Advertisement

Abdominal Radiology

, Volume 43, Issue 4, pp 1013–1028 | Cite as

Hypervascular pancreatic “lesions”: a pattern-based approach to differentiation

  • Prasad R. Shankar
  • Ashish P. Wasnik
  • Mahmoud M. Al-Hawary
  • Isaac R. Francis
  • Ravi K. Kaza
Pictorial essay

Abstract

Hypervascular pancreatic lesions/masses can arise due to a variety of causes, both benign and malignant, leading to a wide differential diagnosis. Accurate differentiation of these lesions into appropriate diagnoses can be challenging; however, this is important for directing clinical management. This manuscript provides a multimodality imaging review of hypervascular pancreatic lesion, with emphasis on an imaging-based algorithmic approach for differentiation of these lesions, which may serve as a decision support tool when encountering these uncommon lesions. Additionally, we stratify these lesions into three categories based on malignant potential, to help guide clinical management.

Keywords

Pancreas Hypervascular masses Decision support Neuroendocrine tumor Pancreatic neoplasm 

Notes

Compliance with ethical standards

Funding

No funding was received for this study.

Conflict of interest

All authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

Statement of informed consent was not applicable since the manuscript does not contain any patient data.

References

  1. 1.
    Stanley JC, Wakefield TW, Graham LM, et al. (1986) Clinical importance and management of splanchnic artery aneurysms. J Vasc Surg 3(5):836–840. doi: 10.1016/0741-5214(86)90059-5 CrossRefPubMedGoogle Scholar
  2. 2.
    Grotemeyer D, Duran M, Park EJ, et al. (2009) Visceral artery aneurysms–follow-up of 23 patients with 31 aneurysms after surgical or interventional therapy. Langenbeck’s Arch Surg 394(6):1093–1100. doi: 10.1007/s00423-009-0482-z CrossRefGoogle Scholar
  3. 3.
    Bhosale PR, Menias CO, Balachandran A, et al. (2013) Vascular pancreatic lesions: spectrum of imaging findings of malignant masses and mimics with pathologic correlation. Abdom Imaging 38(4):802–817. doi: 10.1007/s00261-012-9954-7 CrossRefPubMedGoogle Scholar
  4. 4.
    Vandy FC, Sell KA, Eliason JL, et al. (2017) Pancreaticoduodenal and gastroduodenal artery aneurysms associated with celiac artery occlusive disease. Ann Vasc Surg . doi: 10.1016/j.avsg.2016.09.018 PubMedGoogle Scholar
  5. 5.
    Corey MR, Ergul EA, Cambria RP, et al. (2016) The presentation and management of aneurysms of the pancreaticoduodenal arcade. J Vasc Surg 64(6):1734–1740. doi: 10.1016/j.jvs.2016.05.067 CrossRefPubMedGoogle Scholar
  6. 6.
    Thoeni RF (2012) The revised Atlanta classification of acute pancreatitis: its importance for the radiologist and its effect on treatment. Radiology 262(3):751–764. doi: 10.1148/radiol.11110947 CrossRefPubMedGoogle Scholar
  7. 7.
    Mallick IH, Winslet MC (2004) Vascular complications of pancreatitis. JOP 5(5):328–337PubMedGoogle Scholar
  8. 8.
    Hughey M, Taffel M, Zeman RK, Patel S, Hill MC (2017) The diagnostic challenge of the sequelae of acute pancreatitis on CT imaging: a pictorial essay. Abdom Radiol 42(4):1199–1209. doi: 10.1007/s00261-016-0986-2 CrossRefGoogle Scholar
  9. 9.
    Sfyroeras GS, Antoniou GA, Drakou AA, Karathanos C, Giannoukas AD (2009) Visceral venous aneurysms: clinical presentation, natural history and their management: a systematic review. Eur J Vasc Endovasc Surg 38(4):498–505. doi: 10.1016/j.ejvs.2009.05.016 CrossRefPubMedGoogle Scholar
  10. 10.
    Kwon OS, Sul YH, Kim JS, Kim JD (2016) Endovascular stent graft for traumatic splenic vein aneurysm via percutaneous transsplenic access. Ann Surg Treat Res 91(1):56–58. doi: 10.4174/astr.2016.91.1.56 CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Oberg K (2009) Genetics and molecular pathology of neuroendocrine gastrointestinal and pancreatic tumors (gastroenteropancreatic neuroendocrine tumors). Curr Opin Endocrinol Diabetes Obes 16(1):72–78CrossRefPubMedGoogle Scholar
  12. 12.
    Mortele KJ, Mortele B, Silverman SG (2004) CT features of the accessory spleen. AJR 183(6):1653–1657. doi: 10.2214/ajr.183.6.01831653 CrossRefPubMedGoogle Scholar
  13. 13.
    Halpert B, Gyorkey F (1959) Lesions observed in accessory spleens of 311 patients. Am J Clin Pathol 32(2):165–168CrossRefPubMedGoogle Scholar
  14. 14.
    Coquia SF, Kawamoto S, Zaheer A, et al. (2014) Intrapancreatic accessory spleen: possibilities of computed tomography in differentiation from nonfunctioning pancreatic neuroendocrine tumor. J Comput Assist Tomogr 38(6):874–878. doi: 10.1097/rct.0000000000000127 CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Kawamoto S, Johnson PT, Hall H, et al. (2012) Intrapancreatic accessory spleen: CT appearance and differential diagnosis. Abdom Imaging 37(5):812–827. doi: 10.1007/s00261-011-9830-x CrossRefPubMedGoogle Scholar
  16. 16.
    Bhutiani N, Egger ME, Doughtie CA, et al. (2017) Intrapancreatic accessory spleen (IPAS): a single-institution experience and review of the literature. Am J Surg 213(4):816–820. doi: 10.1016/j.amjsurg.2016.11.030 CrossRefPubMedGoogle Scholar
  17. 17.
    Kim SH, Lee JM, Han JK, et al. (2008) Intrapancreatic accessory spleen: findings on MR Imaging, CT, US and scintigraphy, and the pathologic analysis. Korean J Radiol 9(2):162–174. doi: 10.3348/kjr.2008.9.2.162 CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Spencer LA, Spizarny DL, Williams TR (2010) Imaging features of intrapancreatic accessory spleen. Br J Radiol 83(992):668–673. doi: 10.1259/bjr/20308976 CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Saunders TA, Miller TR, Khanafshar E (2016) Intrapancreatic accessory spleen: utilization of fine needle aspiration for diagnosis of a potential mimic of a pancreatic neoplasm. J Gastrointest Oncol 7(Suppl 1):S62–S65. doi: 10.3978/j.issn.2078-6891.2015.030 PubMedPubMedCentralGoogle Scholar
  20. 20.
    Kalb B, Sarmiento JM, Kooby DA, Adsay NV, Martin DR (2009) MR imaging of cystic lesions of the pancreas. Radiographics 29(6):1749–1765. doi: 10.1148/rg.296095506 CrossRefPubMedGoogle Scholar
  21. 21.
    Kucera JN, Kucera S, Perrin SD, et al. (2012) Cystic lesions of the pancreas: radiologic-endosonographic correlation. Radiographics 32(7):E283–E301. doi: 10.1148/rg.327125019 CrossRefPubMedGoogle Scholar
  22. 22.
    Sahani DV, Kambadakone A, Macari M, et al. (2013) Diagnosis and management of cystic pancreatic lesions. AJR 200(2):343–354. doi: 10.2214/ajr.12.8862 CrossRefPubMedGoogle Scholar
  23. 23.
    Khan A, Khosa F, Eisenberg RL (2011) Cystic lesions of the pancreas. Am J Roentgenol 196(6):W668–W677. doi: 10.2214/AJR.10.4378 CrossRefGoogle Scholar
  24. 24.
    Raman SP, Hruban RH, Cameron JL, et al. (2012) Acinar cell carcinoma of the pancreas: computed tomography features—a study of 15 patients. Abdom Imaging 38:137–143CrossRefGoogle Scholar
  25. 25.
    Tatli S, Mortele KJ, Levy AD, et al. (2005) CT and MRI features of pure acinar cell carcinoma of the pancreas in adults. Am J Roentgenol 184(2):511–519. doi: 10.2214/ajr.184.2.01840511 CrossRefGoogle Scholar
  26. 26.
    Ahmed S, Johnson PT, Hruban R, Fishman EK (2013) Metastatic disease to the pancreas: pathologic spectrum and CT patterns. Abdom Imaging 38(1):144–153. doi: 10.1007/s00261-012-9856-8 CrossRefPubMedGoogle Scholar
  27. 27.
    Triantopoulou C, Kolliakou E, Karoumpalis I, Yarmenitis S, Dervenis C (2012) Metastatic disease to the pancreas: an imaging challenge. Insights Imaging 3(2):165–172. doi: 10.1007/s13244-011-0144-x CrossRefPubMedGoogle Scholar
  28. 28.
    Ballarin R, Spaggiari M, Cautero N, et al. (2011) Pancreatic metastases from renal cell carcinoma: the state of the art. World J Gastroenterol 17(43):4747–4756. doi: 10.3748/wjg.v17.i43.4747 CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Sweeney AD, Wu MF, Hilsenbeck SG, Brunicardi FC, Fisher WE (2009) Value of pancreatic resection for cancer metastatic to the pancreas. J Surg Res 156(2):189–198. doi: 10.1016/j.jss.2009.01.017 CrossRefPubMedGoogle Scholar
  30. 30.
    Klein KA, Stephens DH, Welch TJ (1998) CT characteristics of metastatic disease of the pancreas. Radiographics 18(2):369–378. doi: 10.1148/radiographics.18.2.9536484 CrossRefPubMedGoogle Scholar
  31. 31.
    Nihei K, Sakamoto K, Suzuki S, Mishina T, Otaki M (2016) A case of pancreatic metastasis of renal cell carcinoma. Gan Kagaku Ryoho Cancer Chemother 43(12):2274–2276Google Scholar
  32. 32.
    Sohn TA, Yeo CJ, Cameron JL, Nakeeb A, Lillemoe KD (2001) Renal cell carcinoma metastatic to the pancreas: results of surgical management. J Gastrointest Surg 5(4):346–351. doi: 10.1016/S1091-255X(01)80060-3 CrossRefPubMedGoogle Scholar
  33. 33.
    Ro C, Chai W, Yu VE, Yu R (2013) Pancreatic neuroendocrine tumors: biology, diagnosis, and treatment. Chin J Cancer 32(6):312–324. doi: 10.5732/cjc.012.10295 CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    McKenna LR, Edil BH (2014) Update on pancreatic neuroendocrine tumors. Gland Surgery 3(4):258–275. doi: 10.3978/j.issn.2227-684X.2014.06.03 PubMedPubMedCentralGoogle Scholar
  35. 35.
    Raman SP, Hruban RH, Cameron JL, Wolfgang CL, Fishman EK (2012) Pancreatic imaging mimics: part 2, pancreatic neuroendocrine tumors and their mimics. Am J Roentgenol 199(2):309–318. doi: 10.2214/AJR.12.8627 CrossRefGoogle Scholar
  36. 36.
    Tamm EP, Bhosale P, Lee JH, Rohren E (2016) State-of-the-art imaging of pancreatic neuroendocrine tumors. Surg Oncol Clin N Am 25(2):375–400. doi: 10.1016/j.soc.2015.11.007 CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Kalra MK, Maher MM, Mueller PR, Saini S (2003) State-of-the-art imaging of pancreatic neoplasms. Br J Radiol 76(912):857–865. doi: 10.1259/bjr/16642775 CrossRefPubMedGoogle Scholar
  38. 38.
    Cho JH, Ryu JK, Song SY, et al. (2016) Prognostic validity of the American Joint Committee on Cancer and the European Neuroendocrine Tumors Staging classifications for pancreatic neuroendocrine tumors: a retrospective nationwide multicenter study in South Korea. Pancreas 45(7):941–946. doi: 10.1097/mpa.0000000000000586 CrossRefPubMedGoogle Scholar
  39. 39.
    Intenzo CM, Jabbour S, Lin HC, et al. (2007) Scintigraphic imaging of body neuroendocrine tumors. Radiographics 27(5):1355–1369. doi: 10.1148/rg.275065729 CrossRefPubMedGoogle Scholar
  40. 40.
    Lewis RB, Lattin GE, Paal E (2010) Pancreatic endocrine tumors: radiologic-clinicopathologic correlation. Radiographics 30(6):1445–1464. doi: 10.1148/rg.306105523 CrossRefPubMedGoogle Scholar
  41. 41.
    Fidler JL, Fletcher JG, Reading CC (2003) Preoperative detection of pancreatic insulinomas on multiphasic helical CT. AJR 181:775CrossRefPubMedGoogle Scholar
  42. 42.
    King AD, Ko GT, Yeung VT, et al. (1998) Dual phase spiral CT in the detection of small insulinomas of the pancreas. Br J Radiol 71(841):20–23. doi: 10.1259/bjr.71.841.9534694 CrossRefPubMedGoogle Scholar
  43. 43.
    Sahani DV, Bonaffini PA, Fernández-Del Castillo C, Blake MA (2013) Gastroenteropancreatic neuroendocrine tumors: role of imaging in diagnosis and management. Radiology 266(1):38–61. doi: 10.1148/radiol.12112512 CrossRefPubMedGoogle Scholar
  44. 44.
    Fidler JL, Fletcher JG, Reading CC, et al. (2003) Preoperative detection of pancreatic insulinomas on multiphasic helical CT. Am J Roentgenol 181(3):775–780. doi: 10.2214/ajr.181.3.1810775 CrossRefGoogle Scholar
  45. 45.
    Mojtahedi A, Thamake S, Tworowska I, Ranganathan D, Delpassand ES (2014) The value of (68)Ga-DOTATATE PET/CT in diagnosis and management of neuroendocrine tumors compared to current FDA approved imaging modalities: a review of literature. Am J Nucl Med Mol Imaging 4(5):426–434PubMedPubMedCentralGoogle Scholar
  46. 46.
    Hofman MS, Lau WFE, Hicks RJ (2015) Somatostatin receptor imaging with 68 Ga DOTATATE PET/CT: clinical utility, normal patterns, pearls, and pitfalls in interpretation. Radiographics 35(2):500–516. doi: 10.1148/rg.352140164 CrossRefPubMedGoogle Scholar
  47. 47.
    Geijer H, Breimer LH (2013) Somatostatin receptor PET/CT in neuroendocrine tumours: update on systematic review and meta-analysis. Eur J Nucl Med Mol Imaging 40(11):1770–1780. doi: 10.1007/s00259-013-2482-z CrossRefPubMedGoogle Scholar
  48. 48.
    Zhu L, Xue H, Sun Z, et al. (2017) Prospective comparison of biphasic contrast-enhanced CT, volume perfusion CT, and 3 Tesla MRI with diffusion-weighted imaging for insulinoma detection. J Magn Reson Imaging . doi: 10.1002/jmri.25709 PubMedCentralGoogle Scholar
  49. 49.
    Kittah NE, Vella A (2017) Management of Endocrine Disease: pathogenesis and management of hypoglycemia. Eur J Endocrinol . doi: 10.1530/eje-16-1062 PubMedGoogle Scholar
  50. 50.
    Ellison EC (2008) Zollinger-Ellison syndrome: a personal perspective. Am Surg 74(7):563–571PubMedGoogle Scholar
  51. 51.
    Zollinger RM, Ellison EH (1955) Primary peptic ulcerations of the jejunum associated with islet cell tumors of the pancreas. Ann Surg 142(4):709–723CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  • Prasad R. Shankar
    • 1
  • Ashish P. Wasnik
    • 1
  • Mahmoud M. Al-Hawary
    • 1
  • Isaac R. Francis
    • 1
  • Ravi K. Kaza
    • 1
  1. 1.Department of RadiologyMichigan MedicineAnn ArborUSA

Personalised recommendations