EURORAD ESR

Case 14732

Focal mass-forming chronic pancreatitis: indistinguishable from pancreatic carcinoma?

Author(s)
Tonolini Massimo, MD; Matacena Giovanni, MD; Ippolito Sonia, MD; Roberto Bianco, MD.

"Luigi Sacco" University Hospital, Radiology Department; Via G.B. Grassi 74 20157 Milan, Italy; Email:mtonolini@sirm.org
 
Patient
male, 79 year(s)
 
 
  • Figure 1
    Ultrasound
     

    Sonography showed distended gallbladder (+) with normal mural thickness, dependent echogenic debris interpreted as biliary sludge; mild dilatation of common bile duct (CBD) and left lobe intrahepatic ducts (not shown).

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    Sonography showed distended gallbladder (+) with normal mural thickness, dependent echogenic debris interpreted as biliary sludge; mild dilatation of common bile duct (CBD) and left lobe intrahepatic ducts (not shown).

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    A 3-cm hypoechoic mass (arrowheads) was seen in the pancreatic head, with upstream dilatation of main pancreatic duct (MPD).

     
    Area of Interest: Pancreas; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Inflammation;
     
     
  • Figure 2
    Precontrast and multiphase enhanced CT
     

    Unenhanced images (a,b) confirmed distended gallbladder (+) with normal wall thickness and absent pericholecystic fluid, higher-than-water attenuation (approx. 50 Hounsfield units)content, atrophied pancreatic body...

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    The dorsal pancreatic head showed a homogeneously solid appearance (arrowhead) with lost pancreatic lobulations, corresponding to sonographic finding. Note lack of pancreatic calcifications; absent ascites and...

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    The mass (arrowheads) at dorsal aspect of pancreatic head showed loss of expected pancreatic enhancement in arterial-dominant acquisition (c,d) , without frank hypo- or hypervascularity and signs of vascular invasion.

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    The mass (arrowheads) at dorsal aspect of pancreatic head showed loss of expected pancreatic enhancement in arterial-dominant acquisition (c,d) , without frank hypo- or hypervascularity. Note mildly dilated CBD (1cm,...

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    In portal-venous phase images (e...g) the pancreatic head mass (arrowheads) did not show hypo- or hypervascularity and signs of vascular invasion. No abnormal changes in liver parenchyma, spleen, adrenals and kidneys...

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    In portal-venous phase images (e...g) the pancreatic head mass (arrowheads) did not show hypo- or hypervascularity and signs of vascular invasion. Note atrophied body and tail (arrows) with dilated MPD, distended...

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    In portal-venous phase images (e...g) the pancreatic head mass (arrowheads) did not show hypo- or hypervascularity. Note atrophied body and tail (arrows) with dilated MPD, distended gallbladder (+), mildly dilated CBD...

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    Finally, delayed excretory phase images (h,i) confirmed pancreatic head mass (arrowheads) without frank hypo- or hypervascularity, causing mild CBD dilatation (thick Arrow in h).

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    Finally, delayed excretory phase images (h,i) confirmed pancreatic head mass (arrowheads) without frank hypo- or hypervascularity, causing mild CBD dilatation (thick Arrow in h).

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Inflammation;
     
     
  • Figure 3
    Unenhanced MRI with MR-cholangiopancreatography (MRCP)
     

    On T2-weighted images (a...c) the gallbladder contained mixed, predominantly low-signal fluid (+), the dorsal pancreatic head mass (arrowheads) showed minimally increased signal intensity.

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    On T2-weighted images (a...c) the dorsal pancreatic head mass (arrowheads) showed minimally increased signal intensity. Note absent ascites and lymphadenopathies.

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    On T2-weighted images (a...c) the gallbladder contained mixed, predominantly low-signal fluid (+). Note dilated CBD (thick arrow), atrophied pancreatic body and tail with dilated MPD (arrow).

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    T1-weighted images (d, fat-suppressed e) showed homogeneous hypersignal of gallbladder lumen (+) consistent with highly proteinaceous fluid or blood, with normal mural thickness.

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    On fat-suppressed T1-weighted images the dorsal pancreatic head mass (arrowhead) showed moderately decreased signal intensity compared to usual aspect of pancreatic parenchyma.

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    On high b-value (800) diffusion-weighted acquisition, the pancreatic head mass (arrowhead in upper image) showed visually increased intensity compared to pancreatic body and tail (lower image).

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    Corresponding apparent diffusion coefficient (ADC) maps showed lower ADC values in pancreatic head mass (arrowhead, 1.47x10-3 mm2/sec) compared to remaining pancreatic parenchyma (lower image, 2.05x10-3 mm2/sec),...

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    MRCP (without secretin administration) confirmed and depicted mild dilatation of left intrahepatic branches and CBD (thick Arrow, 1 cm) plus dilated MPD (arrows) and side branches ("double-duct sign") above pancreatic...

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Inflammation;

    Detail MRCP image showed smoothly tapering MPD (thin arrow) entering through the pancreatic head mass ("duct-penetrating sign"), diffuse saccular dilatation of MPD side branches.

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Inflammation;
     
     
  • Figure 4
    Useful features to discriminate between pancreatic head cancer and MF-CP

    Some useful features which should be considered to try discriminate between pancreatic head cancer and mass-forming chronic pancreatitis.

     
    Area of Interest: Pancreas; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Inflammation;
     
     
Sonography showed distended gallbladder (+) with normal mural thickness, dependent echogenic debris interpreted as biliary sludge; mild dilatation of common bile duct (CBD) and left lobe intrahepatic ducts (not shown).
 
Sonography showed distended gallbladder (+) with normal mural thickness, dependent echogenic debris interpreted as biliary sludge; mild dilatation of common bile duct (CBD) and left lobe intrahepatic ducts (not shown).
 
A 3-cm hypoechoic mass (arrowheads) was seen in the pancreatic head, with upstream dilatation of main pancreatic duct (MPD).
 
Unenhanced images (a,b) confirmed distended gallbladder (+) with normal wall thickness and absent pericholecystic fluid, higher-than-water attenuation (approx. 50 Hounsfield units)content, atrophied pancreatic body (arrow) and tail.
 
The dorsal pancreatic head showed a homogeneously solid appearance (arrowhead) with lost pancreatic lobulations, corresponding to sonographic finding. Note lack of pancreatic calcifications; absent ascites and adenopathies.
 
The mass (arrowheads) at dorsal aspect of pancreatic head showed loss of expected pancreatic enhancement in arterial-dominant acquisition (c,d) , without frank hypo- or hypervascularity and signs of vascular invasion.
 
The mass (arrowheads) at dorsal aspect of pancreatic head showed loss of expected pancreatic enhancement in arterial-dominant acquisition (c,d) , without frank hypo- or hypervascularity. Note mildly dilated CBD (1cm, thick Arrow).
 
In portal-venous phase images (e...g) the pancreatic head mass (arrowheads) did not show hypo- or hypervascularity and signs of vascular invasion. No abnormal changes in liver parenchyma, spleen, adrenals and kidneys for age.
 
In portal-venous phase images (e...g) the pancreatic head mass (arrowheads) did not show hypo- or hypervascularity and signs of vascular invasion. Note atrophied body and tail (arrows) with dilated MPD, distended gallbladder (+).
 
In portal-venous phase images (e...g) the pancreatic head mass (arrowheads) did not show hypo- or hypervascularity. Note atrophied body and tail (arrows) with dilated MPD, distended gallbladder (+), mildly dilated CBD (thick arrow).
 
Finally, delayed excretory phase images (h,i) confirmed pancreatic head mass (arrowheads) without frank hypo- or hypervascularity, causing mild CBD dilatation (thick Arrow in h).
 
Finally, delayed excretory phase images (h,i) confirmed pancreatic head mass (arrowheads) without frank hypo- or hypervascularity, causing mild CBD dilatation (thick Arrow in h).
 
On T2-weighted images (a...c) the gallbladder contained mixed, predominantly low-signal fluid (+), the dorsal pancreatic head mass (arrowheads) showed minimally increased signal intensity.
 
On T2-weighted images (a...c) the dorsal pancreatic head mass (arrowheads) showed minimally increased signal intensity. Note absent ascites and lymphadenopathies.
 
On T2-weighted images (a...c) the gallbladder contained mixed, predominantly low-signal fluid (+). Note dilated CBD (thick arrow), atrophied pancreatic body and tail with dilated MPD (arrow).
 
T1-weighted images (d, fat-suppressed e) showed homogeneous hypersignal of gallbladder lumen (+) consistent with highly proteinaceous fluid or blood, with normal mural thickness.
 
On fat-suppressed T1-weighted images the dorsal pancreatic head mass (arrowhead) showed moderately decreased signal intensity compared to usual aspect of pancreatic parenchyma.
 
On high b-value (800) diffusion-weighted acquisition, the pancreatic head mass (arrowhead in upper image) showed visually increased intensity compared to pancreatic body and tail (lower image).
 
Corresponding apparent diffusion coefficient (ADC) maps showed lower ADC values in pancreatic head mass (arrowhead, 1.47x10-3 mm2/sec) compared to remaining pancreatic parenchyma (lower image, 2.05x10-3 mm2/sec), yielding normalised ratio of 0.72.
 
MRCP (without secretin administration) confirmed and depicted mild dilatation of left intrahepatic branches and CBD (thick Arrow, 1 cm) plus dilated MPD (arrows) and side branches ("double-duct sign") above pancreatic head mass.
 
Detail MRCP image showed smoothly tapering MPD (thin arrow) entering through the pancreatic head mass ("duct-penetrating sign"), diffuse saccular dilatation of MPD side branches.
 
Some useful features which should be considered to try discriminate between pancreatic head cancer and mass-forming chronic pancreatitis.
 
 
 
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