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a, b. Axial T2 weighted MR image showing pancreatic main ductal dilatation in the body and tail (a) and head (b) portions.
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Magnetic resonance imaging (MRI) revealed dilatation of the main pancreatic duct throughout the gland, measuring up to 35 mm, accompanied by mild side branch dilatations (Fig. 1a, b).
A hypointense nodular intensity (arrow) is seen at the head of the pancreas inside the dilated duct close to the papilla level on axial T2 weighted MR image.
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A mural nodularity measuring 1.5 cm, that is similar to pancreatic parenchyma on pre-contrast images was noticed in the head region close to ampulla (Fig. 2).
Axial DWI image showing hyperintensity (diffusion restriction) of the nodular intensity (arrow) shown in Fig. 2.
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ADC map (restricted diffusion) (Fig. 3).
Substracted (precontrast from post contrast) T1weighted axial image showing that the nodular lesion is enhanced markedly with contrast (arrow).
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After intravenous contrast administration this lesion enhanced with contrast and this finding was further verified with subtraction images that were obtained after subtraction of pre from post-contrast data (Fig. 4). As far as recent international consensus guidelines about pancreatic mucinous neoplasia's are concerned, the imaging features revealed the presence of both high risk stigmata's (main pancreatic duct measuring >1cm and presence of contrast enhancing solid component).
a, b Histopathological images of resected pancreatic specimen on 40 hpf (a) and 100 hpf (b) showing IPMN (white arrow) and cells of NET (black arrow), at the right lower part of both figures perineural invasion (arrow head) is observed.
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At the pancreatic head adjacent to the IPMN, presence of neuroendocrine carcinoma with perineural invasion was detected, that corresponded to the contrast enhancing nodular lesion seen on MRI (Fig. 5a, b).