at the time of diagnosis
- A 58-year-old man with recurrent episodes of upper abdominal pain undergoes MRCP, which demonstrates pancreatic atrophy and marked dilatation of the main pancreatic duct, which contains high T2-signal material. A low T2-signal nodular filling defect is also identified within the dilated duct. ERCP demonstrates thick mucus protruding from a bulging papilla. What is the most likely diagnosis?
A. intraductal papillary mucinous tumour
B. chronic pancreatitis
C. mucinous cystadenoma
D. pancreatic pseudocyst
E. acute pancreatitis
A. intraductal papillary mucinous tumour
Intraductal papillary mucinous tumour (IPMT) of the pancreas is characterized by a mucin-producing tumour with dilatation of the main or branch ducts of the pancreas due to copious secretions. They may arise in the main duct or branch duct. Main duct tumours typically cause dilatation of all or part of the duct, which is filled with mucinous secretions, appearing hyperintense on T2W images. A T2-hypointense intraductal filling defect may be identified, which may represent the tumour or concretions of mucin. Chronic pancreatitis may result in parenchymal atrophy and duct dilatation, with intraductal filling defects due to calculi or debris, but a bulging papilla at ERCP makes IPMT more likely. The branch duct type usually consists of conglomerated communicating cysts or a unilocular cyst in the uncinate process; these appearances may be mimicked by mucinous cystadenoma and pancreatic pseudocyst.
- A 67-year-old man undergoes Whipple’s procedure for adenocarcinoma of the head of the pancreas. Which finding is of most concern on CT of the abdomen performed 4 days postoperatively for persistent pyrexia?
A. free intraperitoneal gas
B. aerobilia in the left intrahepatic ducts
C. oral contrast within the afferent jejunal loop
D. small thin-walled fluid collection in Morison’s pouch
E. gas-containing fluid collection in the pancreatic bed
E. gas-containing fluid collection in the pancreatic bed
The two main indications for Whipple’s procedure (radical pancreaticoduodenectomy) are tumour in the periampullary region, and chronic pancreatitis involving the head and uncinate process of the pancreas.
Surgery is complex and involves gastrojejunostomy, pancreaticoenterostomy and choledochojejunostomy.
Common post-operative findings include retroperitoneal fat stranding and transient, thin-walled fluid collections, which may be in the pancreatic bed, perianastomotic or in Morison’s pouch.
Free gas is common and aerobilia is seen in around 70% of cases, more commonly in the left intrahepatic ducts.
Filling of the afferent jejunal loop with contrast is normal and occurs in up to 44% of patients.
The commonest complications are delayed gastric emptying, pancreaticojejunal leak and sepsis.
Anastomotic failure can occur at any of the sites, but the pancreaticoenterostomy is most important because of the risk of leakage of pancreatic secretions.
Anastomotic leak is associated with increased free gas, perianastomotic fluid and ascites.
Focal septic collections can occur anywhere, and complex or gas-containing areas are considered suspicious. Other early complications include vascular injury and thrombosis, Clostridium difficile colitis and pancreatitis of the pancreatic remnant.
A 42-year-old man presents with severe central abdominal pain and a raised serum amylase. 4 days later, extremely ill, the patient undergoes a CT of the abdomen which demonstrates that only the head and uncinate process of the pancreas are enhancing and there is extensive free fluid in the peri-pancreatic tissues. How you interpret these findings?
(a) Acute pancreatitis
(b) Acute pancreatitis with necrosis
(c) Acute pancreatitis infected necrosis
(d) Acute pancreatitis with abscess
(e) Acute pancreatitis with pseudocyst formation
(b) Acute pancreatitis with necrosis
The clinical scenario and imaging features clearly indicate acute pancreatitis. Areas of non-enhancement >3 cm, or > 30% of the pancreatic volume are considered reliable CT signs for necrosis. Imaging too early in clinical course will reduce the sensitivity of CT for evaluating pancreatic necrosis. Sepsis tends to complicate severe pancreatitis after first 1-2 weeks, peaking at 3 weeks, and is a common cause of mortality in these patients. A discrete abscess is less common but is suggested by the development of air within a collection. Pseudocysts are common sequelae of acute pancreatitis but take at least 4 weeks to form.
An 18-year-old male patient with known von Hippel Lindau disease is referred for abdominal imaging. Which of the following conditions would you not expect to see in association with this disease?
(a) Pheochromocytoma
(b) Serous cystadenoma of the pancreas
(c) Neuroendocrine pancreatic tumour
(d) Pancreatic cysts
(e) Adrenocortical carcinoma
(e) Adrenocortical carcinoma
There are a number of abdominal manifestations in addition to these including renal cysts and renal cell carcinoma. Epidydimal papillary cystadenoma may be seen on scrotal US in male patients.
A 46-year-old man presents with abdominal pain, fever and vomiting 5 weeks after am episode of acute pancreatitis. A CT study shows a well-circumscribed collection adjacent to the pancreas with an enhancing rim. What is the most likely diagnosis?
(a) Pseudo cyst
(b) Pancreatic abscess
(c) infective necrosis
(d) Acute pancreatitis
(e) Chronic pancreatitis
(b) Pancreatic abscess
A pancreatic abscess complicates 3%of cases of acute pancreatitis and is due to infection within a fluid collection such as a pseudocyst. Such abscesses may be found anywhere within the abdomen or pelvis and require percutaneous drainage. .
Which of the following is true of insulinomas?
(a) Men are affected twice as often as women
(b) Multiple lesions are seen in 25% cases
(c) They account for 25% Of pancreatic endocrine tumours
(d) They are associated with MEN-I syndrome
(e) Approximately 25% cases are malignant
(d) They are associated with MEN-I syndrome
Endocrine tumours account for 1 -2% Of all pancreatic tumours and insulinoma is the most common of these, representing 60% of cases. Approximately 5-10% are malignant; these tend to be the larger lesions (>5 cm). However, most lesions are less than 1.5 cm at presentation and only 5-10% cases have multiple lesions.
@# A patient with a 4-month history of severe upper abdominal pain undergoes an endoscopic US. This reports a combination of echogenic and echo-poor foci throughout the pancreas, an irregular contour of the pancreatic duct and thickening of the duct wall with some side duct dilatation. What is the most likely diagnosis?
(a) Autoimmune pancreatitis
(b) Pancreatic adenocarcinoma
(c) Intraductal papillary mucinous tumour
(d) von Hippel Linda u syndrome
(e) Chronic pancreatitis
(e) Chronic pancreatitis
These are the typical findings of chronic pancreatitis at endoscopic ultrasound.
@# Which of the following is associated with an increased risk of developing pancreatic adenocarcinoma?
(a) Hereditary pancreatitis
(b) High alcohol consumption
(c) High coffee consumption
(d) Low fiber diet
(e) Type-I diabetes mellitus
(a) Hereditary pancreatitis
There is a 70-foId increase in pancreatic adenocarcinoma in this condition. Dietary factors play no role, but cigarette smoking is associated. Diabetes mellitus may be a presenting feature, but is not associated with an increased risk Of malignancy.
A 58-year-old lady undergoes a CT of the abdomen and pelvis identifies a 4 cm cyst within the pancreas. Endoscopic US-FNA shows a unilocular cyst and yields fluid with high amylase and lipase but low CEA antigen levels. What is the diagnosis?
(a) Serous cystadenoma
(b) Mucinous cystadenoma
(c) Intraductal papillary mucinous neoplasm
(d) Mucinous cystadenocarcinoma
(e) Pseudocyst
(e) Pseudocyst
These are typical findings; there may or may not be a clear history of pancreatitis. An elevated CEA > 200 ng/ml is an indicator of malignancy.
A 51-year-old lady with recurrent episodes of central abdominal pain undergoes a CT study. This is reported to diffuse enlargement of the pancreas with a peripancreatic ‘halo’. What is the most likely diagnosis?
(a) Intraductal papillary mucinous neoplasm
(b) Autoimmune pancreatitis
(c) Chronic pancreatitis
(d) Primary pancreatic lymphoma
(e) Acute pancreatitis
(b) Autoimmune pancreatitis
This is a typical clinical presentation and characteristic imaging finding. The diagnosis needs to be confirmed histopathologically and then treated with corticosteroids, unlike other forms of pancreatitis. Relapse is well documented. Patients may progress to develop biliary complications, atrophy and chronic symptoms.
39 A 28-year-old patient is referred to the radiology department for abdominal imaging following extensive neck surgery to remove a medullary thyroid cancer and hyperplastic parathyroid glands. What, in particular, would you look for in this patient?
(a) Pancreatic islet cell tumour
(b) Gastrointestinal stromal tumour
(c) Adrenal cortical tumour
(d) Gastrointestinal ganglioneuroma
(e) Adrenal medullary tumour
(e) Adrenal medullary tumour
The patient has 2/3 components of MEN Type IIA adrenal medullary tumour being the 3rd component. NEN Type I comprises parathyroid adenoma/hyperplasia, pancreatic islet cell tumours and pituitary adenoma. NEN Type IIB comprises medullary thyroid carcinoma, adrenal medullary tumour and a variety of mucosal and cutaneous neurogenic lesions.
A 42-year-old mam undergoes a CT of the abdomen which demonstrates the presence of a 4 cm diameter cystic lesion in the pancreas. Further evaluation with endoscopic US demonstrated that the lesion comprises innumerable small cysts each less than 1.5 cm in diameter. What is the most likely diagnosis?
(a) Serous cystadenoma
(b) Pseudo cyst
(c) Intraductal papillary mucinous neoplasm
(d) Mucinous cystadenoma
(e) Mucinous cystadenocarcinoma
(a) Serous cystadenoma
This is the typical appearance of this benign cystic lesion, formerly referred to as a microcystic tumour. Mucinous tumours tend to produce larger cysts and IPMN may extend along the main or side pancreatic ducts. A pseudocyst is often unilocular but may contain debris.
A 45-year-old female patient undergoes simultaneous pancreas and kidney transplantation. A Doppler US of the pancreatic graft 1 week later shows a normal systolic low but complete reversal of diastolic blood flow in the artery. What is the most likely diagnosis?
(a) Arterial thrombosis
(b) Acute rejection
(c) Acute pancreatitis
(d) Venous thrombosis
(e) Arterio-venous shunt
(d) Venous thrombosis
This is the effect of the entire blood supply to the graft passing back and forth through the artery and is well recognised in pancreatic renal transplantation. This requires prompt intervention and may in graft loss.
A 45-year-old man is referred for abdominal imaging with a history of watery diarrhoea, hypokalaemia and achlorhydria. CT imaging demonstrates a 4 cm diameter lesion within the pancreas which demonstrates uptake of 111In-pentetreotide at scintigraphy. What is the most likely diagnosis?
(a) Insulinoma
(b) Gastrinoa
(c) Glucagonoa
(d) VIPoma
(e) Soatostatinoma
(d) VIPoma
These are the characteristic clinical features (Verner-Morrison syndrome) associated with these uncommon tumours. 90% of tumours are intrapancreatic and they measure 2-7 cm at diagnosis. Extrapancreatic lesions are usually benign, but 50% of pancreatic lesions are malignant. Lesions also take up.
- A 48 year old woman with upper abdominal pain is found to have a 4 cm hypervascular lesion in the head of the pancreas on contrast-enhanced CT. She subsequently has an MR scan; the lesion is of low intensity on fat-saturated T1-weighted and high intensity on T2-weighted imaging. Which of the following is the most likely diagnosis?
a. Pancreatic adenocarcinoma
b. Gastrinoma
c. Insulinoma
d. Macrocystic adenoma
e. Pancreatic pseudocyst
b. Gastrinoma
Pancreatic adenocarcinoma is a hypovascular lesion. Macrocystic adenoma is also hypovascular, and is only rarely found in the head of the pancreas, with a predilection for the tail. The differential therefore lies between insulinoma and gastrinoma. Although both CT and MR imaging characteristics are similar, the majority of insulinomas are less than 1 cm in size, whereas gastrinomas tend to be larger at presentation with an average size of approximately 3 cm. Gastrinoma is associated with peptic ulceration and Zollinger–Ellison syndrome.
- A 56 year old woman is diagnosed with pancreatic adenocarcinoma. Which one of the following features on the pancreatic MR contraindicates curative surgery?
a. Splenic vein invasion
b. Tumour size of 2 cm
c. Portal vein invasion
d. Hepatic artery invasion
e. Invasion of the second part of the duodenum
d. Hepatic artery invasion
The only widely recognised absolute contraindication to curative surgical resection of the options listed is invasion of the hepatic artery. Invasion of the splenic and portal veins are relative contraindications as long as the veins are not completely occluded. Invasion of the second part of the duodenum is not a contraindication as it is resected at surgery. Other features that make the tumour unsuitable for curative resection are distant metastases, ascites, distant organ invasion, SMA/ coeliac/ aortic invasion and involved lymph nodes outside the boundaries of the resection.
- A 72 year old woman has a pancreatic MR to investigate recurrent episodes of pancreatitis. There is generalised pancreatic atrophy with dilatation of the main pancreatic duct and branch ducts, particularly in the tail. No focal lesion or intraductal calculi are present. Which one of the following diagnoses is most likely?
a. Microcystic cystadenoma
b. Intraductal papillary mucinous tumour of the pancreas
c. Cystic metastases
d. Cystic islet cell tumour
e. Pancreatic lipomatosis
b. Intraductal papillary mucinous tumour of the pancreas
Intraductal papillary mucinous tumour (IPMT) of the pancreas is a rare tumour. It tends to present in the elderly population and can be a cause of recurrent pancreatitis. Two recognised types include main duct IPMT, in which the main pancreatic duct is dilated, and branch duct IPMT, in which the main duct is usually uninvolved. It is a risk factor for mucinous carcinoma of the pancreas. Pancreatic atrophy is often present. Imaging characteristics are often similar to those seen in ch pancreatitis, although calcification is not a feature of IPMT
- A 58 year old male has a CT staging scan following a diagnosis of adenocarcinoma of the body of the pancreas. The tumour is 3 cm in size and extends beyond the boundaries of the pancreas but does not invade any vessels or adjacent organs. Two 1 cm lymph nodes lie adjacent to the tumour. No other nodes, or metastatic disease in the chest, abdomen or pelvis, are identified. The tumour is best staged as which one of the following?
a. T1N0M0
b. T1N1M0
c. T2N0M0
d. T3N0M0
e. T3N1M0
e. T3N1M0
T1 tumour is disease confined to the pancreas and less than 2 cm in diameter. T2 tumour is also confined to the pancreas but greater than 2 cm in diameter. As the tumour extends beyond the boundary of the pancreas, it is at least T3. Invasion of the coeliac or superior mesenteric arteries would make this a T4 tumour, but as these features are not present it is T3. The presence of regional nodes make it N1 rather than N0 (no nodes involved), and there is no metastatic disease so it is M0. Therefore the correct radiological stage is T3N1M0.
- A 68 year old female has a pancreatic MR for characterisation of an isolated lesion within the pancreas seen initially on CT performed for unexplained weight loss. The lesion is 3 cm in diameter, isointense on T1, isointense on T2 STIR and hypointense to pancreatic parenchyma during the arterial phase of gadolinium enhancement. It remains hypointense on the venous and delayed phases of contrast enhancement. Which one of the following is the most likely diagnosis?
a. Ductal adenocarcinoma
b. Insulinoma
c. Simple pancreatic cyst
d. Gastrinoma
e. Glucagonoma
a. Ductal adenocarcinoma
Insulinoma tends to be hyperintense on contrast-enhanced images. Gastrinoma is usually hyperintense on STIR imaging and on contrast-enhanced sequences. In a series of 25 patients, an article by Chandaranaet al. showed that pancreatic adenocarcinomas were either iso- or hypointense on T1-weighted imaging and iso- or hyperintense on T2 or STIR. All adenocarcinomas were hypointense to pancreatic parenchyma during the arterial phase of gadolinium enhancement on MR, 80% remained hypointense in the venous phase of enhancement and 68% remained hypointense in the delayed phase.