DOI: 10.1148/rg.253045104
Imaging Diagnosis of Cystic Pancreatic Lesions: Pseudocyst versus Nonpseudocyst1
Young H. Kim, MD, PhD,
Sanjay Saini, MD,
Dushant Sahani, MD,
Peter F. Hahn, MD, PhD,
Peter R. Mueller, MD and
Yong H. Auh, MD, PhD
1 From the Department of Radiology, UMass Memorial, University of Massachusetts Medical School, 55 Lake Ave North, Worcester, MA 01655 (Y.H.K.); the Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (S.S., D.S., P.F.H., P.R.M.); and the Department of Radiology, New York Presbyterian Hospital, Cornell University, New York, NY (Y.H.A.). Presented as an education exhibit at the 2003 RSNA Scientific Assembly. Received May 14, 2004; revision requested July 26 and received September 21; accepted September 22. All authors have no financial relationships to disclose.
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Figure 1a. Developing pseudocyst in a 63-year-old woman with epigastric pain. (a) Unenhanced CT scan shows an edematous pancreas and an ill-defined, acute fluid collection surrounding the tail of the pancreas (arrow) with peripancreatic inflammatory changes, an appearance compatible with acute pancreatitis. (b) On a follow-up contrast-enhanced CT scan obtained 1 month later, the lesion appears as a bilobed cystic mass with a septum in the pancreatic body and tail (arrow). The peripancreatic inflammatory changes are markedly decreased. (c) On a follow-up CT scan obtained 2 years later, the lesion appears as a unilocular, low-attenuation fluid collection with a well-defined thin wall (arrow). This is the typical appearance of a postinflammatory pseudocyst.
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Figure 1b. Developing pseudocyst in a 63-year-old woman with epigastric pain. (a) Unenhanced CT scan shows an edematous pancreas and an ill-defined, acute fluid collection surrounding the tail of the pancreas (arrow) with peripancreatic inflammatory changes, an appearance compatible with acute pancreatitis. (b) On a follow-up contrast-enhanced CT scan obtained 1 month later, the lesion appears as a bilobed cystic mass with a septum in the pancreatic body and tail (arrow). The peripancreatic inflammatory changes are markedly decreased. (c) On a follow-up CT scan obtained 2 years later, the lesion appears as a unilocular, low-attenuation fluid collection with a well-defined thin wall (arrow). This is the typical appearance of a postinflammatory pseudocyst.
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Figure 1c. Developing pseudocyst in a 63-year-old woman with epigastric pain. (a) Unenhanced CT scan shows an edematous pancreas and an ill-defined, acute fluid collection surrounding the tail of the pancreas (arrow) with peripancreatic inflammatory changes, an appearance compatible with acute pancreatitis. (b) On a follow-up contrast-enhanced CT scan obtained 1 month later, the lesion appears as a bilobed cystic mass with a septum in the pancreatic body and tail (arrow). The peripancreatic inflammatory changes are markedly decreased. (c) On a follow-up CT scan obtained 2 years later, the lesion appears as a unilocular, low-attenuation fluid collection with a well-defined thin wall (arrow). This is the typical appearance of a postinflammatory pseudocyst.
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Figure 2a. Progressive evolution and spontaneous resolution of a pancreatic pseudocyst in a 31-year-old man with left upper quadrant pain. (a) Initial contrast-enhanced CT scan shows an edematous pancreas and peripancreatic inflammatory changes, an appearance compatible with acute pancreatitis. (b) Follow-up CT scan obtained 2 months later shows a relatively thick-walled cyst in the pancreatic tail (arrow). This lesion represents a maturing pseudocyst. (c) CT scan obtained 4 months later shows resolution of the pseudocyst.
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Figure 2b. Progressive evolution and spontaneous resolution of a pancreatic pseudocyst in a 31-year-old man with left upper quadrant pain. (a) Initial contrast-enhanced CT scan shows an edematous pancreas and peripancreatic inflammatory changes, an appearance compatible with acute pancreatitis. (b) Follow-up CT scan obtained 2 months later shows a relatively thick-walled cyst in the pancreatic tail (arrow). This lesion represents a maturing pseudocyst. (c) CT scan obtained 4 months later shows resolution of the pseudocyst.
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Figure 2c. Progressive evolution and spontaneous resolution of a pancreatic pseudocyst in a 31-year-old man with left upper quadrant pain. (a) Initial contrast-enhanced CT scan shows an edematous pancreas and peripancreatic inflammatory changes, an appearance compatible with acute pancreatitis. (b) Follow-up CT scan obtained 2 months later shows a relatively thick-walled cyst in the pancreatic tail (arrow). This lesion represents a maturing pseudocyst. (c) CT scan obtained 4 months later shows resolution of the pseudocyst.
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Figure 3a. Infected necrosis and pancreatic abscess in a 35-year-old man with acute pancreatitis, abdominal pain, and mild leukocytosis. (a) Contrast-enhanced CT scan shows a heterogeneous hypoattenuating fluid collection with peripheral irregularity in the pancreatic body and tail (arrow). Three weeks after conservative treatment, a spiking fever and marked leukocytosis developed. (b) CT scan obtained 3 weeks after conservative treatment shows an interval increase in the size of the fluid collection, which contains high-attenuation debris (arrow). The presence of infection was confirmed by means of percutaneous aspiration. The patient remained asymptomatic after percutaneous drainage. (c) Follow-up CT scan obtained 2 months later shows a decrease in the size of the fluid collection (arrow), which appears as a small residual cystic mass in the pancreatic tail.
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Figure 3b. Infected necrosis and pancreatic abscess in a 35-year-old man with acute pancreatitis, abdominal pain, and mild leukocytosis. (a) Contrast-enhanced CT scan shows a heterogeneous hypoattenuating fluid collection with peripheral irregularity in the pancreatic body and tail (arrow). Three weeks after conservative treatment, a spiking fever and marked leukocytosis developed. (b) CT scan obtained 3 weeks after conservative treatment shows an interval increase in the size of the fluid collection, which contains high-attenuation debris (arrow). The presence of infection was confirmed by means of percutaneous aspiration. The patient remained asymptomatic after percutaneous drainage. (c) Follow-up CT scan obtained 2 months later shows a decrease in the size of the fluid collection (arrow), which appears as a small residual cystic mass in the pancreatic tail.
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Figure 3c. Infected necrosis and pancreatic abscess in a 35-year-old man with acute pancreatitis, abdominal pain, and mild leukocytosis. (a) Contrast-enhanced CT scan shows a heterogeneous hypoattenuating fluid collection with peripheral irregularity in the pancreatic body and tail (arrow). Three weeks after conservative treatment, a spiking fever and marked leukocytosis developed. (b) CT scan obtained 3 weeks after conservative treatment shows an interval increase in the size of the fluid collection, which contains high-attenuation debris (arrow). The presence of infection was confirmed by means of percutaneous aspiration. The patient remained asymptomatic after percutaneous drainage. (c) Follow-up CT scan obtained 2 months later shows a decrease in the size of the fluid collection (arrow), which appears as a small residual cystic mass in the pancreatic tail.
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Figure 4. Hemorrhagic pseudocyst in a 45-year-old man who experienced an episode of abdominal pain but had no clinical findings suggestive of infection. Contrast-enhanced CT scan shows a cystic mass containing an area of high attenuation (arrow), a finding consistent with recent hemorrhage.
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Figure 5a. Chronic pancreatitis with an intrapancreatic pseudocyst in a 42-year-old man with a history of alcoholic pancreatitis. (a) Contrast-enhanced CT scan shows a dilated pancreatic duct (arrows) with mild pancreatic atrophy, an appearance compatible with chronic pancreatitis. (b) CT scan shows a round mass with diffuse low attenuation in the pancreatic head (curved arrow). The mass represents a pseudocyst. Note the dilated pancreatic duct (straight arrow). (c) Contrast-enhanced CT scan shows pancreatic calcifications (arrow), a finding compatible with chronic pancreatitis.
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Figure 5b. Chronic pancreatitis with an intrapancreatic pseudocyst in a 42-year-old man with a history of alcoholic pancreatitis. (a) Contrast-enhanced CT scan shows a dilated pancreatic duct (arrows) with mild pancreatic atrophy, an appearance compatible with chronic pancreatitis. (b) CT scan shows a round mass with diffuse low attenuation in the pancreatic head (curved arrow). The mass represents a pseudocyst. Note the dilated pancreatic duct (straight arrow). (c) Contrast-enhanced CT scan shows pancreatic calcifications (arrow), a finding compatible with chronic pancreatitis.
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Figure 5c. Chronic pancreatitis with an intrapancreatic pseudocyst in a 42-year-old man with a history of alcoholic pancreatitis. (a) Contrast-enhanced CT scan shows a dilated pancreatic duct (arrows) with mild pancreatic atrophy, an appearance compatible with chronic pancreatitis. (b) CT scan shows a round mass with diffuse low attenuation in the pancreatic head (curved arrow). The mass represents a pseudocyst. Note the dilated pancreatic duct (straight arrow). (c) Contrast-enhanced CT scan shows pancreatic calcifications (arrow), a finding compatible with chronic pancreatitis.
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Figure 6a. Incidentally detected pancreatic pseudocyst in a 77-year-old woman with no known history of pancreatitis. (a) Image obtained with thin-section (2.5-mm section thickness) contrast-enhanced multidetector CT shows an ovoid hypoattenuating mass without internal septa or mural nodules in the pancreatic tail (arrow). (b) Curved coronal reformatted view shows the relationship of the mass (arrow) to the pancreatic parenchyma. The multiplanar capabilities of multidetector CT are particularly useful for surgical planning.
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Figure 6b. Incidentally detected pancreatic pseudocyst in a 77-year-old woman with no known history of pancreatitis. (a) Image obtained with thin-section (2.5-mm section thickness) contrast-enhanced multidetector CT shows an ovoid hypoattenuating mass without internal septa or mural nodules in the pancreatic tail (arrow). (b) Curved coronal reformatted view shows the relationship of the mass (arrow) to the pancreatic parenchyma. The multiplanar capabilities of multidetector CT are particularly useful for surgical planning.
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Figure 7a. Serous cystadenoma in a 45-year-old woman with right upper quadrant pain. (a) Contrast-enhanced CT scan shows a low-attenuation mass with a honeycomb appearance in the pancreatic head and uncinate process (arrow). The honeycomb appearance is produced by numerous tiny cystic structures. (b) US scan shows that the mass has low echogenicity due to the interfaces between the tiny cysts. Note the increased through transmission posterior to the mass. (c) Photograph of the cut surface of the specimen shows innumerable cysts.
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Figure 7b. Serous cystadenoma in a 45-year-old woman with right upper quadrant pain. (a) Contrast-enhanced CT scan shows a low-attenuation mass with a honeycomb appearance in the pancreatic head and uncinate process (arrow). The honeycomb appearance is produced by numerous tiny cystic structures. (b) US scan shows that the mass has low echogenicity due to the interfaces between the tiny cysts. Note the increased through transmission posterior to the mass. (c) Photograph of the cut surface of the specimen shows innumerable cysts.
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Figure 7c. Serous cystadenoma in a 45-year-old woman with right upper quadrant pain. (a) Contrast-enhanced CT scan shows a low-attenuation mass with a honeycomb appearance in the pancreatic head and uncinate process (arrow). The honeycomb appearance is produced by numerous tiny cystic structures. (b) US scan shows that the mass has low echogenicity due to the interfaces between the tiny cysts. Note the increased through transmission posterior to the mass. (c) Photograph of the cut surface of the specimen shows innumerable cysts.
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Figure 8a. Incidentally detected serous cystadenoma in a 75-year-old man. (a) Pancreatic phase image obtained with thin-section (1.25-mm section thickness) contrast-enhanced multidetector CT shows a lobulated hypoattenuating mass in the pancreatic tail (white arrow). Enhancing vessels within fine septa (black arrow) enter the mass from the periphery. (b) Curved coronal reformatted view obtained through the pancreas shows no obvious communication between the tumor (arrow) and a normal pancreatic duct (arrowhead).
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Figure 8b. Incidentally detected serous cystadenoma in a 75-year-old man. (a) Pancreatic phase image obtained with thin-section (1.25-mm section thickness) contrast-enhanced multidetector CT shows a lobulated hypoattenuating mass in the pancreatic tail (white arrow). Enhancing vessels within fine septa (black arrow) enter the mass from the periphery. (b) Curved coronal reformatted view obtained through the pancreas shows no obvious communication between the tumor (arrow) and a normal pancreatic duct (arrowhead).
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Figure 9a. Oligocystic serous cystadenoma in a 56-year-old woman with epigastric pain. (a, b) US scan (a) and CT scan (b) show a well-demarcated cystic mass with peripheral internal septa (arrow) in the pancreatic head. Note the peripheral septum with calcification (arrow in b). (c) Endoscopic pancreatogram shows the pancreatic duct splayed by the tumor. No communication exists between the lesion and the main duct. (d) Photograph of the external surface of the surgical specimen shows the lobulated, multiseptate cystic mass.
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Figure 9b. Oligocystic serous cystadenoma in a 56-year-old woman with epigastric pain. (a, b) US scan (a) and CT scan (b) show a well-demarcated cystic mass with peripheral internal septa (arrow) in the pancreatic head. Note the peripheral septum with calcification (arrow in b). (c) Endoscopic pancreatogram shows the pancreatic duct splayed by the tumor. No communication exists between the lesion and the main duct. (d) Photograph of the external surface of the surgical specimen shows the lobulated, multiseptate cystic mass.
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Figure 9c. Oligocystic serous cystadenoma in a 56-year-old woman with epigastric pain. (a, b) US scan (a) and CT scan (b) show a well-demarcated cystic mass with peripheral internal septa (arrow) in the pancreatic head. Note the peripheral septum with calcification (arrow in b). (c) Endoscopic pancreatogram shows the pancreatic duct splayed by the tumor. No communication exists between the lesion and the main duct. (d) Photograph of the external surface of the surgical specimen shows the lobulated, multiseptate cystic mass.
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Figure 9d. Oligocystic serous cystadenoma in a 56-year-old woman with epigastric pain. (a, b) US scan (a) and CT scan (b) show a well-demarcated cystic mass with peripheral internal septa (arrow) in the pancreatic head. Note the peripheral septum with calcification (arrow in b). (c) Endoscopic pancreatogram shows the pancreatic duct splayed by the tumor. No communication exists between the lesion and the main duct. (d) Photograph of the external surface of the surgical specimen shows the lobulated, multiseptate cystic mass.
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Figure 10. Incidentally detected mucinous cystadenoma in a 67-year-old woman. Contrast-enhanced CT scan shows a complex cystic mass with a few septa in the pancreatic tail (arrow).
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Figure 11. Mucinous cystadenoma in a 47-year-old woman with left upper quadrant pain. Contrast-enhanced CT scan shows a large cystic tumor with small cysts clustered at its periphery (arrow).
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Figure 12. Mucinous cystadenocarcinoma in a 52-year-old woman with epigastric pain. Despite the absence of a history of pancreatitis, the thin cyst wall led to the presumptive diagnosis of a pseudocyst. CT scan shows a thin-walled cyst in the pancreatic tail. There is a tiny peripheral intramural nodular structure (arrow), which was initially overlooked. At surgery, the lesion proved to be a mucinous cystadenocarcinoma.
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Figure 13a. Incidentally detected mucinous cystadenoma in a 65-year-old woman. (a) Contrast-enhanced CT scan shows an ovoid hypoattenuating mass with barely visible septa in the pancreatic head (arrow). (b) Endoscopic US scan shows the complex cystic mass with multiple internal septa (arrow). Endoscopic US–guided fine-needle aspiration was performed, and cytologic analysis revealed abundant mucin with scant glandular epithelial cells, findings suggestive of a mucin-producing tumor. At surgery, the lesion proved to be a mucinous cystadenoma.
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Figure 13b. Incidentally detected mucinous cystadenoma in a 65-year-old woman. (a) Contrast-enhanced CT scan shows an ovoid hypoattenuating mass with barely visible septa in the pancreatic head (arrow). (b) Endoscopic US scan shows the complex cystic mass with multiple internal septa (arrow). Endoscopic US–guided fine-needle aspiration was performed, and cytologic analysis revealed abundant mucin with scant glandular epithelial cells, findings suggestive of a mucin-producing tumor. At surgery, the lesion proved to be a mucinous cystadenoma.
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Figure 14a. Multiple branch duct type of IPMT. (a) Contrast-enhanced CT scan shows multiple cystic masses (straight arrow) in the pancreatic head and body. Note the dilated pancreatic duct (curved arrow). (b) Curved coronal reformatted view obtained along the pancreatic tail shows a communication between a cystic mass and the dilated distal pancreatic duct (arrow).
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Figure 14b. Multiple branch duct type of IPMT. (a) Contrast-enhanced CT scan shows multiple cystic masses (straight arrow) in the pancreatic head and body. Note the dilated pancreatic duct (curved arrow). (b) Curved coronal reformatted view obtained along the pancreatic tail shows a communication between a cystic mass and the dilated distal pancreatic duct (arrow).
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Figure 15a. Branch duct type of IPMT. (a) MR cholangiopancreatogram shows a cystic pancreatic mass (arrow). It is not clear whether there is a communication between the mass and the pancreatic duct. (b) Axial T2-weighted MR image (3,860/1,930 [repetition time msec/echo time msec]) shows a communication between the mass and the pancreatic duct (arrowhead).
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Figure 15b. Branch duct type of IPMT. (a) MR cholangiopancreatogram shows a cystic pancreatic mass (arrow). It is not clear whether there is a communication between the mass and the pancreatic duct. (b) Axial T2-weighted MR image (3,860/1,930 [repetition time msec/echo time msec]) shows a communication between the mass and the pancreatic duct (arrowhead).
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Figure 16a. Combined main duct and branch duct type of IPMT in a 55-year-old man with vague abdominal pain. (a) ERCP image shows dilatation of the main and branch pancreatic ducts. Note the intraductal filling defects due to mucus (arrows). (b) MR cholangiopancreatogram shows a filling defect within the dilated main pancreatic duct (arrow). Note the dilated branch ducts in the pancreatic head and uncinate process.
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Figure 16b. Combined main duct and branch duct type of IPMT in a 55-year-old man with vague abdominal pain. (a) ERCP image shows dilatation of the main and branch pancreatic ducts. Note the intraductal filling defects due to mucus (arrows). (b) MR cholangiopancreatogram shows a filling defect within the dilated main pancreatic duct (arrow). Note the dilated branch ducts in the pancreatic head and uncinate process.
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Figure 17a. SPEN in a 32-year-old woman with epigastric pain. (a) Contrast-enhanced CT scan shows a mixed solid and cystic mass in the pancreatic head (arrows). (b) Axial T1-weighted MR image (500/20) shows areas of high signal intensity due to hemorrhage within the mass (arrow). (c) Photograph of the cut surface of the gross specimen shows the solid mass with irregular cystic degeneration and hemorrhage. Note the thick fibrous capsule.
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Figure 17b. SPEN in a 32-year-old woman with epigastric pain. (a) Contrast-enhanced CT scan shows a mixed solid and cystic mass in the pancreatic head (arrows). (b) Axial T1-weighted MR image (500/20) shows areas of high signal intensity due to hemorrhage within the mass (arrow). (c) Photograph of the cut surface of the gross specimen shows the solid mass with irregular cystic degeneration and hemorrhage. Note the thick fibrous capsule.
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Figure 17c. SPEN in a 32-year-old woman with epigastric pain. (a) Contrast-enhanced CT scan shows a mixed solid and cystic mass in the pancreatic head (arrows). (b) Axial T1-weighted MR image (500/20) shows areas of high signal intensity due to hemorrhage within the mass (arrow). (c) Photograph of the cut surface of the gross specimen shows the solid mass with irregular cystic degeneration and hemorrhage. Note the thick fibrous capsule.
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Figure 18a. Serous cystadenoma in a 77-year-old woman with right upper quadrant pain. (a) Contrast-enhanced CT scan shows a hypoattenuating mass in the pancreatic head (arrow). Septa in the mass are barely visible. (b) Endoscopic US scan shows a central fibrous scar and a stellate configuration of the septa. At surgery, the lesion proved to be a serous cystadenoma.
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Figure 18b. Serous cystadenoma in a 77-year-old woman with right upper quadrant pain. (a) Contrast-enhanced CT scan shows a hypoattenuating mass in the pancreatic head (arrow). Septa in the mass are barely visible. (b) Endoscopic US scan shows a central fibrous scar and a stellate configuration of the septa. At surgery, the lesion proved to be a serous cystadenoma.
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Figure 19a. Mucinous cystadenoma in a 38-year-old woman with recurrent abdominal pain. (a) Contrast-enhanced CT scan shows a well-defined, round, hypoattenuating mass in the pancreatic tail (arrow). Note the fine internal septa (arrowheads). (b) Endoscopic US scan shows the multiple septa in the mass.
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Figure 19b. Mucinous cystadenoma in a 38-year-old woman with recurrent abdominal pain. (a) Contrast-enhanced CT scan shows a well-defined, round, hypoattenuating mass in the pancreatic tail (arrow). Note the fine internal septa (arrowheads). (b) Endoscopic US scan shows the multiple septa in the mass.
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Figure 20a. Incidentally detected mucinous cystadenocarcinoma in a 60-year-old man. (a) Contrast-enhanced CT scan shows a multilocular cystic mass in the pancreatic head (arrow). (b) Endoscopic US scan shows the complex solid and cystic mass. Aspiration of the cyst demonstrated mucin, but the acellular aspirates did not allow exclusion of either a cystic neoplasm or a pseudocyst. At surgery, the lesion proved to be a mucinous cystadenocarcinoma.
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Figure 20b. Incidentally detected mucinous cystadenocarcinoma in a 60-year-old man. (a) Contrast-enhanced CT scan shows a multilocular cystic mass in the pancreatic head (arrow). (b) Endoscopic US scan shows the complex solid and cystic mass. Aspiration of the cyst demonstrated mucin, but the acellular aspirates did not allow exclusion of either a cystic neoplasm or a pseudocyst. At surgery, the lesion proved to be a mucinous cystadenocarcinoma.
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Figure 21a. Intraductal papillary mucinous adenocarcinoma in a 76-year-old man with fever and obstructive jaundice. (a) Contrast-enhanced CT scan shows a markedly dilated side branch duct with wall thickening (arrow). (b) Endoscopic US scan shows the dilated side branch duct with nodular wall thickening, an appearance suggestive of a complex solid and cystic mass. Aspiration biopsy of the nodular wall demonstrated an adenocarcinoma with abundant background mucin. Arrows = aspiration needle. At surgery, the lesion proved to be an intraductal papillary mucinous adenocarcinoma.
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Figure 21b. Intraductal papillary mucinous adenocarcinoma in a 76-year-old man with fever and obstructive jaundice. (a) Contrast-enhanced CT scan shows a markedly dilated side branch duct with wall thickening (arrow). (b) Endoscopic US scan shows the dilated side branch duct with nodular wall thickening, an appearance suggestive of a complex solid and cystic mass. Aspiration biopsy of the nodular wall demonstrated an adenocarcinoma with abundant background mucin. Arrows = aspiration needle. At surgery, the lesion proved to be an intraductal papillary mucinous adenocarcinoma.
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Copyright © 2005 by the Radiological Society of North America.
