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Intraductal Papillary Mucinous Tumor of the Pancreas: A Pictorial Essay¹

¹ From the Department of Radiology, University of Verona, Italy (C.P., G.C., A.G., E.S., C.B., G.F.P.); and the Department of Radiology, New York University Medical Center, New York, NY (A.J.M.). Received December 21, 1998; revision requested March 11, 1999; final revision received May 28; accepted June 16. Address reprint requests to C.P., Department of Radiology, Policlinico Borgo Roma, Via delle Menegone 13, 37134 Verona, Italy.

View larger version (126K): [in a new window]   Figure 1a.   Imaging patterns of intraductal papillary mucinous tumor (IPMT) of the pancreas. (a, b) Drawings show main duct IPMT with segmental (a) and diffuse (b) involvement of the MPD. In diffuse involvement, cystic dilatation of branch ducts and dilatation of the major papilla protruding into the duodenal lumen (arrows) are frequently present. (c, d) Drawings show branch duct IPMT with a macrocystic (c) and microcystic (d) pattern.

View larger version (129K): [in a new window]   Figure 1b.   Imaging patterns of intraductal papillary mucinous tumor (IPMT) of the pancreas. (a, b) Drawings show main duct IPMT with segmental (a) and diffuse (b) involvement of the MPD. In diffuse involvement, cystic dilatation of branch ducts and dilatation of the major papilla protruding into the duodenal lumen (arrows) are frequently present. (c, d) Drawings show branch duct IPMT with a macrocystic (c) and microcystic (d) pattern.

View larger version (126K): [in a new window]   Figure 1c.   Imaging patterns of intraductal papillary mucinous tumor (IPMT) of the pancreas. (a, b) Drawings show main duct IPMT with segmental (a) and diffuse (b) involvement of the MPD. In diffuse involvement, cystic dilatation of branch ducts and dilatation of the major papilla protruding into the duodenal lumen (arrows) are frequently present. (c, d) Drawings show branch duct IPMT with a macrocystic (c) and microcystic (d) pattern.

View larger version (122K): [in a new window]   Figure 1d.   Imaging patterns of intraductal papillary mucinous tumor (IPMT) of the pancreas. (a, b) Drawings show main duct IPMT with segmental (a) and diffuse (b) involvement of the MPD. In diffuse involvement, cystic dilatation of branch ducts and dilatation of the major papilla protruding into the duodenal lumen (arrows) are frequently present. (c, d) Drawings show branch duct IPMT with a macrocystic (c) and microcystic (d) pattern.

View larger version (139K): [in a new window]   Figure 2.   Main duct IPMT with segmental involvement of the pancreatic tail. Computed tomographic (CT) scan shows localized ectasia of the main duct within the pancreatic tail with moderate parenchymal atrophy. The diagnosis of a tumor was made at histologic analysis after splenopancreatectomy.

View larger version (155K): [in a new window]   Figure 3.   Main duct IPMT with segmental involvement of the pancreatic body. ERCP image shows a normal MPD in the region of the pancreatic head. Marked dilatation of the mid-MPD is evident; the proximal MPD is not opacified. The MPD segment involved by the tumor has a sausagelike appearance and contains a long filling defect (arrows), which represents intraductal mucin. Splenopancreatectomy was performed.

View larger version (139K): [in a new window]   Figure 4a.   Main duct IPMT with segmental involvement of the pancreatic body and tail. Contrast material-enhanced CT scans (presented from cephalic [a] to caudal [b]) show dilatation of the MPD within the pancreatic body with atrophy of the surrounding parenchyma. The dilated duct communicates with an area of cystic ectasia in the caudal MPD (*). The area of ectasia resembles a cystic tumor, but the communication with the MPD allows correct diagnosis. The pancreatic head is of normal size. The common bile duct (arrowhead) and the cephalic segment of the MPD (arrow) are normal. Partial pancreatectomy was performed.

View larger version (140K): [in a new window]   Figure 4b.   Main duct IPMT with segmental involvement of the pancreatic body and tail. Contrast material-enhanced CT scans (presented from cephalic [a] to caudal [b]) show dilatation of the MPD within the pancreatic body with atrophy of the surrounding parenchyma. The dilated duct communicates with an area of cystic ectasia in the caudal MPD (*). The area of ectasia resembles a cystic tumor, but the communication with the MPD allows correct diagnosis. The pancreatic head is of normal size. The common bile duct (arrowhead) and the cephalic segment of the MPD (arrow) are normal. Partial pancreatectomy was performed.

View larger version (119K): [in a new window]   Figure 5a.   Main duct IPMT with segmental involvement of the pancreatic head. (a, b) Axial ultrasonographic (US) scans show a dilated MPD (*) within the pancreatic body; there is a direct communication (arrow) between the dilated MPD and an area of cystic ectasia in the cephalic duct (arrowheads). The area of ectasia has sharp margins and inhomogeneous low-level internal echoes. (c) CT scan shows that the cystic lesion is interposed between the duodenum (d) and superior mesenteric vein (arrowhead) and is thin walled. A soft-tissue nodule is seen along the left margin of the lesion (arrow). (d) Axial T2-weighted spin-echo magnetic resonance (MR) image (repetition time msec/echo time msec = 2,400/90) shows overall high signal intensity of the lesion and lower signal intensity of the solid nodule along the left margin (arrow). Pancreatoduodenectomy was performed.

View larger version (130K): [in a new window]   Figure 5b.   Main duct IPMT with segmental involvement of the pancreatic head. (a, b) Axial ultrasonographic (US) scans show a dilated MPD (*) within the pancreatic body; there is a direct communication (arrow) between the dilated MPD and an area of cystic ectasia in the cephalic duct (arrowheads). The area of ectasia has sharp margins and inhomogeneous low-level internal echoes. (c) CT scan shows that the cystic lesion is interposed between the duodenum (d) and superior mesenteric vein (arrowhead) and is thin walled. A soft-tissue nodule is seen along the left margin of the lesion (arrow). (d) Axial T2-weighted spin-echo magnetic resonance (MR) image (repetition time msec/echo time msec = 2,400/90) shows overall high signal intensity of the lesion and lower signal intensity of the solid nodule along the left margin (arrow). Pancreatoduodenectomy was performed.

View larger version (127K): [in a new window]   Figure 5c.   Main duct IPMT with segmental involvement of the pancreatic head. (a, b) Axial ultrasonographic (US) scans show a dilated MPD (*) within the pancreatic body; there is a direct communication (arrow) between the dilated MPD and an area of cystic ectasia in the cephalic duct (arrowheads). The area of ectasia has sharp margins and inhomogeneous low-level internal echoes. (c) CT scan shows that the cystic lesion is interposed between the duodenum (d) and superior mesenteric vein (arrowhead) and is thin walled. A soft-tissue nodule is seen along the left margin of the lesion (arrow). (d) Axial T2-weighted spin-echo magnetic resonance (MR) image (repetition time msec/echo time msec = 2,400/90) shows overall high signal intensity of the lesion and lower signal intensity of the solid nodule along the left margin (arrow). Pancreatoduodenectomy was performed.

View larger version (136K): [in a new window]   Figure 5d.   Main duct IPMT with segmental involvement of the pancreatic head. (a, b) Axial ultrasonographic (US) scans show a dilated MPD (*) within the pancreatic body; there is a direct communication (arrow) between the dilated MPD and an area of cystic ectasia in the cephalic duct (arrowheads). The area of ectasia has sharp margins and inhomogeneous low-level internal echoes. (c) CT scan shows that the cystic lesion is interposed between the duodenum (d) and superior mesenteric vein (arrowhead) and is thin walled. A soft-tissue nodule is seen along the left margin of the lesion (arrow). (d) Axial T2-weighted spin-echo magnetic resonance (MR) image (repetition time msec/echo time msec = 2,400/90) shows overall high signal intensity of the lesion and lower signal intensity of the solid nodule along the left margin (arrow). Pancreatoduodenectomy was performed.

View larger version (115K): [in a new window]   Figure 6a.   Main duct IPMT with apparent diffuse involvement. Axial T2-weighted fast spin-echo MR images (presented from cephalic [a] to caudal [c]) show diffuse dilatation of the MPD, which is more evident in the pancreatic head and is associated with cystic dilatation of the branch ducts within the uncinate process (*). The dilated major papilla (arrowhead) bulges into the fluid-filled duodenal lumen (d). There is also moderate parenchymal atrophy, which is more evident in the region of the pancreatic head. The Whipple operation was performed because a tumor-free surgical margin was demonstrated at analysis of frozen sections.

View larger version (116K): [in a new window]   Figure 6b.   Main duct IPMT with apparent diffuse involvement. Axial T2-weighted fast spin-echo MR images (presented from cephalic [a] to caudal [c]) show diffuse dilatation of the MPD, which is more evident in the pancreatic head and is associated with cystic dilatation of the branch ducts within the uncinate process (*). The dilated major papilla (arrowhead) bulges into the fluid-filled duodenal lumen (d). There is also moderate parenchymal atrophy, which is more evident in the region of the pancreatic head. The Whipple operation was performed because a tumor-free surgical margin was demonstrated at analysis of frozen sections.

View larger version (117K): [in a new window]   Figure 6c.   Main duct IPMT with apparent diffuse involvement. Axial T2-weighted fast spin-echo MR images (presented from cephalic [a] to caudal [c]) show diffuse dilatation of the MPD, which is more evident in the pancreatic head and is associated with cystic dilatation of the branch ducts within the uncinate process (*). The dilated major papilla (arrowhead) bulges into the fluid-filled duodenal lumen (d). There is also moderate parenchymal atrophy, which is more evident in the region of the pancreatic head. The Whipple operation was performed because a tumor-free surgical margin was demonstrated at analysis of frozen sections.

View larger version (139K): [in a new window]   Figure 7a.   Main duct IPMT with diffuse involvement. (a, b) CT scans (presented from cranial [a] to caudal [b]) show marked dilatation of the MPD, along with dilatation of the branch ducts in the uncinate process (white dot) and pancreatic tail (*). Severe parenchymal atrophy is present. Cystlike dilatations of the branch ducts are bounded by thin septa. Filling defects are not appreciable. (c) Axial T2-weighted spin-echo MR image shows overall high signal intensity within the MPD and the dilated branch ducts (⋅, *). (d) Contrast-enhanced axial T1-weighted gradient-echo MR image shows low signal intensity within the MPD and the dilated branch ducts. Again, no filling defects are seen. The diagnosis of borderline malignant mucinous tumor was made with fine-needle aspiration biopsy, but surgery was not performed due to the patient's age (74 years).

View larger version (144K): [in a new window]   Figure 7b.   Main duct IPMT with diffuse involvement. (a, b) CT scans (presented from cranial [a] to caudal [b]) show marked dilatation of the MPD, along with dilatation of the branch ducts in the uncinate process (white dot) and pancreatic tail (*). Severe parenchymal atrophy is present. Cystlike dilatations of the branch ducts are bounded by thin septa. Filling defects are not appreciable. (c) Axial T2-weighted spin-echo MR image shows overall high signal intensity within the MPD and the dilated branch ducts (⋅, *). (d) Contrast-enhanced axial T1-weighted gradient-echo MR image shows low signal intensity within the MPD and the dilated branch ducts. Again, no filling defects are seen. The diagnosis of borderline malignant mucinous tumor was made with fine-needle aspiration biopsy, but surgery was not performed due to the patient's age (74 years).

View larger version (132K): [in a new window]   Figure 7c.   Main duct IPMT with diffuse involvement. (a, b) CT scans (presented from cranial [a] to caudal [b]) show marked dilatation of the MPD, along with dilatation of the branch ducts in the uncinate process (white dot) and pancreatic tail (*). Severe parenchymal atrophy is present. Cystlike dilatations of the branch ducts are bounded by thin septa. Filling defects are not appreciable. (c) Axial T2-weighted spin-echo MR image shows overall high signal intensity within the MPD and the dilated branch ducts (⋅, *). (d) Contrast-enhanced axial T1-weighted gradient-echo MR image shows low signal intensity within the MPD and the dilated branch ducts. Again, no filling defects are seen. The diagnosis of borderline malignant mucinous tumor was made with fine-needle aspiration biopsy, but surgery was not performed due to the patient's age (74 years).

View larger version (139K): [in a new window]   Figure 7d.   Main duct IPMT with diffuse involvement. (a, b) CT scans (presented from cranial [a] to caudal [b]) show marked dilatation of the MPD, along with dilatation of the branch ducts in the uncinate process (white dot) and pancreatic tail (*). Severe parenchymal atrophy is present. Cystlike dilatations of the branch ducts are bounded by thin septa. Filling defects are not appreciable. (c) Axial T2-weighted spin-echo MR image shows overall high signal intensity within the MPD and the dilated branch ducts (⋅, *). (d) Contrast-enhanced axial T1-weighted gradient-echo MR image shows low signal intensity within the MPD and the dilated branch ducts. Again, no filling defects are seen. The diagnosis of borderline malignant mucinous tumor was made with fine-needle aspiration biopsy, but surgery was not performed due to the patient's age (74 years).

View larger version (119K): [in a new window]   Figure 8a.   Main duct IPMT with diffuse involvement. (8) CT scans (presented from cranial [a] to caudal [b]) show marked dilatation of the MPD (*) and cystlike dilatation of the branch ducts in the uncinate process and pancreatic tail. Mucin deposits are evident within the dilated branch ducts of the uncinate process (arrows). Total pancreatectomy was performed.

View larger version (114K): [in a new window]   Figure 8b.   Main duct IPMT with diffuse involvement. (8) CT scans (presented from cranial [a] to caudal [b]) show marked dilatation of the MPD (*) and cystlike dilatation of the branch ducts in the uncinate process and pancreatic tail. Mucin deposits are evident within the dilated branch ducts of the uncinate process (arrows). Total pancreatectomy was performed.

View larger version (121K): [in a new window]   Figure 9a.   CT scans (presented from cranial [a] to caudal [b]) show marked dilatation of the MPD, which is surrounded by a thin neoplastic rind. The dilated minor papilla bulges into the duodenal lumen (black arrow). Also evident are peritoneal fluid and peritoneal nodules of soft-tissue attenuation (white arrows), findings consistent with pseudomyxoma peritonei. The diagnosis of pseudomyxoma peritonei was confirmed with laparoscopy.

View larger version (121K): [in a new window]   Figure 9b.   CT scans (presented from cranial [a] to caudal [b]) show marked dilatation of the MPD, which is surrounded by a thin neoplastic rind. The dilated minor papilla bulges into the duodenal lumen (black arrow). Also evident are peritoneal fluid and peritoneal nodules of soft-tissue attenuation (white arrows), findings consistent with pseudomyxoma peritonei. The diagnosis of pseudomyxoma peritonei was confirmed with laparoscopy.

View larger version (129K): [in a new window]   Figure 10a.   Main duct IPMT with diffuse involvement. (a) CT scan at the level of the pancreatic head shows dilatation of the branch ducts and the major papilla (arrowhead). The major papilla bulges into the duodenal lumen, which is filled with water-soluble oral contrast material. (b) Endoscopic image shows the dilatation of the major papilla (*), which bulges into the duodenal lumen. Cephalad to the major papilla, a catheter within a fistulous tract in the duodenal wall is visible (arrows).

View larger version (109K): [in a new window]   Figure 10b.   Main duct IPMT with diffuse involvement. (a) CT scan at the level of the pancreatic head shows dilatation of the branch ducts and the major papilla (arrowhead). The major papilla bulges into the duodenal lumen, which is filled with water-soluble oral contrast material. (b) Endoscopic image shows the dilatation of the major papilla (*), which bulges into the duodenal lumen. Cephalad to the major papilla, a catheter within a fistulous tract in the duodenal wall is visible (arrows).

View larger version (147K): [in a new window]   Figure 11a.   Branch duct IPMT of the pancreatic neck. (a) Transverse US scan at the level of the upper midabdomen shows the pancreatic parenchyma with no evidence of MPD dilatation. A roughly triangular hypoechoic lesion (cursors) is seen along the left margin of the pancreatic head, close to the mesenteric vessels (*). The common bile duct is slightly dilated (arrow). (b, c) CT scans (presented from cranial [b] to caudal [c]) obtained after intravenous administration of secretin (100 IU) show a communication (arrow) between the cystic lesion (*) and the MPD. The MPD is slightly dilated. c = common bile duct. (d) ERCP image shows passage of contrast material from the MPD to cystically dilated branch ducts in the pancreatic neck. Pancreatoduodenectomy was performed.

View larger version (140K): [in a new window]   Figure 11b.   Branch duct IPMT of the pancreatic neck. (a) Transverse US scan at the level of the upper midabdomen shows the pancreatic parenchyma with no evidence of MPD dilatation. A roughly triangular hypoechoic lesion (cursors) is seen along the left margin of the pancreatic head, close to the mesenteric vessels (*). The common bile duct is slightly dilated (arrow). (b, c) CT scans (presented from cranial [b] to caudal [c]) obtained after intravenous administration of secretin (100 IU) show a communication (arrow) between the cystic lesion (*) and the MPD. The MPD is slightly dilated. c = common bile duct. (d) ERCP image shows passage of contrast material from the MPD to cystically dilated branch ducts in the pancreatic neck. Pancreatoduodenectomy was performed.

View larger version (123K): [in a new window]   Figure 11c.   Branch duct IPMT of the pancreatic neck. (a) Transverse US scan at the level of the upper midabdomen shows the pancreatic parenchyma with no evidence of MPD dilatation. A roughly triangular hypoechoic lesion (cursors) is seen along the left margin of the pancreatic head, close to the mesenteric vessels (*). The common bile duct is slightly dilated (arrow). (b, c) CT scans (presented from cranial [b] to caudal [c]) obtained after intravenous administration of secretin (100 IU) show a communication (arrow) between the cystic lesion (*) and the MPD. The MPD is slightly dilated. c = common bile duct. (d) ERCP image shows passage of contrast material from the MPD to cystically dilated branch ducts in the pancreatic neck. Pancreatoduodenectomy was performed.

View larger version (131K): [in a new window]   Figure 11d.   Branch duct IPMT of the pancreatic neck. (a) Transverse US scan at the level of the upper midabdomen shows the pancreatic parenchyma with no evidence of MPD dilatation. A roughly triangular hypoechoic lesion (cursors) is seen along the left margin of the pancreatic head, close to the mesenteric vessels (*). The common bile duct is slightly dilated (arrow). (b, c) CT scans (presented from cranial [b] to caudal [c]) obtained after intravenous administration of secretin (100 IU) show a communication (arrow) between the cystic lesion (*) and the MPD. The MPD is slightly dilated. c = common bile duct. (d) ERCP image shows passage of contrast material from the MPD to cystically dilated branch ducts in the pancreatic neck. Pancreatoduodenectomy was performed.

View larger version (144K): [in a new window]   Figure 12a.   Branch duct IPMT of the uncinate process. (a-c) CT scans (presented from cranial [a] to caudal [c]) show ectasia of branch ducts (*) within the uncinate process and dilatation of the MPD (white arrow). Black arrow = common bile duct. (d) ERCP image shows the dilated MPD, which contains a filling defect (arrowhead) attributed to mucin. The thick mucin prevents the contrast material from filling the dilated branch ducts seen on the CT scans. Pancreatoduodenectomy was performed.

View larger version (133K): [in a new window]   Figure 12b.   Branch duct IPMT of the uncinate process. (a-c) CT scans (presented from cranial [a] to caudal [c]) show ectasia of branch ducts (*) within the uncinate process and dilatation of the MPD (white arrow). Black arrow = common bile duct. (d) ERCP image shows the dilated MPD, which contains a filling defect (arrowhead) attributed to mucin. The thick mucin prevents the contrast material from filling the dilated branch ducts seen on the CT scans. Pancreatoduodenectomy was performed.

View larger version (140K): [in a new window]   Figure 12c.   Branch duct IPMT of the uncinate process. (a-c) CT scans (presented from cranial [a] to caudal [c]) show ectasia of branch ducts (*) within the uncinate process and dilatation of the MPD (white arrow). Black arrow = common bile duct. (d) ERCP image shows the dilated MPD, which contains a filling defect (arrowhead) attributed to mucin. The thick mucin prevents the contrast material from filling the dilated branch ducts seen on the CT scans. Pancreatoduodenectomy was performed.

View larger version (117K): [in a new window]   Figure 12d.   Branch duct IPMT of the uncinate process. (a-c) CT scans (presented from cranial [a] to caudal [c]) show ectasia of branch ducts (*) within the uncinate process and dilatation of the MPD (white arrow). Black arrow = common bile duct. (d) ERCP image shows the dilated MPD, which contains a filling defect (arrowhead) attributed to mucin. The thick mucin prevents the contrast material from filling the dilated branch ducts seen on the CT scans. Pancreatoduodenectomy was performed.

View larger version (148K): [in a new window]   Figure 13a.   Branch duct IPMT of the uncinate process. (a) CT scan shows a unilocular, thin-walled, lobulated lesion (*). The MPD is normal. (b) Axial T2-weighted spin-echo MR image shows a hyperintense lesion (*) with the morphologic features seen on the CT scan. (c) Coronal T2-weighted fast spin-echo MR image shows the lobulated contour and unilocular, macrocystic architecture of the lesion more clearly. The lesion partially overlaps the slightly dilated common bile duct. (d) ERCP image shows the dilated common bile duct and passage of contrast material into the lesion, which is in the uncinate process. Pancreatoduodenectomy was performed.

View larger version (136K): [in a new window]   Figure 13b.   Branch duct IPMT of the uncinate process. (a) CT scan shows a unilocular, thin-walled, lobulated lesion (*). The MPD is normal. (b) Axial T2-weighted spin-echo MR image shows a hyperintense lesion (*) with the morphologic features seen on the CT scan. (c) Coronal T2-weighted fast spin-echo MR image shows the lobulated contour and unilocular, macrocystic architecture of the lesion more clearly. The lesion partially overlaps the slightly dilated common bile duct. (d) ERCP image shows the dilated common bile duct and passage of contrast material into the lesion, which is in the uncinate process. Pancreatoduodenectomy was performed.

View larger version (125K): [in a new window]   Figure 13c.   Branch duct IPMT of the uncinate process. (a) CT scan shows a unilocular, thin-walled, lobulated lesion (*). The MPD is normal. (b) Axial T2-weighted spin-echo MR image shows a hyperintense lesion (*) with the morphologic features seen on the CT scan. (c) Coronal T2-weighted fast spin-echo MR image shows the lobulated contour and unilocular, macrocystic architecture of the lesion more clearly. The lesion partially overlaps the slightly dilated common bile duct. (d) ERCP image shows the dilated common bile duct and passage of contrast material into the lesion, which is in the uncinate process. Pancreatoduodenectomy was performed.

View larger version (130K): [in a new window]   Figure 13d.   Branch duct IPMT of the uncinate process. (a) CT scan shows a unilocular, thin-walled, lobulated lesion (*). The MPD is normal. (b) Axial T2-weighted spin-echo MR image shows a hyperintense lesion (*) with the morphologic features seen on the CT scan. (c) Coronal T2-weighted fast spin-echo MR image shows the lobulated contour and unilocular, macrocystic architecture of the lesion more clearly. The lesion partially overlaps the slightly dilated common bile duct. (d) ERCP image shows the dilated common bile duct and passage of contrast material into the lesion, which is in the uncinate process. Pancreatoduodenectomy was performed.

View larger version (122K): [in a new window]   Figure 14a.   Multifocal branch duct IPMT. (a) CT scan shows multiple intrapancreatic and peripancreatic cystlike lesions (*) involving the whole gland. Total pancreatectomy was performed. (b) Radiograph of the resected specimen shows multifocal ductal ectasia from the head to the tail of the gland.

View larger version (51K): [in a new window]   Figure 14b.   Multifocal branch duct IPMT. (a) CT scan shows multiple intrapancreatic and peripancreatic cystlike lesions (*) involving the whole gland. Total pancreatectomy was performed. (b) Radiograph of the resected specimen shows multifocal ductal ectasia from the head to the tail of the gland.

View larger version (139K): [in a new window]   Figure 15a.   Branch duct IPMT of the uncinate process. (a, b) CT scans (presented from cranial [a] to caudal [b]) show marked dilatation of the MPD and parenchymal atrophy. A multilocular, microcystic lesion is visible in the uncinate process as well. The tumor compresses the duodenal lumen. (c, d) Gadolinium-enhanced coronal T1-weighted gradient-echo MR images (presented from anterior [c] to posterior [d]) show the internal microcystic architecture of the lesion (arrows) more clearly. Pancreatoduodenectomy was performed; the frozen section from the surgical margin was free of tumor.

View larger version (147K): [in a new window]   Figure 15b.   Branch duct IPMT of the uncinate process. (a, b) CT scans (presented from cranial [a] to caudal [b]) show marked dilatation of the MPD and parenchymal atrophy. A multilocular, microcystic lesion is visible in the uncinate process as well. The tumor compresses the duodenal lumen. (c, d) Gadolinium-enhanced coronal T1-weighted gradient-echo MR images (presented from anterior [c] to posterior [d]) show the internal microcystic architecture of the lesion (arrows) more clearly. Pancreatoduodenectomy was performed; the frozen section from the surgical margin was free of tumor.

View larger version (144K): [in a new window]   Figure 15c.   Branch duct IPMT of the uncinate process. (a, b) CT scans (presented from cranial [a] to caudal [b]) show marked dilatation of the MPD and parenchymal atrophy. A multilocular, microcystic lesion is visible in the uncinate process as well. The tumor compresses the duodenal lumen. (c, d) Gadolinium-enhanced coronal T1-weighted gradient-echo MR images (presented from anterior [c] to posterior [d]) show the internal microcystic architecture of the lesion (arrows) more clearly. Pancreatoduodenectomy was performed; the frozen section from the surgical margin was free of tumor.

View larger version (142K): [in a new window]   Figure 15d.   Branch duct IPMT of the uncinate process. (a, b) CT scans (presented from cranial [a] to caudal [b]) show marked dilatation of the MPD and parenchymal atrophy. A multilocular, microcystic lesion is visible in the uncinate process as well. The tumor compresses the duodenal lumen. (c, d) Gadolinium-enhanced coronal T1-weighted gradient-echo MR images (presented from anterior [c] to posterior [d]) show the internal microcystic architecture of the lesion (arrows) more clearly. Pancreatoduodenectomy was performed; the frozen section from the surgical margin was free of tumor.

View larger version (135K): [in a new window]   Figure 16a.   Branch duct IPMT. (a-c) CT scans (presented from cranial [a] to caudal [c]) show a multilocular, macrocystic lesion in the uncinate process and dilatation of the MPD. Inside the main cyst, a filling defect is visible in the gravity-dependent portion (arrow). (d) CT scan obtained with the patient in the prone position shows that the defect has moved to the opposite side (arrow), a finding indicative of inspissated mucin. Pancreatoduodenectomy was performed.

View larger version (134K): [in a new window]   Figure 16b.   Branch duct IPMT. (a-c) CT scans (presented from cranial [a] to caudal [c]) show a multilocular, macrocystic lesion in the uncinate process and dilatation of the MPD. Inside the main cyst, a filling defect is visible in the gravity-dependent portion (arrow). (d) CT scan obtained with the patient in the prone position shows that the defect has moved to the opposite side (arrow), a finding indicative of inspissated mucin. Pancreatoduodenectomy was performed.

View larger version (120K): [in a new window]   Figure 16c.   Branch duct IPMT. (a-c) CT scans (presented from cranial [a] to caudal [c]) show a multilocular, macrocystic lesion in the uncinate process and dilatation of the MPD. Inside the main cyst, a filling defect is visible in the gravity-dependent portion (arrow). (d) CT scan obtained with the patient in the prone position shows that the defect has moved to the opposite side (arrow), a finding indicative of inspissated mucin. Pancreatoduodenectomy was performed.

View larger version (144K): [in a new window]   Figure 16d.   Branch duct IPMT. (a-c) CT scans (presented from cranial [a] to caudal [c]) show a multilocular, macrocystic lesion in the uncinate process and dilatation of the MPD. Inside the main cyst, a filling defect is visible in the gravity-dependent portion (arrow). (d) CT scan obtained with the patient in the prone position shows that the defect has moved to the opposite side (arrow), a finding indicative of inspissated mucin. Pancreatoduodenectomy was performed.

View larger version (147K): [in a new window]   Figure 17a.   IPMT of uncertain origin but presumably originating from branch ducts of the uncinate process. (a) CT scan shows significant dilatation of the MPD and a conspicuous mass of fluid and soft-tissue attenuation that involves the pancreatic head and uncinate process. The lesion seems to involve the mesenteric vessels. A tiny calcification is seen in the MPD at the level of the pancreatic body (arrow). The gastric antrum is pushed ventrally (*). (b) Gadolinium-enhanced axial T1-weighted gradient-echo MR image clearly shows the focal lesion and the MPD dilatation upstream. Centrally located liquid lacunae, gross septa, and intraluminal nodules are seen. Exploratory laparotomy was performed.

View larger version (136K): [in a new window]   Figure 17b.   IPMT of uncertain origin but presumably originating from branch ducts of the uncinate process. (a) CT scan shows significant dilatation of the MPD and a conspicuous mass of fluid and soft-tissue attenuation that involves the pancreatic head and uncinate process. The lesion seems to involve the mesenteric vessels. A tiny calcification is seen in the MPD at the level of the pancreatic body (arrow). The gastric antrum is pushed ventrally (*). (b) Gadolinium-enhanced axial T1-weighted gradient-echo MR image clearly shows the focal lesion and the MPD dilatation upstream. Centrally located liquid lacunae, gross septa, and intraluminal nodules are seen. Exploratory laparotomy was performed.

View larger version (157K): [in a new window]   Figure 18a.   Branch duct IPMT of the pancreatic body. (a) CT scan shows a normal-sized pancreas with multifocal slight ectasia of the branch ducts and slight dilatation of the MPD. (b) CT scan obtained 8 months later shows more severe dilatation of the branch ducts and of the involved MPD segment. (c) Intraoperative pancreatogram shows passage of contrast material from the MPD to the ectatic branch ducts (arrows). The dilated branch ducts demonstrate mass effect at the level of the pancreatic body and tail.

View larger version (143K): [in a new window]   Figure 18b.   Branch duct IPMT of the pancreatic body. (a) CT scan shows a normal-sized pancreas with multifocal slight ectasia of the branch ducts and slight dilatation of the MPD. (b) CT scan obtained 8 months later shows more severe dilatation of the branch ducts and of the involved MPD segment. (c) Intraoperative pancreatogram shows passage of contrast material from the MPD to the ectatic branch ducts (arrows). The dilated branch ducts demonstrate mass effect at the level of the pancreatic body and tail.

View larger version (128K): [in a new window]   Figure 18c.   Branch duct IPMT of the pancreatic body. (a) CT scan shows a normal-sized pancreas with multifocal slight ectasia of the branch ducts and slight dilatation of the MPD. (b) CT scan obtained 8 months later shows more severe dilatation of the branch ducts and of the involved MPD segment. (c) Intraoperative pancreatogram shows passage of contrast material from the MPD to the ectatic branch ducts (arrows). The dilated branch ducts demonstrate mass effect at the level of the pancreatic body and tail.