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SERVIÇO DE DIAGNÓSTICO POR IMAGEM

TUMORES PANCREÁTICOS

R2 RÉGIS SILVA

ADENOCARCINOMA

-Representa mais de 90% dos tumores malignos do pâncreas

-5º maior maior causa de morte por câncer.

-2/3 deles ocorrem na cabeça com intensa reação desmoplásica, medindo em média 2-3cm.

-Clínica: astenia, perda de peso, dor abdominal, DM(10%), icterícia

-CA 19.9 raramente é positivo em tumores < 1cm.

-A ressecçao cirurgica é o melhor tratamento curativo, porém menos de 20% dos pacientes candidatos a cirurgia.

- A probabilidade de invasão vascular é menor do que 3%, quando a superfície de contato com o vaso for inferior a 90º

-Irressecabilidade: invasão extrapancreática de grandes vasos e metástase a distância.

-Invasão parcial da VMS pode ser ressecável

-Quimioterapia apresenta apenas pequena vantagem em termos de sobrevida.

ADENOCARCINOMA

-TCMD: 1ª escolha para diagnóstico.

- Arterial 30-40s e porta 60-70s - 150 ml

- Adenocarcinoma aparece hipodenso na fase arterial

- Nos casos de massas isoatenuadas, deve-se buscar sinais indiretos

-RM: 2ª escolha

- É uma técnica complementar quando a tc é inconclusiva.

- Hipo em T1 e variável em T2

- Colangio RM

- Detecção e caracterização de implantes hepáticos e peritoneais

-PET-TC: pâncreas não capta, importância no estadiamento e diferenciação com pancreatite formadora de massa.

Adenocarcinoma of the pancreas. Axial contrast-enhanced pancreatic-phase image shows a poorly defined area of hypodensity in the neck and body of the pancreas (white arrow), infiltrating the retroperitoneum. The superior mesenteric vein is severely reduced in caliber, is circumscribed by the lesion for more than 180 degrees, and is teardrop shaped (black arrow), suggesting infiltration.

Adenocarcinoma of the pancreas. Axial contrast-enhanced portal venous—phase image shows a mass (arrows) in the neck and body of the pancreas, with poorly defined and infiltrating margins. The mass exhibits reduced and inhomogeneous contrast enhancement, and there is upstream dilation of the pancreatic duct (single arrowhead). The mass surrounds the superior mesenteric artery (wavy

arrow). Peritoneal fluid and thickening (two arrowheads) represent metastatic implants.

Adenocarcinoma of the pancreas. Coronal contrast-enhanced (A) and coronal MIP (B) MDCT images demonstrate a mass in the head and uncinate process of the pancreas (white arrows). It appears hypodense after contrast administration, exhibits poorly defined margins, infiltrates surrounding fat tissue, and reduces the

caliber of the superior mesenteric artery (SMA) (arrowheads). Multiple small, rounded, hypodense metastatic foci are seen in the liver (black arrows in A)

Adenocarcinoma of the pancreas. A, Coronal portal venous—phase MDCT demonstrates a mass in the head and uncinate process of the pancreas (short arrows), infiltrating the third portion of the duodenum (long arrow), and surrounding the superior mesenteric artery (arrowhead). Coronal (B) and axial (C) curved reformatted images of the same patient display the tumor (arrows) and dilation of the main pancreatic duct (arrowheads), which abruptly terminates in the mass. A biliary stent is

seen in situ (asterisk).

Adenocarcinoma of the pancreas. Curved reformatted MDCT shows an oval mass in the tail of the pancreas, with ill-defined margins and poor enhancement (arrow).

Adenocarcinoma of the pancreas. Axial contrast-enhanced pancreatic-phase MDCT (A) and curved reformatted MDCT (B) along the course of the main pancreatic duct display a hypodense mass in the body of the pancreas (arrows), with upstream dilation of the main pancreatic duct (arrowheads).

Adenocarcinoma of the pancreas. Coronal oblique MRCP (A), axial T1-weighted image (B), axial T2-weighted image (C), axial contrast-enhanced T1-weighted image in the arterial phase (D), and axial pancreatic-phase MDCT (E) display the “double duct” sign, consisting of common bile duct and pancreatic duct dilation

(arrowheads in A). A biliary stent is in situ (thin arrow). An abrupt biliary tree and pancreatic duct obstruction (thick arrows in A) caused by the cancer (wavy arrow) is observed.

Adenocarcinoma of the pancreas. Coronal oblique MRCP (A), axial T1-weighted image (B), axial T2-weighted image (C), axial contrast-enhanced T1-weighted image (D), and axial MDCT pancreatic-phase image (E) demonstrate the “double duct” sign (arrowheads in A) and a head—uncinate process mass that appears ill-defined and hypointense on the T1-weighted image, hyperintense on the T2-

weighted image, and poorly enhancing after the administration of gadolinium and iodinated contrast material (arrow in B to E).

Adenocarcinoma of the pancreas. Coronal single-shot FSE T2-weighted image (A), axial T1-weighted image (B), axial T2-weighted image (C), axial contrast-enhanced T1-weighted image in the pancreatic phase (D), delayed contrast-enhanced T1-weighted image (E), and axial contrast-enhanced MDCT (F) show dilation and distal stenosis of the pancreatic duct (arrow in A), displacement and

stenosis of the common hepatic duct (arrowhead in A), and a contour-deforming mass in the head of the pancreas (arrows in B to F) that appears poorly defined and hypointense on the T1-weighted image, hyperintense on the T2-weighted image, and poorly enhancing after contrast administration. It diffusely infiltrates the adjacent retroperitoneum (arrowheads in E and F). A necrotic metastatic node

is indicated by the wavy arrow in E and F.

TUMORES ENDÓCRINOS

-2% das neoplasias pancreáticas

-Funcionais e não funcionais

-Até 90% dos não funcionais são malignos, grandes e tem melhor resposta a quimio do que os adeno.

-INSULINOMAS

- 50% dos tumores endocrinos, sendo 10% malignos.

- 30-60 anos, 1H:1M

- Em 90% dos casos tem menos de 2cm,

- Tendem a ser muito vascularizados

-GASTRINOMAS

- 20% dos tu endócrinos, sendo 60% malignos

- Mais comum no sexo masculino – 5ª década de vida

- Síndrome de Zollinger Ellison e associação com NEM 1

TUMORES ENDÓCRINOS

-VIPOMAS

- Predileção pelo sexo feminino

- Diarréia, hipocalemia e hipocloridria.

-Glucagonomas e somatostinomas

-ACHADOS:

- Forte realce na fase arterial e na fase portal

- Podem ter aparência cística e calcificações discretas

- Os tu não funcionantes frequentemente são heterogêneos.

- Calcificação em 20% dos casos

- RM: hipo em T1 e hiper em T2

- MTS para fígado e lnf regionais

Insulinoma. Axial T2-weighted fat-suppressed image (A), axial arterial-phase T1-weighted fat-suppressed image (B), and axial portal venous—phase T1-weighted fat-suppressed image (C) demonstrate a small, rounded, well-demarcated, hyperintense lesion in the tail of the pancreas (arrow). The lesion exhibits avid contrast

enhancement in the arterial phase of the dynamic image and retains contrast in the portal venous phase. D, Corresponding axial MDCT in the arterial phase of enhancement displays the same finding (arrow).

Gastrinoma. Coronal (A) and axial (B and C) contrast-enhanced MDCT images in the arterial phase display a rounded, well-circumscribed, homogeneously and intensely enhancing lesion (arrow) close to the junction of the third and fourth portions of the duodenum and the mesenteric vessels. Diffuse thickening and enhancement of the gastric folds (arrowheads

in C) are seen in this patient with Zollinger-Ellison syndrome.

Gastrinoma. Coronal (A) and axial (B and C) contrast-enhanced MDCT images in the arterial phase display a rounded, well-circumscribed, homogeneously and intensely enhancing lesion (arrow) close to the junction of the third and fourth portions of the duodenum and the mesenteric vessels. Diffuse thickening and

enhancement of the gastric folds (arrowheads in C) are seen in this patient with Zollinger-Ellison syndrome.

Nonfunctioning pancreatic endocrine tumor. Axial contrast-enhanced MDCT shows a large, well-defined, lobulated lesion in the tail of the pancreas. It appears inhomogeneous with enhancing solid areas (arrow) and has a poorly enhancing, partially necrotic component (arrowheads).

LINFOMA

-0,5% das neoplasias pancreáticas

-Dor abdominal, perda de peso e icterícia

-Pode haver elevação do CA 19.9

-Média de idade: 55 anos

-Habitualmente ocorre na cabeça pancreática.

-Tendem a ser infiltrativos e geralmente tem hiposinal e T1 e T2

Pancreatic lymphoma. Axial T1-weighted opposed-phase (A), axial T2-weighted fat-suppressed (B), and axial arterial-phase T1-weighted fat-suppressed (C) MR images display enlargement and rounding of the pancreatic head, with a well-demarcated area of low signal intensity within, corresponding to lymphoma (arrows). The low-signal-intensity area does

not significantly enhance compared with the highly enhancing normal pancreatic parenchyma.

Pancreatic lymphoma. Axial contrast-enhanced MDCT shows a well-demarcated hypodense area in the head of the pancreas (arrow). The pancreatic duct is not dilated (arrowhead).

Pancreatic lymphoma. Axial T1-weighted opposed-phase (A), axial contrast-enhanced T1-weighted fat-suppressed (B), and axial T2-weighted fat-suppressed (C) images show enlargement and rounding of the head of the pancreas. An area of low signal intensity (arrow) is best seen on the contrast-enhanced image in the dorsal aspect (B). MRCP (D)

displays smooth tapering of the distal common bile duct (large arrow) and of the duct of Wirsung (arrows), main pancreatic duct prominence (large arrowheads), and widening of the duodenal loop (small arrowheads).

Fi Pancreatic lymphoma. Axial T1-weighted opposed-phase (A), axial contrast-enhanced T1-weighted fat-suppressed (B), and axial T2-weighted fat-suppressed (C) images show enlargement and rounding of the head of the pancreas. An area of low signal intensity (arrow) is best seen on the contrast-enhanced image in the dorsal aspect (B). MRCP (D)

displays smooth tapering of the distal common bile duct (large arrow) and of the duct of Wirsung (arrows), main pancreatic duct prominence (large arrowheads), and widening of the duodenal loop (small arrowheads).

METÁSTASE INTRAPANCREÁTICA

-Raras: 2% dos tumores pancreáticos

-Rim – pulmão – mama – colorretal – melanoma.

-As caracteristicas de imagem tendem a repetir as características do tu primário.

Intrapancreatic metastases from renal cancer. Axial contrast-enhanced MDCT in the arterial phase shows a rounded, relatively homogeneous, well-circumscribed area of enhancement in the uncinate process (arrow). This patient had undergone left nephrectomy for renal cancer.

Intrapancreatic metastases from renal cancer. Coronal portal venous—phase (A) and axial arterial-phase (B) MDCT images demonstrate a rounded, well-demarcated lesion in the tail of the pancreas (arrow). It exhibits heterogeneous contrast enhancement.

LESOES CISTICAS

-A existência de lesões pancreáticas císticas benignas e malignas , justifica a importância diagnóstico.

-Cistoadenomas serosos, cistoadenoma mucinoso e NMIP

-TCMD e RM – colagio RM

-Assintomatico ou dor abdominal, icterícia e pancreatite recorrente.

CISTOADENOMA SEROSO

-Corresponde a 30% das neoplasias císticas e são mais comuns nas mulheres.

-Evidenciam-se com padrão policístico ou microcístico (1mm até 2cm)

-Pode parecer sólida

-Cicatriz central fibrosa

-Os septos podem realçar

-Crescimento de 4 mm por ano.

A, Axial contrast-enhanced MDCT reveals a finely lobulated lesion (arrow) with a microcystic appearance in the proximal body of the pancreas. B, Corresponding coronal T2-weighted MR image demonstrates the same findings (arrow) and also reveals a central scar (arrowhead) that is virtually pathognomonic for serous cystadenoma.

Axial contrast-enhanced MDCT reveals a lobulated lesion with internal septations and a calcified central scar (arrow), a characteristic finding in serous cystadenoma.

CISTOADENOMA MUCINOSO

-Contituem 44-49% das lesões císticas

-Predomina em mulheres, com média de idade de 47 anos

-A maioria das lesões são solitárias e multiloculadas, com compartimentos grandes (2-6cm)

-Maioria tem contorno regular

-Não se comunicão com o ducto pancreátco, mas podem causar obstrução do mesmo.

-Septos e nódulos murais são melhor apreciado pela RM e USE

-Calcificações periféricas ou septais são fortemente sugestiva de C. mucinoso.

Axial contrast-enhanced MDCT reveals a macrocystic or oligocystic variety of serous cystadenoma with fewer large (>2 cm) internal cysts (arrow). This variant may be difficult to differentiate from a mucinous cystic lesion.

Mucinous cystic neoplasm. Axial contrast-enhanced MDCT shows a large, smooth cystic lesion with internal septations (arrow) and peripheral and septal calcification (arrowheads).

Mucinous cystic neoplasm. A, Axial contrast-enhanced MDCT reveals a cystic lesion with an eccentric mural nodule (arrow). B, Corresponding coronal reformatted MDCT reveals the same findings (arrow). The presence of a mural nodule increases the likelihood of malignancy; however, it is sometimes difficult to distinguish a mural nodule from debris or

inspissated mucin.

Mucinous lesion. A, Axial contrast-enhanced MDCT image reveals a macrocystic lesion in the uncinate process (horizontal arrow in A and B). B, Corresponding axial T2-weighted fat-saturated MR image reveals a mural nodule (long arrow), which was not evident on CT, as an area of low signal intensity.

NEOPLASIAS MUCINOSAS INTRADUCTAIS PAPILARES

-Desenvolve-se a partir do revestimento epitelial do ducto pancreático principal ou de seus ramos laterais.

-Tem prognóstico melhor do que as outras neoplasia pancreáticas.

-21-33% das neoplasias císticas, leve predominância no sexo masc.

-A secreção excessiva de mucina pode causar protrusão das papilas maiores na luz duodenal (cpre)

-Superfície interna do ducto principal frequentemente tem nódulos murais.

-NMIP dos ramos laterais manifesta-se por lesões císticas uniloculadas ou multiloculadas e a não visualização da comunicação com o ducto pancreático principal não afasta o diagnóstico.

-A presença de nodulos murais, septos espessos, calcificações e ducto principal > 10mm sugere malignidade.

-Sobrevida em 5 anos é de 50 - 75% nos tumores malignos.

Main-duct intraductal papillary mucinous neoplasm A, Coronal reformatted MDCT shows diffuse dilation of the main pancreatic duct (arrows), which is filled with mucin. The ductal dilation is disproportionate to the degree of parenchymal atrophy. B, ERCP reveals the diffuse ductal dilation (arrows) without any evidence of side-branch irregularity.

Main-duct intraductal papillary mucinous neoplasm. Axial contrast-enhanced (A) and coronal reformatted (B) MDCT images show the major papilla bulging into the duodenal lumen (arrow), which is considered a pathognomonic sign.

Main-duct intraductal papillary mucinous neoplasm. Coronal reformatted MDCT (A) and coronal MRCP (B) reveal diffuse dilation of the main pancreatic duct due to excessive mucin secretin (arrows in A). The distal duct (arrow in B) is not seen on the MRCP image, possibly owing to inspissated mucin.

Side-branch intraductal papillary mucinous neoplasm. A, Axial contrast-enhanced MDCT reveals a small cystic lesion (arrow) in the inferior body of the pancreas. B, Coronal reformatted image demonstrates the communication (arrow) of the lesion with the pancreatic duct. C and D, Two-dimensional (C) and three-dimensional (D)

MR pancreatograms demonstrate the lobulated cystic lesion and its communication (arrow) with the main pancreatic duct.

Side-branch intraductal papillary mucinous neoplasm. A, Axial contrast-enhanced MDCT reveals a small cystic lesion (arrow) in the inferior body of the pancreas. B, Coronal reformatted image demonstrates the communication (arrow) of the lesion with the pancreatic duct. C and D, Two-dimensional (C) and three-dimensional (D) MR pancreatograms

demonstrate the lobulated cystic lesion and its communication (arrow) with the main pancreatic duct.

Side-branch intraductal papillary mucinous neoplasm. A, Axial contrast-enhanced MDCT reveals a well-defined cystic lesion in the neck of the pancreas and its narrow communication (arrow) with the pancreatic duct. B, The cystic lesion and communication (arrow) are well demonstrated on a two-dimensional MR pancreatogram acquired in the coronal oblique

plane.

Axial curved reformatted MDCT reveals multiple communicating side-branch intraductal papillary mucinous neoplasms (arrows) along the main pancreatic duct.

Combined or mixed intraductal papillary mucinous neoplasm. Axial curved reformatted MDCT reveals a loculated cystic lesion in the head, neck, and uncinate process of the pancreas (arrows), with diffuse dilation of the main pancreatic duct (arrowheads). Histopathology revealed a mixed intraductal papillary mucinous

neoplasm with papillary growth and mucin extending from the cystic lesion in the main pancreatic duct.

Main-duct intraductal papillary mucinous neoplasm. A, Axial contrast-enhanced MDCT reveals an isoattenuating lesion (arrow) in the terminal main pancreatic duct. B, 18FDG PET shows a hot spot (arrow) in the same location. C, Findings are confirmed on a fused PET CT image (arrow). Histopathology revealed a high-grade malignancy.

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