European Radiology

, Volume 25, Issue 3, pp 751–759 | Cite as

Contrast enhancement pattern on multidetector CT predicts malignancy in pancreatic endocrine tumours

  • Carla Cappelli
  • Ugo Boggi
  • Salvatore Mazzeo
  • Rosa Cervelli
  • Daniela Campani
  • Niccola Funel
  • Benedetta Pontillo Contillo
  • Carlo Bartolozzi



Preoperative suspicion of malignancy in pancreatic neuroendocrine tumours (pNETs) is mostly based on tumour size. We retrospectively reviewed the contrast enhancement pattern (CEP) of a series of pNETs on multiphasic multidetector computed tomography (MDCT), to identify further imaging features predictive of lesion aggressiveness.


Sixty pNETs, diagnosed in 52 patients, were classified based on CEP as: type A showing early contrast enhancement and rapid wash-out; type B presenting even (B1) or only (B2) late enhancement. All tumours were resected allowing pathologic correlations.


Nineteen pNETs showed type A CEP (5–20 mm), 29 type B1 CEP (5–80 mm) and 12 type B2 (15–100 mm). All tumours were classified as well differentiated tumours, 19 were benign (WDt-b), 15 with uncertain behaviour (WDt-u) and 26 carcinomas (WDC). None of A lesions were malignant (12 WDt-b; 7 WDt-u), all B2 lesions were WDC, 7 B1 lesions were WDt-b, 8 WDt-u and 14 WDC; 4/34 (12 %) lesions ≤2cm were WDC.

CEP showed correlation with all histological prognostic indicators.


Correlating with the lesion grading and other histological prognostic predictors, CEP may preoperatively suggest the behaviour of pNETs, assisting decisions about treatment. Moreover CEP allows recognition of malignant small tumours, incorrectly classified on the basis of their dimension.

Key Points

Neuroendocrine pancreatic tumours (pNETs) show different post-contrast behaviour on CT.

P NETs can be classified on the basis of contrast enhancement into three categories.

CT classification of pNETs shows strong correlation with histological prognostic factors.

CT pattern may suggest the optimal management of pNETs.


Pancreas Neuroendocrine tumours Multidetector computed tomography Prognosis Neoplasm grading 



The scientific guarantor of this publication is Salvatore Mazzeo M.D. The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article. The authors state that this work has not received any funding. No complex statistical methods were necessary for this paper. Institutional review board approval was not required because our study is a retrospective review of standard preoperative CT examinations. Written informed consent was not required for this study because our study is a retrospective review of standard preoperative CT examinations. Methodology: retrospective, diagnostic or prognostic study, performed at one institution.

Conflict of interest



  1. 1.
    Asa SL (2011) Pancreatic endocrine tumors. Mod Pathol 24(Suppl 2):S66–S77CrossRefPubMedGoogle Scholar
  2. 2.
    Klöppel G, Rindi G (2010) The ENETS and AJCC/UICC TNM classifications of the neuroendocrine tumors of the gastrointestinal tract and the pancreas: a statement. Virchows Arch 456:595–597CrossRefPubMedGoogle Scholar
  3. 3.
    Klöppel G (2011) Classification and pathology of gastroenteropancreatic neuroendocrine neoplasms. Endocr Relat Cancer 18(Suppl 1):S1–S16CrossRefPubMedGoogle Scholar
  4. 4.
    Klimstra DS, Modlin IR (2010) The pathologic classification of neuroendocrine tumors; review of nomenclature, grading, and staging systems. Pancreas 39:707–712CrossRefPubMedGoogle Scholar
  5. 5.
    De Lellis RA, Lloyd RV (2004) Pathology and genetics of tumors of endocrine organs. IARC, LyonsGoogle Scholar
  6. 6.
    Klöppel G, Rindi G (2007) Site-specific biology and pathology of gastroenteropancreatic neuroendocrine tumors. Virchows Arch 451(Suppl 1):S9–S27CrossRefPubMedGoogle Scholar
  7. 7.
    Rindi G (2010) The ENETS guidelines: the new TNM classification system. Tumori 96:806–809PubMedGoogle Scholar
  8. 8.
    Rindi G, Wiedenmann B (2012) Neuroendocrine neoplasms of the gut and pancreas: new insights. Nat Rev Endocrinol 8:54–64CrossRefGoogle Scholar
  9. 9.
    Edge SB, Byrd DR (2009) AJCC cancer staging manual, 7th edn. Springer, New YorkGoogle Scholar
  10. 10.
    Scarpa A, Mantovani W (2010) Pancreatic endocrine tumors: improved TNM staging and histopathological grading permit a clinically efficient prognostic stratification of patients. Mod Pathol 23:824–833CrossRefPubMedGoogle Scholar
  11. 11.
    Hamilton NA, Liu TC (2012) Ki-67 predicts disease recurrence and poor prognosis in pancreatic neuroendocrine neoplasms. Surgery 152:107–113CrossRefPubMedCentralPubMedGoogle Scholar
  12. 12.
    Anlauf M (2011) Neuroendocrine neoplasms of the gastroenteropancreatic system: pathology and classification. Horm Metab Res 43:825–831CrossRefPubMedGoogle Scholar
  13. 13.
    Schmitt AM, Anlauf M (2007) WHO 2004 criteria and CK19 are reliable prognostic markers in pancreatic endocrine tumors. Am J Surg Pathol 31:1677–1682CrossRefPubMedGoogle Scholar
  14. 14.
    Ekebald S, Skogseid B (2008) Prognostic factors and survival in 324 patients with pancreatic endocrine tumor treated at a single institution. Clin Cancer Res 14:7798–7803CrossRefGoogle Scholar
  15. 15.
    Fisher L, Kleeff J (2008) Clinical outcome and long term survival in 118 consecutive patients with neuroendocrine tumors of the pancreas. Br J Surg 95:627–635CrossRefGoogle Scholar
  16. 16.
    La Rosa S, Klersy C (2009) Improved histologic and clinicopathologic criteria for prognostic evaluation of pancreatic endocrine tumors. Hum Pathol 40:30–40CrossRefPubMedGoogle Scholar
  17. 17.
    Scarpa A, Mantovani W (2010) Pancreatic endocrine tumors: improved TNM staging and histopathological grading permit a clinically efficient prognostic stratification of the patients. Mod Pathol 23:824–833CrossRefPubMedGoogle Scholar
  18. 18.
    Rodallec M, Vilgrain V (2006) Endocrine pancreatic tumours and helical CT: contrast enhancement is correlated with microvascular density, histoprognostic factors and survival. Pancreatology 6:77–85CrossRefPubMedGoogle Scholar
  19. 19.
    Couvelard A, O’Toole D (2005) Microvascular density and hypoxia-inducible factor pathway in pancreatic endocrine tumours: negative correlation of microvascular density and VEGF expression with tumour progression. Br J Cancer 92:94–101CrossRefPubMedCentralPubMedGoogle Scholar
  20. 20.
    D’Assignies G, Couvelard A (2009) Pancreatic endocrine tumors: tumor blood flow assessed with perfusion CT reflects angiogenesis and correlates with prognostic factors. Radiology 50:407–416CrossRefGoogle Scholar
  21. 21.
    Horton KM, Hruban RH (2006) Multi-detector row CT of pancreatic islet cell tumors. Radiographics 26:453–464CrossRefPubMedGoogle Scholar
  22. 22.
    Pereira PL, Wiskirchen J (2003) Morphological and functional investigations of neuroendocrine tumors of the pancreas. Eur Radiol 13:2133–2146CrossRefPubMedGoogle Scholar
  23. 23.
    Kulke MH, Anthony LB (2010) North American Neuroendocrine Tumor Society (NANETS). NANETS treatment guidelines: well-differentiated neuroendocrine tumors of the stomach and pancreas. Pancreas 39(6):735–752CrossRefPubMedCentralPubMedGoogle Scholar
  24. 24.
    Marion-Audibert AM, Barel C (2003) Low microvessel density is an unfavorable histoprostognostic factor in pancreatic endocrine tumors. Gastroenterology 125:1094–1101CrossRefPubMedGoogle Scholar
  25. 25.
    Takahashi Y, Akishima-Fukasawa Y (2007) Prognostic value of tumor architecture, tumor-associated vascular characteristics, and expression of angiogenic molecules in pancreatic endocrine tumors. Clin Cancer Res 13:187–196CrossRefPubMedGoogle Scholar
  26. 26.
    Jani N, Moser AJ (2007) Pancreatic endocrine tumors. Gastroenterol Clin N Am 36:431–439CrossRefGoogle Scholar
  27. 27.
    Oberg K, Eriksson B (2005) Endocrine tumours of the pancreas. Best Pract Res Clin Gastroenterol 19:753–781CrossRefPubMedGoogle Scholar
  28. 28.
    Rockall AG, Reznek RH (2007) Imaging of neuroendocrine tumours (CT/MR/US). Best Pract Res Clin Endocrinol Metab 21:43–68CrossRefPubMedGoogle Scholar
  29. 29.
    Bergers G, Benjamin LE (2003) Tumorigenesis and the angiogenic switch. Nat Rev Cancer 3:401–410CrossRefPubMedGoogle Scholar
  30. 30.
    Fidler JL, Johnson CD (2001) Imaging of neuroendocrine tumors of the pancreas. Int J Gastrointest Cancer 30:73–85CrossRefPubMedGoogle Scholar
  31. 31.
    Koito K, Namieno T (1997) Delayed enhancement of islet cell carcinoma on dynamic computer tomography: a sign of its malignancy. Abdom Imaging 22(3):304–306CrossRefPubMedGoogle Scholar
  32. 32.
    Ichikawa T, Peterson MS (2000) Islet cell tumor of the pancreas: biphasic CT versus MR imaging in tumor detection. Radiology 216:163–171CrossRefPubMedGoogle Scholar
  33. 33.
    Anlauf M, Sipos B (2005) Tumors of the endocrine pancreas. Pathologe 26:46–51CrossRefPubMedGoogle Scholar
  34. 34.
    Thoeni RF, Mueller-Lisse UG (2000) Detection of small, functional islet cell tumors in the pancreas: selection of MR imaging sequences for optimal sensitivity. Radiology 214:483–494CrossRefPubMedGoogle Scholar
  35. 35.
    Moayedoddin B, Booya F (2006) Spectrum of malignant somatostatin-producing neuroendocrine tumors. Endocr Pract 12:394–400CrossRefPubMedGoogle Scholar

Copyright information

© European Society of Radiology 2014

Authors and Affiliations

  • Carla Cappelli
    • 1
    • 4
  • Ugo Boggi
    • 2
  • Salvatore Mazzeo
    • 1
  • Rosa Cervelli
    • 1
  • Daniela Campani
    • 3
  • Niccola Funel
    • 3
  • Benedetta Pontillo Contillo
    • 1
  • Carlo Bartolozzi
    • 1
  1. 1.Diagnostic and Interventional Radiology, Department of Translational Research and New Technologies in Medicine and SurgeryUniversity of PisaPisaItaly
  2. 2.General and Transplant Surgery, Department of Translational Research and New Technologies in Medicine and SurgeryUniversity of PisaPisaItaly
  3. 3.Pathology, Department of Surgical, Medical, Molecular and Critical Area PathologyUniversity of PisaPisaItaly
  4. 4.Azienda Ospedaliero-Universitaria Pisana-Radiodiagnostica IPisaItaly

Personalised recommendations