evaluation of common pancreatic condition
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The single-slice thick-slab acquisition method is
attractive because a snapshot of the pancreaticobiliary
system is obtained while respiratory and bowel
motion is virtually eliminated, and no postprocessing
of the images is required (Fig. 1). Typically, 30-mm
to 50-mm thick slabs are prescribed in several oblique
planes to depict the extrahepatic biliary and pancre-
atic ducts, each requiring less than a 2-second breath
hold. Alternatively, images may be acquired at endexpiration during relaxed natural breathing. Regard-
less, it is important to wait at least 10 seconds
between acquisitions, to allow for recovery from the
previous overlapping radial excitation. An imaging
plane parallel to the pancreatic duct in the body and
tail of the pancreas is employed and prescribed from
an axial image (Fig. 2). Because fat is bright on
SSFSE images, chemically selective fat saturation is
utilized to increase duct-to-background contrast. A
significant advantage of the single-slice method is its
short acquisition time, which allows for the perform-ance of a dynamic MRCP. Repeated sequential
imaging of the same slab demonstrating the pancre-
atic duct and extrahepatic biliary tree, performed over
several minutes, will resolve the possibility of sphinc-
ter of Oddi dysfunction. It may also demonstrate
changes in the pancreatic duct following secretin
administration [2931].
The main drawback of the single-section acquisi-
tion is that ductal visibility may be degraded by
overlap with other fluid-containing structures or asci-
tes included in the field of view (Fig. 3). To overcome
overlap by fluid in the stomach, ideally, patientsshould fast 4 hours before the examination or be
given a T2-negative oral contrast agent such as high-
concentrate ferric ammonium citrate [32]. Negative
oral contrast may interfere with identification of the
duodenum and ampulla of Vater, however. Overlap
also can be overcome by tailoring the orientation and
positioning of the thick slab to the patients ductal
anatomy. Alternatively, a multislice thin-section
acquisition can be performed.
A multislice acquisition is typically performed
with 4-mm or 5-mm thick slices with a shorter echotime (TE) than is used for single-section thick-slab
acquisition (see Fig. 2). With intermediate TE, (100
300 milliseconds), fluid is bright and periductal
structures are well seen, a feature particularly useful
when malignant obstruction is suspected or an over-
lap artifact is noted on single-section acquisition.
Fig. 1. Thick-section MRCP. (A) Coronal, oblique, thick-section SSFSE image showing a normal pancreatic duct ( P) with a loop
configuration (L). Also shown are the common bile duct (B), common hepatic duct (H), and the cystic duct (C). (B) Coronal,
oblique, thick-section SSFSE image of the patient in Fig. 1, acquired at a different obliquity, showing unfolding of the pancreaticduct loop configuration (L).
Fig. 2. Thin-section MRCP. Axial, thin-section SSFSE
image showing a dilated pancreatic duct (arrow). A thick-
section coronal oblique image may be prescribed parallel to
the main pancreatic duct, as defined by the white rectangle.
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Image quality is unaffected by motion because each
slice is acquired in less than 1 second, but motion will
cause slice-to-slice misregistration. Even thinner sec-
tions of the pancreaticobiliary tree (as thin as 2 mm),
can be performed and used for reconstructing a 3D
data set in any plane via maximum-intensity projec-tion, although the quality of projection images is
usually superior with a fast thick-slab acquisition.
Secretin-enhanced dynamic MRCP (s-MRCP) is a
technique for functional imaging and improved ana-
tomic depiction of the pancreatic ductal system.
Secretin stimulates the secretion of fluid and bicar-
bonate by the exocrine pancreas, with a consequent
increase in the volume of fluids inside the pancreatic
ducts [33]. In the first 5 minutes, secretin also causes
the sphincter of Oddi to contract, resulting in tem-
porary increased pancreatic ductal pressure in healthysubjects [34]. A thick-slab acquisition, showing the
full length of the pancreatic duct, extrahepatic biliary
tree, and duodenum in one projection, can be per-
formed dynamically with good temporal resolution to
evaluate flow of pancreatic fluid from the pancreatic
ducts into the duodenum. Secretin improves visu-
alization of the pancreatic duct and reduces the
false-positive depiction of strictures [29,31,35,36].
Administration of secretin also provides an estimate
of pancreatic exocrine function [31,37 39] and better
evaluation of sphincter and ductal anatomy, including
pancreas divisum. The main limitation to the perform-ance of s-MRCP is the additional cost and limited
availability of secretin.
Evaluation of pancreatic disease:
MRCP or ERCP?
Several studies have found MRCP comparable
with ERCP for diagnosing extrahepatic biliary and
pancreatic ductal abnormalities [2,9,15,20,29,40 43]. At many institutions, MRCP has replaced ERCP
for some indications. MRCP is noninvasive, whereas
ERCP-related morbidity and mortality is not trivial,
with potential complications including pancreatitis
(3.9%), hemorrhage (1%), perforation (1%), sepsis
(0.5%), and even death in up to 0.5% of cases
[44,45]. In addition, the risk of sedation-related
complications looms. MRCP is also less expensive
than is ERCP, uses no ionizing radiation, and is less
dependent on the operators skill. No preparation is
required for MRCP (other than brief fasting at somecenters), and no exogenous contrast is needed. Fur-
thermore, MRCP shows the ductal diameter more
accurately than does ERCP, because contrast injec-
tion during ERCP may increase biliary duct caliber
by as much as 6 mm [46,47], falsely giving the
impression of ductal dilation.
MRCP has a high success rate, whereas ERCP
failure rates range between 3% and 10% [44,48].
Failure of ERCP may be due to limited operator skill.
In the case of duodenal and gastric obstruction,
periampullary diverticula, and in patients who have
had an operative choledochoenteric or pancreaticoen-teric anastomosis, however, ERCP may be techni-
cally impossible and fail in up to 20% of cases (Fig. 4)
Fig. 3. MRCP with overlap of fluid-containing structures. (A) Coronal, oblique, thick-section SSFSE image in a patient with
autosomal-dominant polycystic kidney disease and multiple small liver cysts (small arrows) and renal cysts (R) depicted on the
thick-section MRCP. These fluid-containing structures obscure view of the pancreatic duct (P) in the pancreatic tail. (B) Axial,
thin-section SSFSE image of the same patient shows delineation of the pancreatic duct ( P) in the pancreatic tail. Enlarged
kidneys containing multiple cysts (R) are noted bilaterally.
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[18,49]. With MRCP, a duct can be visualized beyond
an obstructing lesion. Combined with traditional
T1-weighted and T2-weighted sequences, MRCP
also allows for complementary imaging of extraduc-
tal disease. Thus, in most patients, and especially in
the 40% to 70% of patients who undergo ERCP whohave normal studies [50,51], MRCP appears to be an
excellent first choice in the workup of patients with
pancreatic disease and should be considered the test
of choice in all patients with failed or incomplete
ERCP [49,52,53].
There are two main limitations of MRCP. First,
unlike ERCP, MRCP offers no therapeutic options at
the time of diagnosis. Such options include sphinc-
terotomy, endoscopic lithotomy, brush cytology, col-
lection of pancreatic juice, stricture dilation, stent
placement, and biopsy. Proponents of MRCP, how-ever, argue that MRCP provides guidance for these
therapeutic alternatives. Second, the higher level of
spatial resolution achievable by ERCP may be of
critical importance in situations in which precise
delineation of the pancreatic side branches is needed.
Such situations include the recently advocated less-
invasive pancreatic surgeries, segmental pancreatic
resection, and cyst enucleation, in which management
of the pancreatic duct and its ductules is vital to
prevent postoperative pancreatic leaks leading to
fistula formation, abscess, and hemorrhage. Usually,
more precise definition of the pancreatic sidebranches can be attained by ERCP than by MRCP
[54]. The development of s-MRCP may offset the
lack of spatial resolution of conventional MRCP [30],
but further technical developments are needed to
adequately rival the spatial resolution of ERCP.
Pancreatic ductal anatomy and the significance ofanatomic variants
The normal pancreatic duct, less than 3 mm in
caliber, is challenging to visualize completely by
MRCP. The caliber of the duct increases slightly
from the pancreatic tail to the head. The main duct
receives 20 to 35 short tributaries that enter perpen-
dicularly, but are not usually seen in the normal
pancreas by MRCP. The pancreatic duct course varies
greatly, but it most commonly descends. It can have a
loop configuration, particularly at the point of fusionof the ducts of Santorini and Wirsung in the pancre-
atic neck (see Fig. 1) [28].
Patterns of drainage of the pancreas also vary. In
90% of cases, the pancreas drains primarily through
the duct of Wirsung, which joins the bile duct at the
major papilla [28]. An accessory duct of Santorini
that drains through the minor papilla is present in
44% of individuals, and is not always visualized by
MRCP, due to its limited spatial resolution. The
normal main pancreatic duct, however, is visualized
in more than 80% of patients, depending on the
Fig. 4. Duodenal diverticulum. Coronal, oblique, thick-section SSFSE image showing a duodenal diverticulum with
an air-fluid level (long arrow) lateral to a normal common bile
duct (B). The pancreatic duct (P) also appears normal. A
duodenal diverticulum is a common cause for ERCP failure.
Fig. 5. Choledochal cyst and anomalous pancreaticobiliary
junction. Coronal, oblique, thick-section SSFSE image
showing an anomalous union of the common bile duct with
the pancreatic duct (P) and a long common channel (long
arrow), in a patient with a choledochal cyst (C).
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MRCP sequence used [28,55]. Fulcher and Turner
[28] depicted the main pancreatic duct in the head
and body in 97% of cases and in the tail in 83% of
cases. Fortunately, an abnormally dilated duct can be
seen in 100% of cases [40].
In 1.5% to 3% of individuals, there is an anom-alous union of the pancreatic and bile ducts, which
results in an unusually long common channel prox-
imal to the duodenum. This channel is present in 33%
to 83% of patients with choledochal cysts and is
important to identify, because its presence may alter
the operative approach undertaken at surgical resec-
tion (Fig. 5) [56,57]. Gallbladder carcinoma is also
more frequent in patients with an anomalous union
than in those without such a union. Elnemr et al [58]
reported that 18.3% of patients with gallbladder
cancer had an anomalous union.The most common anatomic abnormality of the
pancreaspancreas divisumoccurs in 5% to 14%
of the population [59,60], when the dorsal (Santorini)
and ventral (Wirsung) pancreatic ducts fail to fuse
(Fig. 6). When standard cannulation of the major
papilla is performed on ERCP, only the ventral duct is
opacified, resulting in incomplete ductography. The
termination of the ventral duct can be mistaken for
occlusion of the main duct, potentially mimicking
pancreatic cancer. An astute endoscopist will recog-
nize this pattern, but MRCP can easily demonstrate
the anomaly and is an accurate method for diagnosing
pancreas divisum, because it shows a continuous
dominant dorsal pancreatic duct. The accuracy of
MRCP in the diagnosis of pancreas divisum has been
demonstrated to be 100% [41].
In a patient with pancreas divisum, the minorpapilla may provide a functional obstruction, resulting
in elevated pancreatic duct pressure that may precipi-
tate pancreatitis, because no communication with the
major papilla exists for adequate decompression. Pan-
creas divisum is commonly detected incidentally in
asymptomatic patients, but it occurs more frequently
in patients who present with acute recurrent pancre-
atitis than in the general population [6165].
There is no consensus regarding the appropriate
endoscopic treatment for recurrent pancreatitis asso-
ciated with pancreas divisum. Papillotomy of theminor papilla appears to yield improvement in most
cases, and placement of a transpapillary pancreatic
stent has been touted as a safe and effective endo-
scopic treatment [66]. A potential role of MRCP in
the diagnosis of pancreas divisum is to identify a
subset of patients with pancreas divisum and pancre-
atitis who may benefit from these invasive treat-
ments. Such a subset includes patients with a true
functional obstruction at the level of the minor
papilla with or without a santorinicelea cystic
dilation of the distal dorsal duct just proximal to the
minor papilla. A santorinicele is believed to resultfrom relative obstruction and weakness of the distal
ductal wall and has been suggested as a possible
cause of relative stenosis of the accessory papilla
[67,68]. Manfredi et al [30] showed that a santorini-
cele is associated with a partial functional obstruction
at the level of the minor papilla. Following secretin
administration, the onset of duodenal filling was
delayed significantly in patients with pancreas divi-
sum and a santorinicele compared with patients with
pancreas divisum alone. Furthermore, after sphincter-
otomy of the minor papilla, the size of the mainpancreatic duct and of the santorinicele was signifi-
cantly reduced, and patients had symptomatic
improvement. In this study [30], conventional MRCP
detected fewer cases of pancreas divisum with or
without santorinicele compared with s-MRCP (50%
and 57%, respectively).
The role of MRCP in pancreatitis
What is the state of the pancreaticobiliary tree in
patients with acute and chronic pancreatitis? Thisfrequent indication for ERCP may now be answered
by MRCP. Sica et al [69] showed sensitive detection
Fig. 6. Pancreas divisum. Coronal, oblique, thick-section
SSFSE image showing pancreas divisum with the dorsal (D)
and ventral (V) ducts. Cannulation of the major papilla (long
arrow) during ERCP results in opacification of the small
ventral duct only.
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and accurate characterization of duct segments with
MRCP that were comparable with ERCP.
In the setting of a single episode of acute pancre-
atitis, MRCP is focused on the noninvasive detection
or exclusion of choledocholithiasis, noting that only
30% to 52% of suspected calculi are present in
patients referred for ERCP (Fig. 7) [50]. The high
incidence of negative results using ERCP suggests
that a noninvasive test such as MRCP should be usedto screen these patients to avoid unnecessary morbid-
ity and mortality.
In the setting of recurrent acute pancreatitis,
MRCP may be used to suggest its cause and to
detect complications of pancreatitis. Possible causes
of recurrent acute pancreatitis include choledocho-
lithiasis, pancreatic cancer, or an anatomic abnor-
mality such as pancreas divisum. Sphincter of Oddi
dysfunction is also a cause of recurrent pancreatitis
that, in some instances, may be suggested by
MRCP [70].
In patients with chronic pancreatitis, MRCP can
be used to support a clinical diagnosis, especially in
the early stages of chronic pancreatitis. Chronic
pancreatitis is a chronic inflammatory process that
results in pancreatic parenchymal atrophy and fib-
rosis. Alcoholism is the cause of at least 70% of
cases. Approximately 10% of cases are attributed tochronic ductal obstruction, autoimmune disorders,
inflammatory disease, and inherited diseases causing
abnormal pancreatic enzymes or ductal secretion.
Remaining cases are idiopathic. Alcoholic pancre-
atitis is usually heterogeneous and characterized by
side-branch dilation and ductal calcifications (Fig. 8),
whereas obstructive pancreatitis is more homogen-
eous, lacks calcifications, and is associated more
often with main duct dilation. Nonalcoholic duct-
Fig. 7. Acute pancreatitis secondary to stones. (A) Coronal, oblique, thick-section SSFSE image showing gallstones (short
arrows) and common bile duct stones (long arrows) in the setting of acute pancreatitis. (B) Axial, thin-section SSFSE image
showing gallstones (short arrow) and common bile duct stones (long arrow). The pancreas (P) is enlarged and heterogeneous in
this patient with acute pancreatitis.
Fig. 8. Chronic pancreatitis. (A) Coronal, oblique, thick-section SSFSE image showing a markedly dilated pancreatic duct (large
arrow) with markedly dilated side-branches (small arrows) in a patient with chronic alcoholic pancreatitis. (B) Axial, thin-
section, fat-suppressed, 2D FSE image showing small hypointense filling defects in the pancreatic duct and its side branches,
representing pancreatic duct stones (arrows) in a patient with chronic alcoholic calcific pancreatitis.
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destructive pancreatitisor autoimmune pancre-
atitisis characterized by a narrow pancreatic duct
and diffuse parenchymal abnormality, typically involv-
ing the pancreatic body and tail, without ductal calci-
fications [71,72].
Early alcoholic chronic pancreatitis manifests asirregularities and dilation of the ductal side branches.
These side branches may be below the limits of
resolution of MRCP, so ERCP is generally more
sensitive to early side-branch changes. Side-branch
ectasia is the most specific and prominent feature of
alcoholic chronic pancreatitis. At a later stage, the
main pancreatic duct is dilated with loss of the normal
tapering of the duct in the tail. Areas of focal
narrowing produce a characteristic beaded chain of
lakes appearance. Even the biliary tract may become
dilated as a result of fibrosis in the head of the
pancreas. MRCP has demonstrated the pancreatic
duct, after stimulation with secretin, loses distensi-
bility and has decreased exocrine function [31,37].
In addition, MRCP may be used in conjunction
with other MR sequences, especially nonenhancedT1-weighted images, which show low pancreatic
signal intensity in patients with chronic pancreatitis.
MRCP is not only important for detecting chronic
pancreatitis, but is also valuable for the identification
of a surgically or endoscopically correctable lesion
(Fig. 9). The location of strictures, degree of ductal
dilation, presence of ductal filling defects, and asso-
ciated complications such as pseudocysts all influ-
ence the therapy of patients with chronic pancreatitis.
MRCP agrees with ERCP in 83% to 100% of ductal
Fig. 9. Chronic pancreatitis. (A) Coronal, oblique, thick-section SSFSE image showing changes of chronic pancreatitis, including
a dilated pancreatic duct (large arrow) with filling defects representing mucus (small arrows), and two pseudocysts (C). (B)
Coronal, thin-section SSFSE image showing the findings in Fig. 9A in greater detail. (C) Coronal, thin-section SSFSE image
acquired more anteriorly. C, pseudocysts. (D) Axial, nonenhanced, T1-weighted, gradient echo image showing decreased signal
in the pancreas (P) from fibrosis. The dilated pancreatic duct (arrow) and two pseudocysts (C) are again noted.
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dilation cases, in 70% to 92% of ductal narrowing
cases, and in 92% to 100% of filling defect cases
[36,43]. On MRCP, filling defectsrepresenting
mucus, calculi and debriscan be reliably identified
with a diameter as small as 2 mm [40]. MRCP is,however, superior for detecting pseudocysts, which
are missed approximately 50% of the time by ERCP
[73], although ERCP can consistently determine the
presence or site of communication of a pseudocyst
with the main pancreatic duct.
Therapeutic options for chronic pancreatitis
include surgical decompression, partial pancreatec-
tomy, total pancreatectomy, and endoscopic decom-
pression, which relieve pain in 75% to 90% of
patients. Ductal decompression is the main principle
of therapy, because early decompression delays theonset of exocrine dysfunction, as well as endocrine
dysfunction that occurs in 33% of patients with
chronic pancreatitis [74]. Filling defects such as
calculi, mucus, and debris may be removed endo-
scopically through a pancreatic duct sphincterotomy,
and strictures can be dilated with short-term stent
placement to improve pain [75]. Duct decompression
by surgery depends, in part, on the size of the main
pancreatic duct. For example, duct-destructive chron-
ic pancreatitis, with a main duct diameter of less than
3 mm, requires a drainage procedure different from
that required for a duct diameter over 7 mm [75,76].Hence, when using MRCP it is important to fully
describe the state of the pancreatic duct in the
setting of chronic pancreatitis to adequately guide
treatment options.
Chronic pancreatitis or carcinoma?
When findings of chronic pancreatitis are iden-
tified in a patient without a prior history of chronic
pancreatitis or of ethanol abuse, an obstructing lesion
should be suspected (Fig. 10). Pancreatic ductal
adenocarcinoma is the usual cause of chronic
obstructive pancreatitis and comprises 75% to 90%
of all pancreatic carcinomas [77]. Differentiating
adenocarcinoma from mass-forming chronic pancre-
atitis with MR imaging is sometimes difficult. Typ-
ically, the chronically inflamed pancreas will enhancemore than will pancreatic tumors on immediate post-
gadolinium images, particularly those tumors arising
in the head. Unfortunately, the degree of enhance-
ment cannot be used to reliably distinguish these
entities because abundant fibrosis is seen in both
chronic pancreatitis and carcinoma, accounting for
their similar appearances [78].
MRCP may be helpful to aid in this differenti-
ation, because chronic alcoholic pancreatitis, com-
pared with chronic obstructive pancreatitis due to
adenocarcinoma, is more frequently associated with
an irregularly dilated duct with intraductal calcifica-tion [79]. The ratio of duct caliber to pancreatic gland
width is higher in patients with carcinoma [80]. Also,
Fig. 10. Focal obstructive pancreatitis due to adenocarcinoma of the pancreas. (A) Coronal, thick-section SSFSE image showing
a dilated pancreatic duct (thick arrows) in the body and tail of the pancreas with termination ( thin arrow) of the duct in the body.
(B) Axial, T1-weighted, 3D, gradient echo image of the pancreas obtained in the arterial phase following the administration of
intravenous gadolinium shows a hypoenhancing mass (arrow) that is responsible for obstruction of the pancreatic duct with
resultant obstructive pancreatitis distally.
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the duct-penetrating sign, seen in 85% of chronic
pancreatitis and in only 4% of patients with cancer,
helps to distinguish an inflammatory pancreatic mass
from pancreatic carcinoma. The duct-penetrating
sign refers to a nonobstructed main pancreatic duct
penetrating an inflammatory pancreatic mass, unlikeits usual obstruction by pancreatic carcinoma. [81].
Furthermore, MRCP can depict the classic double
duct sign of pancreatic carcinoma (enlargement and
noncommunication of the pancreatic and common
bile ducts) and the imaging counterpart of Cour-
voisiers sign (an enlarged, nontender gallbladder
caused by an obstructing tumor) (Fig. 11) [82]. A
normal-sized pancreatic duct is present in up to 20%
of patients with adenocarcinoma, however, and
should not dissuade its diagnosis in the setting of
common bile duct dilation.These latter signs are useful when present, but
MRCP (like ERCP) is thought to be a poor way to
differentiate benign from malignant strictures.
Because morphologic features of benign and malig-
nant strictures overlap, ERCP may be the imaging
modality of choice because of its ability to obtain a
diagnostic sample with brush cytologic biopsy
[75,83]; however, MRCP, including MR imaging
pulse sequences, has a sensitivity of 84% for diag-
nosing pancreatic carcinoma, whereas the corres-
ponding sensitivity for ERCP with brush cytology
varies between 33% and 85% [42,83]. Adding MRCPto conventional T1-weighted and T2-weighted
sequences improves specificity by depicting extra-
ductal structures not seen with ERCP [84]. Compre-
hensive MR imaging is also useful to accurately
determine resectability [85].
Cystic pancreatic masses
The incidence of detected cystic pancreatic
masses is increasing because of the widespread use
of cross-sectional imaging. Cystic pancreatic lesions
include benign entities such as pseudocysts and
epithelial pancreatic cysts, as well as malignant
lesions. Epithelial cysts are usually associated with
entities such as polycystic kidney disease and von
Hippel-Lindau disease. Other cystic lesions are dis-
cussed below.
Pancreatic pseudocysts occur as a complication ofacute or chronic pancreatitis and represent 90% of
cystic pancreatic masses [86]. They are encapsulated
collections of pancreatic fluid, caused by pancreatic
duct disruption and tissue dissolution in acute pancre-
atitis, and microperforation of the pancreatic duct in
chronic pancreatitis. The surgical definition of a
pseudocyst requires that it be present for at least
6 weeks. These lesions may communicate with the
main pancreatic duct and may be identified on ERCP
(Fig. 12). Less than 50% of pseudocysts are detected
at ERCP [73], however, giving MR imaging a large
advantage for their diagnosis. Pseudocysts are usuallyaccompanied by a clinical history of pancreatitis and
are associated with pancreatic parenchymal and ductal
Fig. 11. Pancreatic adenocarcinoma. (A) Coronal, thick-section SSFSE image showing the classic double-duct sign of
pancreatic carcinoma; both the pancreatic duct (P) and common bile duct (C) are dilated and abruptly terminate (large arrow) inthe head of the pancreas. In this case, the intrahepatic biliary ducts are also dilated. (B) Axial, nonenhanced, T1-weighted,
gradient echo image showing an ill-defined hypointense mass (arrow) in the head of the pancreas. A biopsy of this mass revealed
pancreatic adenocarcinoma.
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changes that suggest pancreatitis, making their differ-
entiation from pancreatic neoplasms possible in most
cases. Pseudocysts resolve spontaneously in 60% of
cases [87].
Treatment options for persistent pseudocysts
include endoscopic, radiologic, and surgical drainage.
These must be considered cautiously, in the event that
a cystic neoplasm is misdiagnosed as a pseudocyst
[88]. Misdiagnosis, usually by CT, has been reported
as high as one third of the time [8991]. The tra-
ditional approach for treating pseudocysts that require
drainage has been surgical. Treatment is considered
when the patient is symptomatic, if the pseudocyst
demonstrates enlargement or complications including
hemorrhage, or if there is suspicion of a malignancy
[88]. Enlargement and hemorrhage are two factors that
can be determined with MR imaging (Fig. 13).
Cystic neoplasms of the pancreas are uncommon,
representing 10% of cystic lesions [86]. Classification
of cystic neoplasms is based on the location of the
lesion, the size of the cysts, the serous or mucinous
nature of the contents, and the most dedifferentiated
epithelial change recognizable at pathology [92,93].
Additionally, almost any pancreatic neoplasm can
present as a cystic mass, including adenocarcinoma,
which is the most common pancreatic neoplasm.
Fig. 12. Communicating pseudocyst. Axial, thin-section SSFSE image showing an uncomplicated pseudocyst (C) with
communication to the pancreatic duct (arrow) in a patient with pancreatitis.
Fig. 13. Hemorrhage pseudocyst. (A) Axial, thin-section SSFSE image showing a large complex cystic collection with a fluid
fluid level (arrow) representing a hemorrhagic pseudocyst in a patient with pancreatitis. The head of the pancreas (P) is denoted.
(B) Axial, T1-weighted, gradient echo image showing hyperintensity (arrows) at the posterior aspect of the pseudocyst,
representing hemorrhage. The head of the pancreas (P) is again denoted.
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Parenchymal cystic lesions include serous and muci-
nous cystic neoplasms. Intraductal neoplasms are
referred to as intraductal papillary mucinous tumors
(IPMTs). Cystic neoplasms can easily be detected on
MRCP because of their high fluid content, but full
examination requires T1-weighted, T2-weighted, andpostgadolinium sequences.
Serous microcystic adenomas are benign pancre-
atic parenchymal lesions with a relatively equal
distribution throughout the pancreas. Although typi-
cally appearing solid on CT or US, a serous adenoma
is cystic with more than six internal cysts, each
measuring less than 2 cm in diameter. Approximately
40% of these tumors have calcifications and 15%
have a central stellate scar (Fig. 14). Their soft tissue
component is typically hypervascular and aspirated
contents contain glycogen [94]. A small seroustumor adjacent to the main pancreatic duct or a
branch duct may be difficult to distinguish from an
intraductal neoplasm.
Mucinous cystic neoplasms are also parenchymal
lesions. In the past, this neoplasm was subcategorized
into macrocystic adenomas and adenocarcinomas,
which are indistinguishable on the basis of imaging.
In fact, all mucinous cystic neoplasms should be
considered malignant or potentially malignant; thus,
this subcategorization is not appropriate. Mucinous
neoplasms, with strict histologic criteria, probablyoccur only in women and are usually located in the
pancreatic body and tail. Most mucinous cystic neo-
plasms have fewer than six cysts, each greater than
2 cm in diameter. Twenty-five percent of these lesions
have calcification, and the soft tissue component is
hypovascular. Aspiration of these lesions yields
mucin [92]. Because these lesions are frequently
unilocular, they may be confused with pseudocysts.
In such cases, changes of pancreatitis should be
sought to confirm the possibility of a pseudocyst
(Fig. 15).Intraductal tumors, previously described in the
literature under different names such as ductectatic
mucinous cystadenocarcinomas, predominate in men
and older individuals. These tumors, now referred to
as IPMTs, usually grow slowly, with a good prog-
Fig. 14. Serous tumor. (A) Coronal, thick-section SSFSE image showing a round, well-defined, cystic mass ( large arrow) in the
head of the pancreas with a conglomerate of small cysts measuring less than 2 cm each. The common bile duct (B), pancreatic
duct (P), and cystic duct (C) are denoted on this image. (B) Axial, thin-section SSFSE image showing the cystic mass ( thick
arrow) with a suggestion of a central scar (thin arrow), characteristic of a serous tumor.
L.M. Fayad et al / Radiol Clin N Am 41 (2003) 97114 107
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nosis. IPMTs arise from the epithelial lining of the
pancreatic ductal system and include lesions repre-
senting the histologic progression of epithelial hyper-
plasia, dysplasia, adenoma, carcinoma-in-situ, and
invasive carcinoma [9598]. Hyperplasia, dysplasia,
and adenoma may undergo malignant transformation
over many years [98]. Multiple IPMTs can be present
in an individualapproximately 23% of the timeas
described in a series by Megibow et al [99]. IPMT is
associated with excessive mucin secretion, resulting
in progressive ductal dilation or cyst formation
(Fig. 16). IPMT may involve the main duct or branch
ducts of the pancreas. Imaging patterns include seg-
mental or diffuse involvement of the main pancreatic
duct, and microcystic or macrocystic masslike lesions
involving the branch ducts [95,97,98].
Fig. 15. Mucinous tumor. (A) Coronal, thick-section SSFSE image depicting a cystic mass ( thick arrow) in the tail of the
pancreas, without associated dilation of the pancreatic duct (thin arrow). (B) Axial, thin-section SSFSE image showing the cystic
mass (thick arrow) with internal complex signal. The pancreatic duct (thin arrows) is not dilated. Resection of this mass yielded a
benign mucinous cystic tumor.
Fig. 16. IPMT. (A) Coronal, thick-section SSFSE image showing a cystic mass ( large arrow) associated with a dilated pancreatic
duct (P) with dilated side branches. Incidental note is made of a cystic duct remnant ( C). (B) Coronal, thin-section SSFSE image
showing the cystic mass (large arrow) in communication with a dilated draining pancreatic duct ( P), a finding that is highly
suggestive of an intraductal papillary mucinous tumor.
L.M. Fayad et al / Radiol Clin N Am 41 (2003) 97114108
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When an IPMT involves the full length of the
main pancreatic duct without a localized cystic mass,
differentiation from chronic pancreatitis may be dif-
ficult [100,101]. A finding virtually pathognomonic
of IPMTs is dilation of the major papilla, minor
papilla, or both, with bulging into the duodenallumen. This finding, which can be seen on MR
imaging and is well appreciated by ERCP, is demon-
strated with CT imaging approximately 25% of the
time (Fig. 17) [97].
With segmental involvement of the main pancre-
atic duct, the adjacent pancreatic parenchyma is
normal or thin. IPMTs such as this can be difficult
to differentiate from localized chronic obstructive
pancreatitis. In such cases, hypointense filling defects
representing mucin facilitate the diagnosis of IPMT.
When the IPMT is located in the head, it may be
difficult to differentiate between diffuse invasion of
the main pancreatic duct and simple ductal dilationfrom mechanical obstruction. In difficult cases, ERCP
is valuable to demonstrate intraluminal mucinous
filling defects with jellylike mucin leaking from the
papilla, another pathognomonic finding for IPMT. On
occasion, mucin can be viscous enough to obstruct
the pancreatic duct, preventing successful ERCP.
Nevertheless, the endoscopist can confirm the pres-
Fig. 17. IPMT. (A) Coronal, thick-section SSFSE image showing an IPMT ( thick arrow) with a dilated draining pancreatic duct
(P) and bulging papilla (thin arrow). The latter finding is pathognomonic of IPMTs. (B) Coronal, thick-section SSFSE image
obtained in a different projection showing the dilated main pancreatic duct ( thin arrows) in association with this IPMT (thick
arrow). (C) Coronal, thin-section SSFSE image again demonstrating a cystic mass representing an IPMT ( thick arrow) with a
dilated draining pancreatic duct and bulging papilla (thin arrow). On thin-section MRCP images, a bulging papilla is seen as a
filling defect in the duodenum. In this case, possible papillary projections are noted within the cystic mass.
L.M. Fayad et al / Radiol Clin N Am 41 (2003) 97114 109
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ence of an IPMT by observing copious drainage of
mucin from the papilla [97,102].
Branch-duct IPMT is most frequently located in
the uncinate process and can have a macrocystic or
microcystic appearance [97,98]. Communication withthe main pancreatic duct is a valuable finding that is
often demonstrated best on ERCP [103] and s-MRCP.
A branch-duct IPMT may be differentiated from a
communicating pseudocyst if the IPMT contains
papillary proliferations. If an IPMT manifests as a
more cystic masslike lesion, it can resemble a muci-
nous cystic tumor or necrotic adenocarcinoma
(Fig. 18). With the latter entities, however, the main
pancreatic duct central to the tumor should not be
dilated as it is in the presence of an IPMT.
A number of researchers have concluded thatMRCP is more sensitive and effective than is ERCP
in evaluating IPMT [54,104107]. MRCP, however,
does not offer definitive pathologic information to
decide whether a lesion is malignant, but features
have been described that suggest malignancy. Gen-
erally, a less-favorable histology is noted with the
main-duct type of IPMT [99,108,109]. The obser-
vation of thick walls and mural nodules aids the
diagnosis of malignancy [104,108,110]; the detection
of nodules in the cystic lesion is better accomplished
with MRCP than with ERCP [104,105]. The size of
the lesion is also important: in one series, Obara et al[111] found that 83% of tumors larger than 4 cm were
malignant. The size of the main pancreatic duct is
valuablemain pancreatic ductal dilation greater
than 15 mm [109], as well as diffuse main pancreatic
duct dilation with the branch-duct type of IPMT [95],
is associated with malignancy.
The features described above are influential in
deciding whether an IPMT is benign or malignant,but at this time, imaging cannot reliably distinguish
benign from malignant tumors [111 113]. Surgical
management is usually recommended when these
lesions are encountered [99,114,115]. A review of
cystic pancreatic masses by Megibow et al [99],
however, concluded that surveillance might be pos-
sible if lesions are smaller than 2.5 cm, spare the main
pancreatic duct, and demonstrate no solid compo-
nents. Because many of these patients are asympto-
matic elderly individuals and growth may be slow or
negligible over several years, surgical removal maynot be the only appropriate management.
Summary
In the evaluation of common pancreatic diseases,
MRCP is a noninvasive alternative to ERCP. Ductal
anatomy can be ascertained without risk of compli-
cations. MRCP is valuable in defining common
anatomic variants, determining the state of the pan-
creatic duct in pancreatitis, and characterizing neo-plasms, especially combined with other MR imaging
sequences. With the advent of MRCP, techniques
requiring endoscopy and percutaneous access are
largely reserved for histologic diagnosis and treat-
ment, or for cases in which MRCP fails to establish
a diagnosis.
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