Pancreas Neoplasms

Congenital Anomalies

-ectopic pancreatic tissue

-pancreatic divisum

-annular pancreas

-cystic fibrosis

Ectopic Pancreatic Tissue

-common pancreatic anomaly

-composed of acinar and ductal tissue

-tissues are small (0.5 - 2 cm)

-found in various places in GI tract

-susceptible to any disease that the pancreas is susceptible to esp tumor or acute pancreatits

-no vascular or structural connection to body of pancreas

Ectopic Pancreatic Tissue Locations

-stomach

-duodenum

-small and large bowel

Ectopic Pancreatic Tissue Sonographic Appearance

-polypoid tissue mass w/ central dimple

-difficult to detect sonographically

Pancreas Divisum

-most common congenital variant

-failure of dorsal and ventral ducts to fuse

-increased incidence of pancreatitis

Annular Pancreas

-ring like

-rare anomaly caused by ventral portion of pancreas not migrating normally

-pancreatic head surrounds the 2nd portion of the duodenum

Annular Pancreas Etiology

-more common in males

-may be partial or complete

-subject to same pancreatic pathologies

-associated w/ duodenal atrasia (partial or complete)

Cystic Fibrosis

-autosomal recessive exocrine gland disorder

-involves an increase in secretion of mucous by the exocrine glands

-coagulation of secretions in smaller pancreatic ducts that become hardened and obstructive

-distended areas may degenerate and undergo cystic replacement

Cystic Fibrosis Incidence

-1 in 2000

-5% are genetic carriers

-almost exclusively in caucasians

-associated w/ abdominal problems (pancreas, liver, biliar system + increases w/ age)

Cystic Fibrosis S/S

-abdominal pain

-bloating and flatulence

-failure to thrive (don't want to eat)

-glucose intolerance and diabetes mellitus

Cystic Fibrosis Sonographic Appearance

-generally hyperechoic due to microcystic changes and increased fatty and fibrotic infiltration

-inhomogenous

-cannot compare echo texture of liver to pancreas (either organ may display abnormal echo texture)

Cystic Fibrosis

Biliary/Liver Sonographic Appearance

-biliary stasis

-focal biliary cirrhosis/fibrosis is common as pt ages

-portal HTN

-cannot compare echo texture of liver to pancreas (either organ may display abnml echo texture)

Liver/Biliary Tract

GI Sonographic Appearance

-meconium ileus in neonates

-chronic obstructions (inflammatory bowel processes)

-thickened irregular folds = donut sign

-redundant GI tract and unavailable scan window thru LT lobe of liver

-non visualized GB or GB filled w/ thick echogenic bile (sludge)

True Cysts

-usually due to anomalous development of ducts

-generally asymptomatic unless large

Congenital True Cyst

-may be unilocular or multilocular

-extremely rare

-multiple cysts associated w/ polycystic renal disease

-fluid filled sac w/ epithelial lining

Acquired True Cysts

-retention cyst (secondary to dilatation of pancreatic duct)

-parasitic cyst (echinococcal)

-have an epithelial lining

True Cyst Sonographic Appearance

-round to oval

-smooth

-thin, well defined walls

-anechoic

-w/ posterior enhancement

-may be multilocular

-be sure to differentiate from fluid (surrounding GI structures)

True Cysts Treatment

-laparotomy and draining

-drained true cysts often are replaced by a fistula

True Cyst

Islet Cell Tumor/Adenoma

-endocrine tumors

-uncommon

-small and difficult to localize

-found mostly in tail of the gland

-may represent either benign adenoma or malignant tumor

-classified as functioning and non functioning (most are functional 85% and benign; non functional are generally malignant)

Islet Cell Tumor/Adenoma Associated W/

-von hippel/lindau disease

-MEN syndrome

Common Functional Tumors

-insulinoma

-gastrinoma

Von Hippel Lindau Disease

-inherited disorder characterized by the formation of tumor and fluid filled sacs (cyst) in kidney, pancreas, and genital tract

-20-50% of pts (pancreatic syts + serous cystadenomas)

-15% of pts (neuroendocrine tumors)

MEN Syndrome

-multiple endocrine neoplasia

-inherited condition

-types 1 and 2

-associated tumors

MEN Syndrmoe Associated Tumors

-insulinoma

-gastrinoma

-medullary thyroid carcinoma

-pheochromocytoma

-parathyroid gland hyperplasia

-pituitary tumors

Insulinoma

-tumor of the insulin secreting cells (islets of langerhans-beta cell tumors)

-most common islet cell tumor

-usually benign

-associated w/ hyperinsulinism or hypoglycemia (insulin shock, dizziness, n/v, psychic disturbances)

Gastrinoma

-2nd most common tumor

-found in pancreas and duodenum

-causes hypergastric secretions

-associated w/ peptic ulcer disease (PUD)

-high malignant potential

Islet Cell Tumor (Adenoma) Sonographic Appearance

-generally homogenous and solid

-frequently hypoechoic

-larger tumors may become moderatly echogenic

-calcifications and fluid areas seen in larger lesions

-solid masses are generally functional while those w/ cystic areas of necrosis are generally non functional

-small 1-2cm tumors difficult to identify

Islet Cell Tumor (Adenoma)

Microcystic/Serous Cystadenoma

-50% of pancreatic cystic neoplasms

-F>M 4:1; > 60 y/o

-may be diffuse

-typically benign

-associated w/ von hippel lindau syndrome

Microcystic/Serous Adenoma S/S

-pain

-weight loss

-palpable mass

-jaundice

Microcystic/Serous Cystadenoma Sonographic Appearance

-lobulated echogenic mass compromised of numerous small cysts

-may appear solid due to numerous small cysts found anywhere in pancreas (slightly > occurende in head)

-may be diffuse

-mass effect on pancreatic duct/CBD

Microcystic/Serous Cystadenoma

Macrocystic/Mucinous Cystadenoma

-uncommon

-slow growing, arising from the ducts

-thick walled, irregular cystic mass

-females > makes 9:1

-mean age 25 y/o

-increased in AA/east Asia

-60% in tail; 5% in head

-signification malignant potential

Macrocystic/Mucinous Cystadenoma S/S

-vague upper abdominal discomfort

-usually increased CEA and CA 19-9 serum levels therefore considered premalignant

Macrocystic/Mucinous Cystadenoma Sonographic Appearance

-large cyst w/ thick septa

-well circumscribed mass w/ thick/thin walls

-ranges from simple cysts to cysts w/ debris to cysts w/ mural nodules

-cysts w/ an increased # of papillary nodules have a > chance of malignancy

-may contain calcifications

-if mass is large enough it may cayse an obstruction of CBD. pancreatic duct or SPLV

Macrocystic/Mucinous Cystadenoma

Microcystic

Macrocystic

Carcinoma of Pancreas

involves exocrine portion of gland

Adenocarcinoma

-4th leading cause of death from CA in US

->99% originate from the ductal epithelium

-most lethal

-5 year survival rate of 7%

Carcinoma of Pancreas Incidence

-occurs after 5th decade

-M>F

Carcinoma of Pancreas Risk Factors

-increased risk for smokers

-high fat diet

-chronic pancreatitis

-diabetes

-cirrhosis

Carcinoma of Pancreas Occurence

-60-70% in head of pancreas (may cause obstruction of CBD)

-20-30% in body of pancreas

-5-10% in tail of pancreas

-may be diffuse w/i pancreas

Carcinoma of Pancreas S/S

-depends on location of mass (early vs late findings)

-weight loss

-anorexia

-n/v

-weakness

-malaise

-back and/or abdominal pain (steady mid epigastric aching; generally associated w/ lesions of the body of panc)

-painless jaundice (obstructive)

Painless Jaundice

-obstructive

-associated w/ lesions in head of panc

-palpable GB (courvoisier's sign)

Tail and Body Tumors

-produce late symptoms

-often silent until they have spread

-very poor prognosis due to metastasis

-may cause thrombophlebitis

-mets to lungs, liver, and stomach common

Carcinoma of Pancreas Labs

-increased bilirubin

-increased alk phos

-increased amylase

Carcinoma of Pancreas Sonographic Appearance

-80% are focal lesions

-loss of normal pancreatic parenchymal pattern

-irregular, nodular border

-localized change in echo texture

-gland enlarges at mass site

-henerally hypoechoic

-CBD, CHDs and pancreatic ducts may be dilated (courvoisier's)

-normal vascular landmarks may be obliterated or displaced (compressed IVC, spleen enlarged due to cmopression of SPLV)

-metastases to surrounding organs (liver, adrenal, GB, lymph nodes)

-ascites

Carcinoma of Pancreas

Carcinoma of Pancreas Associated Findings

-pancreatitis

-liver metastases

-lymphadenopathy

-portal venous system invovlement

-splenic vein dilatation

-SMA displacement

-ascites