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CASOLA Pancreas

CASOLA Pancreas

• Acute pancreatitis

• Pancreatic Tumors

Acute Pancreatitis Acute Pancreatitis Clinical Spectrum

The most terrible of all calamities Mild Severe that occur in connection with the abdominal viscera. interstitial necrotizing edematous fulminant Moynihan B. Ann Surg. 1925;81:132-142 self-limiting lethal

Acute Pancreatitis Pathophysiology Mild Acute Pancreatitis

Activation of Pancreatic Enzymes Netter Ciba Collection

Mediators, cytokines release

Systemic manifestations

SIRS MODS ARDS SEPSIS Severe Acute Pancreatitis Predictors of Severity

• Clinical scores: Ranson, Apache II

• Biologic Markers: CRP, IL

Netter Ciba Collection • Contrast enhanced CT

Acute Pancreatitis Radiologic Imaging

Patients Peak • CT: modality of choice present to cytokine End organ hospital production dysfunction • US: assess biliary tree, F/U PC, Doppler

• MRI: MRCP • ERCP: therapeutic stone removal 12 -18 30 48 - 96 Hours CECT • Angio/IR: complications Biological Ranson Markers Apache II

Segmental Acute Pancreatitis

Focal Pancreatitis CT Staging Systems Pancreatic Necrosis Balthazar Classification • 20 - 30 % of cases • Pancreatic Necrosis • Early presentation < 96 hours

• CT Grade: A - E Grade E • Focal or diffuse • Decreased enhancement on CT • CT severity index • CT accuracy 80 - 90% • Increased risk of MOF

Pancreatic Necrosis Pancreatic Necrosis

< 30% 30-50%

Disconnected Pancreatic Duct Pancreatic Necrosis Syndrome >50%

• Viable pancreatic tail is isolated and unable to drain into duodenum • 30% cases necrotizing pancreatitis • Usually occurs at the neck (watershed region) • CT: necrosis body / neck with intact perfusion of the tail • MRCP: discreet duct cut- off with downstream fluid collection 4 months later Acute Pancreatitis: CT Grade Grade D

A - Normal 0

B - Focal or diffuse enlargement 1

C - Peripancreatic inflammation 2 D - Solitary fluid collection 3

E - Fluid collections, hemorrhage, gas 4

Grade E Grade E

CT Severity Index (CTSI) CT: Severity Index (CTSI)

100 92 90 80 70 CT Grade 60 50 Mortality 40 35 Morbidity + 30 20 17 8 Necrosis 10 3 6 0 0 - 3 4 - 6 7 - 10 Grade E Grade E W/O Necrosis > 50% PN

CTSI = 4

Resolved 3 weeks later CTSI = 10

Acute Pancreatitis: Pancreatic Fluid Collections Complications

• Sterile collections

• Necrosis

• Infected collections

• Vascular

Sterile Collections Pancreatic Fluid Collections 40 - 50% of cases

30 - 50% may

50% resolve progress to spontaneously pseudocyst Pseudocysts Pseudocysts

Abdominal Pain Pain Better,Hypotensive

Pancreatic Abscess

Collections of pus

HIV and MAI 3 - 4 weeks to form Infected Pancreatic Necrosis Mortality

Infected Necrosis 39 - 67%

Pancreatic Abscess 20 - 35%

Infected PC

Vascular Complications Vascular Complications Pseudoaneurysm

• Pseudoaneurysms

• Venous occlusion

• Hemorrhage

Vascular Complications Vascular Complications Pseudoaneurysm Pseudoaneurysm Vascular Complications SMV Thrombosis AUTOIMMUNE PANCREATITIS

Cystic lesions

General Enlargement with loss of lobularity

Hypoattenuated Rim

AUTOIMMUNE PANCREATITIS

Elevated IgG4

s/p 1 mo prednisone

—53-year-old man with autoimmune pancreatitis.

Lee T Y et al. AJR 2009;193:343-348

©2009 by American Roentgen Ray Society Chronic Pancreatitis PANCREATIC

• Calcifications

• Dilated Cystic tumors pancreatic duct Islet cell tumors • Atrophy

Netter Ciba Collection

Staging: Stepwise assessment

• Distant metastases (, peritoneum, lung) • Beware of ascites! • Adjacent organs • Peripancreatic arteries • Celiac trunk, common hepatic artery, SMA • IDENTIFY variant arterial anatomy! • Peripancreatic veins • Portal confluence, SMV • Note length and location of contact • Splenic vein OK unless up to PV • Lymph nodes Perineural extension Duodenal involvement Reporting Arterial Evaluation: Reporting Arterial Evaluation:

Reporting Arterial Evaluation: Reporting Venous Assessment:

CYSTIC PANCREATIC TUMORS

1. Serous 2. Mucinous 3. SPEN Netter Ciba Collection 4. IPMT:Intraductal papillary mucinous tumors SEROUS SEROUS CYSTADENOMA

• Benign imp. to Dx fluid analysis: • Honeycomb (3-7 mm) • Low tumor markers • Sponge-like • Oligocystic (1-10 cm) • Glycogen rich • Central Ca++ w stellate pattern • Low amylase • No communication with MPD • Low viscosity • Delayed septal enhancement

• grandmother tumor

SEROUS CYSTADENOMA MUCINOUS CYSTADENOMA

• Premalignant, surgical • Single large cyst with or without smaller • Tail location • Thin central septum • Thick fibrous wall PAS positive for mucin • Peripheral Ca++ High viscosity fluid • mother tumor High CEA or CA19-9

25 y.o. black woman with Abd pain SPEN

• Solid and Papillary Epithelial Neoplasm

• Well-demarcated mass with solid and cystic components

• Classically a palpable mass in young African American Female

• Low malignant potential

• granddaughter tumor

MAIN DUCT IPMT

• Portion or all of duct involved • Branch ducts involved in advanced cases • Bulging papilla • BEST considered as malignant • grandfather tumor BRANCH DUCT IPMT

• Communication with MPD at ERCP or MRCP • Uncinate Location most common • Malignant ??

A Practical Approach

• Exclude history of pancreatitis – Compare with old films • Measure the lesion – If less than 2cm- follow-up

IPMT

A Practical Approach A Practical Approach

• Diagnose SCA • Exclude MCT – Radial pattern – Location – Delayed septal – Gender enhancement – Aspiration – 3D duct imaging – EUS aspiration Metastatic Pancreatic Adenocarcinoma A Practical Approach Possible Malignant Degeneration of Side-Branch IPMN

• Diagnose Branch Duct IPMT – 3D CTCP – 3D MRCP • Pure Branch duct lesions without solid elements may be followed – No Diabetes – No Main Duct extension

PANCREATIC ISLET-CELL TUMORS SECRETORY ISLET-CELL TUMORS

Two types • (60-75%)

http://www-medlib.med.utah.edu/WebPath/HISTHTML/HISTO.html • Secretory • (20%) (usually small) Z-E syndrome • • Non-functioning (usually large) • VIPoma • Somatostinoma Netter Ciba Collection Netter Ciba Collection

Two arterially enhancing lesions post to panc head

PORTO VENOUS PHASE

Gastrinoma Triangle HAP THE END

Intraductal Papillary Pancreatic Lipoma Mucinous Tumors (IPMT) of • Very rare the Pancreas – Less than 10 cases reported in literature • Distinguished by the site of origin • Must be distinguished from local fatty – Main duct IPMT with clinical appearance of infiltration obstructive pancreatitis. – Fatty replacement associated with chronic • Segmental Main duct involvement pancreatitis, obesity, aging, CF, EtOH hepatitis, and Cushings syndrome • Diffuse Main duct involvement – If none of above risk factors and no contact between mass and peri-pancreatic fat then can – Branch Duct IPMT reasonably exclude fatty replacement or • Previously thought to involve the Uncinate process only lipomatous pseudohypertrophy • Now known to be found throughout the Pancreas, - Barutcu O. et al., Fat containing unusual tumor of the pancreas, Eur Radiol (2002) 12: 770-773 particularly the Tail

IPMT (cont) IPMT (cont) • Branch Duct IPMT – Round lobulated morphology • To precisely diagnose branch duct IPMT, – Resembles a pseudocyst demonstration of its communication with – Cluster of cysts common raising the problem the main duct is mandatory. of DDX (serous cystoadenoma, mucinous cystic tumors) – ERCP (beneficial since samples are possible) – Specific topographical & morphological findings for branch IPMT are: – MRCP • Uncinate.most common site • Intraluminal filling defects (hanging papillary – Endocavitary US growths w/ dependent thickened Mucin).rare to see in small lesions!!!

Management?

 RECOMMENDATIONS:

1. Early Stage/<2.5 cm without filling defects and thick walls and absence of Main Duct Dilation.serial imaging.

2. Advanced stages/larger lesions with filling defects, thick walls, and ductal dilation and or local structure infiltration.surgical.

Metastatic Pancreatic Adenocarcinoma Possible Malignant Degeneration of Side-Branch IPMN

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