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Peripancreatic Masses That Simulate Pancreatic Disease: Spectrum of Disease and Role of CT¹

¹ From the Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, 601 N Caroline St, Rm 3254, Baltimore, MD 21287-0801. Presented as an education exhibit at the 2002 RSNA scientific assembly. Received January 27, 2003; revision requested March 6 and received April 18; accepted May 14. Address correspondence to L.P.L. (e-mail: efishman@jhmi.edu).

View larger version (141K): [in a new window]   Figure 1a.  Normal jejunum that simulates a mass in a 77-year-old man. (a) On a CT scan, the jejunum (M) simulates a mass in the region of the pancreatic tail (arrowheads). (b) CT scan demonstrates jejunal loops (white arrowheads) containing some neutral contrast material in the region of the pancreatic tail (black arrowhead).

View larger version (142K): [in a new window]   Figure 1b.  Normal jejunum that simulates a mass in a 77-year-old man. (a) On a CT scan, the jejunum (M) simulates a mass in the region of the pancreatic tail (arrowheads). (b) CT scan demonstrates jejunal loops (white arrowheads) containing some neutral contrast material in the region of the pancreatic tail (black arrowhead).

View larger version (164K): [in a new window]   Figure 2a.  Gastric tumor in a 50-year-old man with abdominal pain. (a) CT scan demonstrates a GIST (M) in the region of the fundus of the stomach (G). (b) On a CT scan obtained inferior to a, the gastric tumor (M) simulates a mass of the pancreas (arrowheads). G = stomach.

View larger version (168K): [in a new window]   Figure 2b.  Gastric tumor in a 50-year-old man with abdominal pain. (a) CT scan demonstrates a GIST (M) in the region of the fundus of the stomach (G). (b) On a CT scan obtained inferior to a, the gastric tumor (M) simulates a mass of the pancreas (arrowheads). G = stomach.

View larger version (136K): [in a new window]   Figure 3.  Duodenal mass in a 70-year-old woman with abdominal pain. Contrast-enhanced CT scan demonstrates a GIST of the duodenum (arrowheads). The tumor causes circumferential thickening and aneurysmal enlargement and could be mistaken for a pancreatic mass.

View larger version (145K): [in a new window]   Figure 4.  Duodenal mass in a 70-year-old woman with abdominal pain. CT scan shows a solid GIST of the duodenum (M) that simulates a mass of the pancreatic head. Arrowheads indicate the neck and body of the pancreas.

View larger version (156K): [in a new window]   Figure 5a.  Duodenal carcinoma in a 78-year-old woman with abdominal pain. (a) CT scan shows a mass (black arrowheads) with a central cavity containing air and blood (white arrowhead). The mass is difficult to differentiate from the pancreatic head (arrow). (b) MPR image reveals that the cavitating mass (black arrowheads) arises from the second portion of the duodenum (white arrowheads). Arrow indicates the pancreas. (c) VR image shows that the cavitating mass (arrowheads) arises from the second portion of the duodenum (long arrow) and is located inferior to the pancreas (short arrow).

View larger version (164K): [in a new window]   Figure 5b.  Duodenal carcinoma in a 78-year-old woman with abdominal pain. (a) CT scan shows a mass (black arrowheads) with a central cavity containing air and blood (white arrowhead). The mass is difficult to differentiate from the pancreatic head (arrow). (b) MPR image reveals that the cavitating mass (black arrowheads) arises from the second portion of the duodenum (white arrowheads). Arrow indicates the pancreas. (c) VR image shows that the cavitating mass (arrowheads) arises from the second portion of the duodenum (long arrow) and is located inferior to the pancreas (short arrow).

View larger version (155K): [in a new window]   Figure 5c.  Duodenal carcinoma in a 78-year-old woman with abdominal pain. (a) CT scan shows a mass (black arrowheads) with a central cavity containing air and blood (white arrowhead). The mass is difficult to differentiate from the pancreatic head (arrow). (b) MPR image reveals that the cavitating mass (black arrowheads) arises from the second portion of the duodenum (white arrowheads). Arrow indicates the pancreas. (c) VR image shows that the cavitating mass (arrowheads) arises from the second portion of the duodenum (long arrow) and is located inferior to the pancreas (short arrow).

View larger version (132K): [in a new window]   Figure 6.  Duodenal carcinoma in a 61-year-old woman with abdominal pain. CT scan demonstrates circumferential thickening of the third portion of the duodenum (black arrowheads). The second portion of the duodenum is well enhanced (white arrowhead).

View larger version (138K): [in a new window]   Figure 7.  Duodenal carcinoma in a 60-year-old woman with abdominal pain. CT scan shows an infiltrating mass of the third portion of the duodenum (arrow). It is difficult to determine whether the mass is duodenal or pancreatic in origin.

View larger version (150K): [in a new window]   Figure 8a.  Duodenal lymphoma in a 63-year-old woman. (a) Follow-up CT scan demonstrates a large, lobulated mass of the duodenum (arrows) that obscures normal tissue planes. The second portion of the duodenum contains a biliary stent (arrowhead). (b) VR image demonstrates a large, lobulated lymphoma (arrowheads) that infiltrates the pancreas and obscures known tissue boundaries. The biliary stent (long arrow) is seen in the second portion of the duodenum (short arrow).

View larger version (135K): [in a new window]   Figure 8b.  Duodenal lymphoma in a 63-year-old woman. (a) Follow-up CT scan demonstrates a large, lobulated mass of the duodenum (arrows) that obscures normal tissue planes. The second portion of the duodenum contains a biliary stent (arrowhead). (b) VR image demonstrates a large, lobulated lymphoma (arrowheads) that infiltrates the pancreas and obscures known tissue boundaries. The biliary stent (long arrow) is seen in the second portion of the duodenum (short arrow).

View larger version (151K): [in a new window]   Figure 9a.  Duodenal renal cell metastasis in a 70-year-old woman. (a) Follow-up early phase contrast-enhanced CT scan shows a hyperattenuating mass (long arrow) of the duodenum (arrowheads). The mass could be mistaken for an islet cell tumor of the pancreas (short arrow). (b) On a delayed phase contrast-enhanced CT scan, the duodenal mass is washed out (arrow). Arrowheads indicate the duodenum.

View larger version (155K): [in a new window]   Figure 9b.  Duodenal renal cell metastasis in a 70-year-old woman. (a) Follow-up early phase contrast-enhanced CT scan shows a hyperattenuating mass (long arrow) of the duodenum (arrowheads). The mass could be mistaken for an islet cell tumor of the pancreas (short arrow). (b) On a delayed phase contrast-enhanced CT scan, the duodenal mass is washed out (arrow). Arrowheads indicate the duodenum.

View larger version (119K): [in a new window]   Figure 10.  Extrinsic duodenal diverticulum in a 70-year-old woman with abdominal pain. CT scan shows an air-filled duodenal diverticulum (long arrow) that extends into the region of the pancreatic head (arrowhead) and could be mistaken for a pancreatic abscess. Short arrow indicates the duodenum. P = pancreatic body and tail.

View larger version (133K): [in a new window]   Figure 11.  Duodenal duplication cyst in a 42-year-old man with abdominal pain. CT scan shows a fluid-filled duplication cyst (arrowheads) of the medial second portion of the duodenum (arrow). The cyst simulates a cystic mass of the pancreas (P).

View larger version (149K): [in a new window]   Figure 12a.  Intraluminal duodenal diverticulum in a 61-year-old woman with abdominal pain. (a) CT scan shows a debris-filled intrinsic "windsock" diverticulum (large arrowhead) that distorts the pancreas (short arrow) and the second portion of the duodenum (small arrowhead), part of which is well enhanced (long arrow). The diverticulum simulates a pancreatic mass. (b) MPR image demonstrates the diverticulum (T), which distorts the pancreas (short arrows) and the second and third portions of the duodenum (arrowhead) and simulates a pancreatic mass. Long arrow indicates the ligament of Treitz. (c) VR image demonstrates the diverticulum (T) within the proximal jejunum (arrow). The diverticulum distorts the pancreas (P) and duodenum (arrowheads), thereby simulating a pancreatic mass.

View larger version (160K): [in a new window]   Figure 12b.  Intraluminal duodenal diverticulum in a 61-year-old woman with abdominal pain. (a) CT scan shows a debris-filled intrinsic "windsock" diverticulum (large arrowhead) that distorts the pancreas (short arrow) and the second portion of the duodenum (small arrowhead), part of which is well enhanced (long arrow). The diverticulum simulates a pancreatic mass. (b) MPR image demonstrates the diverticulum (T), which distorts the pancreas (short arrows) and the second and third portions of the duodenum (arrowhead) and simulates a pancreatic mass. Long arrow indicates the ligament of Treitz. (c) VR image demonstrates the diverticulum (T) within the proximal jejunum (arrow). The diverticulum distorts the pancreas (P) and duodenum (arrowheads), thereby simulating a pancreatic mass.

View larger version (152K): [in a new window]   Figure 12c.  Intraluminal duodenal diverticulum in a 61-year-old woman with abdominal pain. (a) CT scan shows a debris-filled intrinsic "windsock" diverticulum (large arrowhead) that distorts the pancreas (short arrow) and the second portion of the duodenum (small arrowhead), part of which is well enhanced (long arrow). The diverticulum simulates a pancreatic mass. (b) MPR image demonstrates the diverticulum (T), which distorts the pancreas (short arrows) and the second and third portions of the duodenum (arrowhead) and simulates a pancreatic mass. Long arrow indicates the ligament of Treitz. (c) VR image demonstrates the diverticulum (T) within the proximal jejunum (arrow). The diverticulum distorts the pancreas (P) and duodenum (arrowheads), thereby simulating a pancreatic mass.

View larger version (126K): [in a new window]   Figure 13.  Duodenal hematoma in a 41-year-old coagulopathic man who presented with acute duodenal obstruction. CT scan demonstrates a hematoma with heterogeneous attenuation (H) in the third portion of the duodenum (arrowheads). Such a hematoma may simulate a pancreatic mass or cyst.

View larger version (142K): [in a new window]   Figure 14.  Colorectal carcinoma in a 75-year-old woman who underwent follow-up CT for colon cancer. CT scan shows an enlarged portocaval node (short arrow) just anterior to the inferior vena cava (arrowhead). Such a lesion may simulate a mass of the pancreas (long arrow).

View larger version (153K): [in a new window]   Figure 15.  Merkel cell tumor in a 62-year-old woman with known tumor. CT scan shows infiltrating Merkel cell tumor metastases (arrowheads) that simulate a mass originating from the pancreas (long arrow). Short arrow indicates the second portion of the duodenum.

View larger version (123K): [in a new window]   Figure 16.  Lymphoma in a 65-year-old woman with an abdominal mass. CT scan demonstrates low-attenuation nodes of lymphoma (arrowheads) that encase the pancreas (arrows).

View larger version (137K): [in a new window]   Figure 17.  Metastatic breast carcinoma in a 62-year-old woman with abdominal pain. CT scan shows peripancreatic adenopathy (arrowhead) that simulates a primary pancreatic mass. Arrow indicates a normal pancreas.

View larger version (128K): [in a new window]   Figure 18.  Lymphoma in a 68-year-old woman with an abdominal mass. CT scan demonstrates bulky adenopathy from lymphoma (arrows) that encases the vasculature and obscures the planes with the pancreas (arrowheads).

View larger version (145K): [in a new window]   Figure 19.  Seminoma in a 41-year-old man with abdominal pain. CT scan shows a metastatic lymph node from seminoma (M) that obscures the tissue plane with the pancreas (arrowhead).

View larger version (125K): [in a new window]   Figure 20a.  Adrenal cyst in a 52-year-old man with abdominal pain. CT scans show an adrenal cyst (C), which may simulate a cyst of the pancreas (P in a, arrowheads in b).

View larger version (123K): [in a new window]   Figure 20b.  Adrenal cyst in a 52-year-old man with abdominal pain. CT scans show an adrenal cyst (C), which may simulate a cyst of the pancreas (P in a, arrowheads in b).

View larger version (148K): [in a new window]   Figure 21a.  Renal cyst in a 40-year-old woman with abdominal pain. MPR images demonstrate a partially calcified cyst (C) that arises from the upper pole of the left kidney (arrow) and is separate from the pancreatic tail (arrowhead). G = stomach.

View larger version (155K): [in a new window]   Figure 21b.  Renal cyst in a 40-year-old woman with abdominal pain. MPR images demonstrate a partially calcified cyst (C) that arises from the upper pole of the left kidney (arrow) and is separate from the pancreatic tail (arrowhead). G = stomach.

View larger version (156K): [in a new window]   Figure 22.  Sclerosing mesenteritis in a 49-year-old woman with abdominal pain. CT scan demonstrates infiltrative sclerosing mesenteritis (arrowheads) that encases the celiac vasculature in a fashion similar to that of adenocarcinoma of the pancreas (P). The diagnosis was made at core biopsy.

View larger version (139K): [in a new window]   Figure 23a.  Peripancreatic varices in a 71-year-old man with elevated liver enzyme levels. (a) Arterial phase CT scan shows how low-attenuation peripancreatic varices (long arrow) in the region of the pancreatic head (short arrow) can simulate a pancreatic mass. Arrowhead indicates the second portion of the duodenum. (b) On a venous phase contrast-enhanced CT scan, the varices (long arrow) are more clearly distinguished from the pancreatic head (short arrow). Arrowhead indicates the duodenum.

View larger version (144K): [in a new window]   Figure 23b.  Peripancreatic varices in a 71-year-old man with elevated liver enzyme levels. (a) Arterial phase CT scan shows how low-attenuation peripancreatic varices (long arrow) in the region of the pancreatic head (short arrow) can simulate a pancreatic mass. Arrowhead indicates the second portion of the duodenum. (b) On a venous phase contrast-enhanced CT scan, the varices (long arrow) are more clearly distinguished from the pancreatic head (short arrow). Arrowhead indicates the duodenum.

View larger version (130K): [in a new window]   Figure 24.  Pseudoaneurysm of the gastroduodenal artery in a 60-year-old man. CT scan shows a pseudoaneurysm (arrowheads) with a central high-attenuation lumen (short arrow). The pseudoaneurysm is intimately associated with the pancreatic head (long arrow). P = pancreas.

View larger version (128K): [in a new window]   Figure 25.  Pseudoaneurysm in a 40-year-old man with abdominal pain. CT scan shows a partially thrombosed peripancreatic arterial pseudoaneurysm (arrowheads) with a high-attenuation lumen (a). This lesion may simulate a mass on unenhanced images. Arrow indicates the pancreatic tail.

View larger version (136K): [in a new window]   Figure 26.  Pseudoaneurysm in a 53-year-old man with abdominal pain. CT scan demonstrates a large, partially thrombosed peripancreatic pseudoaneurysm (arrowheads) with a patent lumen (a). Arrow indicates the pancreas.

View larger version (153K): [in a new window]   Figure 27.  Neurofibroma in a 56-year-old woman who presented for evaluation of a pancreatic mass. CT scan shows a neurofibroma (arrowhead) in the region of the pancreas (arrow). The neurofibroma simulates a primary pancreatic lesion.