Sex: female
Age: 54 years
History
Recurrent episodes of pancreatitis, jaundice.
Laboratory data
Elevated lipase and amylase. Increase of serum bilirubin.
Physical findings
Radiating pain in the midabdomen during episodes of pancreatitis.
Case text
Patient was admitted for suspected choledocholithiasis. At sonography, no stones were observed in the gallbladder. The common bile duct was dilated, but no stone was seen.
Image 1-2
- MRCP (Image 2)
- ERCP (performed 2 days later) (Image 1)
MRCP was performed with a T2-weighted respiratory-triggered multi-slice 3D-TSE pulse sequence (TR 1800/TE 650 msec); MIP reconstruction.
Image 3-4
Contrast-enhanced CT scan of the pancreatic head.
Helical acquisition with 3 mm slice thickness; imaging delay 40 sec after the start of intravenous injection of 140 ml of contrast material at 4 ml/sec.
Image 5-9
Contrast-enhanced MRI of the pancreas and the liver (see image 10-11).
Image 5: Precontrast T1-weighted 2D FLASH sequence.
Image 6: T2-weighted fatsat TSE sequence.
Images 7-9: Contrast-enhanced T1-weighted 2D FLASH sequence.
Image 10-11
Contrast-enhanced MRI of the liver (performed in the same session as the pancreatic MRI).
Image 10: T2-weighted fatsat TSE sequence.
Image 11: Contrast-enhanced T1-weighted 2D FLASH sequence.
Image 1-2
1. What is the abnormality shown by MRCP?
Moderately dilated common bile duct and a severely dilated pancreatic duct. No biliary duct stones are seen.
2. Can you rely only on the MIP image for detection or exclusion of bile duct stones?
No. The thin-slice source images should always be scrutinized to detect small non-obstructive stones
3. What is your diagnosis after MRCP?
Papillary tumor (e.g. carcinoma or adenoma).
4. What is the differential diagnosis?
Benign papillary stenosis. However, marked dilatation of the pancreatic duct renders this diagnosis unlikely.
5. What does ERCP show?
Obstruction of the common bile duct and the pancreatic duct at the papilla. No papillary tumor was seen at endoscopy. A spincterotomy was performed. Biopsies were negative for tumor.
Image 3-4
6. Is there any abnormality seen?
There is dilatation of the common bile duct, a plastic stent has been inserted into the pancreatic duct. There is slight swelling of the papilla after ERCP and stent insertion, but there is no tumor seen.
7. Which oral contrast agent has been used for opacification of the upper GI tract?
Water.
8. Why?
After administration of positive contrast agents such as dilute barium the duodenum and the contrast-enhanced pancreas may have equal density. Therefore small pancreatic tumors and lymph nodes may be missed.
image 5-9
9. Is there any abnormality seen at the pre-contrast T1-weighted FLASH image?
No.
10. Is there any abnormality seen at the T2-weighted TSE image?
There is a minimal inhomogeneity of the pancreatic head.
11. Is there any abnormality seen at the mangafodipir-enhanced images?
There is dilatation of the common bile duct. At the junction of the common bile duct and the pancreatic duct there is a small hypointense mass seen (arrow).
12. What is the differential diagnosis?
Small carcinoma of the distal common duct (cholangiocarcinoma) or pancreatic carcinoma. Repeat biopsies revealed pancreatic carcinoma.
13. Is the locally lesion resectable?
Yes. There is no invasion into the celiac trunk, the superior mesenteric artery and vein or the portal vein.
Image 10-11
14. What is the abnormality seen at the T2-weighted image?
There is a moderately hyperintense lesion in the dome of the liver, suspicious for metastatic disease. This would render the pancreatic carcinoma unresectable.
15. What is seen at the mangafodipir-enhanced T1-weighted FLASH image?
There is homogeneous uptake of contrast material. No focal lesion can be seen, which rules out metastaticd isease. At intraoperative ultrasound the liver was unremarkable.
Final diagnosis
Pancreatic carcinoma pT3 [invasion of the duodenum] N0 M0.
Differential diagnosis
None.
Discussion
For detection and staging of pancreatic carcinoma, plain MRI has been shown to be inferior to contrast-enhanced CT. The administration of gadolinium-chelate contrast agents does not increase the sensitivity of MR for detection of adenocarcinoma. Contrast material is taken up by normal pancreatic and hepatic parenchyma. The tumor and liver metastases are visualized as markedly hypointense lesions on T1-weighted images. The effect of contrast-enhancement is most pronounced on gradient-echo pulse sequences (with or without fat suppression).