Pancreatic Tumors: Diagnostic Patterns by 3D Gradient-Echo Post Contrast Magnetic Resonance Imaging with Pathologic Correlation  Khaled M. Elsayes, MD, Vamsidhar R. Narra, MD, Hatem A. Abou El Abbass, MD, Tarek S. Aly, MD, Sherif M. Radwan, MD, Zong-Ming Chen, MD  Current Problems in Diagnostic Radiology  Volume 35, Issue 4, Pages 125-139 (July 2006) DOI: 10.1067/j.cpradiol.2006.02.002 Copyright © 2006 Mosby, Inc. Terms and Conditions

FIG 1 Axial postcontrast 3D GRE VIBE (A), after coronal reconstruction (B), and axial oblique (C), showing the high signal intensity of the pancreas and the ability to obtain high-quality multiplanar reconstruction images as well as generation of high-quality images, depicting vascular structures (arrows). Current Problems in Diagnostic Radiology 2006 35, 125-139DOI: (10.1067/j.cpradiol.2006.02.002) Copyright © 2006 Mosby, Inc. Terms and Conditions

FIG 2 Axial postcontrast T1 GRE after injection of Mangafodipir, showing the sensitivity of this contrast agent in depiction of pancreatic tumors. Pancreatic adenocarcinoma is seen as nonenhancing lesion (arrow) relative to the high signal intensity pancreatic tissue, due to the uptake of this contrast agent by normal pancreatic parenchyma. Current Problems in Diagnostic Radiology 2006 35, 125-139DOI: (10.1067/j.cpradiol.2006.02.002) Copyright © 2006 Mosby, Inc. Terms and Conditions

FIG 3 Thick slab HASTE, showing compromised quality by the fluid in the stomach (A). This improves after administration of gastromark (B), with consequent better delineation of the pancreatic duct (arrows). Current Problems in Diagnostic Radiology 2006 35, 125-139DOI: (10.1067/j.cpradiol.2006.02.002) Copyright © 2006 Mosby, Inc. Terms and Conditions

FIG 4 Axial postcontrast T1 3D GRE VIBE (A and B), showing a hypoenhancing tumor focus involving the pancreatic body (arrows). Current Problems in Diagnostic Radiology 2006 35, 125-139DOI: (10.1067/j.cpradiol.2006.02.002) Copyright © 2006 Mosby, Inc. Terms and Conditions

FIG 5 Postcontrast 3D GRE VIBE in axial (A), and after coronal reconstruction (B and C), showing ductal adenocarcinoma involving the pancreatic head with sensitive depiction of the vascular relation. Microscopic picture (D), showing moderately differentiated infiltrating malignant glands and individual cells in a desmoplastic background. (Color version of figure is available online.) Current Problems in Diagnostic Radiology 2006 35, 125-139DOI: (10.1067/j.cpradiol.2006.02.002) Copyright © 2006 Mosby, Inc. Terms and Conditions

FIG 6 Axial postcontrast T1 3D GRE VIBE (A) and thick slab HASTE (B), showing a low-signal area (arrow in A) mimicking ductal adenocarcinoma, found at pathology to represent focal chronic pancreatitis. Note: Arrows in B show the penetrating duct sign, characteristic for focal fibrosis. Current Problems in Diagnostic Radiology 2006 35, 125-139DOI: (10.1067/j.cpradiol.2006.02.002) Copyright © 2006 Mosby, Inc. Terms and Conditions

FIG 7 Axial postcontrast CT (A), axial in-phase (B), and out-of-phase (C), showing a low attenuation lesion on CT (arrows). The lesion shows dropout of signal on out-of-phase, denoting focal fatty infiltration of the pancreas. Current Problems in Diagnostic Radiology 2006 35, 125-139DOI: (10.1067/j.cpradiol.2006.02.002) Copyright © 2006 Mosby, Inc. Terms and Conditions

FIG 8 Coronal T2 HASTE (A) and axial postcontrast T1 3D GRE VIBE in arterial (B) and delayed (C) phases, showing an oval well-circumscribed tumor (arrows) exhibiting heterogeneous T2 signal with hypoenhancement on early phase and progressive fill-in on late phase—typical signal intensity and enhancement pattern of solid pseudopapillary tumor. Gross photograph (D), showing an expansile solid mass with nodular appearance. (Color version of figure is available online.) Current Problems in Diagnostic Radiology 2006 35, 125-139DOI: (10.1067/j.cpradiol.2006.02.002) Copyright © 2006 Mosby, Inc. Terms and Conditions

FIG 9 Axial T2 IR (A) and axial T1 out-of-phase (B), showing a large well-circumscribed mass arising from the pancreatic body and tail, exhibiting heterogeneous signal, due to blood products. Current Problems in Diagnostic Radiology 2006 35, 125-139DOI: (10.1067/j.cpradiol.2006.02.002) Copyright © 2006 Mosby, Inc. Terms and Conditions

FIG 10 Axial postcontrast T1 3D GRE VIBE, showing an enhancing lesion involving the pancreatic head, with central hypoenhancing area (arrow), in a patient with a history of renal cell carcinoma. Proximal biliary ductal dilation is also noted. Note absent right kidney due to right nephrectomy. Current Problems in Diagnostic Radiology 2006 35, 125-139DOI: (10.1067/j.cpradiol.2006.02.002) Copyright © 2006 Mosby, Inc. Terms and Conditions

FIG 11 Axial postcontrast T1 3D GRE (A and B), showing multiple enhancing gastrinomas (arrows). Microscopic examination (C) showing tumor cells forming nests and pseudoglands. (Color version of figure is available online.) Current Problems in Diagnostic Radiology 2006 35, 125-139DOI: (10.1067/j.cpradiol.2006.02.002) Copyright © 2006 Mosby, Inc. Terms and Conditions

FIG 12 Axial postcontrast T1 3D GRE, showing single small enhancing insulinoma (arrow). Current Problems in Diagnostic Radiology 2006 35, 125-139DOI: (10.1067/j.cpradiol.2006.02.002) Copyright © 2006 Mosby, Inc. Terms and Conditions

FIG 13 Axial postcontrast T1 3D GRE (A) and axial T2 IR (B), showing an oval heterogeneous lesion involving the pancreatic body (arrows), with low T1 and high T2 signal intensity. The mass also exhibits heterogeneous pattern of contrast enhancement. Gross photograph (C), showing an infiltrating mass in the pancreas with central necrosis. (Color version of figure is available online.) Current Problems in Diagnostic Radiology 2006 35, 125-139DOI: (10.1067/j.cpradiol.2006.02.002) Copyright © 2006 Mosby, Inc. Terms and Conditions

FIG 14 Axial postcontrast T1 3D GRE VIBE (A), showing an enhancing area at the pancreatic head (arrow). This area was misinterpreted—based on its enhancement—as an islet cell tumor. Histopathological examination (B) revealed focal duct hyperplasia, showing a duct with mild epithelial mucinous metaplasia and reactive nuclear changes and periductal chronic inflammation and fibrosis. (Color version of figure is available online.) Current Problems in Diagnostic Radiology 2006 35, 125-139DOI: (10.1067/j.cpradiol.2006.02.002) Copyright © 2006 Mosby, Inc. Terms and Conditions

FIG 15 Axial T1 3D GRE VIBE before (A), after injection of gadolinium chelates (B), and axial T2 IR (C), showing a large multilocular tumor with enhancing septa (arrow). Gross photograph (D) shows a well-circumscribed pathologically proven mucinous cystdenocarcinoma, with extensive intraductal mucinous neoplasm, with areas of cystic change and papillary projections. (Color version of figure is available online.) Current Problems in Diagnostic Radiology 2006 35, 125-139DOI: (10.1067/j.cpradiol.2006.02.002) Copyright © 2006 Mosby, Inc. Terms and Conditions

FIG 16 Axial T2 IR (A) and axial postcontrast T1 3D GRE (B), showing a small high T2 and low T1 signal intensity. No intralesional postcontrast enhancement is noted. Cyst was pathologically proven as serous cystadenoma. Current Problems in Diagnostic Radiology 2006 35, 125-139DOI: (10.1067/j.cpradiol.2006.02.002) Copyright © 2006 Mosby, Inc. Terms and Conditions

FIG 17 Axial T2 IR (A) and thick slab HASTE (B), showing a large serous cystadenoma involving the pancreatic head with central scarring (arrows). Current Problems in Diagnostic Radiology 2006 35, 125-139DOI: (10.1067/j.cpradiol.2006.02.002) Copyright © 2006 Mosby, Inc. Terms and Conditions

FIG 18 Axial postcontrast VIBE (A) and T2 HASTE (B), showing a main duct IPMT, in the form of diffuse dilation of the main pancreatic duct (arrows). Gross and microscopic pathology images (C and D) confirm the diagnosis. (Color version of figure is available online.) Current Problems in Diagnostic Radiology 2006 35, 125-139DOI: (10.1067/j.cpradiol.2006.02.002) Copyright © 2006 Mosby, Inc. Terms and Conditions

FIG 19 Axial postcontrast VIBE (A), and MRCP (B), showing a branch duct, intraductal papillary mucinous tumor (IPMT). MRCP shows the communication of this cystic mass to the main duct (arrow). Current Problems in Diagnostic Radiology 2006 35, 125-139DOI: (10.1067/j.cpradiol.2006.02.002) Copyright © 2006 Mosby, Inc. Terms and Conditions

FIG 20 Classification of solid pancreatic neoplasms. Current Problems in Diagnostic Radiology 2006 35, 125-139DOI: (10.1067/j.cpradiol.2006.02.002) Copyright © 2006 Mosby, Inc. Terms and Conditions

FIG 21 Classification of cystic pancreatic neoplasms. Current Problems in Diagnostic Radiology 2006 35, 125-139DOI: (10.1067/j.cpradiol.2006.02.002) Copyright © 2006 Mosby, Inc. Terms and Conditions