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DOI: 10.1148/rg.256045161
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Right arrow Gastrointestinal Radiology

Cystic Pancreatic Lesions: A Simple Imaging-based Classification System for Guiding Management1

Dushyant V. Sahani, MD, Rajgopal Kadavigere, MD, Anuradha Saokar, MD, Carlos Fernandez-del Castillo, MD, William R. Brugge, MD and Peter F. Hahn, MD, PhD

1 From the Department of Radiology, Division of Abdominal Imaging, Massachusetts General Hospital, 55 Fruit St, White 270, Boston, MA 02114. Presented as an education exhibit at the 2003 RSNA Annual Meeting. Received August 19, 2004; revision requested October 19 and received February 17, 2005; accepted March 16. All authors have no financial relationships to disclose.


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  		Figure 1a.  Drawings illustrate the four morphologic types of cystic lesions of the pancreas: unilocular cyst (a), microcystic lesion (b), macrocystic lesion (c), and cyst with a solid component (d). Note the multiple small cysts and central scar in b, the septa and large cysts in c, and the two solid components in d.

 


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  		Figure 1b.  Drawings illustrate the four morphologic types of cystic lesions of the pancreas: unilocular cyst (a), microcystic lesion (b), macrocystic lesion (c), and cyst with a solid component (d). Note the multiple small cysts and central scar in b, the septa and large cysts in c, and the two solid components in d.

 


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  		Figure 1c.  Drawings illustrate the four morphologic types of cystic lesions of the pancreas: unilocular cyst (a), microcystic lesion (b), macrocystic lesion (c), and cyst with a solid component (d). Note the multiple small cysts and central scar in b, the septa and large cysts in c, and the two solid components in d.

 


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  		Figure 1d.  Drawings illustrate the four morphologic types of cystic lesions of the pancreas: unilocular cyst (a), microcystic lesion (b), macrocystic lesion (c), and cyst with a solid component (d). Note the multiple small cysts and central scar in b, the septa and large cysts in c, and the two solid components in d.

 


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  		Figure 2a.  Pseudocyst. (a) Contrast material–enhanced CT scan shows a well-defined unilocular cyst (arrow) in the head of the pancreas. (b) Endoscopic US image helps confirm the unilocular nature of the cyst. PV = portal vein, SPL V = splenic vein. (c) Photograph of the gross specimen shows a unilocular chronic pseudocyst (arrow).

 


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  		Figure 2b.  Pseudocyst. (a) Contrast material–enhanced CT scan shows a well-defined unilocular cyst (arrow) in the head of the pancreas. (b) Endoscopic US image helps confirm the unilocular nature of the cyst. PV = portal vein, SPL V = splenic vein. (c) Photograph of the gross specimen shows a unilocular chronic pseudocyst (arrow).

 


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  		Figure 2c.  Pseudocyst. (a) Contrast material–enhanced CT scan shows a well-defined unilocular cyst (arrow) in the head of the pancreas. (b) Endoscopic US image helps confirm the unilocular nature of the cyst. PV = portal vein, SPL V = splenic vein. (c) Photograph of the gross specimen shows a unilocular chronic pseudocyst (arrow).

 


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  		Figure 3a.  Pseudocyst in a patient with a recent history of pancreatitis. (a, b) Axial CT scan (a) and coronal contrast-enhanced T1-weighted MR image (b) depict a well-defined unilocular cyst (arrow) in the tail of the pancreas. (c) T2-weighted MR image shows the cyst (arrow) with homogeneously bright signal intensity, a finding that confirms the unilocular nature of the cyst.

 


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  		Figure 3b.  Pseudocyst in a patient with a recent history of pancreatitis. (a, b) Axial CT scan (a) and coronal contrast-enhanced T1-weighted MR image (b) depict a well-defined unilocular cyst (arrow) in the tail of the pancreas. (c) T2-weighted MR image shows the cyst (arrow) with homogeneously bright signal intensity, a finding that confirms the unilocular nature of the cyst.

 


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  		Figure 3c.  Pseudocyst in a patient with a recent history of pancreatitis. (a, b) Axial CT scan (a) and coronal contrast-enhanced T1-weighted MR image (b) depict a well-defined unilocular cyst (arrow) in the tail of the pancreas. (c) T2-weighted MR image shows the cyst (arrow) with homogeneously bright signal intensity, a finding that confirms the unilocular nature of the cyst.

 


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  		Figure 4a.  Side-branch IPMN manifesting as a unilocular cyst. (a) Contrast-enhanced CT scan demonstrates a small cyst (arrow) in the head of the pancreas. (b) Coronal oblique single-shot fast spin-echo MR cholangiopancreatogram shows communication of the cyst (arrow) with the main pancreatic duct (arrowheads), a finding that helped establish the diagnosis.

 


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  		Figure 4b.  Side-branch IPMN manifesting as a unilocular cyst. (a) Contrast-enhanced CT scan demonstrates a small cyst (arrow) in the head of the pancreas. (b) Coronal oblique single-shot fast spin-echo MR cholangiopancreatogram shows communication of the cyst (arrow) with the main pancreatic duct (arrowheads), a finding that helped establish the diagnosis.

 


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  		Figure 5.  Multiple unilocular cysts in a patient with von Hippel–Lindau disease. Contrast-enhanced CT scan shows multiple unilocular cysts (arrows) scattered throughout an otherwise healthy-looking pancreas.

 


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  		Figure 6a.  Serous cystadenoma. (a) Contrast-enhanced CT scan shows a classic serous cystadenoma (arrow) in the head and neck of the pancreas. The lesion has the appearance of a solid mass with numerous small cysts ("honeycomb" effect). The lobulated outlines and the calcified central scar (arrowhead) are typical findings in these tumors. (b) Photograph of the gross specimen clearly demonstrates the microcystic nature of the tumor (arrow).

 


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  		Figure 6b.  Serous cystadenoma. (a) Contrast-enhanced CT scan shows a classic serous cystadenoma (arrow) in the head and neck of the pancreas. The lesion has the appearance of a solid mass with numerous small cysts ("honeycomb" effect). The lobulated outlines and the calcified central scar (arrowhead) are typical findings in these tumors. (b) Photograph of the gross specimen clearly demonstrates the microcystic nature of the tumor (arrow).

 


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  		Figure 7a.  Serous cystadenoma. (a) CT scan shows a serous cystadenoma (arrow) of the pancreatic head, with the classic findings of lobulated outlines, lack of vascular encasement, and a central scar (arrowhead). (b) T2-weighted MR image shows the internal morphologic features of the cyst, with high-signal-intensity microcysts (arrows) being clearly distinguished from the dark central scar (arrowhead).

 


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  		Figure 7b.  Serous cystadenoma. (a) CT scan shows a serous cystadenoma (arrow) of the pancreatic head, with the classic findings of lobulated outlines, lack of vascular encasement, and a central scar (arrowhead). (b) T2-weighted MR image shows the internal morphologic features of the cyst, with high-signal-intensity microcysts (arrows) being clearly distinguished from the dark central scar (arrowhead).

 


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  		Figure 8.  Serous cystadenoma (macrocystic variant). Contrast-enhanced CT scan demonstrates a variant of a serous cystadenoma in the pancreatic body. The mass appears as a septated lesion that contains a few macrocysts (arrow). Note the lobulated outlines of the lesion, a feature that is often seen in microcystic tumors (cf Figs 6, 7). Serous cystadenoma was confirmed at surgery and histopathologic analysis.

 


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  		Figure 9a.  Mucinous cystadenoma manifesting as a multiseptated cyst. (a) Axial CT scan shows a cystic lesion with thin septa (arrow). (b) Coronal reformatted image also depicts the lesion (arrow). (c) High-resolution endoscopic US image demonstrates the septated internal architecture of the cyst.

 


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  		Figure 9b.  Mucinous cystadenoma manifesting as a multiseptated cyst. (a) Axial CT scan shows a cystic lesion with thin septa (arrow). (b) Coronal reformatted image also depicts the lesion (arrow). (c) High-resolution endoscopic US image demonstrates the septated internal architecture of the cyst.

 


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  		Figure 9c.  Mucinous cystadenoma manifesting as a multiseptated cyst. (a) Axial CT scan shows a cystic lesion with thin septa (arrow). (b) Coronal reformatted image also depicts the lesion (arrow). (c) High-resolution endoscopic US image demonstrates the septated internal architecture of the cyst.

 


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  		Figure 10a.  Mucinous cystadenocarcinoma. Contrast-enhanced CT scans (a obtained at a lower level than b) show a large cystic mass (arrows) with internal septa in the head of the pancreas. The peripheral and septal calcifications (arrowheads) indicate the malignant nature of the lesion.

 


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  		Figure 10b.  Mucinous cystadenocarcinoma. Contrast-enhanced CT scans (a obtained at a lower level than b) show a large cystic mass (arrows) with internal septa in the head of the pancreas. The peripheral and septal calcifications (arrowheads) indicate the malignant nature of the lesion.

 


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  		Figure 11a.  Mucinous cystic tumor. (a) Endoscopic US image shows a complex pancreatic cyst with internal septa. (b) Photograph of the gross specimen shows large cysts and septa.

 


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  		Figure 11b.  Mucinous cystic tumor. (a) Endoscopic US image shows a complex pancreatic cyst with internal septa. (b) Photograph of the gross specimen shows large cysts and septa.

 


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  		Figure 12.  Mucinous cystadenoma. Contrast-enhanced CT scan shows a cystic mass (arrow) with rim calcification (arrowhead) in the tail of the pancreas.

 


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  		Figure 13a.  Islet cell tumor manifesting as a cyst with a solid component. CT scans (a, b) and endoscopic US image (c) obtained in a patient with a malignant primary neuroendocrine tumor of the pancreas show a cystic lesion in the pancreatic body with peripheral mural nodules (arrows).

 


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  		Figure 13b.  Islet cell tumor manifesting as a cyst with a solid component. CT scans (a, b) and endoscopic US image (c) obtained in a patient with a malignant primary neuroendocrine tumor of the pancreas show a cystic lesion in the pancreatic body with peripheral mural nodules (arrows).

 


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  		Figure 13c.  Islet cell tumor manifesting as a cyst with a solid component. CT scans (a, b) and endoscopic US image (c) obtained in a patient with a malignant primary neuroendocrine tumor of the pancreas show a cystic lesion in the pancreatic body with peripheral mural nodules (arrows).

 


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  		Figure 14a.  Solid pseudopapillary tumor manifesting as a cyst with a solid component. (a) Contrast-enhanced CT scan shows a lesion in the body of the pancreas with cystic areas and a solid component or mural nodule (arrow). (b) T1-weighted MR image more clearly demonstrates the solid component (arrow).

 


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  		Figure 14b.  Solid pseudopapillary tumor manifesting as a cyst with a solid component. (a) Contrast-enhanced CT scan shows a lesion in the body of the pancreas with cystic areas and a solid component or mural nodule (arrow). (b) T1-weighted MR image more clearly demonstrates the solid component (arrow).

 


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  		Figure 15a.  Metastases manifesting as cysts with solid components. (a) CT scan obtained in a patient with pancreatic adenocarcinoma demonstrates a solid tumor with cystic degeneration (arrow). (b) CT scan obtained in a patient with malignant IPMN shows a multiseptated cyst with solid components (arrow). (c) Photograph of the gross specimen obtained in a different patient with malignant IPMN shows a complex cyst with a large solid component (arrow).

 


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  		Figure 15b.  Metastases manifesting as cysts with solid components. (a) CT scan obtained in a patient with pancreatic adenocarcinoma demonstrates a solid tumor with cystic degeneration (arrow). (b) CT scan obtained in a patient with malignant IPMN shows a multiseptated cyst with solid components (arrow). (c) Photograph of the gross specimen obtained in a different patient with malignant IPMN shows a complex cyst with a large solid component (arrow).

 


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  		Figure 15c.  Metastases manifesting as cysts with solid components. (a) CT scan obtained in a patient with pancreatic adenocarcinoma demonstrates a solid tumor with cystic degeneration (arrow). (b) CT scan obtained in a patient with malignant IPMN shows a multiseptated cyst with solid components (arrow). (c) Photograph of the gross specimen obtained in a different patient with malignant IPMN shows a complex cyst with a large solid component (arrow).

 


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  		Figure 16.  Schematic illustrates an algorithmic approach for the management of cystic pancreatic lesions based on the morphologic features of the lesion. MPD = main pancreatic duct, sr = serum. Management decisions (* at lower left and lower right) are based on several factors, including the patient’s age and surgical risk and the size and location of the cyst. Surgery should be considered for larger cysts and younger patients. Imaging follow-up is recommended for small cysts and older patients, including those who are at higher risk for surgical complications.

 




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