Axial fat suppressed FSE T2 weighted image (TR=6000/TE=136/ETL=16)
Findings
Axial contrast enhanced CT shows a solid hyperdense mass (*), which is located antero-laterally to the head of the pancreas (arrow). The duodenal loop was anteriorly located and interposed between the mass and the head of the pancreas (arrowheads)
Axial SE T1W image showed an hypointense lesion which was well cleavable from the inferior surface of the liver and the gallbladder (arrow)
Axial FSE T2W image confirmed the findings observed on SE T1W images. The lesion is of intermediate signal intensity, with some hyperintense spots indicating colliquative necrosis (arrow)
In the axial fat suppressed FSE T2 weighted image the selective saturation of the adipose tissue signal allowed the appreciation of the inner structure of the mass (arrow) and its relationship with the duodenal loop (arrowheads)
A barium exam was performed. A lesion originating from the duodenal wall was shown.
Finally a CT guided FNAB was executed which allowed the histological diagnosis.
Diagnosis
Duodenal leiomyoma. The diagnosis was confirmed by the histological exam of the bioptical material and of the duodeno-cephalopancreatectomy, performed at surgery. Benign muscular cells mixed with hyaline material were found at histology.
Discussion
Leiomyoma of the gastro-enteric tract is a rare benign neoplasm which derives from the parietal smooth musculature. The most frequent localization is the stomach. Duodenal localization is a rare finding. In such cases the correct diagnosis may be extremely difficult because of the contiguity of the duodenal loop with the adjoining organs (pancreas, gallbladder, large vessels).
Therefore the mass has to be differentiated from a carcinoma either of the pancreas or of the gallbladder.
The duodenal loop was anteriorly located and interposed between the mass and the head of the pancreas. This aspect was helpful in defining the duodenal origin of the lesion. The barium exam confirmed the duodenal localization of the lesion and showed its submucosal origin. The integration of the results form various methods suggested the diagnosis of a mass originating from the duodenal wall, with some areas of colliquative degeneration.
References
1) Bruneton JN, Druillard J, Roux P, et al. Leiomyoma and leiomyosarcoma of the digestive tract. A report of 45 cases and review of the literature. Eur J Radiol 1981, 1 :291-300.
2) Gourtsoyannis NC, Bay D, Malamas M, et al. Radiological appearance of small intestinal leiomyomas. Clinical Radiology 1992, 45 : 94-103.
3) Megibow AJ, Balthazar EJ, et al. CT evaluation of gastrointestinal leiomyoma and leiomyosarcoma. AJR 1985, 144 : 727-731.
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University of Palermo, Institute of Radiology "P. Cignolini"
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