1175
`
`Pancreas:
`the
`of
`Tumors
`Cell
`Islet
`Correlation
`Among
`Pathologic-Imaging
`Size, Necrosis
`and Cysts, Calcification,
`Malignant
`Behavior,
`and Functional
`Status
`
`and pathologic
`the imaging
`necrosis
`and cysts,
`calcifica-
`
`of our study was to correlate
`The purpose
`OBJECTIVE.
`with
`regard
`to tumor
`size,
`cell
`tumors
`islet
`features
`of
`behavior,
`and functional
`status.
`tion, malignant
`and
`AND METHODS. We retrospectively
`MATERIALS
`the clinical,
`reviewed
`pathologic,
`imaging features
`of pathologically
`the pancreas
`of all 133
`of
`cell
`tumors
`proved
`Islet
`cases
`including
`the patients’
`symp-
`Clinical
`data,
`Forces
`Institute
`of Pathology.
`seen
`at
`the Armed
`characteristics,
`were
`used
`and serologic
`hyperfunctioning
`to distinguish
`tumors
`toms
`from nonhyper-
`causing
`symptoms
`related
`levels)
`to elevated
`(those
`serum
`polypeptide
`further
`functioning
`tumors;
`into
`insulin-producing
`hyperfunctioning
`tumors
`were
`divided
`and non-insulin-producing
`one cross-sectional
`types. All patients
`had at
`least
`imaging
`CT (n = 118), sonography
`study,
`including
`(n = 42), or MR imaging
`(n = 22). Clinical,
`patho-
`features
`were evaluated
`and correlated
`with tumor
`size, necrosis
`and
`logic,
`and
`imaging
`calcification,
`local
`invasion,
`vascular
`invasion, metastases,
`and functional
`status.
`cysts,
`RESULTS.
`Islet cell
`tumors
`with areas
`of necrosis
`or cystic
`change
`found
`patholog-
`ically and on imaging
`studies
`(5611 33) were larger
`(8.4 cm in mean
`transverse
`diame-
`ter)
`than homogeneous
`solid lesions
`(2.9 cm in mean
`transverse
`diameter)
`and were
`predominantly
`non-insulin
`producing
`(48156)
`and nonhyperfunctioning
`(36/56).
`Of
`the
`43 insulinomas,
`35 were
`small
`(2.2 cm in mean
`transverse
`diameter),
`solid,
`and homo-
`geneous.
`Larger
`size also was associated
`with calcification
`and malignant
`behavior,
`including
`local
`invasion,
`vascular
`invasion,
`and distant metastases.
`tumors
`CONCLUSION.
`Our
`findings
`show that
`cystic
`and necrotic
`islet cell
`ally non-insulin-producing
`and nonhyperfunctioning
`neopiasms
`and larger
`typically
`solid
`and small
`insulinomas.
`Calcification,
`local
`invasion,
`vascular
`and metastatic
`disease
`are more commonly
`seen with larger neoplasms.
`
`are usu-
`than the
`invasion,
`
`AJR
`
`1995;165:1175-1179
`
`are
`They
`neopiasms.
`of endocrine
`group
`a broad
`constitute
`tumors
`cell
`Islet
`so-called
`are hyperfunctioning
`(the
`into those
`that
`on clinical
`grounds
`best
`divided
`islet
`cell
`tumors)
`and those
`that are nonhyperfunctioning
`(the so-called
`functioning
`islet
`cell
`tumors).
`One would
`expect
`hyperfunctioning
`tumors
`to be
`nonfunctioning
`earlier
`and
`to
`be
`small
`in
`comparison
`with
`nonhyperfunctioning
`manifested
`later
`one would
`expect
`to be manifested
`by virtue
`of mass
`effect,
`which
`tumors,
`on metastases.
`Furthermore,
`one would
`expect
`larger
`tumors
`to
`invasion,
`local
`areas
`of necrosis
`or cystic
`degeneration.
`We studied
`the imaging
`and
`patho-
`have
`features
`of 1 33 cases
`and correlated
`the findings
`of size,
`necrosis
`and cysts,
`logic
`calcification,
`malignant
`behavior,
`and functional
`status
`of
`the islet
`cell
`tumors.
`
`and Methods
`Materials
`and pathologic
`appearance,
`radiologic
`records,
`the clinical
`We retrospectively
`reviewed
`findings
`of all 133 islet
`Armed
`Forces
`the
`imaging
`at
`by
`cross-sectional
`studied
`cell
`tumors
`tumors
`occurred
`1994. These
`1980 and January
`institute
`of Pathology
`between
`January
`124 patients; multiple
`tumors were found
`in seven
`patients.
`All cases were
`pathologically
`by biopsy
`results. Results of
`immuno-
`proved
`by
`surgical
`resection
`or surgical
`inspection
`and
`histochemical
`staining
`performed
`to determine
`specific
`hormone
`production
`within
`each
`tumor
`varied from case to case. A single case of nesidioblastosis
`was excluded
`from the study.
`ARGENTUM
`Exhibit 1007
`
`in
`
`PeterC.
`Tremont
`James
`
`Buetow1’2
`V. Parrino2’3
`L.
`
`2
`(cid:1) 2
`R. Ros1’4
`Pablo
`H. Dachman1’5
`David
`F. Cruess6
`
`Linda
`
`Abraham
`
`22,
`
`1995;
`
`accepted
`
`after
`
`rovi-
`
`meeting
`the annual
`at
`Aay Society, Washington,
`
`of
`
`the Amen-
`DC, April-
`
`Bldg. 54, Am. M-121 ,Alaska
`
`Received
`March
`sion June
`15, 1995.
`The opinions
`herein
`contained
`assertions
`and
`views of the authors
`and are not
`to
`are the private
`as official or as reflecting
`the views of
`be construed
`the Departments
`of Defense,
`Army. or Navy.
`Presented
`can Roentgen
`May
`1995.
`1 DepartmontofRadiologic
`es Institute
`of Pathology,
`Ave. and Fom St., NW., Washington,
`DC 20306-
`6000. Address
`correspondence
`to P. C. Buetow.
`2Departments
`of Aadiolo9y
`and Nuclear Medi-
`cine,
`Uniformed
`Services
`University
`of
`the Health
`Sciences, Bethesda, MD 2081 4-4799.
`300partment
`of Radiology,
`National
`ical Center, Bethesda, MD 2081 4-4799.
`
`Pathology,Armed
`
`Forc-
`
`Naval Mod-
`
`4Department
`Gainesville,
`
`of Radiology,
`FL 32610.
`
`University
`
`of Florida,
`
`of Radiology,
`5Department
`Chicago,
`IL 60637.
`6Department
`Preventive
`of
`University
`of
`formed
`Services
`Bethesda,
`MD 2081 4-4799.
`
`University
`
`of Chicago,
`
`Uni-
`Medicine,
`the Health
`Sciences,
`
`0361-803X/95/1655-1175
`© American
`Roentgen
`
`Aay Society
`
`Downloaded from www.ajronline.org by 66.28.38.188 on 07/13/16 from IP address 66.28.38.188. Copyright ARRS. For personal use only; all rights reserved
`
`000001
`
`(cid:1)
`

`

`1176
`
`BUETOW
`
`ET AL.
`
`AJR:165,
`
`November
`
`1995
`
`the patients’
`data regarding
`symptoms
`and
`signs
`presenting
`Clinical
`islet cell
`tumors
`to diagnose
`functioning
`used
`were
`recorded.
`Criteria
`were as follows:
`insulinoma-symptomatic
`hypoglycemia with inappropri-
`ately elevated plasma insulin levels; gastnnoma-symptoms
`and signs of
`ulcer disease and elevated serum gastnn
`levels;
`glucagonoma-
`peptic
`and painful
`diabetes
`mellitus,
`dermatitis,
`glossitis;
`somatostatinoma-ele-
`disease,
`vated serum somatostatin
`levels, diabetes mellitus, gallbladder
`and steatorrhea;
`vipoma-profuse
`secretory diarrhea and elevated
`vase-
`hormone
`active
`intestinal
`levels;
`and adrenocorticotropin
`polypeptide
`causing
`(ACTH)-producing
`tumors-Cushing’s
`syndrome.
`Tumors
`serum peptide levels
`or positive
`immunohistochemical
`slightly
`elevated
`as nonhyper-
`staining
`results
`but not causing
`symptoms
`were
`classified
`1ev-
`Tumors
`pancreatic
`functioning
`tumors.
`causing
`elevated
`polypeptide
`els also were
`classified
`as nonhyperfunctioning
`tumors.
`Three
`patients
`with type 1 multiple endocrine
`had gastnnomas.
`neoplasia
`syndrome
`One hundred
`22
`had
`eighteen
`patients
`had CT, 42
`sonography,
`and
`had MR imaging.
`Imaging features were analyzed independently
`by two
`and surgical
`findings.
`with
`pathologic
`radiologists
`and
`were
`correlated
`These features
`included the size and location of the mass;
`the presence
`of cystic changes;
`findings of
`local
`invasion into surrounding
`organs or
`adenopathy;
`vascular
`invasion into the splenic vein, superior mesentenc
`vein, or splenic artery; and the presence
`of metastatic
`disease involving
`the liver or other distant organs. MR imaging and CT findings also were
`to identify
`solid nonenhancing
`areas and solid homogeneously
`used
`masses. CT alone was used to detect
`i-
`enhancing
`the
`presence
`of calcif
`cation. Any discrepancies
`were resolved
`by consensus. With regard to
`in two cases
`in which the lesions were extremely
`large and
`location,
`
`as being within
`the center was recorded
`the entire pancreas,
`replaced
`the body of
`the pancreas.
`Imaging studies were performed
`on
`a wide
`variety
`of equipment
`over many
`years,
`and
`protocols
`regarding
`imaging
`parameters,
`contrast
`injections, and other details were not standardized.
`Correlation was made
`the description
`and photographs
`among
`of
`the
`the histopathologic
`and the internal morphology
`gross
`specimen,
`findings,
`classified
`as solid homogeneous
`on
`imaging
`studies.
`Tumors
`were
`seen pathologically
`and
`masses
`when
`no necrosis
`or cystic
`change
`was
`when
`a uniform
`solid
`tumor
`was
`identified
`by CT, sonography,
`or MR imag-
`tumors were
`dass(cid:1)d
`as heterogeneous
`and as
`ing.
`,AJI the
`remaining
`having areas of necrosis;
`tumors were
`dassif(cid:1)d
`further as
`some
`of
`these
`fluki-filled or empty cavhes
`cystic.
`Tumors
`were
`daSS(cid:1)d
`as cystic
`when
`were seen pathologically
`with areas of water density
`and were
`correlated
`on CT scans, anechoic areas with acoustic enhancement
`on sonograms,
`or areas ofwater
`signal
`intensity on Ti- and T2-weighted MR images. Cor-
`for
`between
`the imaging
`and pathoIogk(cid:1)
`findings
`relation
`also was made
`the clinically hyperfunctioning
`(which were grouped
`as insulin pro-
`tumors
`producing)
`and the nonhyperfunctioning
`tumors.
`duang
`and
`non-insulin
`
`Results
`the various
`distribution
`and
`features,
`imaging
`sizes,
`The
`cell
`tumors
`islet
`nonhyperfunctioning
`and
`hyperfunctioning
`cell
`tumors,
`islet
`the hyperfunctioning
`1 . Of
`are given
`in Table
`the most
`common
`and the smallest,
`with
`insulinomas
`were
`mean
`diameter
`of 2.2 cm. Most
`insulinomas
`(35 of 43) were
`solid
`homogeneous
`masses
`(Fig.
`1). All eight
`lesions
`that had
`
`of
`
`a
`
`TABLE
`
`1 :
`
`Imaging
`
`Features
`
`of Hyperfunctioning
`
`and Nonhyperfunctioning
`
`Islet Cell Tumors
`
`T umor
`
`No. of
`Patients
`
`No. of
`Lesions
`
`lnsulinoma
`Gastrinoma
`Glucagonoma
`Stomatostatinoma
`Vipoma
`producing
`ACTHb
`Non-insulin
`producingc
`Nonfunctioning
`
`39
`18
`11
`5
`4
`2
`40
`45
`
`43
`18
`11
`5
`4
`2
`40
`50
`
`Total
`
`--
`
`1 24
`
`133
`
`2
`4
`6
`7
`4
`5
`5
`8
`
`5
`
`No. of Tumors with the Fol lowing
`
`Ima ging Featuresa:
`
`SH
`
`35
`15
`5
`2
`4
`2
`28
`14
`
`77
`
`HE
`
`8
`3
`6
`3
`0
`0
`12
`36
`
`56
`
`C
`
`3
`2
`6
`6
`0
`2
`12
`27
`
`42
`
`CA
`
`4
`4
`2
`1
`1
`2
`10
`15
`
`30
`
`LI
`
`11
`6
`4
`3
`2
`2
`17
`24
`
`52
`
`VI
`
`8
`3
`2
`3
`0
`2
`7
`13
`
`28
`
`DM
`
`4
`4
`6
`0
`0
`0
`12
`11
`
`27
`
`= mean
`
`diameter
`
`in centimeters,
`
`SH = solid
`
`homogeneous
`
`appearance,
`
`HE = heterogeneous
`
`appearance,
`
`C = cystic
`
`appearance,
`
`CA = calcification,
`
`aSizo
`LI = local
`bACTH
`CSubtotal
`
`= vascular
`VI
`invasion,
`= adronocorticotropin
`for
`functioning
`
`invasion,
`hormone.
`tumors,
`excluding
`
`DM = distant
`
`metastases.
`
`insulinomas.
`
`who had Insulino-
`included
`confusion,
`and
`hypoglycemia.
`small
`solid
`lesions,
`
`woman
`Fig. 1.-22-year-old
`and whose
`symptoms
`ma
`agitation,
`blurred
`vision,
`sulinomas
`are usually
`this
`case.
`solid
`shows
`sonogram
`A,
`lntraoperatlve
`iso-
`echoic mass within tail of pancreas
`(TAIL PANC);
`mass measured
`2 cm In diameter.
`approximately
`B, Contrast-enhanced
`CT scan
`shows
`home-
`geneously
`enhancing
`solid mass within
`tail of
`pancreas.
`
`In-
`as in
`
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`
`000002
`
`

`

`AJA:165,
`
`November
`
`1995
`
`ISLET
`
`CELL
`
`TUMORS
`
`OF PANCREAS
`
`1177
`
`and
`examination
`on gross
`seen
`components
`cystic
`than
`the mean.
`Calcification,
`larger
`studies
`were
`ing
`and distant metastases
`were
`invasion,
`invasion,
`vascular
`nonhyperfunctioning
`tumors.
`common
`than with
`insulinomas
`The
`18
`gastrinomas
`were
`larger
`than
`the
`lesions
`(1 5 of
`(mean
`diameter,
`4.2 cm). The majority
`of
`these
`18) also were
`solid
`homogeneous
`masses.
`The three
`lesions
`that had cystic
`characteristics
`measured
`1 , 6, and 3 cm. Vipo-
`
`on imag-
`local
`less
`
`and were
`(4.1 cm)
`in size to gastninomas
`similar
`mas were
`hyperfunctioning
`masses.
`The
`other
`solid
`homogeneous
`somatostatinomas,
`glucagonomas,
`cell
`tumors,
`including
`(Figs.
`2 and 3).
`ACTH-pnoducing
`tumors,
`were
`larger
`a mean
`tumors
`had
`The
`nonhyperfunctioning
`islet
`cell
`heteroge-
`tumors
`had
`diameter
`of 7.7 cm. Thirty-six
`of
`these
`neous
`areas,
`and
`oven half
`(n = 27) had cystic
`degeneration
`(Fig.
`4). Only
`14 of
`the 50 nonhyperfunctioning
`tumors
`were
`
`all
`islet
`and
`
`had glu-
`who
`woman
`2.-69-year-old
`Fig.
`symptoms
`and whose
`Included
`rash
`cagonoma
`mass noted
`Six-centimeter
`glossltis.
`and
`painful
`area of cys-
`had crescentic
`tall of pancreas
`within
`Note central
`tic degeneration
`area of cal-
`(arrow).
`Note
`also evidence
`of
`clflcatlon
`(arrowhead).
`vascular
`Invasion Into splenic vein, with multiple
`perlsplenic
`varices. MetastasIs was noted within
`findings were document-
`Iiver(notshown).
`These
`ad at attempted
`surgical
`resectIon. CalcIfIcation
`findings with
`and vascular
`Invasion
`are common
`non-insulIn-producing
`as well
`as
`such
`tumors
`cell tumors.
`with
`nonhypertunctionlng
`
`islet
`
`man who had necrotlzlng
`Fig. 3-42-year-old
`by glucagonoma.
`CT
`mIgratory
`erythema
`caused
`scan shows
`10-cm heterogeneous
`mass with
`Inter-
`of cystic degeneration.
`liver
`Hypodense
`nal
`focus
`also were noted. Cystic
`metastases
`degeneration
`fIndings with
`and metastatic
`dIsease
`are common
`nonhyperfunctionlng
`Islet cell
`tumors
`as well.
`
`10-
`and
`area
`with cystic
`
`man who had nonfunc-
`Fig. 4.-45-year-oId
`tional
`islet cell
`tumor and whose
`symptoms
`in-
`history ofvague
`abdominal
`pain.
`cluded
`8-month
`lesions such as this one are predisposed
`Large
`to cystic
`degeneration
`and aggressive
`behavior
`(splenlc
`vein Invasion was
`noted
`on this
`Image
`as well as on other
`Images [not
`shown]).
`A, Sonogram shows well-circumscribed
`cm mass
`wIth
`large
`anechoic
`central
`acoustic
`enhancement
`compatible
`degeneration.
`CT scan shows central
`B, Contrast-enhanced
`of
`simIlar
`to attenuation
`area of fluid attenuation
`gallbladder.
`Thick line of enhancing
`viable tumor
`was noted around periphery.
`Cand D, Contrast-enhancedTl-weighted(6851/
`(0) axIal
`15 [TR/TE])(C)
`and 72-weighted
`(6751/90)
`MR Images confIrm central
`cystic degeneration.
`signal
`intensity on TI-weighted
`Decreased
`Image
`and markedly
`signal
`IntensIty
`on 72-
`Increased
`weighted
`signal
`Intensity
`of CSF.
`image
`parallel
`Enhancing vlabletumorwas
`noted peripherally
`on
`Ti-weighted
`Image (C).
`contrast-enhanced
`
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`
`000003
`
`

`

`1178
`
`BUETOW
`
`ET AL.
`
`AJR:165,
`
`November
`
`1995
`
`de-
`
`man with
`Fig. 5.-60-year-old
`nonhyperfunc-
`Tumor
`shows
`cystic
`tioning
`islet
`cell
`tumor.
`and liver metastasis.
`generation,
`calcification,
`13-cm mass was noted within
`A, Lobulated
`head
`of pancreas.
`Note
`central
`areas
`of cystic
`degeneration
`with
`attenuation
`similar
`to that of
`gallbladder.
`Small
`punctate
`area
`of calcification
`also was noted
`(arrow).
`B, Unenhanced
`CT scan
`sls within
`right
`lobe of
`liver
`ture of nonhyperfunctioning
`
`shows
`(arrows),
`islet cell
`
`large metasta-
`typical
`fea-
`tumors.
`
`Discussion
`
`be
`
`polypeptides.
`of producing
`are capable
`tumors
`cell
`islet
`All
`one
`more
`than
`elaborate
`tumors
`may
`individual
`Although
`parts
`of
`the tumor,
`degrees
`in different
`to various
`hormone
`of patients
`have
`symptoms
`related
`to the
`the
`vast majority
`of a single
`hormone
`or have
`no hormone-
`overproduction
`at all
`[1-5].
`However,
`because
`of
`this
`van-
`related
`symptoms
`tumors
`can
`divided,
`on
`clinical
`grounds,
`ability,
`islet
`cell
`into
`hyperfunctioning
`and
`nonhyperfunctioning
`tumors.
`may
`be subdivided
`into insulin-pro-
`tumors
`Hyperfunctioning
`ducing
`and non-insulin-producing
`types.
`and
`consistency,
`size,
`Our data
`demonstrate
`that
`function,
`The most
`common
`malignant
`behavior
`are integrally
`related.
`hyperfunctioning
`islet
`cell
`tumors,
`the
`insulinomas,
`were
`typi-
`about
`cally
`small
`homogeneous
`masses
`measuring
`2 cm in
`uncommon
`diameter.
`Cystic
`changes
`and
`necrosis
`were
`fea-
`islet
`tunes.
`the
`other
`hand,
`nonhyperfunctioning
`cell
`On
`with
`tumors
`tumors
`typically
`larger,
`heterogeneous
`a
`were
`of necro-
`areas
`propensity
`for cystic
`degeneration
`and central
`These
`sis;
`these
`tumors
`measured
`almost
`8 cm in diameter.
`was
`differences
`were
`statistically
`significant,
`although
`there
`some
`overlap.
`The
`other
`hyperfunctioning
`islet
`cell
`tumors,
`including
`gastninomas,
`giucagonomas,
`somatostatinomas,
`vipomas,
`and
`ACTH-producing
`tumors,
`were,
`as
`a group,
`larger
`than
`the insulinomas
`and shared
`a number
`of
`the char-
`actenistics
`noted
`for nonhyperfunctioning
`islet cell
`tumors.
`In our
`study,
`larger
`tumors,
`regardless
`of
`their
`hyperfunc-
`tioning
`or nonhyperfunctioning
`status,
`were more
`likely
`be associated
`with
`cystic
`necrotic
`areas,
`calcification,
`and
`local
`invasion,
`vascular
`invasion,
`and
`liver
`or
`distant
`metastases.
`Other
`associations,
`in fewer
`patients,
`have
`been
`found
`between
`nonhyperfunctioning
`tumors
`the
`and
`presence
`of calcification
`[6, 7],
`increased
`size
`and
`necrosis
`[8],
`and metastases
`[9]. Seven
`of 10 islet
`cell
`tumors
`with
`calcification
`were
`shown
`to have malignant
`characteristics
`with
`[10].
`Venous
`invasion
`was
`shown
`in 10 of 76 patients
`islet
`cell
`tumors;
`seven
`of
`these
`10 patients
`had
`hepatic
`all
`metastases
`[11].
`However,
`not
`of
`these
`findings
`have
`been
`specifically
`addressed
`in a large
`series
`and
`correlated
`with
`the
`size,
`consistency,
`and
`functional
`status
`of
`the
`
`to
`
`vascular
`were more
`
`inva-
`com-
`
`40
`
`invasion,
`Local
`masses.
`homogeneous
`solid
`metastases
`and
`distant
`calcification,
`sion,
`5).
`insulinomas
`(Fig.
`than
`with
`mon
`components
`cystic
`with
`tumors
`of
`the
`Twenty-seven
`tumors.
`Heterogeneous
`were
`nonhyperfunctioning
`islet
`cell
`areas
`corresponding
`to necrosis
`on cystic
`degeneration
`were
`cm.
`noted
`in 56 tumors
`with
`a mean
`diameter
`of 8.4
`The
`mean
`diameter
`of
`the cystic
`tumors
`was
`7.9 cm. Thirty-six
`of
`the
`tumors
`with
`heterogeneous
`areas
`were
`nonhyperfunc-
`tioning
`islet
`cell
`tumors.
`Solid
`homogeneous
`masses
`were
`seen
`in 76 cases.
`Only
`14 of
`these
`lesions
`were
`nonhyper-
`cell
`functioning
`islet
`tumors.
`The mean
`diameter
`of
`the solid
`tumors
`homogeneous
`was
`2.9 cm.
`multiple-
`Duncan’s
`analysis
`and
`Using
`an
`of
`variance
`diameter
`in mean
`we
`found
`range
`test,
`the
`difference
`nonhyper-
`between
`the two
`largest
`groups,
`insulinomas
`and
`(p =
`.0001).
`functioning
`tumors,
`to be statistically
`significant
`correlation
`Using
`a t
`test, we found
`a statistically
`significant
`between
`the size
`of
`the tumors
`and whether
`they were
`cystic
`(p <
`.0005),
`solid
`homogeneous
`(p =
`.0001),
`or heteroge-
`neous
`(p =
`.0001).
`Similarly,
`we found
`statistically
`significant
`differences
`in size
`between
`tumors
`that were
`cystic
`(mean
`diameter,
`7.9
`cm)
`or
`heterogeneous
`(mean
`diameter,
`8.4
`cm)
`and
`solid
`homogeneous
`tumors
`(mean
`diameter,
`2.9
`cm)
`(p =
`.0001
`for both
`comparisons).
`of
`the
`between
`A statistically
`significant
`correlation
`that
`characteristics
`tumors
`and
`the
`presence
`of
`all
`the
`(mean
`calcification
`analyzed
`also
`was
`documented:
`we
`diame-
`invasion
`(mean
`diameter,
`8.2 cm)
`(p <
`.00005),
`local
`diam-
`invasion
`(mean
`ten, 6.5 cm)
`(p =
`.00006),
`and vascular
`the
`tumor,
`the more
`eter,
`7.2
`cm)
`(p
`.0019).
`The
`larger
`=
`likely
`it was
`to contain
`all of
`these
`features.
`in the
`differences
`We
`also
`found
`statistically
`significant
`internal
`morphology
`of
`the
`tumors,
`depending
`on whether
`they were
`hyperfunctioning
`or nonhyperfunctioning.
`Hetero-
`geneity
`was
`significantly
`correlated
`with
`nonhyperfunctioning
`x2 test).
`tumors
`(p <
`.0005,
`insulinomas.
`with
`common
`least
`Liver metastases
`were
`ACTH-pnoducing
`with
`both
`seen
`Liven metastases
`were
`3), and with
`11 of
`tumors,
`with
`six of 10 glucagonomas
`(Fig.
`50 nonhyperfunctioning
`islet
`cell
`(Fig.
`5).
`
`size
`
`the
`
`tumors
`
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`
`000004
`
`

`

`AJR:165, November
`
`1995
`
`ISLET
`
`CELL
`
`TUMORS
`
`OF PANCREAS
`
`1179
`
`study.
`in this
`not
`addressed
`
`Larger
`these
`
`surgical
`associations
`
`and
`
`of
`
`done
`have
`as we
`tumor,
`have
`series
`pathologic
`directly [6, 7, 12, 13].
`cys-
`and
`the tumor
`the size
`Direct
`correlation
`between
`addressed,
`formally
`yet
`been
`tic or necrotic
`areas
`has
`not
`so fan has
`included
`done
`probably
`because
`the
`research
`the external
`appear-
`in which
`predominantly
`surgical
`series
`ance was
`emphasized
`[1 2]. Cross-sectional
`imaging
`allows
`assessment
`of
`the
`internal
`structure
`as well.
`Before
`this
`study,
`cystic
`changes
`within
`islet
`cell
`tumors
`were
`viewed
`as
`rare,
`with
`only
`20 cases
`previously
`being
`reported
`[14]-
`partly
`because
`the
`surgical
`community
`is not
`familiar
`with
`these
`tumors
`[1 5] and
`partly
`because
`the
`tissue
`examined
`by
`pathologists
`and
`prepared
`for
`slides
`is, appropriately,
`from
`the
`solid
`portion
`of
`the
`tumor.
`Also,
`these
`earlier
`reports
`concerned
`tumors
`that were
`predominantly
`cystic,
`not partially
`cystic.
`from a
`collected
`were
`study
`in this
`The
`cases
`considered
`are unavoidably
`our
`findings
`Thus,
`large
`referral
`population.
`of hyperfunc-
`the proportion
`However,
`biased
`in that
`regard.
`in
`that
`noted
`series
`parallels
`in our
`tioning
`islet
`cell
`tumors
`the
`supporting
`[5,
`16,
`17],
`studies
`larger
`epidemiologic
`from a single
`if
`it was
`not
`even
`of
`the
`sampling
`veracity
`deficiency
`is that
`the
`imag-
`patient
`population.
`An additional
`acquired
`without
`the
`benefit
`ing studies
`and
`protocols
`were
`of
`standardized
`equipment.
`However,
`our
`analysis
`of
`the
`gross
`specimens
`and
`surgical
`reports
`helped
`ensure
`that
`the
`radiologic
`interpretation
`of
`these
`cases
`was
`connect.
`among
`In summary,
`we have
`demonstrated
`an association
`tumors.
`size,
`consistency,
`behavior,
`and
`function
`of
`islet
`cell
`without
`Smaller
`tumors
`tend
`to be
`homogeneous
`masses
`insuli-
`local
`invasion
`or distant
`metastases
`and
`typically
`cystic
`nomas.
`Larger
`tumors
`more
`commonly
`demonstrate
`vascular
`changes,
`necrosis,
`calcification,
`local
`invasion,
`invasion,
`and distant
`metastases
`and
`are nonhyperfunction-
`ing
`lesions
`or are
`associated
`with
`a less
`clinically
`evident
`functional
`syndrome
`than
`that
`seen with
`insulinomas.
`Knowl-
`of
`these
`features
`is important
`to radiologists
`in identify-
`edge
`ing and
`characterizing
`masses
`within
`the pancreas.
`
`are
`
`ACKNOWLEDGMENTS
`whose
`and pathologists
`the radiologists
`to all
`We are indebted
`cases
`to the Armed
`Forces
`Institute
`of
`contributions
`of outstanding
`Pathology
`have made this article possible.
`
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`Downloaded from www.ajronline.org by 66.28.38.188 on 07/13/16 from IP address 66.28.38.188. Copyright ARRS. For personal use only; all rights reserved
`
`000005
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