Imaging Pearls ❯ Pancreas ❯ Pancreatic Adenocarcinoma
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- “Radiology plays an important role in the initial diagnosis and staging of patients with pancreatic ductal adenocarcinoma (PDAC). CT is the preferred modality over MRI due to wider availability, greater consistency in image quality, and lower cost. MRI and PET/CT are usually reserved as problem-solving tools in select patients. The National Comprehensive Cancer Network (NCCN) guidelines define resectability criteria based on tumor involvement of the arteries and veins and triage patients into resectable, borderline resectable, locally advanced, and metastatic categories. Patients with resectable disease are eligible for upfront surgical resection, while patients with high-stage disease are treated with neoadjuvant chemotherapy and/or radiation therapy with hopes of downstaging the disease. The accuracy of staging critically depends on the imaging technique and the experience of the radiologists. Several challenges in accurate preoperative staging include prediction of lymph node metastases, detection of subtle liver and peritoneal metastases, and disease restaging following neoadjuvant therapy.”
Pancreatic ductal adenocarcinoma staging: a narrative review of radiologic techniques and advances
Linda C. Chu, Elliot K. Fishman
International Journal of Surgery (2024) 110:6052–6063 - “Artificial intelligence (AI) has the potential to function as ‘second readers’ to improve upon the radiologists’ detection of small early-stage tumors, which can shift more patients toward surgical resection of potentially curable cancer. AI may also provide imaging biomarkers that can predict disease recurrence and patient survival after pancreatic resection and assist in the selection of patients most likely to benefit from surgery, thus improving patient outcomes.”
Pancreatic ductal adenocarcinoma staging: a narrative review of radiologic techniques and advances
Linda C. Chu, Elliot K. Fishman
International Journal of Surgery (2024) 110:6052–6063 - “Pancreatic ductal adenocarcinoma (PDAC) is the seventh leading cause of cancer mortality worldwide based on GLOBOCAN 2020 estimates, and over 466 000 patients with pancreatic cancer succumbed to the disease in 2020.. The age-standardized incidence of PDAC is fourfold to fivefold higher in countries with a high development index, with the greatest incidence in Europe, North America, Australia, and New Zealand. Therefore, PDAC is expected to surpass breast cancer as the third leading cause of cancer death in the United States and Europe. Despite therapeutic advances, the 5-year survival rate of patients with PDAC remains ~10% since most patients are diagnosed at an advanced stage of disease. Surgical resection remains the only curative therapy for patients with PDAC, and radiology plays a pivotal role in disease staging and patient management."
Pancreatic ductal adenocarcinoma staging: a narrative review of radiologic techniques and advances
Linda C. Chu, Elliot K. Fishman
International Journal of Surgery (2024) 110:6052–6063 - “PDACs classically present as hypoenhancing masses with associated pancreatic duct dilatation and glandular atrophy of the body and tail. Pancreatic head tumors can cause common bile duct dilatation in addition to pancreatic duct dilatation, also known as the ‘double duct sign’. Up to 20% of PDACs enhance to the same degree as the background pancreas, and this isoattenuating pattern is more commonly found with smaller ( ≤20 mm) tumors. These small isoattenuating tumors can be difficult to detect on CT; therefore, radiologists often rely on secondary signs of the pancreatic duct or common bile duct dilatation for tumor detection. MRI and PET/CT have reported sensitivities of 79.2 and 73.7% in the detection of isoattenuating tumors, respectively, and may aid in detecting suspected pancreatic tumors that are occult on CT. Endoscopic ultrasound is crucial in confirming tissue diagnosis of suspected pancreatic malignancy. It is also an important second-line modality in detecting suspected pancreatic tumors that are occult on CT or MRI.”
Pancreatic ductal adenocarcinoma staging: a narrative review of radiologic techniques and advances
Linda C. Chu, Elliot K. Fishman
International Journal of Surgery (2024) 110:6052–6063 
Pancreatic ductal adenocarcinoma staging: a narrative review of radiologic techniques and advances
Linda C. Chu, Elliot K. Fishman
International Journal of Surgery (2024) 110:6052–6063- “Subtle liver or peritoneal metastases can be occult on preoperative CTs in up to 30% of cases, and diagnostic laparoscopy may be useful for patients at high risk of advanced disease. High-quality imaging is essential in the detection of subtle liver or peritoneal metastases. Small liver and peritoneal metastases may be obscured by image noise, thick image slices, or suboptimal contrast injection. Liver metastases from PDAC are typically hypoenhancing on the portal venous phase and can mimic the appearance of cysts or hemangiomas. On arterial phase images, these liver metastases may contain peripheral enhancing rims, and this targetoid appearance can significantly improve the diagnostic confidence of small liver metastases. MRI has improved tissue characterization compared to CT and is valuable for characterizing small indeterminate liver lesions.”
Pancreatic ductal adenocarcinoma staging: a narrative review of radiologic techniques and advances
Linda C. Chu, Elliot K. Fishman
International Journal of Surgery (2024) 110:6052–6063 - “Cinematic rendering, a recently described 3D rendering technique, uses a global illumination model that considers direct and indirect lighting to create images with photorealistic quality. Cinematic rendering can accentuate subtle texture changes and improve tumor conspicuity relative to traditional 2D images, 3D volume rendering, or maximum intensity projection images. Cinematic rendering may be able to enhance the visualization of spatial relationships among the tumor and adjacent vasculature, differentiating true tumor infiltration from simple proximity to vessels. This can potentially improve the assessment of resectability and assist in determining optimal vascular reconstruction options. Cinematic rendering vascular maps illustrate the major arteries and veins with exquisite detail and can highlight the presence of variant vascular anatomy that may increase the risk of complications, such as hemorrhage, ischemia, anastomotic leakage, or pseudoaneurysm formation.”
Pancreatic ductal adenocarcinoma staging: a narrative review of radiologic techniques and advances
Linda C. Chu, Elliot K. Fishman
International Journal of Surgery (2024) 110:6052–6063 - ”Cinematic rendering vascular maps illustrate the major arteries and veins with exquisite detail and can highlight the presence of variant vascular anatomy that may increase the risk of complications, such as hemorrhage, ischemia, anastomotic leakage, or pseudoaneurysm formation. At our institution, cinematic rendering has been routinely incorporated into the multidisciplinary PDAC clinic since 2018, and it has played an important role in tumor staging as well as patient management. Moreover, cinematic rendering data can be imported into augmented reality headsets to provide an immersive experience for the surgeon for operative planning.”
Pancreatic ductal adenocarcinoma staging: a narrative review of radiologic techniques and advances
Linda C. Chu, Elliot K. Fishman
International Journal of Surgery (2024) 110:6052–6063 - “Artificial intelligence (AI) is poised to revolutionize medicine, and radiology is a natural gateway due to the inherent digital nature of radiology data. AI can be broadly defined as using computers to perform tasks typically associated with human intelligence. Machine learning, a branch of AI, enables the extraction of meaningful patterns from examples rather than through explicit programming. Deep learning (DL), a subfield of machine learning first developed in the 1950s, utilizes networks of interconnected nodes that process input data and adjust the network weights to minimize prediction errors. Recent developments in powerful parallel computing hardware, the availability of large training data, and improved network architectures have notably enhanced the performance of deep learning, which has significant potential for clinical translation.”
Pancreatic ductal adenocarcinoma staging: a narrative review of radiologic techniques and advances
Linda C. Chu, Elliot K. Fishman
International Journal of Surgery (2024) 110:6052–6063 - “Radiomics converts imaging data into high-dimensional features that can be used to characterize spatial heterogeneity inherent in disease processes. The features of radiomics can be classified into signal intensity, shape, and texture. Signal intensity (first-order) features are derived from histograms of individual voxel signal intensities, providing measures of central tendency and shape of the distribution. Shape features are extracted from the three-dimensional surface of the region of interest. Texture features are calculated in three dimensions, considering the correlation of signal intensities of adjacent voxels. In addition, feature extraction may be performed after applying a secondary filter, such as a wavelet or Gaussian filter.”
Pancreatic ductal adenocarcinoma staging: a narrative review of radiologic techniques and advances
Linda C. Chu, Elliot K. Fishman
International Journal of Surgery (2024) 110:6052–6063 - “AI can theoretically function as ‘second readers’ to improve radiologists’ sensitivity in the detection of small tumors, which potentially can be cured with surgical resection. A preliminary study by Liu et al. showed promising results suggesting that DL could accurately differentiate CT scans of patients with PDAC from CT scans of healthy controls. More recently, Chen et al. developed a DL tool that differentiated CT scans of patients with PDAC vs. healthy controls with 89.9% sensitivity, 95.9% specificity, and 93.4% accuracy in the local test set. They validated this DL tool on a Taiwanese nationwide external validation set and achieved 89.7% sensitivity, 92.8% specificity, and 91.4% accuracy. Also, Park et al. developed a different DL tool that achieved high sensitivity comparable to radiologists in the detection of not only pancreatic solid masses (98–100%) but also cystic masses 1.0 cm or larger (sensitivity 92–93%), bringing us closer to a universal pancreatic neoplasm detector.”
Pancreatic ductal adenocarcinoma staging: a narrative review of radiologic techniques and advances
Linda C. Chu, Elliot K. Fishman
International Journal of Surgery (2024) 110:6052–6063 - “Other studies have used radiomics to facilitate the detection of PDAC, demonstrating that radiomics signatures from PDAC were distinct from the background pancreas. More impressively, radiomics signatures could identify subtle differences in prediagnostic CT scans obtained with a median of 386 days before PDAC diagnosis, with 95.5% sensitivity, 90.3% specificity, and 92% accuracy. If these promising results are validated in future studies, radiologists will be able to diagnose patients significantly earlier at lower disease stages. In this scenario, a higher proportion of newly diagnosed patients will be eligible for curative surgical resection, which will have a significant positive impact on patient outcomes.”
Pancreatic ductal adenocarcinoma staging: a narrative review of radiologic techniques and advances
Linda C. Chu, Elliot K. Fishman
International Journal of Surgery (2024) 110:6052–6063 - “Researchers have also used radiomics features to predict the development of liver metastases after PDAC resection in multiple studies. Zambirinis et al. analyzed 254 radiomics features from the liver from preoperative CTs in 688 patients with resected PDAC and the radiomics model identified patients at risk for early (< 6 months) liver metastases with an AUC of 0.71. Huang et al. extracted 3906 radiomics features from the pancreatic tumor from preoperative MRIs in 204 patients with resected PDAC, and the radiomics model achieved 75.0% sensitivity, 82.2% specificity, and an AUC of 0.815 in predicting the development of liver metastases. We speculate that radiologic features from both the primary tumor and the liver parenchyma are important in predicting future liver metastases. Future studies should incorporate features from both the tumor and the liver, in combination with clinical features, to optimize the prediction of liver metastases.”
Pancreatic ductal adenocarcinoma staging: a narrative review of radiologic techniques and advances
Linda C. Chu, Elliot K. Fishman
International Journal of Surgery (2024) 110:6052–6063 - “Preliminary studies using emerging technologies such as advanced visualization and AI have revealed the potential of these tools to improve the initial diagnosis and staging of patients with PDAC. However, there remain several limitations. Most of these studies have been single-center retrospective studies, and their promising results should be validated in future multicenter prospective studies. Secondly, one of the major criticisms of AI is its ‘blackbox’ nature, making it difficult for clinicians to decipher the rationale behind AI predictions. Explainable or ‘glassbox’ AI is an active area of research that aims to render AI models more easily understandable and may help improve their clinical acceptance. Thirdly, these tools should be integrated seamlessly into the workflow to ensure widespread clinical implementation.”
Pancreatic ductal adenocarcinoma staging: a narrative review of radiologic techniques and advances
Linda C. Chu, Elliot K. Fishman
International Journal of Surgery (2024) 110:6052–6063
- Background: This study aimed to investigate the effects of changes in clinicopathological factors during preoperative chemotherapy for pancreatic cancer, including skeletal muscle volume, on recurrence and prognosis after pancreatectomy.
Methods: Data from 41 patients who underwent resection for pancreatic cancer after preoperative chemotherapy from 2012 to 2021 were retrospectively reviewed. Skeletal muscle volume was substituted for the psoas muscle area (PMA) at the level of the third lumbar vertebra. We investigated the relationship of clinicopathological factors during preoperative chemotherapy with disease-free survival (DFS) and overall survival (OS). The association between clinicopathological factors and a decrease in PMA was investigated.
Changes in Skeletal Muscle Volume During Preoperative Chemotherapy Affect the Outcome of Pancreatic Cancer
Michinori Matsumoto et al.
The American Surgeon™ 2024, (in press) - Results: In the multivariate analyses for DFS and OS, the factors associated with recurrence were as follows: decrease in PMA (P = 0.003) and the absence of adjuvant therapy (P = 0.03), and the factors associated with poor prognosis were as follows: decrease in PMA (P = 0.04) and the absence of adjuvant therapy (P = 0.008), and the resectability of borderline resectable and unresectable-locally advanced tumors (P = 0.033). All patients with partial response according to the Response Evaluation Criteria in Solid Tumors (version 1.1) had no decrease in PMA (P = 0.01). The proportion of patients with Evans classification ≥ II was significantly higher in the group without a decrease in PMA (P = 0.02). The proportion of patients with an average relative dose intensity of adjuvant therapy ≥0.6 was significantly higher in the group without a decrease in PMA (P = 0.02).
Conclusion: Changes in preoperative skeletal muscle volume during preoperative chemotherapy for pancreatic cancer is a potential predictor of recurrence and prognosis after pancreatectomy.
Changes in Skeletal Muscle Volume During Preoperative Chemotherapy Affect the Outcome of Pancreatic Cancer
Michinori Matsumoto et al.
The American Surgeon™ 2024, (in press) - Key Takeaway
· We evaluated the effects of the changes in inflammatory and nutritional markers, including psoas muscle volume, during preoperative chemotherapy for pancreatic cancer on recurrence and prognosis.
· Changes in preoperative skeletal muscle volume during preoperative chemotherapy for pancreatic cancer are a potential predictor of recurrence and prognosis after pancreatectomy.
· No decrease in psoas muscle volume was significantly associated with partial response according to the RECIST (version 1.1) and average relative dose intensity ≥0.6 for adjuvant therapy. - “According to data from the National Cancer Institute’s SEER program, at diagnosis, 12% of patients with PDA have stage I disease (confinement of the disease within the pancreas); 52% have stage IV (metastatic) disease. Patients with stage I (including stages IA [T1N0M0, tumor size ≤ 2 cm] and IB [T2N0M0, tumor size > 2 cm and ≤ 4 cm]) disease have a 5-year survival rate of around 44%, in contrast to the 3% 5-year survival rate for patients with stage IV metastatic disease. For patients with stage IA pancreatic cancer, 5-year survival rates exceed 80%.”
Imaging for Early Detection of Pancreatic Ductal Adenocarcinoma: Updates and Challenges in the Implementation of Screening and Surveillance Programs
Chenchan Huang et al.
AJR 2024; 223:e2431151 - “In the general U.S. population, lifetime risk of PDA is about 1.7% , and the incidence of PDA in Americans over 50 years old is 0.037% per year. CA 19–9 and CEA are the two most commonly used tumor markers in PDA management, but they lack the sensitivity and specificity needed for early detection. Though there are candidates showing promise , no blood-based biomarkers for early detection of PDA are recommended for use in clinical practice . Therefore, the U.S. Preventive Services Task Force opposes general population screening for PDA . Other challenges in the pursuit of early detection include the complexity of identifying high-risk groups suitable for screening and the limitations of standard-of-care imaging to detect very early PDA.”
Imaging for Early Detection of Pancreatic Ductal Adenocarcinoma: Updates and Challenges in the Implementation of Screening and Surveillance Programs
Chenchan Huang et al.
AJR 2024; 223:e2431151 - “Three groups are recognized as having elevated risk of PDA: high-risk individuals (HRIs) defined by specific criteria, patients with mucinous cystic neoplasms (MCNs), and patients over 50 years old with new-onset diabetes (NOD). Screening protocols are available for the first two groups (although without set guidelines); ongoing randomized controlled trials are being conducted to ascertain approaches for the third group. Imaging findings for patients undergoing surveillance are the same in all three groups; they include a solid mass, secondary signs of obstruction such as pancreatic duct dilatation or parenchymal atrophy in the absence of a history of pancreatitis, or a precursor cystic lesion with one or more worrisome features or high-risk stigmata.”
Imaging for Early Detection of Pancreatic Ductal Adenocarcinoma: Updates and Challenges in the Implementation of Screening and Surveillance Programs
Chenchan Huang et al.
AJR 2024; 223:e2431151 - “Lifetime risk of PDA exceeding 5% has been used to identify individuals at high risk . Multiple guidelines recommend that this population, which makes up 10–15% of persons diagnosed with PDA, undergo screening. HRIs include patientsnwho test positive for a pathogenic germline variant (PGV) and cases of familial PDA . PGVs include genes such as BRCA1; BRCA2; ATM; PALB2; mismatch repair genes MLH1, MSH2, MSH6, and PMS2 (Lynch syndrome); CDKN2A (familial atypical multiple mole melanoma syndromes); STK11 (Peutz-Jeghers syndrome); and PRSS1 (hereditary pancreatitis), with the last four having the highest relative risks for PDA.”
Imaging for Early Detection of Pancreatic Ductal Adenocarcinoma: Updates and Challenges in the Implementation of Screening and Surveillance Programs
Chenchan Huang et al.
AJR 2024; 223:e2431151 - “Familial PDA is the presence of two or more relatives with PDA, including at least one first- or second-degree relative, in the absence of a known PGV; risk escalates as the number of affected first-degree relatives increases (Table 1). Known PGVs explain only 10–20% of cases of familial PDA. Other likely causative factors include shared epigenetic mechanisms, genetic elements, or environmental influences contributing to the inheritance pattern . About 50% of patients with PDA and PGVs do not have a history of familial PDA, suggesting incomplete penetrance of some of the relevant PGVs.”
Imaging for Early Detection of Pancreatic Ductal Adenocarcinoma: Updates and Challenges in the Implementation of Screening and Surveillance Programs
Chenchan Huang et al.
AJR 2024; 223:e2431151 
Imaging for Early Detection of Pancreatic Ductal Adenocarcinoma: Updates and Challenges in the Implementation of Screening and Surveillance Programs
Chenchan Huang et al.
AJR 2024; 223:e2431151
Imaging for Early Detection of Pancreatic Ductal Adenocarcinoma: Updates and Challenges in the Implementation of Screening and Surveillance Programs
Chenchan Huang et al.
AJR 2024; 223:e2431151
Imaging for Early Detection of Pancreatic Ductal Adenocarcinoma: Updates and Challenges in the Implementation of Screening and Surveillance Programs
Chenchan Huang et al.
AJR 2024; 223:e2431151- “Identifying PDA early can be complicated by inherent tumor characteristics or concurrent pathologies that might distract the radiologist’s attention from subtle pancreatic lesions. The biologic understanding of the chronologic order of early PDA imaging findings is still evolving. Retrospective studies of serial prediagnostic CT examinations have shed light on some of the key imaging findings suggestive of early pancreatic cancer. Application of artificial intelligence (AI) to standard-of-care imaging may address current limitations and diagnostic errors that delay identification of PDA. Emerging research highlights AI’s considerable capability in detection of visually occult PDA at least 1 year before clinical diagnosis in addition to fully automated detection [79] and segmentation of small PDAs on standard portal venous phase imaging. Although these studies offer valuable insights and generate considerable hope, the clinical adoption of AI-facilitated early detection of PDA hinges on prospective validation within high-risk groups, especially alongside emerging fluid-based biomarkers of early detection.”
Imaging for Early Detection of Pancreatic Ductal Adenocarcinoma: Updates and Challenges in the Implementation of Screening and Surveillance Programs
Chenchan Huang et al.
AJR 2024; 223:e2431151 - “PDAs up to 20 mm can be isoenhancing and may not produce secondary signs such as pancreatic duct dilatation or cutoff that would be seen with larger tumors, so they go undetected. An isoenhancing mass is a lesion with an attenuation difference of less than 15 HU compared with normal pancreas in all phases. MRI and PET/CT may be useful for detecting these lesions, with MRI reported to have higher diagnostic accuracy than CT for tumors smaller than 2 cm (82% vs 69%). Tumor location such as the uncinate process and pancreatic tail is rarely associated with secondary signs. Systematic examination of parenchymal morphology, such as ensuring the absence of a rounded nodular border in the normal uncinate process and scrutinizing adjacent vessels for abnormal soft-tissue involvement, is recommended.”
Imaging for Early Detection of Pancreatic Ductal Adenocarcinoma: Updates and Challenges in the Implementation of Screening and Surveillance Programs
Chenchan Huang et al.
AJR 2024; 223:e2431151 - Indirect Features of PDA
“Among individuals with PDA, subtle indirect findings hinting at early PDA can manifest on CT during the preclinical phase (i.e., 3–36 months before clinical diagnosis). Focal parenchymal atrophy, also described as the K sign and defined as parenchymal narrowing compared with upstream and downstream parenchyma, has been identified as one of the earliest findings. It has been observed a mean of 1.8–4.6 years before PDA diagnosis [75, 76]. Focal parenchymal atrophy is distinct from the late sign of pancreatic tail atrophy and has been observed on 37.9– 58.5% of prediagnostic CT scans, but it is rarely seen in control patients (0.16%) . The etiology of focal parenchymal atrophy is not well understood, but one hypothesis is that it occurs when precursor pancreatic intraepithelial neoplasia lesions obstruct peripheral branch ducts, destroying acinar cells, which are replaced by fat or fibrosis. This sign often disappears as the pancreatic mass enlarges. The fibrosis may manifest as focal faint parenchymal enhancement, which one study found on 26.2% of prediagnostic CT scans obtained 3.3 years before diagnosis.”
Imaging for Early Detection of Pancreatic Ductal Adenocarcinoma: Updates and Challenges in the Implementation of Screening and Surveillance Programs
Chenchan Huang et al.
AJR 2024; 223:e2431151 - ”Localized steatosis can occur 1.6 years before diagnosis of PDA and has been seen on 19.5% of prediagnostic CT scans . Because diffuse pancreatic steatosis is more common on prediagnostic CT of patients with PDA than on that of control patients after accounting for BMI and DM (adjusted OR, 2.7; 95% CI, 1.06–6.85), it has been proposed as an independent risk factor for future PDA. However, more studies are necessary to validate this finding.”
Imaging for Early Detection of Pancreatic Ductal Adenocarcinoma: Updates and Challenges in the Implementation of Screening and Surveillance Programs
Chenchan Huang et al.
AJR 2024; 223:e2431151 - “Main-duct abnormality, such as cutoff or dilatation without a discrete mass, may be present up to 1.1 years before diagnosis of PDA . However, these observations frequently escape notice in clinical settings, resulting in diagnostic delays. Considerable variation exists among different observers when assessing these findings. Furthermore, these findings lack specificity for early PDA, as they are also seen in control individuals . Most importantly, the pancreas retains a morphologically normal appearance on prediagnostic CT scans for many patients. This poses a significant challenge, given that cancer progression from subclinical status inimaging to stage IV can be swift.
Imaging for Early Detection of Pancreatic Ductal Adenocarcinoma: Updates and Challenges in the Implementation of Screening and Surveillance Programs
Chenchan Huang et al.
AJR 2024; 223:e2431151 - “For patients diagnosed with PDA, survival is impeded by late stage diagnosis. However, the lack of reliable biomarkers and the rarity of the disease make screening the general population impractical. HRIs and persons with precursor cystic lesions are reasonable focus points for surveillance guidelines, yet collectively they represent the minority of cases. The ongoing EDI explores the ENDPAC model’s effectiveness in detecting early PDA in patients over 50 years old with NOD. The ENDPAC model shows promise, but its performance awaits assessment. Although highrisk surveillance programs offer improved outcomes, they raise concerns of unnecessary surgeries. PCL surveillance shares these drawbacks; hence, there is a pressing need for better risk stratification and an accurate noninvasive biomarkers.”
Imaging for Early Detection of Pancreatic Ductal Adenocarcinoma: Updates and Challenges in the Implementation of Screening and Surveillance Programs
Chenchan Huang et al.
AJR 2024; 223:e2431151
- Pancreatic cancer (PaC) incidence is increasing, but our current screening and diagnostic strategies are not very effective. However, screening could be helpful in the case of PaC, as recent evidence shows that the disease progresses gradually. Unfortunately, there is no ideal screening method or program for detecting PaC in its early stages. Conventional imaging techniques, such as abdominal ultrasound, CT, MRI, and EUS, have not been successful in detecting early-stage PaC. On the other hand, biomarkers may be a more effective screening tool for PaC and have greater potential for further evaluation compared to imaging. Recent studies on biomarkers and artificial intelligence (AI)-enhanced imaging have shown promising results in the early diagnosis of PaC. In addition to proteins, non-coding RNAs are also being studied as potential biomarker for PaC. This review consolidates the current literature on PaC screening modalities to provide an organized framework for future studies. While conventional imaging techniques have not been effective in detecting early-stage PaC, biomarkers an AI-enhanced imaging are promising avenues of research. Further studies on the use of biomarkers, particularly non-coding RNAs, in combination with imaging modalities may improve the accuracy of PaC screening and lead to earlier detection of this deadly disease.
Imaging Techniques and Biochemical Biomarkers: New Insights into Diagnosis of Pancreatic Cancer
Seyed Hamed Jafari et al.
Cell Biochemistry and Biophysics (2024) https://doi.org/10.1007/s12013-024-01437-z - “According to the NCCN guidelines, when there are clinical indications or signs of dilated pancreatic and/or bile duct, pancreatic protocol computed tomography (CT) should be the primary diagnostic tool used for diagnosis. Enhanced CT scans may offer the most effective method for evaluating whether a tumor can be surgically removed, as they have a high level of sensitivity and specificity, and tend to produce less variability between different observers than ultrasound. With recent improvements in CT technology, the sensitivity of these scans can be as high as 90%, and specificity can reach 99%.”
Imaging Techniques and Biochemical Biomarkers: New Insights into Diagnosis of Pancreatic Cancer
Seyed Hamed Jafari et al.
Cell Biochemistry and Biophysics (2024) https://doi.org/10.1007/s12013-024-01437-z - “Tumor tissues have a higher metabolic rate and glucose uptake, which is exploited by PET scan using fluorine 18- fluorodeoxyglucose, a radioactive glucose analogue, to detect these masses. However, PET scans have lower diagnostic sensitivity for pancreatic cancer than MDCT. PET scans are more useful for monitoring therapeutic response following chemoradiotherapy and detecting post-resection tumor recurrence due to its wide anatomic coverage, which enables the detection of all possible sites of metastatic in the entire body. Nevertheless, the high number of falsely positive cases and poor quality of visualization due to high metabolic rates in other tissues, such as sites of inflammation, are limitations of this imaging technique.”
Imaging Techniques and Biochemical Biomarkers: New Insights into Diagnosis of Pancreatic Cancer
Seyed Hamed Jafari et al.
Cell Biochemistry and Biophysics (2024) https://doi.org/10.1007/s12013-024-01437-z - “However, one of the disadvantages of this biomarker is that it is not specific to pancreatic cancer and can be increased in other types of cancer as well as noncancerous conditions. It also has relatively low sensitivity and specificity and may not increase in the early stages of pancreatic cancer. According to reports in the literature, the combination of serum CA19-9 and CEA increased specificity by 84%. The meta-analysis showed that a CEA-based panel was better at diagnosing pancreatic cancer than CA19-9 or CA 125 alone in terms of test specificity. In a retrospective study of pancreatic cancer patients, Liu et al. reported that serum CA125 level had the strongest correlation with pancreatic cancer metastasis and was higher in patients with metastatic disease than in patients without cancer. In nearly half of the patients with pancreatic cancer, the serum CA 125 level shows an increase. In PaC patients, high baseline CA125 levels (18.4 U/mL or higher) predicted early distant metastasis after pancreatectomy and poor surgical outcomes.”
Imaging Techniques and Biochemical Biomarkers: New Insights into Diagnosis of Pancreatic Cancer
Seyed Hamed Jafari et al.
Cell Biochemistry and Biophysics (2024) https://doi.org/10.1007/s12013-024-01437-z - “Despite its low prevalence, the incidence of pancreatic cancer is increasing. PaC has a high mortality rate, underscoring the importance of developing a screening strategy for early diagnosis. However, existing modalities such as imaging and biomarker studies have not been very successful for screening PaC. The challenge with biomarkers is that no single biomarker is perfect, and a combination of different biomarkers may be necessary for effective screening and detection of PaC. Furthermore, by using machine learning algorithms to analyze large datasets, AI can identify patterns and relationships between different biomarkers and imaging features that may be difficult for human experts to detect. This can help to develop an organized algorithm for early diagnosis of PaC that can be used in clinical practice. Overall, combining multiple biomarkers and novel biomarkers, such as, with imaging, and leveraging AI for interpretation of combine noncoding RNAs data may further improve screening efficacy and provide an organized algorithm for early diagnosis of PaC.”
Imaging Techniques and Biochemical Biomarkers: New Insights into Diagnosis of Pancreatic Cancer
Seyed Hamed Jafari et al.
Cell Biochemistry and Biophysics (2024) https://doi.org/10.1007/s12013-024-01437-z 
Imaging Techniques and Biochemical Biomarkers: New Insights into Diagnosis of Pancreatic Cancer
Seyed Hamed Jafari et al.
Cell Biochemistry and Biophysics (2024) https://doi.org/10.1007/s12013-024-01437-z- “Pancreatic ductal adenocarcinoma (PDA) is one of the most aggressive cancers. It has a poor 5-year survival rate of 12%, partly because most cases are diagnosed at advanced stages, precluding curative surgical resection. Early-stage PDA has significantly better prognoses due to increased potential for curative interventions, making early detection of PDA critically important to improved patient outcomes. We examine current and evolving early detection concepts, screening strategies, diagnostic yields among high-risk individuals, controversies, and limitations of standard of- care imaging.”
Imaging for Early Detection of Pancreatic Ductal Adenocarcinoma: Updates and Challenges in the Implementation of Screening and Surveillance Programs
Chenchan Huang, MD1, Elizabeth M. Hecht, MD2, Erik V. Soloff et al.
AJR 2024; 223:e2431151 - “Three groups are recognized as having elevated risk of PDA: high-risk individuals (HRIs) defined by specific criteria, patients with mucinous cystic neoplasms (MCNs), and patients over 50 years old with new-onset diabetes (NOD). Screening protocols are available for the first two groups (although without set guidelines); ongoing randomized controlled trials are being conducted to ascertain approaches for the third group. Imaging findings for patients undergoing surveillance are the same in all three groups; they include a solid mass, secondary signs of obstruction such as pancreatic duct dilatation or parenchymal atrophy in the absence of a history of pancreatitis, or a precursor cystic lesion with one or more worrisome features or high-risk stigmata.”
Imaging for Early Detection of Pancreatic Ductal Adenocarcinoma: Updates and Challenges in the Implementation of Screening and Surveillance Programs
Chenchan Huang, MD1, Elizabeth M. Hecht, MD2, Erik V. Soloff et al.
AJR 2024; 223:e2431151 - “Approximately 10–15% of PDA is thought to arise from precursor mucinous cystic lesions, namely intraductal papillary mucinous neoplasms (IPMNs) and MCNs. IPMNs are further classified into branch-duct, main-duct, and mixed-type IPMNs depending on extent of involvement on imaging, which is helpful for management guidance. Due to higher mean rates of malignancy— 43.1% (range, 11–81%) for resected main-duct IPMNs , 6–37% for mixed-type IPMNs depending on extent of main duct involvement, and 11–16% for MCNs—these lesions typically undergo resection. Branch-duct IPMNs (BDIPMNs) typically undergo surveillance because they are prevalent in the general population yet carry a much lower rate of malignancy Long-term surveillance studies have reported malignancy rates from 1.8% to 4.3% at 5 years and up to 15% at 15 years.”
Imaging for Early Detection of Pancreatic Ductal Adenocarcinoma: Updates and Challenges in the Implementation of Screening and Surveillance Programs
Chenchan Huang, MD1, Elizabeth M. Hecht, MD2, Erik V. Soloff et al.
AJR 2024; 223:e2431151 - “For patients diagnosed with PDA, survival is impeded by late stage diagnosis. However, the lack of reliable biomarkers and the rarity of the disease make screening the general population impractical. HRIs and persons with precursor cystic lesions are reasonable focus points for surveillance guidelines, yet collectively they represent the minority of cases. The ongoing EDI explores the ENDPAC model’s effectiveness in detecting early PDA in patients over 50 years old with NOD. The ENDPAC model shows promise, but its performance awaits assessment. Although high-risk surveillance programs offer improved outcomes, they raise concerns of unnecessary surgeries. PCL surveillance shares these drawbacks; hence, there is a pressing need for better risk stratification and an accurate noninvasive biomarker.”
Imaging for Early Detection of Pancreatic Ductal Adenocarcinoma: Updates and Challenges in the Implementation of Screening and Surveillance Programs
Chenchan Huang, MD1, Elizabeth M. Hecht, MD2, Erik V. Soloff et al.
AJR 2024; 223:e2431151
- “Lymph node metastasis is one of the strongest prognostic factors for poor prognosis. However, CT findings in the absence of lymph node metastasis were not found to be a predictor of the 5-y RFS due to its low negative predictive value. In contrast, its positive predictive value was high (93.2%). Therefore, the presence of lymph node metastasis on CT findings is accurate and generally used to predict poor prognosis in patients. Recently, Bian et al reported that an automated preoperative artificial intelligence (AI) algorithm for lymph nodes showed favorable accuracy in predicting lymph node metastasis on CT in patients with PC. In the future, AI may be able to predict patient prognosis even more accurately using preoperative images.”
Predictive factors of actual 5-y recurrence-free survival after upfront surgery for resectable pancreatic cancer
Masao Uemura1 | Teiichi Sugiura1 | Ryo Ashida1 et al
Ann Gastroenterol Surg. 2024;00:1–11. - “CA 19-9 is also well known to be associated with early recurrence and poor prognosis; however, we failed to detect it as a predictor of 5-y RFS. In fact, in the current series, the higher the CA 19-9 value, the higher was the rate of early recurrence (data not shown). However, among 166 patients with a preoperative CA 19-9 value <120 U/mL, 130 (78%) experienced recurrence within 5 y after surgery. Given these results, tumor biomarkers, primarily CA 19-9, appear to be useful in predicting early recurrence and survival, but have limited power in predicting long-term RFS.”
Predictive factors of actual 5-y recurrence-free survival after upfront surgery for resectable pancreatic cancer
Masao Uemura | Teiichi Sugiura | Ryo Ashida1 et al
Ann Gastroenterol Surg. 2024;00:1–11. - “The present study showed that 16.7% of patients who underwent upfront surgery for R-PC achieved an actual 5-y RFS. To identify long-term recurrence-free survivors, prognostic factors were investigated using actual survival, excluding censoring before the end of observation. In model 1, a tumor size ≤23 mm, absence of radiological serosal invasion, and NLR <1.0 were identified as independent predictors for the 5-y RFS. In model 2, the absence of serosal invasion, absence of PL invasion, and PNI ≥58 were identified. These preoperative predictors focusing on peripancreatic tissue invasion and a nutritional index could identify the groups with an extremely favorable RFS among patients treated with upfront surgery and could be feasible in many centers without specific tests, tools, or additional costs. Patients who fulfill these predictors are likely to achieve 5-y RFS, even if upfront surgery is performed without NATand to be a population that does not require NAT.”
Predictive factors of actual 5-y recurrence-free survival after upfront surgery for resectable pancreatic cancer
Masao Uemura | Teiichi Sugiura | Ryo Ashida1 et al
Ann Gastroenterol Surg. 2024;00:1–11.
- Pancreatic ductal adenocarcinoma (PDAC) has poor prognosis mostly due to the advanced stage at which disease is diagnosed. Early detection of disease at a resectable stage is, therefore, critical for improving outcomes of patients. Prior studies have demonstrated that pancreatic abnormalities may be detected on CT in up to 38% of CT studies 5 years before clinical diagnosis of PDAC. In this review, we highlight commonly missed signs of early PDAC on CT. Broadly, these commonly missed signs consist of small isoattenuating PDAC without contour deformity, isolated pancreatic duct dilatation and cutoff, focal pancreatic enhancement and focal parenchymal atrophy, pancreatitis with underlying PDAC, and vascular encasement.
Hidden in plain sight: commonly missed early signs of pancreatic cancer on CT
Taha M. Ahmed · Linda C. Chu · Ammar A. Javed · Mohammad Yasrab · Alejandra Blanco · Ralph H. Hruban · Elliot K. Fishman · Satomi Kawamoto
Abdominal Radiology 2024 (in press) https://doi.org/10.1007/s00261-024-04334-4 
Hidden in plain sight: commonly missed early signs of pancreatic cancer on CT
Taha M. Ahmed · Linda C. Chu · Ammar A. Javed · Mohammad Yasrab · Alejandra Blanco · Ralph H. Hruban · Elliot K. Fishman · Satomi Kawamoto
Abdominal Radiology 2024 (in press) https://doi.org/10.1007/s00261-024-04334-4- Surgical resection, which represents the sole avenue for curative treatment, can therefore only be offered to a fraction (10–20%) of newly diagnosed patients. Early detection of disease at a resectable stage is, therefore, critical to improving outcomes for patients. Given the nonspecific clinical presentation and lack of robust tumor markers, early diagnosis remains challenging, and radiologists are often the first physicians to diagnose or raise the possibility of PDAC.”
Hidden in plain sight: commonly missed early signs of pancreatic cancer on CT
Taha M. Ahmed · Linda C. Chu · Ammar A. Javed · Mohammad Yasrab · Alejandra Blanco · Ralph H. Hruban · Elliot K. Fishman · Satomi Kawamoto
Abdominal Radiology 2024 (in press) https://doi.org/10.1007/s00261-024-04334-4 - “Though early imaging features of PDAC can be subtle and challenging to interpret, prior studies have demonstrated that pancreatic abnormalities may be detected on CT in up to 38% of CT studies 5 years before diagnosis and up to 85% of CT studies at 3 months before clinical diagnosis of PDAC. In addition, recent studies with CT, MRI and endoscopic ultrasound (EUS) suggest that multifocal high-grade intraepithelial neoplasia (PanIN) without invasion, traditionally referred to as carcinoma in situ (CIS), may be seen as patchy parenchymal atrophy. Familiarity with these radiological features of early PDAC may represent an avenue for earlier diagnosis of PDAC and, therefore, holds particular clinical significance.”
Hidden in plain sight: commonly missed early signs of pancreatic cancer on CT
Taha M. Ahmed · Linda C. Chu · Ammar A. Javed · Mohammad Yasrab · Alejandra Blanco · Ralph H. Hruban · Elliot K. Fishman · Satomi Kawamoto
Abdominal Radiology 2024 (in press) https://doi.org/10.1007/s00261-024-04334-4 - “Conventional PDAC on computed tomography typically appears as an indistinct infiltrative focal mass with extensive surrounding desmoplastic reaction. Due to the decreased vascularity and intermixed desmoplastic stroma of PDAC, these masses appear hypoattenuating on PPCT in 75–90% of cases but may appear as isoattenuating or hyperattenuating on delayed phase images. Obstruction and dilation of the main pancreatic duct and the distal common bile duct (double duct sign) are also classically present in 80% of tumors of the head and dilation of the main pancreatic duct is seen in 50% of tumors of the body of the pancreas. Other secondary signs may include abrupt pancreatic duct cut-off and upstream parenchymal atrophy with decreased distal parenchymal enhancement in pancreatic parenchymal phase in 47% of patients.”
Hidden in plain sight: commonly missed early signs of pancreatic cancer on CT
Taha M. Ahmed · Linda C. Chu · Ammar A. Javed · Mohammad Yasrab · Alejandra Blanco · Ralph H. Hruban · Elliot K. Fishman · Satomi Kawamoto
Abdominal Radiology 2024 (in press) https://doi.org/10.1007/s00261-024-04334-4 
Hidden in plain sight: commonly missed early signs of pancreatic cancer on CT
Taha M. Ahmed · Linda C. Chu · Ammar A. Javed · Mohammad Yasrab · Alejandra Blanco · Ralph H. Hruban · Elliot K. Fishman · Satomi Kawamoto
Abdominal Radiology 2024 (in press) https://doi.org/10.1007/s00261-024-04334-4
Hidden in plain sight: commonly missed early signs of pancreatic cancer on CT
Taha M. Ahmed · Linda C. Chu · Ammar A. Javed · Mohammad Yasrab · Alejandra Blanco · Ralph H. Hruban · Elliot K. Fishman · Satomi Kawamoto
Abdominal Radiology 2024 (in press) https://doi.org/10.1007/s00261-024-04334-4- “PDAC commonly results in obstruction of the pancreatic duct. Dilatation of the main pancreatic duct (>3 mm) and abrupt duct cut-off are, therefore, the most classically associated secondary signs of PDAC, and are present in 61 and 55% of cases, respectively. Though closely associated, the presence of ductal dilatation and duct cut-off are not specific to PDAC and may also be caused by a range of pathologies, including chronic pancreatitis and intraductal calculi or may also be entirely idiopathic. Nonetheless, the presence of duct dilatation and/or abrupt cut-off warrants a high level of suspicion and careful further workup to exclude malignancy should be considered. Prior studies have demonstrated that up to 58% of patients identified as having pancreatic duct cut-off were subsequently diagnosed with malignancy, of whom 62% were diagnosed with PDAC. Focal main pancreatic duct changes may also be seen in 13.6% of patients with PDAC 13 months before diagnosis of PDAC is clinically established.”
Hidden in plain sight: commonly missed early signs of pancreatic cancer on CT
Taha M. Ahmed · Linda C. Chu · Ammar A. Javed · Mohammad Yasrab · Alejandra Blanco · Ralph H. Hruban · Elliot K. Fishman · Satomi Kawamoto
Abdominal Radiology 2024 (in press) https://doi.org/10.1007/s00261-024-04334-4 - “Focal parenchymal atrophy, defined as a slit-like narrowing of parenchyma compared with upstream and downstream parenchyma, was reported by Toshima et al. as the most commonly noted CT abnormality on prediagnostic scans. Focal atrophy was present in 37.9% of prediagnostic CT at a mean duration of 4.6 years before diagnosis and may therefore represent the earliest of all discernable indicators of PDAC on CT. The pathophysiology of the fatty replacement and fibrosis of parenchymal atrophy is hypothesized to be due to either paracrine mediation from the neoplastic cells, pancreatic drainage dysfunction due to focal obstruction by tumor or pancreatic juice stagnation and obstruction due to tumor-related changes to the viscosity of pancreatic secretions.”
Hidden in plain sight: commonly missed early signs of pancreatic cancer on CT
Taha M. Ahmed · Linda C. Chu · Ammar A. Javed · Mohammad Yasrab · Alejandra Blanco · Ralph H. Hruban · Elliot K. Fishman · Satomi Kawamoto
Abdominal Radiology 2024 (in press) https://doi.org/10.1007/s00261-024-04334-4 - “There exists a significant overlap in the imaging features, clinical presentation, and risk factors of pancreatitis and PDAC. This overlap is partially rooted in the synergistic pathophysiological interplay between inflammatory pancreatic processes and pancreatic neoplasia. When PDAC and pancreatitis present synchronously, clinical and histopathological diagnosis can be challenging, with a prior study demonstrating that the sensitivity of EUS-FNA for diagnosing PDAC was markedly lower when superimposed with chronic pancreatitis. Similarly, radiological diagnosis in this context can also be challenging, and early PDAC is often mistakenly reported as pancreatitis even when clinical history suggestive of malignancy, such as new-onset diabetes or weight loss are provided.”
Hidden in plain sight: commonly missed early signs of pancreatic cancer on CT
Taha M. Ahmed · Linda C. Chu · Ammar A. Javed · Mohammad Yasrab · Alejandra Blanco · Ralph H. Hruban · Elliot K. Fishman · Satomi Kawamoto
Abdominal Radiology 2024 (in press) https://doi.org/10.1007/s00261-024-04334-4 - “The association between chronic pancreatitis and PDAC is well established, with an estimated cumulative risk of pancreatic cancer of 4% after 15–20 years of chronic alcoholic pancreatitis. Chronic pancreatitis may also coexist with PDAC in 1.8–4% of patients . Though infrequently encountered, radiological diagnosis in such cases can be challenging due to the overlapping imaging features of the two entities. This is partially because both PDAC and chronic pancreatitis are associated with extensive stromal fibrosis, making morphological differentiation difficult. Further compounding this diagnostic dilemma is the fact that ductal dilatation may also be present in chronic pancreatitis, with the classic ‘double duct’ obstruction present in 36–50% of cases of chronic pancreatitis operated on for suspected PDAC.”
Hidden in plain sight: commonly missed early signs of pancreatic cancer on CT
Taha M. Ahmed · Linda C. Chu · Ammar A. Javed · Mohammad Yasrab · Alejandra Blanco · Ralph H. Hruban · Elliot K. Fishman · Satomi Kawamoto
Abdominal Radiology 2024 (in press) https://doi.org/10.1007/s00261-024-04334-4 - “A critically important yet frequently overlooked secondary finding of PDAC is vascular invasion. PDAC is an aggressive and highly invasive malignancy, and gross large vessel involvement is a common finding seen in between 21 and 64% of cases. Microscopically detectable vascular invasion is estimated to be even more prevalent. When present, detection of large vessel involvement is not only essential to clueing in the diagnosis of PDAC but may also critically inform discussions regarding surgical resectability of disease, given how major vessel involvement may constitute a contraindication to surgery. On imaging, circumferential perivascular soft tissue cuffing or stranding, with associated loss of a fat plane, is characteristic of vascular involvement. On CT, however, differentiation of true vascular invasion from perivascular stranding from inflammatory changes due to pancreatitis or vasculitis can be difficult.”
Hidden in plain sight: commonly missed early signs of pancreatic cancer on CT
Taha M. Ahmed · Linda C. Chu · Ammar A. Javed · Mohammad Yasrab · Alejandra Blanco · Ralph H. Hruban · Elliot K. Fishman · Satomi Kawamoto
Abdominal Radiology 2024 (in press) https://doi.org/10.1007/s00261-024-04334-4 - “PDAC arising from the pancreatic head, which accounts for 66% of cases, typically involves the celiac artery, common hepatic artery and superior mesenteric artery (SMA), and these structures may be the only initial sites of appreciable disease in cases of pancreatic head PDAC. Similarly, prior studies have demonstrated that SMA invasion is most commonly associated with PDAC arising in the uncinate, and subtle soft tissue cuffing of the SMA may be the only detectable sign of early uncinate PDAC. Tumors of the uncinate are also more likely to manifest with vascular involvement than are tumors arising elsewhere in the gland (96 vs 54%), and vascular involvement in the context of a subtle mass in the uncinatemay also be easily missed.”
Hidden in plain sight: commonly missed early signs of pancreatic cancer on CT
Taha M. Ahmed · Linda C. Chu · Ammar A. Javed · Mohammad Yasrab · Alejandra Blanco · Ralph H. Hruban · Elliot K. Fishman · Satomi Kawamoto
Abdominal Radiology 2024 (in press) https://doi.org/10.1007/s00261-024-04334-4 
Hidden in plain sight: commonly missed early signs of pancreatic cancer on CT
Taha M. Ahmed · Linda C. Chu · Ammar A. Javed · Mohammad Yasrab · Alejandra Blanco · Ralph H. Hruban · Elliot K. Fishman · Satomi Kawamoto
Abdominal Radiology 2024 (in press) https://doi.org/10.1007/s00261-024-04334-4- “Pancreatic ductal adenocarcinoma (PDAC) is the third leading cause of cancer-related mortality and it is often diagnosed at advanced stages due to non-specific clinical presentation. Disease detection at localized disease stage followed by surgical resection remains the only potentially curative treatment. In this era of precision medicine, a multifaceted approach to early detection of PDAC includes targeted screening in high-risk populations, serum biomarkers and “liquid biopsies”, and artificial intelligence augmented tumor detection from radiologic examinations. In this review, we will review these emerging techniques in the early detection of PDAC.”
Early detection of pancreatic cancer in the era of precision medicine
Taha M. Ahmed . Satomi Kawamoto . Felipe Lopez‑Ramirez . Mohammad Yasrab . Ralph H. Hruban . Elliot K. Fishman . Linda C. Chu
Abdominal Radiology 2024 (in press) https://doi.org/10.1007/s00261-024-04358-w 
Early detection of pancreatic cancer in the era of precision medicine
Taha M. Ahmed . Satomi Kawamoto . Felipe Lopez‑Ramirez . Mohammad Yasrab . Ralph H. Hruban . Elliot K. Fishman . Linda C. Chu
Abdominal Radiology 2024 (in press) https://doi.org/10.1007/s00261-024-04358-w- “IPMNs are mucin producing epithelial pancreatic neoplasms that originate from the larger pancreatic ducts. Main duct and mixed type IPMNs exhibit high rates of progression to invasive carcinoma ranging from 31 to 45%, necessitating surgical resection. Branch duct IPMNs have a lower rate of progression to invasive carcinoma, ranging from 3 to 15%, so these lesions are often followed clinically unless they have other high-risk features (enhancing solid components, main pancreatic duct dilatation).”11
Early detection of pancreatic cancer in the era of precision medicine
Taha M. Ahmed . Satomi Kawamoto . Felipe Lopez‑Ramirez . Mohammad Yasrab . Ralph H. Hruban . Elliot K. Fishman . Linda C. Chu
Abdominal Radiology 2024 (in press) https://doi.org/10.1007/s00261-024-04358-w - “PanIN is a microscopic precursor lesion and these lesions are divided into low-grade and high-grade lesions based on the degree of dysplasia present. Typically ranging from < 5 mm, radiological identification is particularly difficult. While imaging characteristics such as multifocal lobulocentric atrophy have been associated with the presence of multiple lesions, these associations are not well established, and preoperative diagnosis remains challenging.”
Early detection of pancreatic cancer in the era of precision medicine
Taha M. Ahmed . Satomi Kawamoto . Felipe Lopez‑Ramirez . Mohammad Yasrab . Ralph H. Hruban . Elliot K. Fishman . Linda C. Chu
Abdominal Radiology 2024 (in press) https://doi.org/10.1007/s00261-024-04358-w - “Identification of small stage 1 pancreatic cancer lesions is perhaps of greatest importance. Retrospective studies have demonstrated that early signs of PDAC may be detected at CT in up to 38% and 85% of CT studies at 5 years and 3 months before clinical diagnosis, respectively. While this apparent wide detection window is ideal for implementation of screening protocols, evidence on this is conflicting with other studies demonstrating that PDAC mayin fact rapidly progresses from T1-stage to T4-stage in just over a year. Furthermore, up to 10% of PDACs under 1 cm are distantly metastatic at time of detection and up to 30% may have developed nodal metastases. Therefore, while early detection can certainly improve outcomes, the margin for error remains unforgiving.”
Early detection of pancreatic cancer in the era of precision medicine
Taha M. Ahmed . Satomi Kawamoto . Felipe Lopez‑Ramirez . Mohammad Yasrab . Ralph H. Hruban . Elliot K. Fishman . Linda C. Chu
Abdominal Radiology 2024 (in press) https://doi.org/10.1007/s00261-024-04358-w - ‘Liquid biopsy’, which refers to the sampling of biomarkers from bodily fluids, has garnered increased attention in recent years. Compared to traditional biopsies, liquid biopsies are minimally invasive, allow for convenient serial sampling and may better capture tumor heterogeneity—rendering them ideal screening tools. Currently, targets of liquid biopsy primarily include circulating tumor DNA (ctDNA), circulating tumor cells (CTCs), and exosomes ( . While CTCs and exosomes have been an exciting area of new research, ctDNA remains the most widely studied targets for liquid biopsy and hold greatest clinical utility.
Early detection of pancreatic cancer in the era of precision medicine
Taha M. Ahmed . Satomi Kawamoto . Felipe Lopez‑Ramirez . Mohammad Yasrab . Ralph H. Hruban . Elliot K. Fishman . Linda C. Chu
Abdominal Radiology 2024 (in press) https://doi.org/10.1007/s00261-024-04358-w
- “Pancreatic adenocarcinoma is an aggressive disease marked by high rates of both local and distant failure. In the minority of patients with potentially resectable disease, multimodal treatment paradigms have allowed for prolonged survival in an increasingly larger pool of well selected patients. Therefore, it is critical for surgical oncologists to be abreast of current guideline recommendations for both surgical management and multimodal therapy for pancreas cancer. We discuss these guidelines, as well as the underlying data supporting these positions, to offer surgical oncologists a framework for managing patients with pancreatic adenocarcinoma.”
ASO Practice Guidelines Series: Management of Resectable, Borderline Resectable, and Locally Advanced Pancreas Cancer
Kevin M. Turner, Gregory C. Wilson,Sameer H. Patel and Syed A. Ahmad
Ann Surg Oncol. 2023 Nov 19. doi: 10.1245/s10434-023-14585-y. Epub ahead of print. PMID: 37980709. - “Only 15–20% of patients present with potentially resectable disease. Even then 5-year survival rates remain at 10% with surgery alone, primarily due to distant failure. Decades of clinical evidence of distant failure in seemingly resectable disease as well as preclinical studies showing proof of concept have led many to consider PDAC a systemic disease at diagnosis. However, among appropriately selected patients, long-term survival with multimodality therapy is attainable.1”1
ASO Practice Guidelines Series: Management of Resectable, Borderline Resectable, and Locally Advanced Pancreas Cancer
Kevin M. Turner, Gregory C. Wilson,Sameer H. Patel and Syed A. Ahmad
Ann Surg Oncol. 2023 Nov 19. doi: 10.1245/s10434-023-14585-y. Epub ahead of print. PMID: 37980709. - Resectable Pancreatic Cancer—The NCCN guidelines suggest surgery-first or neoadjuvant both as appropriate treatment paradigms. Among these patients, neoadjuvant therapy allows for increased delivery of multimodalitytherapy while also acting as a biologic test of time. In the PREOPANC-1 clinical trial, completion of 1 cycle of chemotherapy and average cumulative dose of chemotherapy were both significantly higher in the perioperative therapy arm compared with the surgery-first arm.Similar results were seen in SWOG 1505, where 84% of resectable patients completed neoadjuvant therapy, compared to only 63% of patients who underwent resection that were able to complete adjuvant therapy (45% of all enrolled patients).High rates of early recurrence and translational evidence supporting signs of micrometastatic disease in the vast majority (> 95%) of patients with resectable disease highlight the benefit of biologic selection with preoperative therapy.
ASO Practice Guidelines Series: Management of Resectable, Borderline Resectable, and Locally Advanced Pancreas Cancer
Kevin M. Turner, Gregory C. Wilson,Sameer H. Patel and Syed A. Ahmad
Ann Surg Oncol. 2023 Nov 19. doi: 10.1245/s10434-023-14585-y. Epub ahead of print. PMID: 37980709. - Borderline Resectable Pancreatic Cancer—The NCCN guidelines suggest neoadjuvant therapy for all patients, with systemic therapy as first line radiation therapy. Among these patients, neoadjuvant therapy potentially allows for sterilization of the surgical margin, in addition to the stated goals above. Margin positive rates with upfront surgery in BRPC are reported to be 70% in a phase II/III trial. Conversely, margin positive rates were reduced to 12–26% following neoadjuvant +/-chemotherapy +/- neoadjuvant radiation in the Alliance A021501 trial.
ASO Practice Guidelines Series: Management of Resectable, Borderline Resectable, and Locally Advanced Pancreas Cancer
Kevin M. Turner, Gregory C. Wilson,Sameer H. Patel and Syed A. Ahmad
Ann Surg Oncol. 2023 Nov 19. doi: 10.1245/s10434-023-14585-y. Epub ahead of print. PMID: 37980709. - “Locally Advanced Pancreatic Cancer—The NCCN guidelines prefer treatment on a clinical trial, with systemic therapy or induction chemotherapy considered first-line for those patients able to tolerate and chemoradiation reserved for those unable to tolerate chemotherapy. Surgical resection is only considered in those patients who have no disease progression after upfront therapy; most of these patients are classified as LAPC Type A. The term “neoadjuvant” therapy is most commonly a misrepresentation. Only 5% of patients progress to surgical resection, and therefore, therapy in this setting should be considered definitive.As for radiographic down-staging to resectable disease, this is a rare phenomenon and does not accurately represent response to therapy.”
ASO Practice Guidelines Series: Management of Resectable, Borderline Resectable, and Locally Advanced Pancreas Cancer
Kevin M. Turner, Gregory C. Wilson,Sameer H. Patel and Syed A. Ahmad
Ann Surg Oncol. 2023 Nov 19. doi: 10.1245/s10434-023-14585-y. Epub ahead of print. PMID: 37980709. - Short interval surveillance every 3–6 months +/- ~ 2 years is recommended for all patients, consisting of: (1) history and physical exam; (2) CA 19-9; and (3) CT chest and CT/ MRI of abdomen/pelvis with contrast.After 2 years, surveillance is increased to every 6–12 months as long as clinically indicated. In the small minority of patients who suffer local only recurrence, surgical resection can be considered in highly select cases.It remains unclear whether the reported long-term survival is due to re-resection or selection. Unfortunately, the vast majority of patients recur with metastatic disease, where clinical trial enrollment, systemic therapy, and palliative care are the only remaining treatment options.13
ASO Practice Guidelines Series: Management of Resectable, Borderline Resectable, and Locally Advanced Pancreas Cancer
Kevin M. Turner, Gregory C. Wilson,Sameer H. Patel and Syed A. Ahmad
Ann Surg Oncol. 2023 Nov 19. doi: 10.1245/s10434-023-14585-y. Epub ahead of print. PMID: 37980709. - “Pancreatic adenocarcinoma remains a disease marked by distant failure and poor survival. Despite these dismal outcomes, advances in multimodality therapy have allowed for long-term survival in a subset of patients. Improvements in anatomical staging have allowed for better treatment selection and resulting improved outcomes. Standardization of treatment modalities, including surgical resection, promises to further improve outcomes. As our understanding of this deadly disease and its molecular underpinnings continues to evolve, refinement in treatment guidelines to marry the appropriate therapy to the individual patient promises to optimize results.”
ASO Practice Guidelines Series: Management of Resectable, Borderline Resectable, and Locally Advanced Pancreas Cancer
Kevin M. Turner, Gregory C. Wilson,Sameer H. Patel and Syed A. Ahmad
Ann Surg Oncol. 2023 Nov 19. doi: 10.1245/s10434-023-14585-y. Epub ahead of print. PMID: 37980709.
- “Our group has reported a significant difference in wound complications after minimally invasive PD in a propensity-matched retrospective analysis, but this outcome was not reported separately in the current randomized study. With longer operative times and minimal confirmed benefits, the reader may wonder if a minimally invasive pancreatectomy is “worth it” after all. Nonetheless, we commend the authors for this valuable contribution. The laparoscopic approach (or robotic, in some institutions) works well in experienced hands, both regarding oncologic results and perioperative safety. Documenting the benefits of the minimally invasive approach is an ongoing effort. However, patients and surgeons are eager to use these techniques when appropriate while we await confirmatory data.”
Seeking the Real Benefits of Laparoscopic Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma
Norman G. Nicolson, MD, MHS; Jin He,MD, PhD
JAMA Surgery Published online October 25, 2023 - “PDAC is more frequent in diabetic individuals. Type 2 diabetes mellitus has been increasing in recent years, and some authors believe that this is one of the causes of the increase in pancreatic cancer. The risk is increased by 1.5 to 2 fold However, the relationship between diabetes type 2 and PDAC is a complex and non-linear one. The fact that many patients with PC are also diabetic is not clear evidence of causality. Furthermore, there are conflicting statistics regarding diabetes prevalence in PDAC patients. Noy and Bilezikian reported a wide range of prevalence that goes from 4% to reach 20% . Importantly, these researchers identified a form of diabetes with specific hallmarks (they call it atypical diabetes) that preceded PDAC and could help to identify early-stage PDAC.”
Earlier Diagnosis of Pancreatic Cancer: Is It Possible?
Tomas Koltai
Cancers 2023, 15, 4430. https://doi.org/10.3390/cancers15184430 - Importantly, these researchers identified a form of diabetes with specific hallmarks (they call it atypical diabetes) that preceded PDAC and could help to identify early-stage PDAC. It is characterized by: (a) brief history of diabetes; (b) lack of family history; (c) lack of obesity; (d) rapid progression to insulin dependence. Diabetes treatment also plays a role in PC risk. Bodmer et al. found that diabetics treated with metformin had a low risk of PC (OR 0.87), but those receiving sulfonylureas (OR 1.9) or insulin (OR 2.29) had a markedly increased risk.
Earlier Diagnosis of Pancreatic Cancer: Is It Possible?
Tomas Koltai
Cancers 2023, 15, 4430. https://doi.org/10.3390/cancers15184430 
Earlier Diagnosis of Pancreatic Cancer: Is It Possible?
Tomas Koltai
Cancers 2023, 15, 4430. https://doi.org/10.3390/cancers15184430
Earlier Diagnosis of Pancreatic Cancer: Is It Possible?
Tomas Koltai
Cancers 2023, 15, 4430. https://doi.org/10.3390/cancers15184430
- “Pancreatic ductal adenocarcinoma (PDAC) is the most common primary pancreatic malignancy, ranking fourth in cancer-related mortality in the United States. Typically, PDAC appears on images as a hypovascular mass with upstream pancreatic duct dilatation and abrupt duct cutoff, distal pancreatic atrophy, and vascular encasement, with metastatic involvement including lymphadenopathy.However, atypical manifestations that may limit detection of the underlying PDAC may also occur. Atypical PDAC features include findings related to associated conditions such as acute or chronic pancreatitis, a mass that is isointense to the parenchyma, multiplicity, diffuse tumor infiltration, associated calcifications, and cystic components. Several neoplastic and inflammatory conditions can mimic PDAC, such as paraduodenal “groove” pancreatitis, autoimmune pancreatitis, focal acute and chronic pancreatitis,neuroendocrine tumors, solid pseudopapillary neoplasms, metastases, and lymphoma. Differentiation of these conditions from PDAC can be challenging due to overlapping CT and MRI features; however, certain findings can help in differentiation.”
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054 - “In the United States, PDAC accounts for 3.2% of all new cancer cases and 8% of all cancer deaths, ranking fourth in cancer-related mortality. Although surgery is the only curative treatment, at diagnosis an estimated 10%–20% of patients have resectable tumors, 30%–40% have borderline resectable or locally advanced or unresectable neoplasms, and 50%–60% have metastatic or systemic disease. PDAC is frequently detected late because of its nonspecific clinical presentation and lack of specific tumor markers and the limitations in imaging early-stage neoplasms, resulting in a poor prognosis.”
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054 - “AIP may be difficult to distinguish from PDAC at imaging because both can appear as a focal or infiltrative mass. Features favoring AIP include homogeneous enhancement during the portal venous phase, a hypointense capsulelike rim, extrapancreatic manifestations, the absence of pancreatic atrophy, and excellent response to steroid treatment.”
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054 - “Small neuroendocrine tumors can cause ductal dilatation and obstruction and upstream pancreatic atrophy secondary to secretion of serotonin and other metabolites, causing fibrotic narrowing of the main pancreatic duct. Marked pancreatic duct dilatation and stenosis and pancreatic atrophy out of proportion to an underlying hypervascular mass suggest a serotonin-producing PanNET.”
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054 - “The abrupt pancreatic duct cutoff sign is associated with a high incidence of PDAC. Gangi et al studied patients with pancreatic cancer who were asymptomatic before the diagnosis of cancer and found features suspicious for cancer in 50% of patients 2–18 months before diagnosis, including pancreatic duct dilatation with a cutoff. Johnston et al showed that 58% of patients identified with duct cut off received a diagnosis of malignancy, 62% of whom had PDAC.”
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054 - “Although most PDACs show classic imaging features, patients can present with atypical features that radiologists must recognize to avoid misdiagnosis. These atypical findings can relate to associated conditions such as acute or chronic pancreatitis and may limit detection of an underlying PDAC. Other atypical features include a mass that is isoattenuating to the parenchyma, multiplicity, diffuse tumor infiltration, associated calcifications, and cystic components.”
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054 - “The indirect signs of isoattenuating PDACs that provide clues to the diagnosis include upstream parenchymal atrophy, focal contour abnormality, mass effect, interrupted duct sign, and perivascular tumor infiltration. Secondary signs such as biliary and pancreatic duct dilatation are not seen in 14% of PDACs, especially those that are isoattenuating to the uncinate process and are present at an earlier stage compared with PDACs with secondary signs. Pancreatic tail tumors also are less likely to show pancreatic duct dilatation and instead show subtle changes in texture and loss of normal fatty lobulations that may indicate an underlying mass.”
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054 - "Diffuse infiltrating pancreatic lymphoma may mimic pancreatitis, while focal masslike lymphoma can mimic PDAC. Masslike lymphoma often occurs in the pancreatic head and, similar to PDAC, hypoenhances at CT and MRI compared with the background pancreas. Lymphomatous lesions tend to show mild to moderate homogeneous enhancement, are T1 hypointense and mildly T2 hyperintense, and restrict diffusion. Calcifications are uncommon in untreated lymphoma.”
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054 - “Metastases to the pancreas are rare, accounting for 2%–5% of pancreatic malignancies, and most commonly occur from renal cell carcinoma . Pancreatic metastatic disease may be a single tumor or multiple tumors, or it may involve the pancreas diffusely and have a variable appearance, depending on the primary site. Metastases from hypovascular or hypoenhancing primary malignancies (lung, breast, and colorectal cancer) can mimic PDAC, while hypervascular or arterially enhancing neoplasms (eg, renal cell carcinoma; melanoma; breast, thyroid, or hepatocellular carcinoma; and osteosarcoma) are typically hyperenhancing and multiple tumors, unlike PDACs.”
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054 - Solid pseudopapillary neoplasms, also referred to as solid and papillary epithelial neoplasms of the pancreas, are rare, accounting for 1%–2% of all pancreatic tumors . Unlike PDACs, solid pseudopapillary neoplasms tend to manifest in young women (mean age, 28.5 years at presentation) and show a low potential for malignant transformation. The behavior and prognosis of solid pseudopapillary neoplasms are generally favorable. Solid pseudopapillary neoplasms tend to be large at presentation (2.5–17.0 cm; mean size, 9 cm) and well defined , and they can be found throughout the pancreas. Large lesions can be distinguished from PDACs because they contain solid and cystic components due to hemorrhage, necrosis, and cystic degeneration.
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054 - “Compared with PDACs, solid pseudopapillary neoplasms often occur in younger patients. They are typically large at diagnosis, often associated with hemorrhage, and well defined and encapsulated, without metastases. Unlike PDACs, solid pseudopapillary neoplasms are less commonly associated with pancreatic and biliary duct dilatation, upstream parenchymal atrophy, or vascular invasion . Biopsy maybe required for definitive diagnosis.”
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054 - “At imaging, AIP may show three distinct patterns of pancreatic involvement: diffuse (70% of the pancreas), focal (up to 30% in type 1 and 80% in type 2), and multifocal (5%). Diffuse enlargement of the pancreas, with an enlarged tail, loss of normal lobulations, and a “sausage-shaped” appearance, and a capsule-like rim are the most classic imaging features of AIP, but they are only seen in 30%–40% of cases.”
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054 - “AIP may be difficult to distinguish from PDAC at imaging, because both can appear as focal or infiltrative mass. Features favoring AIP include homogeneous enhancement during the portal venous phase, a hypointense capsule-like rim, extrapancreatic manifestations , the absence of pancreatic atrophy, and excellent response to steroid treatment . Ductal findings favoring focal AIP include the “duct-penetrating” sign (best seen using secretin-enhanced MRCP); only mild dilatation of the main pancreatic duct, usually limited to an area of less than 4 mm; longer length of the narrowing of the main pancreatic duct (3 cm or more) in the involved segment of the pancreas, without an abrupt cutoff; the enhanced duct sign (wall enhancement of the main pancreatic duct in the lesion); multiple areas of narrowing or strictures of the main pancreatic duct; and the “icicle sign” (smoothly tapered narrowing of the upstream pancreatic duct) . When AIP is associated with biliary involvement, the imaging appearance can mimic primary sclerosing cholangitis. Multiple pancreatic lesions also favor a diagnosis of AIP over that of PDAC. Vascular encasement, fluid collections, or an increased number of lymph nodes are rare with AIP and favor a diagnosis of PDAC.”
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054 
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054- Mimics of Pancreatic Cancer
- Mass-forming Chronic Pancreatitis
- Focal Acute Pancreatitis
- Paraduodenal Pancreatitis and Paraduodenal Cancer
- Autoimmune Pancreatitis
- Solid Pseudopapillary Neoplasm
- Metastases Involving the Pancreas
- Lymphoma
- “The relationship of pancreatic ductal adenocarcinoma (PDAC) to important peripancreatic vasculature dictates resectability. As per the current guidelines, tumors with extensive, unreconstructible venous or arterial involvement are staged as unresectable locally advanced pancreatic cancer (LAPC). The introduction of effective multiagent chemotherapy and development of surgical techniques, have renewed interest in local control of PDAC. High-volume centers have demonstrated safe resection of short-segment encasement of the common hepatic artery. Knowledge of the unique anatomy of the patient’s vasculature is important in surgical planning of these complex resections. Hepatic artery anomalies are common and insufficient knowledge can result in iatrogenic vascular injury during surgery.”
Concepts and techniques for revascularization of replaced hepatic arteries in pancreatic head resections.
Floortje van Oosten A, Al Efishat M, Habib JR, Kinny-Köster B, Javed AA, He J, Fishman EK, Quintus Molenaar I, Wolfgang CL.
HPB (Oxford). 2023 Jun 3:S1365-182X(23)00547-6 - ”A dual-phase CT scan is the primary modality for the clinical staging of patients with PDAC. The CT-imaging is combined with a post-processing technique, called a 3D-rendering, which generates detailed vascular maps with improved depth perception. These vascular maps assist surgeons in determining tumor resectability, and the need for vascular resection and reconstruction. In addition, cinematic rendering is applied to the CT-imaging data creating photorealistic 3D-images that are physically accurate representations of the imaging data .This provides improved visualization of potential vascular abutment, encasement, or invasion. Moreover, it generates meticulous vascular maps that can highlight vascular variations, such as replaced or accessory hepatic arteries.”
Concepts and techniques for revascularization of replaced hepatic arteries in pancreatic head resections.
Floortje van Oosten A, Al Efishat M, Habib JR, Kinny-Köster B, Javed AA, He J, Fishman EK, Quintus Molenaar I, Wolfgang CL.
HPB (Oxford). 2023 Jun 3:S1365-182X(23)00547-6 - “LAPC is defined as unresectable at the time of diagnosis due to a significant involvement of adjacent vasculature. Despite advancements, the prognosis remains poor for patients with LAPC. R0 resection is the only potentially curative treatment option, and resection should only be attempted when complete resection is attainable. The goal of therapy in patients with good performance status should be evaluating the tumor biology for appropriate patient selection, downsizing the tumor, and minimizing the extent of vascular involvement to facilitate a complete surgical resection. Efforts are focused on developing novel treatment modalities with durable responses.”
Current Approaches to the Management of Locally Advanced Pancreatic Cancer
Hannah R. Malinosky · John H. Stewart · Omeed Moaven
Current Surgery Reports https://doi.org/10.1007/s40137-023-00370-z - Radiologic findings of locally advanced pancreatic cancer
- “The management of LAPC remains unstandardized as tumor characteristics vary much from patient to patient but usually include induction chemotherapy to downstage for resection. Based on the benefits reported in the clinical trials, FOLFIRINOX and gemcitabine + nab-paclitaxel are the current standards of care in LAPC. The role of radiation is unclear, but there could be potential benefits in converting patients to resectable and improving the chances of R0 resection.”
Current Approaches to the Management of Locally Advanced Pancreatic Cancer
Hannah R. Malinosky · John H. Stewart · Omeed Moaven
Current Surgery Reports https://doi.org/10.1007/s40137-023-00370-z - “This scoping review has provided evidence that 12 artificial intelligence-based machine learning models have sufficient capacity to evaluate the risk of malignancy in IPMN. However, the methodological quality of the included studies is inadequate, and the clinical value of the proposed models has not been proven. As a result, caution should be advised when interpreting these results, and the findings must be corroborated by additional high-quality studies. Future research should focus on developing rigorous models and investigating their usefulness in clinical practice to ensure that they are dependable tools for assessing the risk of malignancy in IPMN.”
Artificial intelligence-based models to assess the risk of malignancy on radiological imaging in patients with intraductal papillary mucinous neoplasm of the pancreas: scoping review
Alberto Balduzzi et al.
Br J Surg. 2023 Jul 4:znad201. doi: 10.1093/bjs/znad201. (in press) - “Most patients diagnosed with IPMN will be kept under surveillance, aimed at monitoring progression of the cyst, which may require surgical resection in highly selected patients. Still, the risk of clinicians missing IPMN progression to malignancy is concerning5, with burdensome consequences for the patient. This concern must be balanced against the risk of complications after major pancreatic surgery. Therefore, patient selection is crucial both to avoid unnecessary surgery for benign lesions, and to continue surveillance safely. Typically, diagnostic imaging plays a central role in guiding patient selection for, and the timing of, surgery. However, current imaging approaches fall short for optimal decision-making.”
Artificial intelligence-based models to assess the risk of malignancy on radiological imaging in patients with intraductal papillary mucinous neoplasm of the pancreas: scoping review
Alberto Balduzzi et al.
Br J Surg. 2023 Jul 4:znad201. doi: 10.1093/bjs/znad201. (in press) - “Future research should concentrate on developing methodologically sound, generalizable, and clinically validated models. Multiple methodological elements are frequently missed or ignored, as is evident from the mRQS scores of the research included. Once robust and generalizable models have been constructed, their performance and value should be validated in clinical settings. Currently available studies have focused on assessing the discriminative performance of machine learning models for malignant IPMNs. However, ideally, models would exclude the presence of malignancy with a high negative predictive value and ‘safely’ advise surveillance in patients who would have been selected for surgical treatment according to current criteria. This would represent a true added value to current clinical practice.”
Artificial intelligence-based models to assess the risk of malignancy on radiological imaging in patients with intraductal papillary mucinous neoplasm of the pancreas: scoping review
Alberto Balduzzi et al.
Br J Surg. 2023 Jul 4:znad201. doi: 10.1093/bjs/znad201. (in press)
- Key Content and Findings: Each imaging modality (endoscopic ultrasonography, endoscopic retrograde cholangiopancreatography, computed tomography, positron emission tomography/computed tomography, staging laparoscopy) has its own diagnostic advantages and limitations. The sensitivity, specificity and accuracy for each image set are reported. Data that support the increasing role of neoadjuvant therapy (radiotherapy and chemotherapy) and the meaning of a patient-tailored treatment selection, based on tumour staging, are also discussed.
Conclusions: A multimodal pre-treatment workup should be searched as it improves staging accuracy, orienting patients with resectable tumors towards surgery, optimizing patient selection with locally advanced tumors to neoadjuvant or definite therapy and avoiding surgical resection or curative radiotherapy in those with metastatic disease.
Advances in pre-treatment evaluation of pancreatic ductal adenocarcinoma: a narrative review
Michele Fiore et al.
J Gastrointest Oncol 2023 | https://dx.doi.org/10.21037/jgo-22-1034 - “An accurate staging of PDAC is challenging for its aggressive biological behavior, frequently associated with extra-pancreatic dissemination to lymph nodes and distant organs, which may be occult or difficult to identify by single imaging technique. The effort of the pre-treatment evaluation should be to identify an overt or potentially occult systemic disease, and the possibility of a complete surgical resection. Each imaging modality has its own diagnostic advantages and limitations.”
Advances in pre-treatment evaluation of pancreatic ductal adenocarcinoma: a narrative review
Michele Fiore et al.
J Gastrointest Oncol 2023 | https://dx.doi.org/10.21037/jgo-22-1034 
Advances in pre-treatment evaluation of pancreatic ductal adenocarcinoma: a narrative review
Michele Fiore et al.
J Gastrointest Oncol 2023 | https://dx.doi.org/10.21037/jgo-22-1034
Advances in pre-treatment evaluation of pancreatic ductal adenocarcinoma: a narrative review
Michele Fiore et al.
J Gastrointest Oncol 2023 | https://dx.doi.org/10.21037/jgo-22-1034
- Purpose: To characterize the prevalence of missed pancreatic masses and pancreatic ductal adenocarcinoma (PDAC)-related findings on CT and MRI between pre-diagnostic patients and healthy individuals.
Materials and methods: Patients diagnosed with PDAC (2010–2016) were retrospectively reviewed for abdominal CT- or MRI-examinations 1 month—3 years prior to their diagnosis, and subsequently matched to controls in a 1:4 ratio. Two blinded radiologists scored each imaging exam on the presence of a pancreatic mass and secondary features of PDAC. Additionally, original radiology reports were graded based on the revised RADPEER criteria.
Prevalence, features, and explanations of missed and misinterpreted pancreatic cancer on imaging: a matched case–control study
Sanne A. Hoogenboom et al.
Abdominal Radiology (2022) 47:4160–4172 - Results: The cohort of 595 PDAC patients contained 60 patients with a pre-diagnostic CT and 27 with an MRI. A pancreatic mass was suspected in hindsight on CT in 51.7% and 50% of cases and in 1.3% and 0.9% of controls by reviewer 1 (p < .001) and reviewer 2 (p < .001), respectively. On MRI, a mass was suspected in 70.4% and 55.6% of cases and 2.9% and 0% of the controls by reviewer 1 (p < .001) and reviewer 2 (p < .001), respectively. Pancreatic duct dilation, duct interruption, focal atrophy, and features of acute pancreatitis is strongly associated with PDAC (p < .001). In cases, a RADPEER-score of 2 or 3 was assigned to 56.3% of the CT-reports and 71.4% of MRI-reports. Conclusion Radiological features as pancreatic duct dilation and interruption, and focal atrophy are common first signs of PDAC and are often missed or unrecognized. Further investigation with dedicated pancreas imaging is warranted in patients with PDAC-related radiological findings.
Prevalence, features, and explanations of missed and misinterpreted pancreatic cancer on imaging: a matched case–control study
Sanne A. Hoogenboom et al.
Abdominal Radiology (2022) 47:4160–4172 
Prevalence, features, and explanations of missed and misinterpreted pancreatic cancer on imaging: a matched case–control study
Sanne A. Hoogenboom et al.
Abdominal Radiology (2022) 47:4160–4172- “PDAC arises from ductal epithelial cells and precursor lesions are common in the general elderly population, including pancreatic intraepithelial neoplasia (PanIN), intraductal pancreatic mucinous neoplasia (IPMN), and mucinous cystic neoplasia. Although these precursor lesions predominantly harbor low-grade dysplasia, a fraction will evolve into high-grade dysplasia and these are considered immediate precursors of PDAC. The estimated time of progression from the initiation of PanIN to PDAC and from PDAC to potential metastasis is 12 and 7 years, respectively. Considering this slow progression, there is a notable window of opportunity to detect early-stage PDAC or even precursor lesions with high-grade dysplasia.”
Prevalence, features, and explanations of missed and misinterpreted pancreatic cancer on imaging: a matched case–control study
Sanne A. Hoogenboom et al.
Abdominal Radiology (2022) 47:4160–4172 - “As stated earlier, PanIN with high-grade dysplasia and early invasive PDAC lesions do not generally form clear hypodense masses. Still, they may cause visible changes of the pancreatic parenchyma and the pancreatic duct, and these changes are rarely observed in patients who do not subsequently develop PDAC, as demonstrated in this study. Focal parenchymal atrophy may be a less known PDAC related imaging feature, but was observed on CT and MRI in 46%–49% of cases and only in one control patient. These results confirm the conclusion of recently published papers, who recognized focal atrophy as one of the first radiological features of early-stage PDAC.”
Prevalence, features, and explanations of missed and misinterpreted pancreatic cancer on imaging: a matched case–control study
Sanne A. Hoogenboom et al.
Abdominal Radiology (2022) 47:4160–4172 - “To conclude, our findings indicate that PDAC-related features on abdominal imaging can be present long before PDAC is diagnosed. These features are rarely present in individuals who are not diagnosed with PDAC, and therefore dedicated pancreas imaging is warranted if these features are found. Future research should focus on an automated second review that can detect otherwise missed lesions or secondary signs, aided by artificial intelligence. In addition, prospective studies should point out if early detection of PDAC would indeed lead to improved survival.”
Prevalence, features, and explanations of missed and misinterpreted pancreatic cancer on imaging: a matched case–control study
Sanne A. Hoogenboom et al.
Abdominal Radiology (2022) 47:4160–4172
- “Pancreatic ductal carcinoma (PDAC) is one of the leading causes of cancer-related death worldwide. Computed tomography(CT) remains the primary imaging modality for diagnosis of PDAC. However, CT has limitations for early pancreatic tumor detection and tumor characterization so that it is currently challenged by magnetic resonance imaging. More recently, a particular attention has been given to radiomics for the characterization of pancreatic lesions using extraction and analysis of quantitative imaging features. In addition, radiomics has currently many applications that are developed in conjunction with artificial intelligence (AI) with the aim of better characterizing pancreatic lesions and providing a more precise assessment of tumor burden.”
Imaging of Pancreatic Ductal Adenocarcinoma: An Update on Recent Advances
Maxime Barat, Ugo Marchese, Elliot K. Fishman et al.
Canadian Association of Radiologists’ Journal 2022, Vol. 0(0) 1–11 - “Studies showed that radiomic features can be used for risk stratification of PDAC and can predict survival after surgical resection. Hypoattenuating PDAC on CT images are associated with shorter overall survival (OS) and disease-free survival (DFS) after surgery. Similarly, radiomic features that are representative of tumor hypoattenuation are associated with poorer outcome. By contrast, the association between radiomic features representative of tumor homogeneity on CT and DFS is less clear. One study found that PDAC with homogenous texture features conveyed shorter DFS whereas another reported that greater dissimilarity (heterogeneity) was associated with longer OS.”
Imaging of Pancreatic Ductal Adenocarcinoma: An Update on Recent Advances
Maxime Barat, Ugo Marchese, Elliot K. Fishman et al.
Canadian Association of Radiologists’ Journal 2022, Vol. 0(0) 1–11 - “Despite major progress in imaging, PDAC remains a severe disease with limited OS. CT is still the front-line imaging modality for the detection and initial assessment of PDAC, with limited capabilities in terms of detection of small PDAC and preoperative assessment of resectability and prediction of R0 margins. Radiomics shows encouraging results in terms of tumor resectability prediction and discriminating between border line and locally advanced PDAC. AI is a field of major ongoing research but has major drawbacks, and for the majority of tasks it remains inferior to the radiologist and requires an important amount of work for radiologist for features extraction. One goal for AI could be the detection of small PDAC at an early stage, as a substantial proportion of these cancers remain not visible to the human eyes. Future studies should also include sophisticated models that associate imaging data with clinical and biological data. The recent introduction of new therapies should also stimulate further studies for a better evaluation of tumor response.”
Imaging of Pancreatic Ductal Adenocarcinoma: An Update on Recent Advances
Maxime Barat, Ugo Marchese, Elliot K. Fishman et al.
Canadian Association of Radiologists’ Journal 2022, Vol. 0(0) 1–11 - “Besides estimation of vascular involvement, preoperativeplanning of PDAC requires precise visualization of vascular structures in relation to the tumor and also identification of anatomical variations, such as celiac axis stenosis, that may make surgery difficult or increase the risk of intraoperative vascular complications.This is also because in selected situations, resection of the celiac axis may be required, so that careful evaluation of potential spontaneous anastomoses that preserve liver vascularization is of paramount importance. To address this issue, three-dimensional imaging has a major role in identifying vascular variations such as arcuate ligament or celiomesenteric trunk. More recently, cinematic rendering, which is a recent form of three dimensional volume rendering that generates photorealistic images, has demonstrated utility as it helps surgeon to better identify presence of arterial anatomic variants and vascular involvement.”
Imaging of Pancreatic Ductal Adenocarcinoma: An Update on Recent Advances
Maxime Barat, Ugo Marchese, Elliot K. Fishman et al.
Canadian Association of Radiologists’ Journal 2022, Vol. 0(0) 1–11 - Background: Deep learning (DL) may facilitate the diagnosis of various pancreatic lesions at imaging.
Purpose: To develop and validate a DL-based approach for automatic identification of patients with various solid and cystic pancreatic neoplasms at abdominal CT and compare its diagnostic performance with that of radiologists.
Materials and Methods: In this retrospective study, a three-dimensional nnU-Net–based DL model was trained using the CT data of patients who underwent resection for pancreatic lesions between January 2014 and March 2015 and a subset of patients without pancreatic abnormality who underwent CT in 2014. Performance of the DL-based approach to identify patients with pancreatic l ) lesions was evaluated in a temporally independent co-hort (test set 1) and a temporally and spatially independent cohort (test set 2) and was compared with that of two board-certified radiologists. Performance was assessed using receiver operating characteristic analysis.
Results: The study included 852 patients in the training set (median age, 60 years [range, 19–85 years]; 462 men), 603 patients in test set 1 (median age, 58 years [range, 18–82 years]; 376 men), and 589 patients in test set 2 (median age, 63 years [range, 18–99 years]; 343 men). In test set 1, the DL-based approach had an area under the receiver operating characteristic curve (AUC) of 0.91 95% CI: 0.89, 0.94) and showed slightly worse performance in test set 2 (AUC, 0.87 [95% CI: 0.84, 0.89]). The DL-based approach showed high sensitivity in identifying patients with solid lesions of any size (98%–100%) or cystic lesions measuring 1.0 cm or larger (92%–93%), which was comparable with the radiologists (95%–100% for solid lesions [P = .51 to P . .99]; 93%–98% for cystic lesions 1.0 cm [P = .38 to P . .99]).
Conclusion: The deep learning–based approach demonstrated high performance in identifying patients with various solid and cystic pancreatic lesions at CT.
Deep Learning–based Detection of Solid and Cystic Pancreatic Neoplasms at Contrast-enhanced CT
Hyo Jung Park, et al.
Radiology 2022; 000:1–11 - IMPORTANCE The identification of incidental pancreas cystic lesions (PCLs) has increased in recent decades with the expanded use and improved sensitivity of cross-sectional imaging. Because the overall risk of malignancy associated with PCLs is low, yet the relative morbidity of pancreatic surgery is high, evidence-based guidelines are necessary for appropriate surveillance and management. Therefore, this article provides a review of existing guidelines regarding surveillance and management of PCLs and highlights recent advances in the diagnostic evaluation of cysts and the postresection management of mucinous lesions.
CONCLUSIONS AND RELEVANCE PCL guidelines should be viewed within the context of the data limitations on which they are based. PCL subtype-specific guidelines on surveillance and treatment are needed. In the future, the integration of cyst-specific genomic analysis, as well as evolutions in advanced diagnostic tools, such as cyst fluid next-generation sequencing and EUS-guided confocal laser endomicroscopy, may also better inform treatment guidelines. Owing to the current low-quality evidence on which many guidelines are based and the inherent morbidity of pancreas surgery, it is imperative that patients with PCLs are referred toi nstitutions with advanced diagnostics and a multidisciplinary approach to patientsurveillance and management.
Comparison of Society Guidelines for the Management and Surveillance of Pancreatic Cysts: A Review
Hassan Aziz et al.
JAMA Surg. 2022;157(8):723-730.
- Objectives: To investigate the risk factors for early recurrence after curative pancreatoduodenectomy for resectablepancreatic ductal adenocarcinoma.
Conclusions: Tumor size > 4 cm from the preoperative imaging study was a poor prognostic factor for early recurrence after curative pancreatoduodenectomy for resectable pancreatic adenocarcinoma indicated that they may have radiological occult metastasis, thus, staging laparoscopy may reduce the number of unnecessary laparotomies and avoid missing radiologically negative metastases.
Analysis of preoperative risk factors for early recurrence after curative pancreatoduodenectomy for resectable pancreatic adenocarcinoma
Pipit Burasakarn et al.
Innov Surg Sci 2022; (in press) - “The independent preoperative risk factor associated with adverse disease-free survival was tumor size > 4 cm (hazard ratio [HR], 14.34, p=0.022). The perioperative risk factors associated with adverse disease-free survival were pathological lymphovascular invasion (HR,4.31; p=0.048) and non-hepatopancreatobiliary surgeon (HR, 5.9; p=0.022). Risk factors associated with poor overall survival were microscopical margin positive (R1) resection(HR, 3.68; p=0.019) and non-hepatopancreatobiliary surgeon(HR, 3.45; p=0.031).”
Analysis of preoperative risk factors for early recurrence after curative pancreatoduodenectomy for resectable pancreatic adenocarcinoma
Pipit Burasakarn et al.
Innov Surg Sci 2022; (in press) - "Tumor size >4 cm from the preoperative imaging study was a poor prognostic factor for early recurrence after curative pancreatoduodenectomy for resectable pancreatic adenocarcinoma indicated that they may have radiological occult metastasis, thus, staging laparoscopy may reduce thenumber of unnecessary laparotomies and avoid missing radiologically negative metastases.”
Analysis of preoperative risk factors for early recurrence after curative pancreatoduodenectomy for resectable pancreatic adenocarcinoma
Pipit Burasakarn et al.
Innov Surg Sci 2022; (in press) - Methods In this retrospective, diagnostic study, contrast-enhanced CT images of 370 patients with pancreatic cancer and 320 controls from a Taiwanese centre were manually labelled and randomly divided for training and validation (295 patients with pancreatic cancer and 256 controls) and testing (75 patients with pancreatic cancer and 64 controls; local test set 1). Images were preprocessed into patches, and a CNN was trained to classify patches as cancerous or non-cancerous. Individuals were classified as with or without pancreatic cancer on the basis of the proportion of patches diagnosed as cancerous by the CNN, using a cutoff determined using the training and validation set. The CNN was further tested with another local test set (101 patients with pancreatic cancers and 88 controls; local test set 2) and a US dataset (281 pancreatic cancers and 82 controls). Radiologist reports of pancreatic cancer images in the local test sets were retrieved for comparison.
Deep learning to distinguish pancreatic cancer tissue from non-cancerous pancreatic tissue: a retrospective study with cross-racial external validation
Kao-Lang Liu et al.
Lancet Digital Health 2020; 2: e303–13 - Findings Between Jan 1, 2006, and Dec 31, 2018, we obtained CT images. In local test set 1, CNN-based analysis hada sensitivity of 0·973, specificity of 1·000, and accuracy of 0·986 (area under the curve [AUC] 0·997 (95% CI 0·992–1·000). In local test set 2, CNN-based analysis had a sensitivity of 0·990, specificity of 0·989, and accuracy of 0·989 (AUC 0·999 [0·998–1·000]). In the US test set, CNN-based analysis had a sensitivity of 0·790, specificity of 0·976, and accuracy of 0·832 (AUC 0·920 [0·891–0·948)]. CNN-based analysis achieved higher sensitivity than radiologists did (0·983 vs 0·929, difference 0·054 [95% CI 0·011–0·098]; p=0·014) in the two local test sets combined. CNN missed three (1·7%) of 176 pancreatic cancers (1·1–1·2 cm). Radiologists missed 12 (7%) of 168 pancreatic cancers (1·0–3·3 cm), of which 11 (92%) were correctly classified using CNN. The sensitivity of CNN for tumours smaller than 2 cm was 92·1% in the local test sets and 63·1% in the US test set.
Deep learning to distinguish pancreatic cancer tissue from non-cancerous pancreatic tissue: a retrospective study with cross-racial external validation
Kao-Lang Liu et al.
Lancet Digital Health 2020; 2: e303–13 - Added value of this study We trained a CNN using contrast enhanced-CT images of Asian patients to distinguish pancreatic cancer from healthy pancreases. CNN achieved excellent accuracy and improved sensitivity compared with radiologist interpretation in independent Asian test sets, with acceptable performance in a North American test set obtained from patients of various races and ethnicities using diverse scanners and settings. These results provide the first solid proof of concept that CNN can capture the elusive CT features of pancreatic cancer to assist and supplement radiologists in the detection and diagnosis of pancreatic cancer.
Deep learning to distinguish pancreatic cancer tissue from non-cancerous pancreatic tissue: a retrospective study with cross-racial external validation
Kao-Lang Liu et al.
Lancet Digital Health 2020; 2: e303–13 - “Implications of all the available evidence CNN can accurately differentiate pancreatic cancer from non-cancerous pancreas, and with improvements mightaccommodate variations in patient race and ethnicity and imaging parameters that are inevitable in real-world clinical practice. CNN holds promise for developing computer-aided detection and diagnosis tools for pancreatic cancer to supplement radiologist interpretation.”
Deep learning to distinguish pancreatic cancer tissue from non-cancerous pancreatic tissue: a retrospective study with cross-racial external validation
Kao-Lang Liu et al.
Lancet Digital Health 2020; 2: e303–13
- Background: Computed tomography (CT) is the first-line staging imaging modality for pancreatic ductal adenocarcinoma (PDAC) which determines resectability and treatment pathways.
Results: Of 131 patients assessed, 117 (89.3%) presented with symptoms, 74 (56.5%) CTs included slices ≤3 mm thickness and CT pancreas protocol was applied in 69 (52.7%) patients. Initial reports lacked synoptic reporting in 131 (100%), tumour identification in 2 (1.6%) and tumour measurement in 13 (9.9%) cases. Tumour vascular relationship reporting was missing in 69–109 (52.7–83.2%) for regarding the key arterial and venous structures that is required to assess resectability. Initial reports had no comment on venous thrombus or venous collaterals in 80 (61.1%) and 109 (83.2%) and lacked locoregional lymphadenopathy interpretation in 13 (9.9%) cases. Complete initial staging report was present in 72 (55.0%) patients. Sub-specialist radiological review resulted in down-staging in 16 (22.2%) and up-staging in 1 (1.4%) patient. Staging discrepancies were mainly regarding metastatic disease (12, 70.6%) and tumour-vascular relationship (5, 29.4%).
Conclusion: Real-world staging imaging in PDAC patients show low proportion of dedicated CT pancreas protocol, high proportion of incomplete staging reports and no synoptic reporting. The most common discrepancy between initial and sub-specialist reporting was regarding metastases and tumour-vascular relationship assessment resulting in sub-specialist down-staging in almost every fifth case.
Real-world staging computed tomography scanning technique and important reporting discrepancies in pancreatic ductal adenocarcinoma
Alexander Grogan et al.
ANZ J Surg (2022 May in press) - Conclusion: Real-world staging imaging in PDAC patients show low proportion of dedicated CT pancreas protocol, high proportion of incomplete staging reports and no synoptic reporting. The most common discrepancy between initial and sub-specialist reporting was regarding metastases and tumour-vascular relationship assessment resulting in sub-specialist down-staging in almost every fifth case.
Real-world staging computed tomography scanning technique and important reporting discrepancies in pancreatic ductal adenocarcinoma
Alexander Grogan et al.
ANZ J Surg (2022 May in press) - “There was a trend towards overcalling of metastatic disease with adrenal, renal and splenic involvement and liver, peritoneal or lung lesions being false positives, which contrasts with a retrospective study by Lauritzen et al. which evaluated 1071 double-read abdominal CTs from five different hospitals. Their study showed a trend towards under-calling of significant findings by initial reporting radiologists compared to sub-specialist review, however, their study included all CT abdominal reports which contained a high proportion of emergency cases and therefore was not selective regarding PDAC staging CTs. Furthermore, as recently described by Chong et al. non-subspecialized reporting has higher risk in erroneous interpretation of key imaging features. This might result in suboptimal patient care.”
Real-world staging computed tomography scanning technique and important reporting discrepancies in pancreatic ductal adenocarcinoma
Alexander Grogan et al.
ANZ J Surg (2022 May in press) - Background and Objectives: To describe the patterns of disease relapse and followup of patients with resected pancreatic adenocarcinoma. Additionally, we looked at patients' characteristics at relapse and survival.
Conclusions: A follow‐up protocol that included imaging studies every 3 months in the first 2 years and every 6 months thereafter is able to diagnose disease relapse when patients have adequate performance status and are still able to undergo additional anticancer treatment.
Patterns of disease relapse and posttreatment follow‐up of patients with resected pancreatic adenocarcinoma: A single‐center analysis
Beatriz A. Gonzales et al.
J Surg Oncol. 2022;1–10. - “To conclude, a structured follow‐up program that encompasses clinical consultations, laboratory exams (including CA 19‐9 measurement), and imaging studies every 3 months in the first 2 years and every 6 months thereafter allowed the vast majority of patients with resected pancreatic adenocarcinoma to undergo cancer‐directed treatment at disease relapse. Even patients with symptoms at disease relapse were able to undergo standard chemotherapy protocols in the first‐line setting. However, more data is needed to evaluate the cost‐effectiveness and potential harms of this surveillance practice.”
Patterns of disease relapse and posttreatment follow‐up of patients with resected pancreatic adenocarcinoma: A single‐center analysis
Beatriz A. Gonzales et al.
J Surg Oncol. 2022;1–10. - Key Objective: To evaluate the stage at diagnosis and outcome of individuals diagnosed with pancreatic cancer and high-grade dysplasia while undergoing recommended, typically annual, pancreas imaging surveillance with magnetic resonance imaging and endoscopic ultrasound for their familial/inherited risk in the multicenter Cancer of Pancreas Screening-5 (CAPS5) study and in the Johns Hopkins CAPS study, initiated 201 years ago.
Knowledge Generated: The majority of patients diagnosed with pancreatic ductal adenocarcinoma while under pancreas surveillance have stage I disease and can achieve long-term survival; the median survival of patients diagnosed with pancreatic ductal adenocarcinoma while under surveillance in the CAPS program is 9.8 years. The predominance of stage I disease is in marked contrast to the advanced stage at presentation for the majority of patients who present with symptomatic pancreatic cancer.
Relevance: Regular pancreatic imaging surveillance should be offered to patients who meet recommended pancreatic surveillance criteria.
The Multicenter Cancer of Pancreas Screening Study: Impact on Stage and Survival
Mohamad Dbouk et al.
J Clin Oncol (2022, in press) - “Of 1,461 high-risk individuals enrolled into CAPS5, 48.5% had a pathogenic variant in a PDAC susceptibility gene. Ten patients were diagnosed with PDAC, one of whom was diagnosed with metastatic PDAC 4 years after dropping out of surveillance. Of the remaining nine, seven (77.8%) had a stage I PDAC (by surgical pathology) detected during surveillance; one had stage II, and one had stage III disease. Seven of these nine patients with PDAC were alive after a median follow-up of 2.6 years. Eight additional patients underwent surgical resection for worrisome lesions; three had high-grade and five had low-grade dysplasia in their resected specimens. In the entire CAPS cohort (CAPS1-5 studies, 1,731 patients), 26 PDAC cases have been diagnosed, 19 within surveillance, 57.9% of whom had stage I and 5.2% had stage IV disease. By contrast, six of the seven PDACs (85.7%) detected outside surveillance were stage IV. Five-year survival to date of the patients with a screen-detected PDAC is 73.3%, and median overall survival is 9.8 years, compared with 1.5 years for patients diagnosed with PDAC outside surveillance (hazard ratio [95% CI]; 0.13 [0.03 to 0.50], P 5 .003).”
The Multicenter Cancer of Pancreas Screening Study: Impact on Stage and Survival
Mohamad Dbouk et al.
J Clin Oncol (2022, in press)
- “Approximately 0.5% to 1% of individuals diagnosed with type 2 diabetes after age 50 will be diagnosed with PDAC within 3 years.40,41 As such, individuals with new-onset diabetes (NOD) may represent an enriched population to target for early diagnosis of PDAC. A study published in 2018 outlined a model that could allow for further stratification of risk in individuals with NOD.42 These investigators used knowledge that PDAC-related NOD was more likely to be associated with weight loss, rapid change in fasting blood glucose levels, and older age of diagnosis than traditional type 2 diabetes. These 3 factors were incorporated into a model called ENDPAC, which stratifies risk for PDAC as high, intermediate, and low.”
Pancreatic Cancer Surveillance and Novel Strategies for Screening
Beth Dudley, Randall E. Brand
Gastrointest Endoscopy Clin N Am 32 (2022) 13–25 - "Pancreatic ductal adenocarcinoma (PDAC) accounts for 3.2% of all cancer diagnoses in the United States, but is responsible for 7.9% of all cancer deaths, with a 5-year survival of 10.8%. The dismal survival is due in large part to a lack of early detection, with more than half of cases being metastatic at time of diagnosis. The lifetime risk for PDAC in the United States is 1.7%. Screening in the general population is not performed, in part because of the disease’s rarity and the lack of a reliable, cost- effective screening tool. Approximately 10% of PDAC is attributed to genetic suscep- tibility, either because of an identified pathogenic variant in a cancer susceptibility gene or a combination of shared genetic, environmental, and lifestyle risk factors, resulting in a familial predisposition.”
Pancreatic Cancer Surveillance and Novel Strategies for Screening
Beth Dudley, Randall E. Brand
Gastrointest Endoscopy Clin N Am 32 (2022) 13–25 - "The target abnormalities for pancreatic cancer surveillance are advanced precursor neoplasia or early-stage PDAC (T1N0). PDAC arises from 1 of 3 pathways, involving the following precursor lesions: pancreatic intraepithelial neoplasia (PanIN), intraductal papillary mucinous neoplasms (IPMN), or mucinous cystic neoplasms (MCNs). The first 2 pathways comprise most cases, with MCNs being less common. PanINs are microscopic lesions that originate from pancreatic ducts, whereas IPMNs and MCNs are mucin-producing cystic neoplasms. IPMNs originate from the main pancreatic duct or its side branches, whereas MCNs do not connect with the duct system. High-grade PanIN lesions (PanIN3) and IPMNs with high-risk features are the ideal advanced precursor lesions that surveillance aims to detect.”
Pancreatic Cancer Surveillance and Novel Strategies for Screening
Beth Dudley, Randall E. Brand
Gastrointest Endoscopy Clin N Am 32 (2022) 13–25 - “Despite the emergence of promising data regarding improved outcomes with PDAC surveillance in high-risk individuals, current options for surveillance have their limitations. First, the ability to identify high-risk individuals for surveillance is currently limited to those individuals who have a single-gene cancer predisposition or individuals from an FPC family. Thus, the majority (w90%) of individuals who develop a PDAC do not qualify for surveillance.”
Pancreatic Cancer Surveillance and Novel Strategies for Screening
Beth Dudley, Randall E. Brand
Gastrointest Endoscopy Clin N Am 32 (2022) 13–25 
Pancreatic Cancer Surveillance and Novel Strategies for Screening
Beth Dudley, Randall E. Brand
Gastrointest Endoscopy Clin N Am 32 (2022) 13–25- "These researchers continued their work, later reporting the development of a test that they named CancerSEEK, designed to detect 8 cancer types, including PDAC. Ninety-three PDACs were included in their data set; most of these were stage II at diagnosis (89%), with a smaller proportion of stage I (4%) and stage III (6%) cancers. Stage IV cancers were not included. This test measures 8 protein levels, including CA19-9, and identifies the presence or absence of mutations in 1933 genomic positions. It detected 75% of PDACs in their study cohort.”
Pancreatic Cancer Surveillance and Novel Strategies for Screening
Beth Dudley, Randall E. Brand
Gastrointest Endoscopy Clin N Am 32 (2022) 13–25 - "The concept behind radiomics is to incorporate quantitative assessment of images by artificial intelligence, which allows for the identification of patterns not detectable visibly. The use of radiomics in pancreatic disease is in its infancy, but there are some published studies. In 2019, Chu and colleagues reported the successful differentiation between PDAC and normal pancreas using radiomic features. In addition, a handful of studies have been published regarding the use of radiomics in evaluating pancreatic cystic lesions.”
Pancreatic Cancer Surveillance and Novel Strategies for Screening
Beth Dudley, Randall E. Brand
Gastrointest Endoscopy Clin N Am 32 (2022) 13–25 - CONCLUSION. Most patients with clinical stage I PDAC showed focal pancreatic abnormalities on CT performed at least 1 year before diagnosis. Focal MPD change exhibited the shortest duration from its development to subsequent diagnosis, whereas atrophy and faint enhancement exhibited a relatively prolonged course.
CLINICAL IMPACT. These findings could facilitate earlier PDAC diagnosis and thus improve prognosis.
CT Abnormalities of the Pancreas Associated With the Subsequent Diagnosis of Clinical Stage I Pancreatic Ductal Adenocarcinoma More Than 1 Year Later: A Case-Control Study
Fumihito Toshima et al.
AJR 2021; 217:1353–1364 - Key Finding
- A total of 55/103 (53.4%) patients with clinical stage I PDAC had focal pancreatic abnormalities on CT per- formed at least 1 year before diagnosis, most common- ly focal atrophy (37.9%), faint enhancement (26.2%), and MPD change (13.6%); atrophy, enhancement, and MPD change appeared 4.6, 3.3, and 1.1 years before diagnosis, respectively.
Importance
- Focal pancreatic abnormalities predicting subsequent PDAC development, including atrophy, faint enhancement, and MPD change, could allow an earlier diagnosis, thereby improving management and prognosis.
CT Abnormalities of the Pancreas Associated With the Subsequent Diagnosis of Clinical Stage I Pancreatic Ductal Adenocarcinoma More Than 1 Year Later: A Case-Control Study
Fumihito Toshima et al.
AJR 2021; 217:1353–1364 
CT Abnormalities of the Pancreas Associated With the Subsequent Diagnosis of Clinical Stage I Pancreatic Ductal Adenocarcinoma More Than 1 Year Later: A Case-Control Study
Fumihito Toshima et al.
AJR 2021; 217:1353–1364- "In conclusion, 53.4% of patients diagnosed with clinical stage I PDAC showed focal pancreatic abnormalities on prediagnostic CT examinations obtained at least 1 year before the diagnosis of PDAC. The most common focal abnormality on prediagnostic CT in patients who had PDAC develop was focal parenchymal atrophy, followed by focal faint parenchymal enhancement and focal MPD change. Among these three findings, focal MPD change exhibited the shortest duration between its new development and the subsequent diagnosis of PDAC, whereas focal atrophy and faint enhancement exhibited more prolonged duration. These observations could facilitate earlier diagnosis of PDAC and thus improve management and prognosis."
CT Abnormalities of the Pancreas Associated With the Subsequent Diagnosis of Clinical Stage I Pancreatic Ductal Adenocarcinoma More Than 1 Year Later: A Case-Control Study
Fumihito Toshima et al.
AJR 2021; 217:1353–1364
- “In this paper, we consider a partially supervised setting, where cheap image-level annotations are provided for all the train- ing data, and the costly per-voxel annotations are only available for a subset of them. We propose an Inductive Attention Guidance Network (IAG-Net) to jointly learn a global image-level classifier for normal/PDAC classification and a local voxel-level classifier for semi-supervised PDAC segmentation. We instantiate both the global and the local classifiers by multiple instance learning (MIL), where the attention guidance, indicating roughly where the PDAC regions are, is the key to bridging them: For global MIL based normal/PDAC classification, attention serves as a weight for each instance (voxel) during MIL pooling, which eliminates the distraction from the background; For local MIL based semi-supervised PDAC segmentation, the attention guidance is inductive, which not only provides bag-level pseudo-labels to training data without per-voxel annotations for MIL training, but also acts as a proxy of an instance-level classifier.”
Learning Inductive Attention Guidance for Partially Supervised Pancreatic Ductal Adenocarcinoma Prediction
Yan Wang , Peng Tang, Yuyin Zhou , Wei Shen, Elliot K. Fishman , Alan L. Yuille,
IEEE TRANSACTIONS ON MEDICAL IMAGING, VOL. 40, NO. 10, OCTOBER 2021 
Learning Inductive Attention Guidance for Partially Supervised Pancreatic Ductal Adenocarcinoma Prediction
Yan Wang , Peng Tang, Yuyin Zhou , Wei Shen, Elliot K. Fishman , Alan L. Yuille,
IEEE TRANSACTIONS ON MEDICAL IMAGING, VOL. 40, NO. 10, OCTOBER 2021
Learning Inductive Attention Guidance for Partially Supervised Pancreatic Ductal Adenocarcinoma Prediction
Yan Wang , Peng Tang, Yuyin Zhou , Wei Shen, Elliot K. Fishman , Alan L. Yuille,
IEEE TRANSACTIONS ON MEDICAL IMAGING, VOL. 40, NO. 10, OCTOBER 2021- “This paper addresses the problem of PDAC prediction i.e., normal/PDAC classification and PDAC segmentation under the partially supervised setting. We present an Inductive Attention Guidance (IAG) strategy for learning a global image-level clas- sifier for normal/PDAC segmentation and a local instance-level classifier for semi-supervised PDAC segmentation, which enjoys the advantages of bridging the MIL-based global and local classifiers. We showed empirically on the JHMI dataset the superiority of the proposed IAG-Net for PDAC predic- tion, which is helpful to computer-assisted clinical diagnoses. Additionally, we verified the generality of IAG-Net on the pancreas tumor segmentation dataset in MSD challenge.”
Learning Inductive Attention Guidance for Partially Supervised Pancreatic Ductal Adenocarcinoma Prediction
Yan Wang , Peng Tang, Yuyin Zhou , Wei Shen, Elliot K. Fishman , Alan L. Yuille,
IEEE TRANSACTIONS ON MEDICAL IMAGING, VOL. 40, NO. 10, OCTOBER 2021
- BACKGROUND. Contrast-enhanced CT performed for pancreatic ductal adeno- carcinoma (PDAC) detection traditionally uses a dual-phase (pancreatic and portal venous) protocol. However, PDAC may exhibit isoattenuation in these phases, hindering detection.
OBJECTIVE. The purpose of this study was to assess the impact on diagnostic performance in detection of small PDAC when a delayed phase is added to dual-phase contrast-enhanced CT.
Adding Delayed Phase Images to Dual-Phase Contrast- Enhanced CT Increases Sensitivity for Small Pancreatic Ductal Adenocarcinoma
Yoshihiko Fukukura et al.
AJR 2021; 217:888–897 - RESULTS. AUC was higher (p < .05) for triple-phase than dual-phase images for all observers (observer 1, 0.97 vs 0.94; observer 2, 0.97 vs 0.94; observer 3, 0.97 vs 0.95). Sen- sitivity was higher (p < .001) for triple-phase than dual-phase images for all observers (observer 1, 74.2% [72/97] vs 59.8% [58/97]; observer 2, 88.7% [86/97] vs 71.1% [69/97]; observer 3, 86.6% [84/97] vs 72.2% [70/97]). Specificity, PPV, and NPV did not differ be- tween image sets for any reader (p ≥ .05). Seventeen tumors showed pancreatic phase visual isoattenuation, of which nine showed isoattenuation and eight hyperattenuation in the delayed phase. Of these 17 tumors, 16 were not detected by any observer on du- al-phase images; of these 16, six were detected by at least two observers and five by at least one observer on triple-phase images. Visual attenuation showed excellent interob- server agreement (κ = 0.89–0.96).
Adding Delayed Phase Images to Dual-Phase Contrast- Enhanced CT Increases Sensitivity for Small Pancreatic Ductal Adenocarcinoma
Yoshihiko Fukukura et al.
AJR 2021; 217:888–897 - CONCLUSION. Addition of a delayed phase to pancreatic and portal venous phase CT increases sensitivity for small PDAC without loss of specificity, partly related to delayed phase hyperattenuation of some small PDACs showing pancreatic phase isoattenuation. CLINICAL IMPACT. Addition of a delayed phase may facilitate earlier PDAC detection and thus improved prognosis.
Adding Delayed Phase Images to Dual-Phase Contrast- Enhanced CT Increases Sensitivity for Small Pancreatic Ductal Adenocarcinoma
Yoshihiko Fukukura et al.
AJR 2021; 217:888–897 - “However, small PDACs show isoattenuation in 5–14% of cases and thus escape detection during both phases. This suggests that a substantial number of early-stage PDACs remain undetected despite the use of an optimal dual-phase contrast-enhanced CT protocol, potential- ly delaying diagnosis until the lesion is at an advanced stage and curative surgical resection is no longer possible.”
Adding Delayed Phase Images to Dual-Phase Contrast- Enhanced CT Increases Sensitivity for Small Pancreatic Ductal Adenocarcinoma
Yoshihiko Fukukura et al.
AJR 2021; 217:888–897 - "PDACs usually have an abundant fibrous stroma that leads to progressive enhancement, reaching a peak in the delayed phase. Delayed phase imaging may therefore help detect PDACs that exhibit visual isoattenuation during the pancreatic and portal venous phases by depicting delayed hyperattenuation. However, the impact on diagnostic performance in the detection of PDAC when a delayed phase is added to the dual-phase protocol has not been clearly elucidated.”
Adding Delayed Phase Images to Dual-Phase Contrast- Enhanced CT Increases Sensitivity for Small Pancreatic Ductal Adenocarcinoma
Yoshihiko Fukukura et al.
AJR 2021; 217:888–897 - Key Finding
- Sensitivity for small PDAC was higher (p < .001) for tri- ple-phase (pancreatic, portal venous, and delayed) than dual-phase (pancreatic and portal venous) con- trast-enhanced CT for three observers (observer 1, 74.2% vs 59.8%; observer 2, 88.7% vs 71.1%; observer 3, 86.6% vs 72.2%) without loss of specificity for any observer (p > .05).
Importance
- The addition of a delayed phase to dual-phase con- trast-enhanced CT may facilitate detection of small PDAC and thus earlier treatment and improved prognosis.
Adding Delayed Phase Images to Dual-Phase Contrast- Enhanced CT Increases Sensitivity for Small Pancreatic Ductal Adenocarcinoma
Yoshihiko Fukukura et al.
AJR 2021; 217:888–897 - “In conclusion, this study showed that triple-phase contrast-enhanced CT resulted in increased sensitivity and accuracy, without a change in specificity, for the detection of small PDAC compared with dual-phase contrast-enhanced CT. This benefit is in part related to hyperattenuation in the delayed phase of some small PDACs showing isoattenuation in the pancreatic phase. This change in pancreatic CT protocol merits further consider- ation to potentially achieve earlier detection and thus improved PDAC prognosis.”
Adding Delayed Phase Images to Dual-Phase Contrast- Enhanced CT Increases Sensitivity for Small Pancreatic Ductal Adenocarcinoma
Yoshihiko Fukukura et al.
AJR 2021; 217:888–897 - "Contrast medium (600 mg I/kg Iomeron 350, Eisai) was injected via the antecubital vein over 25 seconds (range of injection rate, 2.5–5.0 mL/s) using a power injector, followed by a 20-mL saline flush at the same injection rate. Pancreatic and portal venous phase scans started at 20 and 48 seconds, respectively, after the abdominal aorta reached a threshold of a 150-HU increase. The delayed phase was obtained at 180 seconds after the IV injection.”
Adding Delayed Phase Images to Dual-Phase Contrast- Enhanced CT Increases Sensitivity for Small Pancreatic Ductal Adenocarcinoma
Yoshihiko Fukukura et al.
AJR 2021; 217:888–897 
- Pancreas Cancer: Secondary Signs on CT
- pancreatic duct dilatation
- common bile ductal dilatation
- Pancreatic duct and CBD duct cutoff
- pancreatic contour abnormality
- parenchymal atrophy - Simple Summary: Pancreatic ductal adenocarcinoma (PDAC), which accounts for the majority of pancreatic cancers, is highly lethal, and its early diagnosis is difficult. Focal parenchymal atrophy (FPA) observed on computed tomography (CT) has been reported as a characteristic imaging finding of early PDAC without identifiable masses. However, it remains unclear whether FPA is frequently observed on pre-diagnostic CT. In this study, 76 patients with PDAC in whom CT was performed between 6 months and 3 years before PDAC diagnosis, and 76 sex- and age-matched controls without PDAC were reviewed. FPA was observed corresponding to the location of the subsequent tumor detected in 26/76 (34.2%) patients on pre-diagnostic CT, whereas it was observed in 3/76 (3.9%) controls without PDAC (p < 0.001). FPA was less frequently found in tumors in the pancreatic head than in those in the pancreatic body or tail. FPA may predict the subsequent diagnosis of PDAC, thus serving as an important imaging sign for the early diagnosis of PDAC.
Focal Parenchymal Atrophy of the Pancreas Is Frequently Observed on Pre-Diagnostic Computed Tomography in Patients with Pancreatic Cancer: A Case-Control Study
Shin Miura et al.
Diagnostics 2021, 11, 1693 - “FPA is defined as narrowing of the focal parenchyma in comparison to both the head- and tail-side parenchyma, showing a cave-in, slim, or slit-like appearance [15]. Extensive distal pancreatic atrophy, which is often found in advanced PDAC , was not regarded as FPA. Due to the difficulty in its detection, we did not regard the lesion in the edge of the pancreas as FPA. This study did not define an absolute criterion for the degree of depression of the FPA because the thickness of the pancreas tends to be atrophic with age and, to the best of our knowledge, the normal size of the age-corrected pancreas has not been established yet .”
Focal Parenchymal Atrophy of the Pancreas Is Frequently Observed on Pre-Diagnostic Computed Tomography in Patients with Pancreatic Cancer: A Case-Control Study
Shin Miura et al.
Diagnostics 2021, 11, 1693 - “In this case–control study, we showed that FPA, which has been reported as a characteristic imaging sign of early stage PDAC, was observed in about one-third of the patients at least 6 months before PDAC diagnosis. FPA was more frequently observed in patients with PDAC than sex- and age-matched controls without PDAC. Importantly, FPA was observed in the absence of tumor masses on CT in all the 26 patients, indicating that the clinical, if determined was presumably Stage 0 or I at that time. If FPA was recognized properly as a sign suggesting early stage PDAC ,at that time and might have been diagnosed with PDAC at relatively earlier stages.”
Focal Parenchymal Atrophy of the Pancreas Is Frequently Observed on Pre-Diagnostic Computed Tomography in Patients with Pancreatic Cancer: A Case-Control Study
Shin Miura et al.
Diagnostics 2021, 11, 1693 - “In this study, we showed that FPA was present on pre-diagnostic CT scans obtained between 6 months and 3 years before PDAC diagnosis in about one-third of patients with PDAC, and FPA was more frequently found in patients with PDAC than in those without PDAC. FPA might be the earliest sign predicting the subsequent diagnosis of PDAC that appears before MPD changes and mass identification. We recommend close monitoring of FPA in surveillance programs for high-risk populations and in abdominal CT performed or other indications. Further recognition of FPA as an important predictor of subsequent PDAC development would lead to early diagnosis and consequent improvements in the prognosis of this intractable disease.”
Focal Parenchymal Atrophy of the Pancreas Is Frequently Observed on Pre-Diagnostic Computed Tomography in Patients with Pancreatic Cancer: A Case-Control Study
Shin Miura et al.
Diagnostics 2021, 11, 1693
- “Metastatic umbilical nodule was first described in the literature in 1864. This clinical sign later became known as Sister Mary Joseph’s nodule, named after Sister Mary Joseph Dempsey (1856–1939), surgical assistant of Dr William James Mayo, who first noticed the association between abdomino-pelvic malignancies and metastatic umbilical nodules.”
Sister Mary Joseph's nodule: an unusual but important physical finding characteristic of widespread internal malignancy.
Tso,S et al
The British journal of general practice : the journal of the Royal College of General Practitioners, 63(615), 551–552. - "Sister Mary Joseph’s nodule is uncommon, with an estimated 1–3% cases of abdomino-pelvic malignancy metastasising to the umbilicus. Sister Mary Joseph’s nodule is usually associated with primary neoplasm of the gastrointestinal (35–65%) and genitourinary tract (12–35%). Other reported sites included lung, pancreas, liver, gallbladder, lymphoma, breast, kidney, penis, prostate, and testicles. The source of the primary neoplasm may not be found in up to 30% of patients.”
Sister Mary Joseph's nodule: an unusual but important physical finding characteristic of widespread internal malignancy.
Tso,S et al
The British journal of general practice : the journal of the Royal College of General Practitioners, 63(615), 551–552. - "Sister Mary Joseph’s nodule typically presents as an umbilical or paraumbilical nodule with a firm consistency, varying in size between 0.5–15 cm.The nodule may be painful and discharge fluid. It is important to bear in mind that Sister Mary Joseph’s nodule may be the only presenting complaint in an otherwise well patient; other patients can present in a poor clinical state with additional physical signs such as ascites and pleural effusion. A focused history and examination of the chest, abdomen, and regional lymph nodes may reveal the source of the primary neoplasm. Patients who presented with Sister Mary Joseph’s nodule following treatment of a known neoplasm raise the possibility of its recurrence.”
Sister Mary Joseph's nodule: an unusual but important physical finding characteristic of widespread internal malignancy.
Tso,S et al
The British journal of general practice : the journal of the Royal College of General Practitioners, 63(615), 551–552. - “ Mary Joseph nodule or Sister Mary Joseph Sign refers to a palpable nodule bulging into the umbilicus as a result of metastasis of a malignant cancer in the pelvis or abdomen. Gastrointestinal malignancies account for about half of the underlying sources (gastric, colonic, pancreatic cancer), gynecologic (ovarian, uterine cancer), unknown primary tumors and rarely bladder or respiratory malignancies cause umbilical metastasis. Mechanism of spread of cancer to the umbilicus is unknown but proposed mechanisms include direct transperitoneal spread via lymphatic running along the obliterated umbilical vein, hematogenous spread or via remnant structures like the falciform ligament, median umbilical ligament or a remnant of the umbilical duct.”
Sister Mary Joseph nodule-A case report with review of literature.
Dar IH et al.
J Res Med Sci. 2009 Nov;14(6):385-7. - "Umbilical tumors are relatively rare and can be classified as benign or malignant.1 Malignant tumors can be primary or metastatic tumors. Metastatic tumors arise from a variety of primary malignant tumors. The term “Sister Mary Joseph nodule” is used to describe a malignant umbilical tumor usually associated with advanced metastasizing intra-abdominal cancer and generally indicating a poor prognosis. This sign was first identified by Sister Mary Joseph (1856-1939) who as a surgical assistant to Dr William James Mayo drew attention to the presence of a hard umbilical nodule in a patient being prepared for surgery in 1928.”
Sister Mary Joseph nodule-A case report with review of literature.
Dar IH et al.
J Res Med Sci. 2009 Nov;14(6):385-7. - Background: Pancreatic ductal adenocarcinoma (PDAC) is highly lethal, partly due to challenges in early diag- nosis. However, the prognosis for earlier stages (carcinoma in situ or stage T1a invasive carcinoma) is relatively favorable.
Objective: To investigate findings of an earlier diagnosis of PDAC on pre-diagnostic CT examinations performed at least one year before the diagnosis of clinical stage I PDAC.
CT Abnormalities of the Pancreas Associated With the Subsequent Diagnosis of Clinical Stage I Pancreatic Ductal Adenocarcinoma More Than One Year Later: A Case-Control Study
Fumihito Toshima et al.
AJR 2021(in press) https://doi.org/10.2214/AJR.21.26014 - Conclusion: Most patients with clinical stage I PDAC demonstrated focal pancreatic abnormalities on pre-diag- nostic CT obtained at least one year before diagnosis. Focal MPD change exhibited the shortest duration from its development to subsequent diagnosis, where atrophy and faint enhancement exhibited a relatively prolonged course.
Clinical impact: These findings could facilitate earlier PDAC diagnosis and thus improve prognosis.
CT Abnormalities of the Pancreas Associated With the Subsequent Diagnosis of Clinical Stage I Pancreatic Ductal Adenocarcinoma More Than One Year Later: A Case-Control Study
Fumihito Toshima et al.
AJR 2021(in press) https://doi.org/10.2214/AJR.21.26014 - Results: A focal pancreatic abnormality was present on the most recent pre-diagnostic CT in 55/103 (53.4%) patients with PDAC versus 21/103 (20.4%) control patients (p<.001). In patients with PDAC, the most common focal abnormalities on pre-diagnostic CT were atrophy (39/103, 37.9%), faint enhancement (17/65, 26.2%), and MPD change (14/103, 13.6%), which were all more frequent in patients with PDAC than in control patients (p<.05). In 54/55 (98.2%) patients with PDAC, the PDAC corresponded with the site of a focal abnormality (exact location or the abnormality’s upstream or downstream edge) on pre-diagnostic CT. Frequency of focal abnormalities decreased with increasing time before the CT that detected PDAC (1–2 years before diagnosis, 64.9%; 2–3 years, 49.2%; 3–5 years, 41.8%; 5–7 years, 29.7%; 7–10 years, 18.5%; over 10 years, 0%). Mean duration from the finding’s initial appearance to diagnosis of PDAC was 4.6 years for atrophy, 3.3 years for faint enhancement, and 1.1 years for MPD change.
CT Abnormalities of the Pancreas Associated With the Subsequent Diagnosis of Clinical Stage I Pancreatic Ductal Adenocarcinoma More Than One Year Later: A Case-Control Study
Fumihito Toshima et al.
AJR 2021(in press) https://doi.org/10.2214/AJR.21.26014 - Key finding: A total of 55/103 (53.4%) patients with clinical stage I PDAC had focal pancreatic abnormalities on CT obtained at least one year before diagnosis, most commonly focal atrophy (37.9%), faint enhancement (26.2%), and MPD change (13.6%); atrophy, enhancement, and MPD change appeared 4.6, 3.3, and 1.1 years before diagnosis, respectively. Importance: Focal pancreatic abnormalities predicting subsequent PDAC development, including atrophy, faint enhancement, and MPD change, could allow an earlier diagnosis, thereby improving management and prognosis.
CT Abnormalities of the Pancreas Associated With the Subsequent Diagnosis of Clinical Stage I Pancreatic Ductal Adenocarcinoma More Than One Year Later: A Case-Control Study
Fumihito Toshima et al.
AJR 2021(in press) https://doi.org/10.2214/AJR.21.26014 
CT Abnormalities of the Pancreas Associated With the Subsequent Diagnosis of Clinical Stage I Pancreatic Ductal Adenocarcinoma More Than One Year Later: A Case-Control Study
Fumihito Toshima et al.
AJR (in press) https://doi.org/10.2214/AJR.21.26014
CT Abnormalities of the Pancreas Associated With the Subsequent Diagnosis of Clinical Stage I Pancreatic Ductal Adenocarcinoma More Than One Year Later: A Case-Control Study
Fumihito Toshima et al.
AJR (in press) https://doi.org/10.2214/AJR.21.26014- “According to data compiled by the Japan Pancreatic Cancer Registry, the 5-year survival rate in patients with lesions less than 10 mm is 80.4%, and in patients with stage 0 disease (including CIS) is 85.8% . These data demonstrate the importance of early detection and treatment of PDAC for an improved prognosis. However, patients with lesions smaller than 10 mm or with stage 0 disease account for only 0.8% and 1.7% of all patients, respectively.”
CT Abnormalities of the Pancreas Associated With the Subsequent Diagnosis of Clinical Stage I Pancreatic Ductal Adenocarcinoma More Than One Year Later: A Case-Control Study
Fumihito Toshima et al.
AJR 2021(in press) https://doi.org/10.2214/AJR.21.26014 - "The management of incidentally detected focal atrophy or faint focal enhancement is more controversial given the relatively high frequency of these findings among control patients (7.8% and 9.2%, respectively) and the long duration between their appearance and invasive carcinoma development (4.6 and 3.3 years, respectively). If focal atrophy and faint focal enhancement are seen simultaneously, or if either of these abnormalities progress over time, then it is less likely that the finding represents a false- positive, and further evaluation is more strongly warranted.”
CT Abnormalities of the Pancreas Associated With the Subsequent Diagnosis of Clinical Stage I Pancreatic Ductal Adenocarcinoma More Than One Year Later: A Case-Control Study
Fumihito Toshima et al.
AJR 2021(in press) https://doi.org/10.2214/AJR.21.26014 - "In conclusion, 53.4% of patients diagnosed with clinical stage I PDAC demonstrated focal pancreatic abnormalities on pre-diagnostic CT examinations obtained at least one year before the diagnosis of PDAC. The most common focal abnormality on pre-diagnostic CT in patients who developed PDAC was focal parenchymal atrophy, followed by focal faint parenchymal enhancement and focal MPD change. Among these three findings, focal MPD change exhibited the shortest duration between its new development and the subsequent diagnosis of PDAC, while focal atrophy and faint enhancement exhibited more prolonged duration. These observations could facilitate earlier diagnosis of PDAC and thus improve management and prognosis.”
CT Abnormalities of the Pancreas Associated With the Subsequent Diagnosis of Clinical Stage I Pancreatic Ductal Adenocarcinoma More Than One Year Later: A Case-Control Study
Fumihito Toshima et al.
AJR 2021(in press) https://doi.org/10.2214/AJR.21.26014
- Background: Contrast-enhanced CT performed for pancreatic ductal adenocarcinoma (PDAC) detection traditionally uses a dual-phase (pan- creatic and portal venous) protocol. However, PDAC may exhibit isoattenuation in these phases, hindering detection.
Objective: To assess the impact on diagnostic performance in detection of small PDAC of adding a delayed phase to dual-phase contrast-enhanced CT.
Conclusion: Addition of delayed phase to pancreatic and portal venous phase CT increases sensitivity for small PDAC without loss of specificity, partly related to delayed phase hyperattenuation of some small PDACs showing pancreatic phase isoattenuation.
Clinical Impact: Addition of delayed phase may facilitate earlier PDAC detection and thus improved prognosis.
Adding Delayed Phase Images to Dual-Phase Contrast-Enhanced CT Increases Sensitivity for Small Pancreatic Ductal Adenocarcinoma
Yoshihiko Fukukura et al.
AJR 2021 (in press) - “In this retrospective study, we assessed the benefit of adding delayed phase images to a dual-phase contrast-enhanced CT protocol for the detection of small PDACs. Triple-phase images yielded significantly higher diagnostic accuracy and sensitivity than dual-phase images. The detection of PDAC when small increases the chance of curative surgery. Therefore, the addition of delayed phase imaging may ultimately improve the prognosis of patients with PDAC.”
Adding Delayed Phase Images to Dual-Phase Contrast-Enhanced CT Increases Sensitivity for Small Pancreatic Ductal Adenocarcinoma
Yoshihiko Fukukura et al.
AJR 2021 (in press) - "In conclusion, this study showed that triple-phase contrast-enhanced CT resulted in increased sensitivity and accuracy, without change in specificity, for the detection of small PDAC compared with dual-phase contrast-enhanced CT. This benefit in part related to hyperattenuation in the delayed phase of some small PDACs showing isoattenuation in the pancreatic phase. This change in pancreas CT protocols merits further consideration to potentially achieve earlier detection and thus improved PDAC prognosis.”
Adding Delayed Phase Images to Dual-Phase Contrast-Enhanced CT Increases Sensitivity for Small Pancreatic Ductal Adenocarcinoma
Yoshihiko Fukukura et al.
AJR 2021 (in press)
- “Pancreatic cancer continues to be one of the deadliest malignancies and is the third leading cause of cancer-related mortality in the United States. Based on several models, it is projected to become the second leading cause of cancer-related deaths by 2030. Although the overall survival rate for patients diagnosed with pancreatic cancer is less than 10%, survival rates are increasing in those whose cancers are detected at an early stage, when intervention is possible. There are, however, no reli- able biomarkers or imaging technology that can detect early-stage pancreatic cancer or accurately identify precursors that are likely to progress to malignancy.”
Prediagnostic Image Data, Artificial Intelligence, and Pancreatic Cancer A Tell-Tale Sign to Early Detection
Matthew R. Young et al.
Pancreas 2020;49: 882–886 - "The challenge now is to develop imaging biomarkers and models that can further improve sensitivity for the detection of early-stage PDACs and aggressive neoplasms while mitigating diagnostic uncertainty in evaluation of premalignant abnormalities. Augmented reality, artificial intelligence (AI), and related computa- tional techniques can uncover these subtle patterns, improve image interpretation, and streamline diagnostic workflows.”
Prediagnostic Image Data, Artificial Intelligence, and Pancreatic Cancer A Tell-Tale Sign to Early Detection
Matthew R. Young et al.
Pancreas 2020;49: 882–886 - "Currently, identification of localized pancreatic cancer is mostly incidental as localized pancreatic cancer is asymptomatic. What is urgently needed are minimally invasive screening strategies with a high clinical sensitivity and specificity to identity early-stage cancer and improve these grim statistics. To this end, it is particularly important to develop tests that have high specificity because a false-positive test may trigger unnecessary invasive procedures, which add their own risk of morbidity and mortality.”
Prediagnostic Image Data, Artificial Intelligence, and Pancreatic Cancer A Tell-Tale Sign to Early Detection
Matthew R. Young et al.
Pancreas 2020;49: 882–886 - There are many challenges that need to be mitigated in the development of an image repository to enable AI system development. These include the following:
(1) What are the requirements for defining image annotation?
(2) What are the main concerns with depositing patient imaging data?
(3) What are the definitions of an AI-specific clinical use cases?
(4) What are the benefits and drawbacks of alternative data sharing in facilitating AI development? - "Little is known about the other histologic subtypes of PDAC, mainly because of their rarity and lack of specific patterns of disease manifestation. According to the World Health Organization, these variants include adenosquamous carcinoma, colloid carcinoma, hepatoid carcinoma, medullary carcinoma, signet ring cell carcinoma, undifferentiated carcinoma with osteoclast-like giant cells, and undifferentiated carcinoma. Depending on the subtype, they can confer a better or even worse prognosis than that of conventional PDAC.”
Pancreatic Ductal Adenocarcinoma and Its Variants: Pearls and Perils
Schawkat K et al.
RadioGraphics 2020; 40:0000–0000 - "The pathogenesis of PDAC follows a series of stepwise mutations from normal pancreatic tissue that first forms a precursor lesion and eventually mutates to an invasive malignancy (15).The most common neoplastic precursor lesions of PDAC are pancreatic intraepithelial neoplasms, which are microscopic tumors (<5 mm) that are not directly visible at pancreatic imaging (16). Less frequently, PDAC can evolve from intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystic neoplasms.”
Pancreatic Ductal Adenocarcinoma and Its Variants: Pearls and Perils
Schawkat K et al.
RadioGraphics 2020; 40:0000–0000 - “Adenosquamous carcinoma (ASqC) of the pancreas is a malignant epithelial neoplasm, which is defined at pathologic examination as a mixed tumor with ductal and squamous differentiation, with at least a 30% squamous component. ASqC is a rare and still poorly understood variant of PDAC that accounts for only 1%–4% of exocrine pancreatic malignancies.”
Pancreatic Ductal Adenocarcinoma and Its Variants: Pearls and Perils
Schawkat K et al.
RadioGraphics 2020; 40:0000–0000 - "The imaging features of ASqC tumors correlate with the pathologic features and are usually seen as large round lobulated masses with extensive central necrosis and progressive enhancement of the fibrous capsule. The presence of extensive central tumor necrosis was suggested by several reports to be a characteristic imaging feature.The pronounced peripheral enhancement, mostly described as ring enhancement, is gradual progressive enhancement, presumably reflective of progressive accumulation of contrast material in the interstitial space of the fibrous tissue.”
Pancreatic Ductal Adenocarcinoma and Its Variants: Pearls and Perils
Schawkat K et al.
RadioGraphics 2020; 40:0000–0000 - "Colloid carcinoma of the pancreas is characterized by mucin-producing neoplastic ductal epithelial cells dispersed in an accumulation of extracellular mucin. According to the definition by the WHO, the mucinous component should comprise at least 50% of the tumor. Colloid carcinoma accounts for only 1%–3% of all exocrine pancreatic malignancies and has a patient age and sex distribution similar to those of PDAC.”
Pancreatic Ductal Adenocarcinoma and Its Variants: Pearls and Perils
Schawkat K et al.
RadioGraphics 2020; 40:0000–0000 - "Although colloid carcinomas are not true cystic tumors, the abundant mucin production leads to a cystic appearance at imaging.There- fore, these tumors can be confused with mainly cystic tumors, such as IPMNs or mucinous cystic adenocarcinomas. At imaging, colloid carcinomas manifest with a lobulated contour and indiscrete margins.”
Pancreatic Ductal Adenocarcinoma and Its Variants: Pearls and Perils
Schawkat K et al.
RadioGraphics 2020; 40:0000–0000 - "Hepatoid carcinoma (HC) of the pancreas is a primary extrahepatic epithelial malignancy that re- sembles hepatocellular carcinoma (HCC) in terms of morphologic and immunohistochemical properties. On histological specimens, HC is heterogeneous, showing either pure hepatoid differentiation or areas more common to pancreatic neoplasms such as PDAC or neuroendocrine tumors.”
Pancreatic Ductal Adenocarcinoma and Its Variants: Pearls and Perils
Schawkat K et al.
RadioGraphics 2020; 40:0000–0000 - "Medullary carcinoma of the pancreas (MCP) is characterized by a syncytial growth pattern of poorly differentiated highly pleomorphic cells that are accompanied by extensive necrosis. The tumor displays a lymphocytic reaction and clearly defined borders. Microsatellite instability (MSI+) is apparent with polymerase chain reaction. On the basis of our experience, MCP manifests at imaging as a well-circumscribed mass with central hypoenhancement at contrast-enhanced CT, corresponding to hyperintensity with a hypointense rim at T2-weighted MRI.”
Pancreatic Ductal Adenocarcinoma and Its Variants: Pearls and Perils
Schawkat K et al.
RadioGraphics 2020; 40:0000–0000 - "Undifferentiated carcinoma with osteoclast-like giant cells (UCOGC) of the pancreas is a malignant epithelial neoplasm of the pancreas and a histologic variant of PDAC. Histopathologic evaluation reveals at least two distinct but intermixed cell populations: pleomorphic neoplastic mononuclear cells and large nonneoplastic multinucleated osteoclast- like giant cells. Focal intratumoral osteoid formation may be associated.”
Pancreatic Ductal Adenocarcinoma and Its Variants: Pearls and Perils
Schawkat K et al.
RadioGraphics 2020; 40:0000–0000 - “NCCN guidelines classify the resectability of localized PDAC based on preoperative imaging findings into resect- able, borderline resectable, and locally advanced disease and are summarized in Table 3. Arterial abutment (<180 degrees) is considered borderline resectable, whereas arterial encasement (≥180 degrees) is usually considered locally advanced (exception noted below) . Venous abutment, encasement, or thrombosis are considered borderline resectable, as long as the venous segment is reconstructable. Unreconstructable venous involvement is considered locally advanced.102 NCCN guidelines share many common fea- tures with other guidelines (Table 4), with the no- table exception of celiac artery encasement (>180 degrees).”
Multidisciplinary Standards of Care and Recent Progress in Pancreatic Ductal Adenocarcinoma
Aaron J. Grossberg, Linda C. Chu, Christopher R. Deig, Elliot K. Fishman, et al.
CA Cancer J Clin. 2020 Jul 19. doi: 10.3322/caac.21626. - "Despite being relatively uncommon, PDAC is expected to become the second leading cause of cancer death by the end of the decade.The vast majority of patients diagnosed with PDAC in 2020 will die of the disease. On the other hand, 5-year survival among all patients has eclipsed double digits for the first time. Led by improvements in the effectiveness of systemic therapy, an increase in the proportion of patients with early-stage disease, and stage-specific treatment paradigms, a true separation in expected survival is widening between patients with resectable cancer and those with locally advanced or metastatic disease.”
Multidisciplinary Standards of Care and Recent Progress in Pancreatic Ductal Adenocarcinoma
Aaron J. Grossberg, Linda C. Chu, Christopher R. Deig, Elliot K. Fishman, et al.
CA Cancer J Clin. 2020 Jul 19. doi: 10.3322/caac.21626. - "Interpretation of images can be challenging due to intrinsic tumor features (including small and isoenhancing masses, exophytic masses, subtle pancreatic duct irregularities, and diffuse tumor infiltration), presence of coexisting pathology (including chronic pancreatitis and intraductal papillary mucinous neoplasm), mimickers of PDAC (including focal fatty infiltration and focal pancreatitis), distracting findings, and satisfaction of search. Awareness of pitfalls associated with the diagnosis of PDAC along with the strategies to avoid them will help radiologists to minimize technical and interpretation errors. Cognizance and mitigation of these errors can lead to earlier PDAC diagnosis and ultimately improve patient prognosis.”
Pitfalls in the MDCT of pancreatic cancer: strategies for minimizing errors.
Abdom Radiol 45, 457–478 (2020).
Haj-Mirzaian A, Kawamoto S, Zaheer A, Hruban RH, Fishman EK, Chu LC. - “Pancreatic cancer has been associated with the development of diabetes within 4 years before the cancer diagnosis in up to 20% of patients.In the present study, recent-onset diabetes was associated with a 3-fold higher adjusted risk of pancreatic cancer and a 0.29% pancreatic cancer risk at 4 years, which was consistent with findings in previous studies evaluating physician-diagnosed diabetes.”
Diabetes, Weight Change, and Pancreatic Cancer Risk.
Yuan C, Babic A, Khalaf N, et al.
JAMA Oncol. Published online August 13, 2020. doi:10.1001/jamaoncol.2020.2948 - "In this study, recent-onset diabetes accompanied by weight loss was associated with a substantial increase in risk for pancreatic cancer and may represent a high-risk group in the general population for whom early detection strategies would be advantageous. Further elevation of risk was seen in individuals with older age, previous healthy weight, and no intentional weight loss.”
Diabetes, Weight Change, and Pancreatic Cancer Risk.
Yuan C, Babic A, Khalaf N, et al.
JAMA Oncol. Published online August 13, 2020. doi:10.1001/jamaoncol.2020.2948
- “Currently, the operative mortality for pancreaticoduodenectomy is consistently reported as less than 3% at high volume facilities. Numerous studies have demonstrated the association of higher surgical volume and improved postoperative outcomes. Undoubtably, the centralization of care at centers of excellence has helped improve postoperative outcomes through better patient selection, overcoming the learning curve associated with technical proficiency, and early recognition and rescue from complications.”
Pancreatic cancer treatment: better, but a long way to go
Robert J. Torphy · Yuki Fujiwara · Richard D. Schulick
Surgery Today https://doi.org/10.1007/s00595-020-02028-0 
Pancreatic cancer treatment: better, but a long way to go
Robert J. Torphy · Yuki Fujiwara · Richard D. Schulick
Surgery Today https://doi.org/10.1007/s00595-020-02028-0- "Globally, it is estimated that 20% of pancreatic cancer deaths are attributable to smoking, 9% to diabetes, and 6% to obesity. These risk factors in combination may even be multiplica- tive. Inherited genetic predisposition accounts for approximately 5–10% of pancreatic cancer cases. Hereditary risk factors include multiple hereditary tumor predispositions syndromes, hereditary pancreatitis, and familial pancreatic cancer.”
Pancreatic cancer treatment: better, but a long way to go
Robert J. Torphy · Yuki Fujiwara · Richard D. Schulick
Surgery Today https://doi.org/10.1007/s00595-020-02028-0 - "Collectively, we have made substantial progress in the treat- ment of pancreatic cancer. Surgically, we have progressed from the first reports of pancreatic resections in the late 1800 s and early 1900s, to operative mortality rates of lower than 3% in the 1980s, and now to minimally invasive pancreatic resections. Medically, we have progressed from a nihilistic view of the treatment of pancreatic cancer in the 1960s, to the first randomized trials of adjuvant therapy in the 1980s, and now to new trials of neoadjuvant therapy. As we continue to make strides towards better treating pancreatic cancer, future areas of focus will include improving prevention and early detection, refining our molecular under- standing of pancreatic cancer, developing more effective systemic therapies, improving quality of life and surgical outcomes, and multidisciplinary care of our patients.”
Pancreatic cancer treatment: better, but a long way to go
Robert J. Torphy · Yuki Fujiwara · Richard D. Schulick
Surgery Today https://doi.org/10.1007/s00595-020-02028-0
- “Incidentally detected pancreatic adenocarcinomas in the pancreas body/tail were characterized by an earlier tumor stage than in cases of symptomatically detected pancreatic adenocarcinoma. Several CT findings prior to the detection of a tumor may be useful for the early detection of pancreatic adenocarcinoma during the follow-up for other diseases.”
Incidentally detected pancreatic adenocarcinomas on computed tomography obtained during the follow‐up for other diseases
Higashi M et al.
Abdominal Radiology (2020) 45:774–781 - “In this study, incidentally detected pancreatic adenocarcinomas were more likely to localize in the body or tail of the pancreas than the head (body/tail, 64.3% vs. head, 35.7%), although the distribution of tumor location showed no statistically significant differences between the incidental group and non-incidental group. This fact suggests that tumor-induced symptoms may be less likely to occur in the body or tail of the pancreas than the head.”
Incidentally detected pancreatic adenocarcinomas on computed tomography obtained during the follow‐up for other diseases
Higashi M et al.
Abdominal Radiology (2020) 45:774–781 - “Loss of fatty marbling, which has been reported as an imaging finding suggestive of the presence of pancreatic cancer, may reflect intrapancreatic or extrapancreatic neural invasion by pancreatic cancers or associated pancreatitis. Preserved lobulation may reflect tumors being less likely to spread and destroy normal pan- creatic parenchyma.”
Incidentally detected pancreatic adenocarcinomas on computed tomography obtained during the follow‐up for other diseases
Higashi M et al.
Abdominal Radiology (2020) 45:774–781 - "As we mentioned, incidentally detected pancreatic adenocarcinomas in the body/tail of the pancreas tend to be characterized by preserved lobulation and fatty marbling, indicating limited morphologic changes in the pancreatic parenchyma. Therefore, physicians must pay close attention to the presence of hypoattenuated lesions with delayed enhancement for the early detection of incidental pancreatic adenocarcinoma during follow-up CT for other diseases.”
Incidentally detected pancreatic adenocarcinomas on computed tomography obtained during the follow‐up for other diseases
Higashi M et al.
Abdominal Radiology (2020) 45:774–781 - “In conclusion, incidentally detected pancreatic adenocarcinomas in the body or tail of the pancreas were characterized by an earlier tumor stage than symptomatically detected pancreatic adenocarcinomas. Being alert for several CT findings prior to the detection of a tumor may contribute to the early detection of pancreatic adenocarcinomas during the follow-up for other diseases.”
Incidentally detected pancreatic adenocarcinomas on computed tomography obtained during the follow‐up for other diseases
Higashi M et al.
Abdominal Radiology (2020) 45:774–781 - Purpose To assess the role of CT-texture analysis (CTTA) for differentiation of pancreatic ductal adenocarcinoma (PDAC) from pancreatic neuroendocrine neoplasm (PNEN) in the portal-venous phase as compared with visual assessment and tumor-to-pancreas attenuation ratios
Conclusions Our data indicate that CTTA is a feasible tool for differentiation of PNEN from PDAC and also of G1 from G2/3 PNEN in the portal-venous phase. Visual assessment and tumor-to-parenchyma ratios were not useful for discrimination.
Complementary role of computed tomography texture analysis for differentiation of pancreatic ductal adenocarcinoma from pancreatic neuroendocrine tumors in the portal‐venous enhancement phase
Christian Philipp Reinert et al.
Abdominal Radiology (2020) 45:750–758 - “The most current guidelines from the NCCN place patients with PDAC into one of three broad groups: resectable, borderline resectable, and unresectable disease based pre- dominantly on imaging findings. The NCCN’s clinical practice guidelines for PDAC are a consensus statement to aid diagnosis and treatment. The guidelines are reviewed and updated on a continu- ing basis to ensure that the recommendations consider the most current evidence. This section provides an overview of the most recent version of the NCCN guidelines for PDAC (version 2.2019—April 9, 2019).”
White paper on pancreatic ductal adenocarcinoma from society of abdominal radiology’s disease‐focused panel for pancreatic ductal adenocarcinoma: Part I, AJCC staging system, NCCN guidelines, and borderline resectable disease
Kulkarni NM et al.
Abdominal Radiology (2020) 45:716–728 
White paper on pancreatic ductal adenocarcinoma from society of abdominal radiology’s disease‐focused panel for pancreatic ductal adenocarcinoma: Part I, AJCC staging system, NCCN guidelines, and borderline resectable disease
Kulkarni NM et al.
Abdominal Radiology (2020) 45:716–728- "CT is recommended as the preferred technique owing to its wide availability, superior spatial resolution, and rapid acquisition. In addition, clinicians from various specialties (e.g., surgeons, radiation oncologists etc.) have better familiarity with CT than MRI. MRI is therefore recommended as an adjunct tool when CT findings are indeterminate (small pancreatic tumors or liver lesions), or when contrast-enhanced CT is not possible due to a life-threatening allergy to iodinated contrast agent.”
White paper on pancreatic ductal adenocarcinoma from society of abdominal radiology’s disease‐focused panel for pancreatic ductal adenocarcinoma: Part I, AJCC staging system, NCCN guidelines, and borderline resectable disease
Kulkarni NM et al.
Abdominal Radiology (2020) 45:716–728 - "The NCCN suggests that PET/CT be considered following a dedicated pancreatic protocol CT in those patients who are at high risk for distant/disseminated disease (such as large primary tumors or large regional lymph nodes, borderline resectable disease, markedly elevated CA19-9, excessive weight loss and/or marked symptomatology such as severe abdominal pain).”
White paper on pancreatic ductal adenocarcinoma from society of abdominal radiology’s disease‐focused panel for pancreatic ductal adenocarcinoma: Part I, AJCC staging system, NCCN guidelines, and borderline resectable disease
Kulkarni NM et al.
Abdominal Radiology (2020) 45:716–728 - “In addition to the above measures, serum CA 19-9 level (drawn following biliary decompression and with confirmation that serum bilirubin levels have normalized) and baseline standard laboratory studies are also recommended. Not all patients with PDAC have tumors that express CA 19-9, a sialylated Lewis A blood group antigen. CA 19-9 can be a good diagnostic and prognostic marker in those tumors that express it. Preoperative CA 19-9 levels have shown correlation with resectability and can provide additional information for staging. The NCCN recommends measurement of serum CA 19-9 levels before and after neoadjuvant treatment, before surgery, immediately prior to adjuvant treatment, and for the purposes of surveillance.”
White paper on pancreatic ductal adenocarcinoma from society of abdominal radiology’s disease‐focused panel for pancreatic ductal adenocarcinoma: Part I, AJCC staging system, NCCN guidelines, and borderline resectable disease
Kulkarni NM et al.
Abdominal Radiology (2020) 45:716–728 - "Surgical resection is currently the only potentially curative option for PDAC. The median survival of resected patients after adjuvant therapy ranges from 20.1 to 28.0 months even in optimal clinical trial conditions. Patient selection should be based on the probability of achieving an R0 resection; R0 means a negative resection margin based on assessment with microscopy. Small tumor size, R0 margin, and N0 (node-negative) status are the strongest predictors of long- term patient survival. The guidelines advise that patient performance status, symptom burden, and comorbidity profile also be utilized to identify those patients who can undergo major surgery.”
White paper on pancreatic ductal adenocarcinoma from society of abdominal radiology’s disease‐focused panel for pancreatic ductal adenocarcinoma: Part I, AJCC staging system, NCCN guidelines, and borderline resectable disease
Kulkarni NM et al.
Abdominal Radiology (2020) 45:716–728 - “Unlike patients with clearly resectable disease, patients with borderline resectable disease are at high risk for a positive surgical margin and recurrence in the setting of upfront surgery. For patients with borderline resectable disease, the aim of neoadjuvant therapy is to sufficiently treat the tumor so that a negative resection margin can be achieved even though such a change may not be apparent at imaging.”
White paper on pancreatic ductal adenocarcinoma from society of abdominal radiology’s disease‐focused panel for pancreatic ductal adenocarcinoma: Part I, AJCC staging system, NCCN guidelines, and borderline resectable disease
Kulkarni NM et al.
Abdominal Radiology (2020) 45:716–728 - “The current NCCN criteria for borderline resectable disease are based on cross-sectional imaging features for arterial involvement. Borderline resectable disease is defined as solid tumor contact with the common hepatic artery (CHA) without extension to the celiac axis (CA) or hepatic artery (HA) bifurcation, (2) ≤ 180° involvement of the SMA and/or celiac axis (CA), and solid tumor contact with variant arterial anatomy .The NCCN makes an exception for greater than 180° involvement of the CA if the aorta and gastroduodenal artery (GDA) are uninvolved, and the surgeons are able to perform an arterial anastomosis (modified Appleby procedure).”
White paper on pancreatic ductal adenocarcinoma from society of abdominal radiology’s disease‐focused panel for pancreatic ductal adenocarcinoma: Part I, AJCC staging system, NCCN guidelines, and borderline resectable disease
Kulkarni NM et al.
Abdominal Radiology (2020) 45:716–728 - "Surgical resection with R0 margin is the only potentially curative option for PDAC. Unfortunately, only a small subset of patients present at an early enough stage that a potentially curative resection can be considered. Determining resectability and predicting prognosis for PDAC are dependent on accurate staging of the disease. The primary goal of the most recent revision of the AJCC staging system is to aid in the determination of a given patient’s prognosis. In contrast, clinical management guidelines based on clinical and radiographic examinations have been developed by several societies; one of the most notable and comprehensive being those of the NCCN.”
White paper on pancreatic ductal adenocarcinoma from society of abdominal radiology’s disease‐focused panel for pancreatic ductal adenocarcinoma: Part I, AJCC staging system, NCCN guidelines, and borderline resectable disease
Kulkarni NM et al.
Abdominal Radiology (2020) 45:716–728
- “Neoplastic lesions such as high-grade NETs, small SPTs, and metastases and inflammatory lesions including focal AIP and groove pancreatitis can mimic PDAC. Abrupt narrow- ing of a dilated pancreatic duct is a usual imaging finding of PDAC. Although some mimics occasionally accompany pancreatic duct dilatation, they have points of differential diagnosis: presence of tumor thrombus and hypervascular liver metastases, absence of adjacent vascular invasion, and delayed enhancement pattern.”
Pancreas Ductal Adenocarcinoma and its Mimics: Review of Cross- sectional Imaging Findings for Differential Diagnosis.
Kim, SS, et al.
Journal of the Belgian Society of Radiology. 2018; 102(1): 71, 1–8. - Background: The incidence of occult metastatic disease (OMD) in pancreatic ductal adenocarcinoma (PDAC) and associated risk factors are largely unknown.
Conclusions: Occurrence of OMD in PDAC accounts for 8% of cases. Preoperative CA 19‐9 > 192 U/mL, primary tumor size > 30 mm, and identification of indeterminate lesions in preoperative CT may indicate the need for diagnostic laparoscopy.
Incidence and risk factors for abdominal occult metastatic disease in patients with pancreatic adenocarcinoma
Georgios Gemenetzis MD1 | Vincent P. Groot MD1 | Alex B. Blair MD1 |Ding Ding MD, MS1 | Sameer S. Thakker1 | Elliot K. Fishman MD2 | John L. Cameron MD1 | Martin A. Makary MD1 | Matthew J. Weiss MD1 | Christopher L. Wolfgang MD, PhD1 | Jin He MD, PhD1 J Surg Oncol. 2018;1-8. - “As expected, OMD patients had unfavorable outcomes. The median postoperative survival for this cohort was 6 months, similar to patients with metastatic disease at diagnosis.44 A more specific difference on survival based on the site of occult metastases was not identified, probably due to the small cohort size. When compared with historic postoperative survival rates in resectable PDAC,20 survival rates were significantly lower.”
Incidence and risk factors for abdominal occult metastatic disease in patients with pancreatic adenocarcinoma
Georgios Gemenetzis MD1 | Vincent P. Groot MD1 | Alex B. Blair MD1 |Ding Ding MD, MS1 | Sameer S. Thakker1 | Elliot K. Fishman MD2 | John L. Cameron MD1 | Martin A. Makary MD1 | Matthew J. Weiss MD1 | Christopher L. Wolfgang MD, PhD1 | Jin He MD, PhD1 J Surg Oncol. 2018;1-8. - The occurrence of OMD accounts for approximately 8% of patients with PDAC. Preoperative increased CA 19‐9 values, abdominal pain at presentation, and identification of indeterminate lesions and primary tumor size larger than 30 mm in preoperative MDCT suggest increased risk for OMD and may indicate the need for diagnostic laparoscopy. Patient assessment in a multidisciplinary setting within high‐volume centers can increase the yield of accurate preoperative identification of patients with OMD and direct appropriate treatment accordingly.
Incidence and risk factors for abdominal occult metastatic disease in patients with pancreatic adenocarcinoma
Georgios Gemenetzis MD1 | Vincent P. Groot MD1 | Alex B. Blair MD1 |Ding Ding MD, MS1 | Sameer S. Thakker1 | Elliot K. Fishman MD2 | John L. Cameron MD1 | Martin A. Makary MD1 | Matthew J. Weiss MD1 | Christopher L. Wolfgang MD, PhD1 | Jin He MD, PhD1 J Surg Oncol. 2018;1-8.
- "Management changes included a change in diagnosis in 8.7%, change in clinical stage in 8.7%, change in treatment in 17.9%, and further workup needed in 19.0% of patients, respectively. No change in management occurred in the remaining 61.5% of cases."
Subspecialized radiology review at multidisciplinary pancreas conference: impact on patient management.
Chingkoe CM et al.
Abdom Radiol (NY). 2018 Oct;43(10):2783-2789 - "Subspecialized abdominal radiologist reinterpretation in the context of more comprehensive patient information heavily impacts the multidisciplinary management of patients with pancreatic disorders."
Subspecialized radiology review at multidisciplinary pancreas conference: impact on patient management.
Chingkoe CM et al.
Abdom Radiol (NY). 2018 Oct;43(10):2783-2789
- “Pancreatic ductal adenocarcinoma (PDA) accounts for over 90% of all pancreatic malignancies and is the second most common digestive-system cancer after colorectal cancer in the United States. PDA is the third cause of cancer deaths in the United States, with about 53670 new diagnoses and 43090 deaths in 2017. PDA has a sharply rising incidence and is predicted to become the second most common cause of cancer deaths in the United States by 2020 .”
Pancreatic adenocarcinoma staging in the era of Preoperative Chemotherapy and Radiation therapy Zins M et al. Radiology 2018; 287:374–390 - “The risk factors associated with PDA include smoking, long-standing diabetes, obesity, and nonhereditary chronic pancreatitis. Over 80% of PDAs are due to sporadic mutations and fewer than 10% are due to inherited germline mutations.”
Pancreatic adenocarcinoma staging in the era of Preoperative Chemotherapy and Radiation therapy Zins M et al. Radiology 2018; 287:374–390 - “Genetic syndromes and genes known to be associated with an increased risk of PDA are hereditary pancreatitis (PRSS1, SPINK1), familial atypical multiple mole melanoma syndrome (p16), hereditary breast and ovarian cancer syndromes (BRCA1, BRCA2, PALB2), Peutz-Jeghers syndrome (STK11), and hereditary nonpolyposis colon cancer or Lynch syndrome (MLH1, MSH2, MSH6).”
Pancreatic adenocarcinoma staging in the era of Preoperative Chemotherapy and Radiation therapy Zins M et al. Radiology 2018; 287:374–390 - “Patients with pancreatic ductal adenocarcinoma (PDA) must be selected for first-line surgery based on the likelihood of achieving complete curative resection with negative margins (R0); in doubtful cases and when the risk of incomplete resection (R1 or R2) is high, neoadjuvant chemotherapy and radiation therapy should be performed.”
Pancreatic adenocarcinoma staging in the era of Preoperative Chemotherapy and Radiation therapy Zins M et al. Radiology 2018; 287:374–390 - “Excellent spatial resolution makes multidetector CT the reference standard for initial PDA staging; multidetector CT is particularly effective in assessing unresectability criteria related to vascular spread.”
Pancreatic adenocarcinoma staging in the era of Preoperative Chemotherapy and Radiation therapy Zins M et al. Radiology 2018; 287:374–390 - “In patients undergoing neoadjuvant therapy, a radiologic response, however limited, and more specifically decreased vascular involvement and/or tumor size, indicate high likelihood of complete resection with negative margins and therefore support resection surgery.”
Pancreatic adenocarcinoma staging in the era of Preoperative Chemotherapy and Radiation therapy Zins M et al. Radiology 2018; 287:374–390 - “PDA is diagnosed at an advanced stage (T3 or T4) in the majority of patients. Thus, at diagnosis, only 20% of patients meet the criteria for complete resection surgery, which offers the only chance for a cure, with 5-year survival rates of up to 15%–25% in high-volume centers.”
Pancreatic adenocarcinoma staging in the era of Preoperative Chemotherapy and Radiation therapy Zins M et al. Radiology 2018; 287:374–390 
Pancreatic adenocarcinoma staging in the era of Preoperative Chemotherapy and Radiation therapy Zins M et al. Radiology 2018; 287:374–390
Pancreatic adenocarcinoma staging in the era of Preoperative Chemotherapy and Radiation therapy Zins M et al. Radiology 2018; 287:374–390- “Multidetector CT depicts peri- neural invasion as infiltrating extrapancreatic soft tissue extending directly from the intrapancreatic tumor along an established perineural pathway of PDA spread. In some patients with R0 resection, perineural invasion may explain the occurrence of rapid systemic subclinical spread to pre- viously unaffected pancreatic zones or to the retroperitoneum leading to early treatment failure.”
Pancreatic adenocarcinoma staging in the era of Preoperative Chemotherapy and Radiation therapy Zins M et al. Radiology 2018; 287:374–390 - “This body of evidence establishes that neoadjuvant therapy in patients with borderline resectable or even locally advanced PDA can induce a response that allows secondary nega- tive-margin resection of the primary tumor, with acceptable morbidity and survival rates that compare favorably with those obtained in patients who have initially resectable tumors.”
Pancreatic adenocarcinoma staging in the era of Preoperative Chemotherapy and Radiation therapy Zins M et al. Radiology 2018; 287:374–390 - “The mechanisms underlying the diminished performance of imaging studies after neoadjuvant therapy are related to the nature of PDA. The tumor is composed of extensive and dense fibrous stroma containing varying densities of tumor cells. When successful, CRT decreases or eliminates the cancer cells but leaves the preexisting fibrotic tissue and may induce the development of additional fibrosis. This fibrotic component results in persistent high attenu- ation of the perivascular fat, which may be mistakenly interpreted as indicating persistent vascular invasion.”
Pancreatic adenocarcinoma staging in the era of Preoperative Chemotherapy and Radiation therapy Zins M et al. Radiology 2018; 287:374–390 - “Initial PDA staging relies chiefly on optimal-quality multiphasic multidetector CT of the pancreas. The findings serve to help accurately classify the tumor based on relationships with the blood vessels, thereby guiding treatment decisions. MR imaging should be performed routinely if the tumor is potentially resectable to look for liver metastases or not visualized at multidetector CT. Evaluating the treatment response to first-line CRT remains extremely challenging with current imaging techniques. The high risk of underestimating the histologic response warrants surgery in most patients without indisputable evidence of disease progression after CRT.”
Pancreatic adenocarcinoma staging in the era of Preoperative Chemotherapy and Radiation therapy Zins M et al. Radiology 2018; 287:374–390
- “As for the evaluation of the tumor-vascular circumferential contact, our results show that the progression of tumor-vascular contact on MDCT was frequent after CRT, which is concordant with the findings of previous studies. However, the frequency of progression in tumor contact did not show a significant difference between resectable and unresectable diseases.”
Preoperative MDCT Assessment of Resectability in Borderline Resectable Pancreatic Cancer: Effect of Neoadjuvant Chemoradiation Therapy Joo I et al. AJR 2018; 210:1059–1065 - “Our study also found that patients who re- ceived neoadjuvant CRT showed a higher fre- quency of local resectability than did those who underwent upfront surgery (60% [9/15] vs 20% [3/15]), which is in good agreement with recent studies. Given the relatively high resectability after neoadjuvant CRT but insufficient accuracy of MDCT, surgical exploration might be considered even for those considered to have imaging-based unresectable diseases after neoadjuvant CRT.”
Preoperative MDCT Assessment of Resectability in Borderline Resectable Pancreatic Cancer: Effect of Neoadjuvant Chemoradiation Therapy Joo I et al. AJR 2018; 210:1059–1065 - “In conclusion, in patients with borderline resectable pancreatic cancers, neoadjuvant CRT did not significantly decrease the diagnostic performance of MDCT for the prediction of local resectability. However, by considering the interval changes in imaging features during CRT, MDCT may provide better sensitivity for locally resectable diseases.”
Preoperative MDCT Assessment of Resectability in Borderline Resectable Pancreatic Cancer: Effect of Neoadjuvant Chemoradiation Therapy Joo I et al. AJR 2018; 210:1059–1065
- “Second-opinion review by subspecialized oncologic radiologists can impact patient care, specifically in terms of management decision.”
Does Second Reader Opinion Affect Patient Management in Pancreatic Ductal Adenocarcinoma? Corrias G et al. Academic Radiology (in press) - “Cancer staging differed in 13% (9 of 65) of cases for surgeon 1 and in 18.4% (12 of 65) for surgeon 2. Patient management changed in 38.4% (25 of 65) of cases for surgeon 1 and in 20% (13 of 65) for surgeon 2. When compared to the pathologic staging gold standard, second opinion was correct in 85.7% (six of seven) of the time for both surgeons. Recommended patient management from second-opinion reports showed good agreement with the reference standard (weighted K = 0.6467 [0.4014–0.892] and weighted K = 0.6262 [0.3954–0.857] for surgeon 2).”
Does Second Reader Opinion Affect Patient Management in Pancreatic Ductal Adenocarcinoma? Corrias G et al. Academic Radiology (in press) - “In conclusion, our results indicate that second-opinion review by subspecialized oncology radiologists can impact patient care, specifically in terms of management decision. Our findings support the notion that subspecialty radiologic training and subspecialty expertise influence patient care in the setting of multidisciplinary, disease-specific, team-based medicine. Moreover, second-opinion consultations should be viewed as a valuable and reimbursable clinical service within the field of radiology.”
Does Second Reader Opinion Affect Patient Management in Pancreatic Ductal Adenocarcinoma? Corrias G et al. Academic Radiology (in press) - “Pancreatic cancer (PC) has a poor prognosis due to delayed diagnosis. Early diagnosis is the most important factor for improving prognosis. For early diagnosis of PC, patients with clinical manifestations suggestive of PC and high risk for developing PC need to be selected for examinations for PC. Signs suggestive of PC (e.g., symptoms, diabetes mellitus, acute pancreatitis, or abnormal results of blood examinations) should not be missed, and the details of risks for PC (e.g., familial history of PC, intraductal mucin producing neoplasm, chronic pancreatitis, hereditary pancreatitis, or life habit) should be understood. Multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) can be performed for diagnosing PC, but the diagnostic ability of these examinations for PC is limited. Endoscopic diagnostic procedures, such as endoscopic ultrasonography, including fine-needle aspiration, and endoscopic retrograde pancreatocholangiography, including Serial Pancreatic-juice Aspiration Cytologic Examination (SPACE), could be recommended for a detailed examination to diagnose pancreatic carcinoma earlier.”
Early Diagnosis to Improve the Poor Prognosis of Pancreatic Cancer Masataka Kikuyama et al. Cancers 2018, 10, 48; doi:10.3390/cancers10020048 - “Pancreatic cancer (PC) has a poor prognosis due to delayed diagnosis. Early diagnosis is the most important factor for improving prognosis. For early diagnosis of PC, patients with clinical manifestations suggestive of PC and high risk for developing PC need to be selected for examinations for PC. Signs suggestive of PC (e.g., symptoms, diabetes mellitus, acute pancreatitis, or abnormal results of blood examinations) should not be missed, and the details of risks for PC (e.g., familial history of PC, intraductal mucin producing neoplasm, chronic pancreatitis, hereditary pancreatitis, or life habit) should be understood. Multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) can be performed for diagnosing PC, but the diagnostic ability of these examinations for PC is limited.”
Early Diagnosis to Improve the Poor Prognosis of Pancreatic Cancer Masataka Kikuyama et al. Cancers 2018, 10, 48; doi:10.3390/cancers10020048 - “Signs suggestive of PC (e.g., symptoms, diabetes mellitus, acute pancreatitis, or abnormal results of blood examinations) should not be missed, and the details of the risks for PC (e.g., familial history of PC, intraductal mucin producing neoplasm, chronic pancreatitis, hereditary pancreatitis, or life habit) should be understood in order to diagnose PC at an early stage to improve its prognosis.”
Early Diagnosis to Improve the Poor Prognosis of Pancreatic Cancer Masataka Kikuyama et al. Cancers 2018, 10, 48; doi:10.3390/cancers10020048
- “Stage III borderline resectable tumor is characterized by a localized tumor abutting a major artery, including the celiac artery, common hepatic artery, or SMA. With regard to the portovenous axis, any degree of involvement falls into the category of borderline resectable disease as long as the vein can be technically resected and reconstructed.”
Tumor-Vessel Relationships in Pancreatic Ductal Adenocarcinoma at Multidetector CT: Different Classification Systems and Their Influence on Treatment Planning Zaky AM, Wolfgang CL, Weiss MJ, Javed AA, Fishman EK, Zaheer A RadioGraphics 2017; 37:93–112 - “The wall of the artery is thicker than that of the vein, and the flow rate in the artery is higher than that in the vein, so any change in the caliber of the artery or the presence of throm- bus in the artery carries a higher risk of invasion than those findings in the vein.”
Tumor-Vessel Relationships in Pancreatic Ductal Adenocarcinoma at Multidetector CT: Different Classification Systems and Their Influence on Treatment Planning Zaky AM, Wolfgang CL, Weiss MJ, Javed AA, Fishman EK, Zaheer A RadioGraphics 2017; 37:93–112 - “The change of the normal shape of the portal vein or SMV to a teardrop shape on axial multidetector CT images that is caused by tumor encasement or by tethering by adjacent fibrosis is referred to as the “teardrop sign” and is highly associated with vascular invasion.”
Tumor-Vessel Relationships in Pancreatic Ductal Adenocarcinoma at Multidetector CT: Different Classification Systems and Their Influence on Treatment Planning Zaky AM, Wolfgang CL, Weiss MJ, Javed AA, Fishman EK, Zaheer A RadioGraphics 2017; 37:93–112 - “The change of the normal shape of the portal vein or SMV to a teardrop shape on axial multidetector CT images that is caused by tumor encasement or by tethering by adjacent fibrosis is referred to as the “teardrop sign” and is highly associated with vascular invasion. At preoperative multidetector CT, the probability of vascular invasion is up to 40% for tumor abutment ( ≤180° contact), compared with 80% in the presence of tumor encasement (>180° contact), and 100% if the tumor is completely surrounding the portal vein or SMV.”
Tumor-Vessel Relationships in Pancreatic Ductal Adenocarcinoma at Multidetector CT: Different Classification Systems and Their Influence on Treatment Planning Zaky AM, Wolfgang CL, Weiss MJ, Javed AA, Fishman EK, Zaheer A RadioGraphics 2017; 37:93–112 - “A replaced
right hepatic artery is the most common hepatic arterial anatomic variant. The rate of occurrence of this variant, in which the proper hepatic artery gives off only the left hepatic artery while the right hepatic artery originates from the SMA to pass posterolateral to the portal vein, has been reported in the literature to range from 11% to 21%.”
Tumor-Vessel Relationships in Pancreatic Ductal Adenocarcinoma at Multidetector CT: Different Classification Systems and Their Influence on Treatment Planning Zaky AM, Wolfgang CL, Weiss MJ, Javed AA, Fishman EK, Zaheer A RadioGraphics 2017; 37:93–112
- Pancreatic Cancer Facts
- Pancreatic Cancer: New Cases 2016
- “Pancreatic ductal carcinoma continues to be the most lethal malignancy with rising incidence. It is the fourth most common cause of cancer death in the western world due to its low treatment success rate. In addition, because of its rapid growth and silent course, diagnosis is often only established in the advanced stages. As one of the most aggressive malignancies, the treatment of this disease is a great challenge to clinicians. This paper reviewed the natural history of pancreatic cancer, the current clinical practice and the future in pancreatic cancer management.”
How Grim is Pancreatic Cancer? Weledji EP et al. Oncol Rev. 2016 Jul 6;10(1):294 - “Pancreatic cancer is one of the most aggressive human malignancies, as 50% present with metastatic disease and 35% with locally advanced disease. It is the 13th commonest cancer with 200,000 cases per year world-wide, 6000 cases per year in the UK and the fourth leading cause of cancer death in the Western world. There is an increasing incidence of this disease affecting 8-12 per 100,000 of the population per year. Whether this increased incidence is real or whether it reflects advances in diagnostic imaging is unknown.”
How Grim is Pancreatic Cancer? Weledji EP et al. Oncol Rev. 2016 Jul 6;10(1):294 - “Diagnostic problems arise because the symptoms are late and non-specific, there is no effective screening process and there is no specific high-risk group. Since conservative oncological therapies have failed to show any benefit in long-term survival, resection remains the only modality of treatment offering any possibility of cure. Unfortunately, only 10-20% with head and less than 3% of body/tail cancers are candidates for resection. In the past 20 years, there is also only a modest increase in long-term survival with a median survival of 12 months, and 5-year survival rate of 15-26% after potentially curative resection.”
How Grim is Pancreatic Cancer? Weledji EP et al. Oncol Rev. 2016 Jul 6;10(1):294 - “Traditional chemotherapy remains the standard treatment for advanced pancreatic cancer. Regimens like FOLFIRINOX (5-FU, leucovorin, irinotecan, and oxaliplatin) or gemcitabine and nab-paclitaxel have been used to palliate symptoms and prolong survival.” How Grim is Pancreatic Cancer? Weledji EP et al. Oncol Rev. 2016 Jul 6;10(1):294
- “Although there are no specific genetic mutations identified for the majority of FPC (70%), relatives of FPC kindred have a high risk of pancreatic cancer. K-Ras gene mutations have been found in most pancreatic cancers. As a prediction of poor prognosis, the detection of K-ras mutations may be a useful prognostic factor for pancreatic cancer patients. K-Ras mutations are associated with a worse overall survival in pancreatic cancer patients, especially when mutations are detected in liquid biopsies or fresh frozen tumor tissue samples.”
How Grim is Pancreatic Cancer? Weledji EP et al. Oncol Rev. 2016 Jul 6;10(1):294 - “Regional lymph-node metastasis occurred in 30% of patients with very small primary cancers and 64% of T1 primary cancer had lymph node involvement.28 Careful histological studies in a large series of resected pancreatic cancers revealed cancer dissemination in the lymph nodes in 89%; lymph node metastases in 77%, intrapancreatic neural invasion in 92% and a neural and nerve plexus invasion outside the pancreas in 45%.29 Thus even though the surgeon may be able to offer resection to >20% of patients with pancreatic cancer, the possibility of cure is gravely limited by the extent of early or occult micrometastases.”
How Grim is Pancreatic Cancer? Weledji EP et al. Oncol Rev. 2016 Jul 6;10(1):294 - “A tumor is potentially resectable if it can be technically removed with negative margins (R0 resection) without compromising the vascular supply to the liver (hepatic artery) or small bowel (superior mesenteric artery). Involvement of adjacent organs (e.g, duodenum or transverse colon), regional lymph nodes, portal vein (partial involvement), gastroduodenal artery, are not contraindications to resection, as these structures can be removed en bloc with the tumor to achieve an R0 (no tumor cells within 1 mm) resection.”
How Grim is Pancreatic Cancer? Weledji EP et al. Oncol Rev. 2016 Jul 6;10(1):294 - “A tumor is unresectable in the presence of: major comorbidity, metastatic disease (including involved lymph nodes out with the resection field, locally advanced disease with extrapancreatic involvement, superior mesenteric artery or coeliac artery involvement, and main portal venous occlusion/thrombosis. PV encasement from external compression with occlusion and thrombosis is a contraindication to resection because arterial involvement is likely to co-exist. An R0 resection for ductal pancreatic cancer must include an N1 and N2 lymph node dissection, perivascular connective tissue dissection and a standardized retroperitoneal soft-tissue dissection.”
How Grim is Pancreatic Cancer? Weledji EP et al. Oncol Rev. 2016 Jul 6;10(1):294 - “The results of the Gastrointestinal Tumor Study Group using adjuvant radio-chemotherapy following resection of pancreatic cancer revealed a median survival of 21 months in the group randomized to treatment compared to 10.9 months in the control group. The two-year actuarial survival was 46%, and 18% in the control group and the five-year probability survival in the treatment group was above 20%.”
How Grim is Pancreatic Cancer? Weledji EP et al. Oncol Rev. 2016 Jul 6;10(1):294 - “The arguments against surgical resection are: i) pancreatic carcinoma usually has an insidious presentation and physical signs of metastatic spread are commonly present at initial consultation; ii) it is a disease of elderly patients and 50% are >72 years. Many are unfit, weak, emaciated and suffer from other concomitant medical conditions. Endoscopic bypass is all that can be offered iii) bypass procedures are all that can be achieved in the vast majority; iv) an unsuccessful resection for a carcinoma can result in a high mortality, a very high morbidity and an extremely costly period of treatment for the patient”
How Grim is Pancreatic Cancer? Weledji EP et al. Oncol Rev. 2016 Jul 6;10(1):294 - “The results of the Gastrointestinal Tumor Study Group using adjuvant radio-chemotherapy following resection of pancreatic cancer revealed a median survival of 21 months in the group randomized to treatment compared to 10.9 months in the control group.59 The two-year actuarial survival was 46%, and 18% in the control group and the five-year probability survival in the treatment group was above 20%.”
How Grim is Pancreatic Cancer? Weledji EP et al. Oncol Rev. 2016 Jul 6;10(1):294 - “Over 80% of patients have positive regional lymph nodes or distant metastases at the time of diagnosis.77,78 Studies have revealed that even in small pancreatic tumors, which have not spread through the pancreatic capsule and with a diameter of less than 2 cm, there are positive para-aortic lymph nodes in 40% and therefore classified as stage II disease.81,82 Thus small tumor size cannot automatically be equated with early tumor stage.”
How Grim is Pancreatic Cancer? Weledji EP et al. Oncol Rev. 2016 Jul 6;10(1):294 - “The most widely used marker is CA 19-9 antigen as it is expressed in 86% of pancreatic cancers with a sensitivity of 89% compared to the sensitivity of 37% with CEA. 70% of patients with a tumor <4 cm already show elevated serum levels.86 Additionally CA 19-9 levels correlate with prognosis as it is more significantly lower in small resectable tumors than in larger ones. However, its sensitivity is not high enough for the primary diagnosis of pancreatic cancer. CA 19-9 is elevated in patients with non-malignant diseases, such as chronic pancreatitis or obstructive jaundice of various origins and in smoking. Its determination has a high clinical value if a CT scan indicate a pancreatic cancer and in the follow-up of patients following resection. If the CA 19-9 level returns to normal after tumor resection and increases during follow-up, then cancer relapse is extremely probable.”
How Grim is Pancreatic Cancer? Weledji EP et al. Oncol Rev. 2016 Jul 6;10(1):294 - “Progress in identifying new therapies has been hampered by the genetic complexity of the disease with each tumor cell carrying an average of 63 mutations, and the lack of prognostic markers.89 Most alterations occur with very low frequency and so are challenging to exploit therapeutically. The future lies on the better understanding of the molecular oncology of pancreatic cancer, which entails the genetics and the pathophysiology of metastasis of pancreatic cancer. About 75% of human pancreatic adenocarcinomas have acquired a mutation in codon 12 of the K-ras gene and there could be a role for biological therapy countering the effects of specific mutant oncogenes.”
How Grim is Pancreatic Cancer? Weledji EP et al. Oncol Rev. 2016 Jul 6;10(1):294 - “Genetic data have been interpreted to suggest that development of invasive disease from precursor lesions occurs over a considerable length of time (17 years on average), with death following after 2-3 years, highlighting the importance of identifying early diagnostic markers of pre-invasive pancreatic cancer.93,94 The recent major break- through is in the identification of early protein markers (cancer exosomes) that may provide early diagnosis and represent a valid screening test.95 This would lead to early surgical intervention with a better chance of curing this essentially incurable disease.”
How Grim is Pancreatic Cancer? Weledji EP et al. Oncol Rev. 2016 Jul 6;10(1):294 - “Pancreatic ductal adenocarcinoma is still a disease with a very poor prognosis. It is genetically very complex with a high diversity of mutations compared with other cancers. Early diagnosis with the new protein markers may lead to early intervention and better prognosis. The main surgical goal in performing an R0 resection facilitated by improved staging and patient selection would result in hospital mortality of <5% in specialist centers. As pancreatic carcinoma is largely resistant to standard chemotherapy, consideration of multimodal treatment including immunotherapy is necessary.”
How Grim is Pancreatic Cancer? Weledji EP et al. Oncol Rev. 2016 Jul 6;10(1):294
- “Despite advances in multimodality imaging of pancreas, there is still overlap between imaging findings of several pancreatic/peripancreatic disease processes. Pancreatic and peripancreatic non-neoplastic entities may mimic primary pancreatic neoplasms on ultrasound, CT, and MRI. On the other hand, primary pancreatic cancer may be overlooked on imaging because of technical and inherent factors. The purpose of this pictorial review is to describe and illustrate pancreatic imaging pitfalls and highlight the basic radiological features for proper differential diagnosis.”
Common and uncommon pitfalls in pancreatic imaging: it is not always cancer. Vernuccio F et al. Abdom Radiol (NY). 2016 Feb;41(2):283-94. - BACKGROUND: Preoperative differentiation between malignant and benign pancreatic tumors can be difficult. Consequently, a proportion of patients undergoing pancreatoduodenectomy for suspected malignancy will ultimately have benign disease. The aim of this study was to compare preoperative clinical and diagnostic characteristics of patients with unexpected benign disease after pancreatoduodenectomy with those of patients with confirmed (pre)malignant disease.
CONCLUSIONS: Nearly 7 % of patients undergoing pancreatoduodenectomy for suspected malignancy were ultimately diagnosed with benign disease. Although some preoperative clinical and imaging characteristics might indicate absence of malignancy, their discriminatory value is insufficient for clinical use.
Preoperative characteristics of patients with presumed pancreatic cancer but ultimately benign disease: a multicenter series of 344 pancreatoduodenectomies. Gerritsen A et al. Ann Surg Oncol. 2014 Nov;21(12):3999-4006 - INTRODUCTION: Previous studies have shown that 5-14% of patients undergoing pancreatoduodenectomy for suspected malignancy ultimately are diagnosed with benign disease. A "pancreatic mass" on computed tomography (CT) is considered to be the strongest predictor of malignancy, but studies describing its diagnostic value are lacking. The aim of this study was to determine the diagnostic value of a pancreatic mass on CT in patients with presumed pancreatic cancer, as well as the interobserver agreement among radiologists and the additional value of reassessment by expert-radiologists.
CONCLUSION: Clinicians need to be aware of potential considerable disagreement among radiologists about the presence of a pancreatic mass. The specificity for malignancy doubled by expert radiologist reassessment when a uniform definition of "pancreatic mass" was used.
Diagnostic value of a pancreatic mass on computed tomography in patients undergoing pancreatoduodenectomy for presumed pancreatic cancer. Gerritsen A et al. Surgery. 2015 Jul;158(1):173-82 - “Clinicians need to be aware of potential considerable disagreement among radiologists about the presence of a pancreatic mass. The specificity for malignancy doubled by expert radiologist reassessment when a uniform definition of "pancreatic mass" was used.”
Diagnostic value of a pancreatic mass on computed tomography in patients undergoing pancreatoduodenectomy for presumed pancreatic cancer. Gerritsen A et al. Surgery. 2015 Jul;158(1):173-82 - “CT scans of 86 patients with benign and 258 patients with (pre)malignant disease were reassessed. In 66% of patients a pancreatic mass was reported in the original CT report, versus 48% and 50% on reassessment by the 2 expert radiologists separately and 44% in consensus (P < .001 vs original report). Interobserver agreement between the original CT report and expert consensus was fair (kappa = 0.32, 95% confidence interval 0.23-0.42). Among both expert-radiologists agreement was moderate (kappa = 0.47, 95% confidence interval 0.38-0.56), with disagreement on the presence of a pancreatic mass in 29% of cases. The specificity for malignancy of pancreatic masses identified in expert consensus was twice as high compared with the original CT report (87% vs 42%, respectively). Positive predictive value increased to 98% after expert consensus, but negative predictive value was low (12%).”
Diagnostic value of a pancreatic mass on computed tomography in patients undergoing pancreatoduodenectomy for presumed pancreatic cancer. Gerritsen A et al. Surgery. 2015 Jul;158(1):173-82 - “Approximately 5–14% of patients undergoing pancreatoduodenectomy for suspected malignancy will ultimately have benign disease.”
Diagnostic value of a pancreatic mass on computed tomography in patients undergoing pancreatoduodenectomy for presumed pancreatic cancer. Gerritsen A et al. Surgery. 2015 Jul;158(1):173-82 - “A total of 36 of 45 (80%) false-positive pancreatic masses identified in the original CT report were not identified in expert-consensus. In 21 of these patients, features of autoimmune or groove pancreatitis, pseudocysts or focal steatosis were identified by the expert radiologists but not recognized as such by the original radiologist and reported as a pancreatic mass suspicious for malignancy. In the remaining 9 of 45 (20%) patients, a pancreatic mass was identified in both the original CT report and expert- consensus, whereas postoperative histopathology showed chronic pancreatitis (n = 7) and serous cystadenoma (n = 2).”
Diagnostic value of a pancreatic mass on computed tomography in patients undergoing pancreatoduodenectomy for presumed pancreatic cancer. Gerritsen A et al. Surgery. 2015 Jul;158(1):173-82 - “The specificity for malignancy of pancreatic masses identified in expert consensus was twice as high compared with the original CT report (87% vs 42%, respectively). PPV increased to 98% after expert consensus, but NPV was low for both the original CT report and expert consensus (8% and 12%, respectively).”
Diagnostic value of a pancreatic mass on computed tomography in patients undergoing pancreatoduodenectomy for presumed pancreatic cancer. Gerritsen A et al. Surgery. 2015 Jul;158(1):173-82 - “In our study, the number of patients with a false- positive pancreatic mass was decreased from 45 (3% of the entire cohort) in the original report to 11 (1%) in expert consensus. Especially for the 25 patients (29% of patients with unexpected benign disease) in whom features of autoimmune or groove pancreatitis, pseudocysts, or focal steatosis were mistaken for a pancreatic mass suspicious for malignancy by the original radiologists, a resection could potentially have been prevented, based on the assessment by an expert radiologist, since they identified no (n = 21) or a ‘‘benign’’ (n = 4) mass.”
Diagnostic value of a pancreatic mass on computed tomography in patients undergoing pancreatoduodenectomy for presumed pancreatic cancer. Gerritsen A et al. Surgery. 2015 Jul;158(1):173-82
- “Pancreatic ductal adenocarcinoma (PDA) is the 12th most common cancer in the United States. As of January 7, 2016, the American Cancer Society reported that pancreatic cancer had surpassed breast cancer as the third leading cause of cancer related death in the United States. Within the next decade, annual PDA deaths will likely surpass colorectal cancer as well. There were 53,070 new cases of PDA in 2015, and 41,780 deaths in the United States alone. Although the death rates for the most common cancers have declined in recent decades, the death rate for PDA is actually flat to slightly increased, in large part related to the aging demographic.”
Pancreatic Cancer: A Review Yabar CS, Winter JM Gastroenterol Clin N Am 45 (2016) 429–445 - “Although the death rates for the most common cancers have declined in recent decades, the death rate for PDA is actually flat to slightly increased, in large part related to the aging demographic. Over the past 4 decades, disease-specific survival has only improved marginally, with 5-year survival rates increasing from 4% to 7%. The lack of clinical progress, in comparison with other cancers, is attributable to a failure to develop novel and effective therapies.”
Pancreatic Cancer: A Review Yabar CS, Winter JM Gastroenterol Clin N Am 45 (2016) 429–445 - “Although most genetic mutations in PDA are somatic, germline variants have been described that predispose individuals to the development of PDA. Overall, 10% of PDAs are familial, and only 10% of those have been assigned to a previously defined genetic syndrome. Hereditary breast and ovarian cancer is the most common familial syndrome, and Peutz-Jeghers syndrome holds the greatest lifetime risk for the development of pancreatic cancer (approximately 30%).”
Pancreatic Cancer: A Review Yabar CS, Winter JM Gastroenterol Clin N Am 45 (2016) 429–445 - “Whole- genome sequencing was performed in 24 PDA genomes, and more than 1300 different genes were mutated in these tumors. The only high-frequency, “action- able” oncogene was KRAS, which is genetically activated in more than 95% of PDAs. Unfortunately, targeted therapy against this gene has proved elusive.”
Pancreatic Cancer: A Review Yabar CS, Winter JM Gastroenterol Clin N Am 45 (2016) 429–445 - “Oncogenic KRAS remains the best characterized oncogene in PDA. The genetic event occurs early in tumorigenesis, before the development of invasive disease. Activated KRAS activates multiple signaling pathways including BRAF/MAP-K to affect cell proliferation, PI3K/mammalian target of rapamycin to promote cell growth and survival, and phospholipase C/PKC/Ca11 to induce calcium and second messenger signaling. KRAS mutations form the foundation of the most commonly used transgenic mouse model of PDA.”
Pancreatic Cancer: A Review Yabar CS, Winter JM Gastroenterol Clin N Am 45 (2016) 429–445 - “PDA is most often seen in the elderly population, because it results from acquired genetic defects over many years. The median age of onset is 71 years, and 75% of patients are diagnosed between the ages of 55 and 84 years. The age-adjusted incidence rate is 12 out of 100,00 in the United States, and the lifetime risk of developing PDA is 1.5%, or 1 in 67 people. Of note, African Americans have a slightly increased risk compared with Caucasians.”
Pancreatic Cancer: A Review Yabar CS, Winter JM Gastroenterol Clin N Am 45 (2016) 429–445 - “The greatest risk factor for developing PDA is having a strong family history. As mentioned, 10% to 15% of all pancreatic cancers are considered familial, which is defined as at least 2 affected first-degree relatives (FDRs, eg, parents, offspring, sib- lings). The lifetime risk for patients with 3 or more FDRs is 40%, 10% for 2 FDRs, and 6% for 1 FDR (a 4.6-fold increase compared with the general population).”
Pancreatic Cancer: A Review Yabar CS, Winter JM Gastroenterol Clin N Am 45 (2016) 429–445 - “Conceptually speaking, early detection remains a holy grail for PDA management. Patients who present with “early” disease in fact typically have occult micrometastatic disease that becomes clinically relevant within the first 2 years after resection. A recent study of small invasive intraductal papillary mucinous neoplasms (<2 cm invasive component) reveals that a large proportion of small or early PDAs recur after resection, even in the absence of lymph node metastases.”
Pancreatic Cancer: A Review Yabar CS, Winter JM Gastroenterol Clin N Am 45 (2016) 429–445 - “The initial presentation of a patient is related to the location of the tumor. In patients with a mass in the right side of the pancreas (i.e., head, neck, or uncinate process), jaundice (75%) often occurs from obstruction of the common bile duct; other symptoms include weight loss (50%), abdominal pain (40%), new-onset diabetes (10%), and nausea (10%).”
Pancreatic Cancer: A Review Yabar CS, Winter JM Gastroenterol Clin N Am 45 (2016) 429–445 - “According to National Comprehensive Cancer Network guidelines, patients undergoing resection should undergo surveillance every 3 to 6 months for 2 years, then annually thereafter for patients who have had a mass resected. A history and physical examination, surveillance CT scans of the chest and abdomen with oral and intravenous contrast, and trending tumor markers are recommended for a complete assessment.”
Pancreatic Cancer: A Review Yabar CS, Winter JM Gastroenterol Clin N Am 45 (2016) 429–445 - “As the third leading cause of cancer-related death in the United States, PDA is truly a public health problem, and underfunded at that. There has been some progress toward understanding the disease at a molecular level, but genetic and other molecular advances have had a minimal impact on improving outcomes for patients. Surgery can be performed safely in appropriately selected patients, but most patients recur after resection, and the majority of patients with PDA present with advanced disease and are not candidates for resection.”
Pancreatic Cancer: A Review Yabar CS, Winter JM Gastroenterol Clin N Am 45 (2016) 429–445
- “Distal pancreatectomy with coeliac axis resection seems a valuable option for selected patients with pancreatic cancer involving the coeliac axis with acceptable morbidity and mortality, and a median survival of 18 months when combined with (neo)adjuvant therapy.”
Systematic review of outcomes after distal pancreatectomy with coeliac axis resection for locally advanced pancreatic cancer Klompmaker S et al. British Journal of Surgery Volume 103, Issue 8, pages 941–949, July 2016
- "Most pancreatic neoplasms are IDAC, with ASqC being a rare subtype, with a reported incidence of 1%-4% of all adenocarcinomas. According to a previous report, ASqC patients show a slight male preponderance and tend to be in their 60 s, with tumors frequently located in the head of the pancreas, similar to the corresponding features of IDAC. Symptoms and signs including abdominal and back pain, body weight loss, anorexia, and jaundice are also similar to those of IDAC. On the other hand, patients with resected ASqC have a significantly poorer prognosis (median survival 12 months) than do those with IDAC (median survival 16 months)."
Adenosquamous carcinoma of pancreas: CT and MR imaging features in eight patients, with pathologic correlations and comparison with adenocarcinoma of pancreas
Toshima F e al.
Abdom Radiol (2016) 41:508-520 - "The round-lobulated lesions were more frequently seen in ASqC group (ASqC, 100% vs. adenocarcinoma, 57.6%; p = 0.0353). In contrast, the rate of irregular lesions was higher in controlled adenocarcinoma group. Regarding degeneration, the proportion of necrosis was significantly higher in ASqC group than adenocarcinoma group (100% vs. 39.4%, p = 0.0034). The fre- quency of tumor thrombus in the PV system was higher in ASqC group than adenocarcinoma group (37.5% vs. 6.1%, p = 0.0426). Two patients of adenocarcinoma group had tumor thrombus in the PV system, and one of the two was diagnosed as undifferentiated carcinoma with osteoclast-like giant cells on the specimen obtained by surgical resection."
Adenosquamous carcinoma of pancreas: CT and MR imaging features in eight patients, with pathologic correlations and comparison with adenocarcinoma of pancreas
Toshima F e al.
Abdom Radiol (2016) 41:508-520 - "In our study, compared with adenocarcinoma, ASqC was visually judged not to be irregular, and to be round- lobulated shape on the whole with a significant difference. Macroscopically, most lesions also were the nodular type. Recently, the number of reports on imaging features regarding tumor in shape has been increased. Yin et al. reported that ASqC was generally oval or round in shape [4]. Ding et al. also reported that 9 of 12 lesions were circular, ovoid, or lobular , comparable to the corresponding finding in our study."
Adenosquamous carcinoma of pancreas: CT and MR imaging features in eight patients, with pathologic correlations and comparison with adenocarcinoma of pancreas
Toshima F e al.
Abdom Radiol (2016) 41:508-520
- “Level-one evidence has shown that surgical resection, adjuvant chemotherapy, and specifically 6 cycles of adjuvant therapy have the greatest impact of survival. In the past five years the use of new regimens, like FOLFIRINOX and Gemcitabine + Abraxane, and the utilization of neoadjuvant therapy show promise on making an impact on this disease. In order for the next decade to show an impact on survival it is necessary to make sure these new tactics get implemented either through clinical trials or multi-modality therapy. In addition to offering convenience for patients, multi-disciplinary clinics offer exposure to multiple therapies and the latest therapeutics.”
A Pancreatic Cancer Multidisciplinary Clinic: Insights and Outcomes Schiffman SC et al. Journal of Surgical Research (in press) - “In conclusion, evaluation in an MDC did not expedite treatment but improved exposure to all therapeutics and clinical trials. Patients evaluated in an MDC were more likely to receive treatment, multimodality therapy, neoadjuvant therapy, and participate in a clinical trial. There were still treatment gaps (i.e. 55% of operable patients underwent surgery), and further study will be devoted to barriers for undergoing expected treatment. Longer follow up and further patient accrual is required to determine the effects of MDC on patient survival.”
A Pancreatic Cancer Multidisciplinary Clinic: Insights and Outcomes Schiffman SC et al. Journal of Surgical Research (in press) - “Multidisciplinary clinics (MDC) have become increasingly prevalent and allow several specialties to collaborate and develop consensus recommendations. Although the composition and function of MDC may vary by institution, studies have shown that MDC directly facilitate collaboration and may improve quality of care. In recent studies, MDC for cancer treatment have demonstrated decreased time from diagnosis to treatment, more accurate staging of disease, improved survival and greater patient satisfaction. Our study shows increased likelihood of receiving treatment, increased utilization of multi-modality and neoadjuvant therapy, and increased enrollment in clinical trials.”
A Pancreatic Cancer Multidisciplinary Clinic: Insights and Outcomes Schiffman SC et al. Journal of Surgical Research (in press) - “Surgical resection is regarded as the only potentially curative treatment, and adjuvant chemotherapy with gemcitabine or S-1, an oral fluoropyrimidine derivative, is given after surgery. FOLFIRINOX (fluorouracil, folinic acid [leucovorin], irinotecan, and oxaliplatin) and gemcitabine plus nanoparticle albumin-bound paclitaxel (nab-paclitaxel) are the treatments of choice for patients who are not surgical candidates but have good performance status.”
Pancreatic cancer Kamisawa T et al. Lancet (in press) - “Most pancreatic cancers arise from microscopic non-invasive epithelial proliferations within the pancreatic ducts, referred to as pancreatic intraepithelial neoplasias. There are four major driver genes for pancreatic cancer: KRAS, CDKN2A, TP53, and SMAD4. KRAS mutation and alterations in CDKN2A are early events in pancreatic tumorigenesis.” Pancreatic cancer Kamisawa T et al. Lancet (in press)
- “Our results showed that CT and MRI had similar performance in presurgical evaluation of PC. Although CT is the preferred method for initial imaging evaluation of patients with suspected PC, in view of our outcomes and National Comprehensive Cancer Network guidelines, either pancreas-specific CT or pancreas-specific MRI is the preferred technique for evaluating PC. Thus, it is probably best to use the strengths of a given institution in terms of equipment, experience, and skill when choosing which modality to use for presurgical evaluation.”
Presurgical Evaluation of Pancreatic Cancer: A Comprehensive Imaging Comparison of CT Versus MRI Chen FM et al. AJR 2016; 206:526–535
- Clinical Facts to Consider
• Demographics (age and gender)
• Symptoms (pain, weight loss,jaundice)
• Family history (pancreatic cancer)
• Physical exam (mass, nodule)
• Clinical history (alcohol or drug abuse) - Pancreatic Tumors at Specific Ages
- “The staging designation “borderline resectable” has been historically used to characterize local tumor anatomy that confers high risk for a microscopically positive surgical resection and/or early treatment failure after an initial surgical approach. For this reason, borderline resectable disease has been considered an intermediate stage of disease on a spectrum of resectability delimited by “resectable” and “unresectable” PDAC.” Diagnosis and Management of Borderline Resectable Pancreatic Adenocarcinoma Schwarz L, Katz MHG Hematol Oncol Clin N Am 29 (2015) 727–740
- Pancreatic Cancer Staging
- What is “Borderline Resectable”?
• An interface between tumor and the SMV/PV measuring 180degrees or greater of the vessel wall circumference, and/or reconstructible venous occlusion;
• An interface between tumor and the SMA measuring less than 180 degrees of the vessel wall circumference;
• A reconstructible, short-segment interface of any degree between tumor and the common hepatic artery; and/or
• An interface between tumor and the celiac trunk measuring less than 180 degrees of the vessel wall circumference. - CT Evaluation of a Pancreatic Mass
• Superior mesenteric vein/portal vein (SMV/PV) involvement
• Superior mesenteric artery involvement
• Celiac axis involvement
• Common/proper hepatic artery involvement
• Anatomic variants: origin of right and left hepatic artery, origin of common hepatic artery, presence of accessory hepatic arteries
• Regional and distant lymphadenopathy
• Local/regional invasion (inferior vena cava, left renal vein, left adrenal)
• Distant metastases (liver or lung) - Resectable Pancreatic Cancer: CT Findings
• No locoregional vascular invasion
• Intact portal vein/superior mesenteric vein
• No involvement of superior mesenteric artery
• No involvement of common hepatic artery or celiac trunk
• No distant metastases
• No metastatic lymphadenopathy outside boundaries of planned resection - “Surgical resection with vascular reconstruction and after neoadjuvant therapy is increasingly considered in patients previously deemed unresectable because of local invasion. Despite surgical progress, pancreatic cancer has an extremely high rate of systemic recurrence, and further improve- ments in long-term outcomes for this disease will clearly depend on the availability of more effective systemic therapies.” Surgery for Pancreatic Cancer ClancyTE Hematol Oncol Clin N Am 29 (2015) 701–716
- “Surgical resection remains the only potentially curative therapy for pancreatic cancer, although only a minority of patients are candidates for resection. Recent decades have seen a dramatic decrease in perioperative mortality with refinement in surgical technique, improvement in patient selection and perioperative care, and concentration of pancreatic surgery to high-volume providers. Despite these improvements in mortality, pancreatic surgery remains associated with considerable morbidity.” Surgery for Pancreatic Cancer ClancyTE Hematol Oncol Clin N Am 29 (2015) 701–716
- Detection of an Incidental Pancreatic Mass
• Between 3-5% of adults have small incidental pancreatic lesions (based on CT data)
• Most incidental lesions are small cysts or IPMNs
• The role of surveillance in these patients especially for lesions under 3 cm in size is controversial
• Incidental pancreatic cancers or islet cell tumors are rare - Organs beyond the Pancreas and Liver
• Duodenum
• Spleen
• Kidney
• Adrenal
• Colon
• Peritoneal Cavity
• Pelvis including Ovaries. - Duodenum
• Is their duodenal involvement and if so where (1st thru 4th portion)
• Is the duodenum obstructed?
• Factoid: Duodenal invasion does not make a patient unresectable as the duodenum is resected as part of the Whipple’s procedure. - Duodenum (cont)
• Factoid: Duodenal invasion may be a risk for radiation therapy in select cases so it is important to define
• Factoid: Primary duodenal cancer can simulate a primary pancreatic adenocarcinoma
• Carcinoma of the tail of the pancreas can present as bowel obstruction due to involvement at the Ligament of Trietz - Spleen
• Splenic involvement is very common especially in carcinoma of the tail of the pancreas.
• Splenic involvement does not deem a patient unresectable as splenectomy is usually part of a distal pancreatectomy
• Splenic infarction is not uncommon especially in patients with involvement of the splenic artery or vein. - Kidney
• Renal involvement is usually due to large tumors of the tail or body of the pancreas.
• Renal artery and vein involvement is more common in tumors of the tail of the pancreas - Pelvis and Ovaries
• Implants in the pelvis as part of carcinomatosis is not uncommon and represents stage IV disease
• Metastases to the ovaries can occur but is very uncommon
• Scans through the pelvic region can be done of the venous phase imaging. - Peritoneal Cavity
• Implants on the omentum, mesentery, orperitoneal reflections mean the patient has carcinomatosis. The nodules may be small and numerous or more solid (1-4 cm) but mean the patient is unresectable.
• Pearl: the presence of ascites in the absence of cirrhosis or cardiac disease especially in the pelvis is usually indicative of carcinomatosis
- The isoattenuating pancreatic adenocarcinoma is defined as a mass not directly visible on dynamic CT.
• 88% and 100% of the isoattenuating adenocarcinomas <20 mm and >20 mm are recognized only by secondary imaging findings.
• Dynamic MRI can unmask 80% of the isoattenuating pancreatic adenocarcinomas.
• EUS-biopsy is not mandatory to be performed before proceeding to surgery.
• Isoattenuating pancreatic adenocarcinoma patients have a significantly longer median survival associated with the higher rate of well differentiated tumors.
- “The reviewers found 328 peritoneal implants in 36 patients. After accounting for the size, location, and number of lesions as well as multiple readers, a generalized estimating equations model showed that the statistical combination of MIP with standard technique significantly increased the odds of correctly identifying a lesion (OR 2.16; 95% CI 1.86-2.51; p value < 0.0001) compared to standard technique alone. MIP reconstruction as a standalone technique was less sensitive compared to standard technique alone (OR 0.81; 95% CI 0.65-0.99; p value = 0.0468). When compared to standard axial imaging, evaluation via MIP reconstructions resulted in the identification of an additional 50 (15%), 45 (14%), and 55 (17%) lesions by Readers 1-3, respectively.”
Multidetector CT detection of peritoneal metastases: evaluation of sensitivity between standard 2.5 mm axial imaging and maximum-intensity-projection (MIP) reconstructions.
Jensen CT1 et al.
Abdom Imaging. 2015 Feb 10. [Epub ahead of print] - “The axial 6 mm MIP series is complimentary in the CT evaluation of peritoneal metastases. MIP reconstruction evaluation identified a significant number of additional lesions, but is not adequate as a standalone technique for peritoneal cavity assessment.”
Multidetector CT detection of peritoneal metastases: evaluation of sensitivity between standard 2.5 mm axial imaging and maximum-intensity-projection (MIP) reconstructions.
Jensen CT1 et al.
Abdom Imaging. 2015 Feb 10. [Epub ahead of print] - “Chronic pancreatitis often manifests with both pancreatic parenchymal and ductal calcifications, global atrophy of the gland, as well as dilatation, beading, and irregularity of the pancreatic duct. However, in some advanced cases, patients can develop a focal fibroinflammatory “mass” that can mimic pancreatic cancer, with obstruction of both the biliary and pancreatic ducts, and this mass can be virtually indistinguishable from malignancy.”
Cross-Sectional Imaging and the Role of Positron Emission Tomography in Pancreatic Cancer Evaluation.
Raman SP, Chen Y, Fishman EK
Semin Oncol. 2015 Feb;42(1):40-58. - “The venous phase images, on the other hand, are undoubtedly more useful for identifying the vast majority of pancreatic cancers, and in the majority of cases, will be the single most important phase of acquisition. The venous phase images are also critical for gauging tumoral involvement of the central mesenteric venous vasculature (i.e., portal vein [PV] and superior mesenteric vein [SMV]), and are the best images for identifying distant metastatic disease to the liver or peritoneum.”
Cross-Sectional Imaging and the Role of Positron Emission Tomography in Pancreatic Cancer Evaluation.
Raman SP, Chen Y, Fishman EK
Semin Oncol. 2015 Feb;42(1):40-58. - “Arterial phase images allow pancreatic cancers (which are typically hypovascular) to be distinguished from neuroendocrine tumors (which tend to be avidly enhancing), facilitate the identification of a small subset of pancreatic cancers (which are more conspicuous on the arterial phase images relative to the venous phase), and allow optimal assessment of tumoral involvement of the central mesenteric arterial vasculature (i.e., celiac artery, superior mesenteric artery [SMA], hepatic artery). Moreover, vascular maps created using the arterial phase images can be invaluable to surgeons, allowing them to appreciate vascular variants (such as a replaced or accessory hepatic artery), severe atherosclerotic disease, or stenosis of the celiac artery due to a hypertrophied median arcuate ligament (i.e., “median arcuate ligament syndrome”) that might affect their approach at surgery.”
Cross-Sectional Imaging and the Role of Positron Emission Tomography in Pancreatic Cancer Evaluation.
Raman SP, Chen Y, Fishman EK
Semin Oncol. 2015 Feb;42(1):40-58. - “The most important role for MDCT when locally staging a tumor is to determine the degree (if any) to which a tumor involves the central mesenteric vasculature, and more specifically, the celiac artery, SMA, hepatic artery, PV, and SMV. Notably, only these five vessels have true significance for the patient’s ability to undergo a complete (R0) surgical resection. Other vessels, including the gastroduodenal artery (GDA) and the splenic artery, do not impact the patient’s surgical candidacy. It is very likely that our accuracy for vascular involvement has improved over the course of the last decade, as newer scanner technology with improvements in spatial and temporal resolution now allow consistent acquisition of detailed images at peak arterial and venous enhancement, thus allowing the visualization of small arterial and venous branches that may not have been visible a decade ago.”
Cross-Sectional Imaging and the Role of Positron Emission Tomography in Pancreatic Cancer Evaluation.
Raman SP, Chen Y, Fishman EK
Semin Oncol. 2015 Feb;42(1):40-58. - “The diagnosis of peritoneal carcinomatosis can be quite difficult on CT, with an overall sensitivity of only 25%–37% (although certain studies have suggested higher sensitivities), and a sensitivity as low as 7% when tumor implants measure<1 cm. Carcinomatosis can have a variety of appearances on MDCT, including a micronodular pattern with multiple tiny nodules measuring 1–5 mm studding the omentum and mesentery, a nodular pattern with more discrete implants (measuring>5 mm) in the omental fat, and frank omental caking, with confluent soft tissue infiltration of the omental fat. The “micronodular” pattern can be much more difficult to reliably identify compared to the “nodular” and “omental caking” patterns.”
Cross-Sectional Imaging and the Role of Positron Emission Tomography in Pancreatic Cancer Evaluation.
Raman SP, Chen Y, Fishman EK
Semin Oncol. 2015 Feb;42(1):40-58. - "Ultimately, while the literature is somewhat equivocal as to whether PET truly changes patient outcomes and management, the majority of the data in the literature does suggest that PET identifies some metastases that are not visible on CT, and as a result, PET-CT has gradually become an accepted part of the imaging algorithm for patients newly diagnosed with pancreatic cancer.”
Cross-Sectional Imaging and the Role of Positron Emission Tomography in Pancreatic Cancer Evaluation.
Raman SP, Chen Y, Fishman EK
Semin Oncol. 2015 Feb;42(1):40-58. - “While the primary role of MDCT will not be challenged in the near future, MRI and PET-CT both have important ancillary roles, with PET offering an intriguing option for distant staging, with some studies suggesting benefits in terms of identifying distant metastases that are not visible on MDCT, while MRI offers a valuable tool for better characterizing indeterminate or equivocal findings noted on a CT. Understanding the strengths and weaknesses of each modality is critical in correctly using all three modalities in conjunction to appropriately identify and stage pancreatic cancers.”
Cross-Sectional Imaging and the Role of Positron Emission Tomography in Pancreatic Cancer Evaluation.
Raman SP, Chen Y, Fishman EK
Semin Oncol. 2015 Feb;42(1):40-58. - “Pancreatic adenocarcinoma is a rapidly progressive malignancy characterized by its tendency for early metastatic spread. MDCT is the primary diagnostic modality for the preoperative staging of patients with pancreatic cancer, with an accuracy established in multiple studies. However, for a variety of reasons, there is often a prolonged interval between staging MDCT and the surgical intervention. This study examines the relationship between the interval between imaging and surgery and the accuracy of MDCT in determining the presence or absence of metastatic disease at surgery in patients with pancreatic cancer.”
Impact of the time interval between MDCT imaging and surgery on the accuracy of identifying metastatic disease in patients with pancreatic cancer.
Raman SP, Reddy S, Weiss MJ, Manos LL, Cameron JL, Zheng L, Herman JM, Hruban RH, Fishman EK, Wolfgang CL
AJR Am J Roentgenol. 2015 Jan;204(1):W37-42 - “MDCT was more accurate in predicting the absence of metastatic disease if the study was performed within 25 days of surgery than it was if the study was performed within more than 25 days of surgery (89.3% vs 77.0%; p = 0.0097). Furthermore, regression models showed that the negative predictive value of a given MDCT significantly decreased after approximately 4 weeks.”
Impact of the time interval between MDCT imaging and surgery on the accuracy of identifying metastatic disease in patients with pancreatic cancer.
Raman SP, Reddy S, Weiss MJ, Manos LL, Cameron JL, Zheng L, Herman JM, Hruban RH, Fishman EK, Wolfgang CL
AJR Am J Roentgenol. 2015 Jan;204(1):W37-42 - “MDCT is an accurate method to stage patients with pancreatic cancer, but its accuracy in excluding distant metastatic disease depreciates over time. Patients should undergo a repeat MDCT within 25 days of any planned definitive operative intervention for pancreatic cancer to avoid unexpectedly finding metastatic disease at surgery.”
Impact of the time interval between MDCT imaging and surgery on the accuracy of identifying metastatic disease in patients with pancreatic cancer.
Raman SP, Reddy S, Weiss MJ, Manos LL, Cameron JL, Zheng L, Herman JM, Hruban RH, Fishman EK, Wolfgang CL
AJR Am J Roentgenol. 2015 Jan;204(1):W37-42 - “Virtually all of these studies were conducted in 2007 or earlier, and accordingly, were performed on older-generation CT scanners (usually 16-MDCT scanners). As a result, it is conceivable that results with the most recent generation of CT scanners might be superior to the results in those studies.”
Impact of the time interval between MDCT imaging and surgery on the accuracy of identifying metastatic disease in patients with pancreatic cancer.
Raman SP, Reddy S, Weiss MJ, Manos LL, Cameron JL, Zheng L, Herman JM, Hruban RH, Fishman EK, Wolfgang CL
AJR Am J Roentgenol. 2015 Jan;204(1):W37-42 - “MDCT is a highly effective imaging modality for evaluating the resectability of pancreatic adenocarcinoma. However, given the aggressiveness of the tumor and its tendency for rapid metastatic spread, the accuracy of a given MDCT study declines over time. Even though a patient may not have had metastases on a scan performed 1 month before the surgery, there is no guarantee that the patient will be free of metastases at the time of surgery. Given the data in this study, all patients with potentially resectable pancreatic cancer should be imaged within 25 days of a planned resection.”
Impact of the time interval between MDCT imaging and surgery on the accuracy of identifying metastatic disease in patients with pancreatic cancer.
Raman SP, Reddy S, Weiss MJ, Manos LL, Cameron JL, Zheng L, Herman JM, Hruban RH, Fishman EK, Wolfgang CL
AJR Am J Roentgenol. 2015 Jan;204(1):W37-42 - “Structured reporting of pancreatic multiphasic CT provided superior evaluation of pancreatic cancer and facilitated surgical planning. Surgeons were more confident regarding decisions about tumor resectability when they reviewed structured reports before review of multiphasic CT images.”
Structured Reporting of Multiphasic CT for Pancreatic Cancer: Potential Effect on Staging and Surgical Planning.
Brook OR et al
Radiology. 2015 Feb;274(2):464-72 - “When surgeons reviewed reports in combination with multiphasic CT images, they were more likely to convert an answer of "unsure" regarding resectability to a definitive answer (i.e., resectable or unresectable) when the reports were structured than when they were nonstructured.”
Structured Reporting of Multiphasic CT for Pancreatic Cancer: Potential Effect on Staging and Surgical Planning.
Brook OR et al
Radiology. 2015 Feb;274(2):464-72
- “Pancreatic adenocarcinoma is a rapidly progressive malignancy characterized by its tendency for early metastatic spread. MDCT is the primary diagnostic modality for the preoperative staging of patients with pancreatic cancer, with an accuracy established in multiple studies. However, for a variety of reasons, there is often a prolonged interval between staging MDCT and the surgical intervention. This study examines the relationship between the interval between imaging and surgery and the accuracy of MDCT in determining the presence or absence of metastatic disease at surgery in patients with pancreatic cancer.”
Impact of the Time Interval Between MDCT Imaging and Surgery on the Accuracy of Identifying Metastatic Disease in Patients With Pancreatic Cancer.
Raman SP, Reddy S, Weiss MJ, Manos LL, Cameron JL, Zheng L, Herman JM, Hruban RH, Fishman EK, Wolfgang CL
AJR Am J Roentgenol. 2015 Jan;204(1):W37-42 - “MDCT is an accurate method to stage patients with pancreatic cancer, but its accuracy in excluding distant metastatic disease depreciates over time. Patients should undergo a repeat MDCT within 25 days of any planned definitive operative intervention for pancreatic cancer to avoid unexpectedly finding metastatic disease at surgery.”
Impact of the Time Interval Between MDCT Imaging and Surgery on the Accuracy of Identifying Metastatic Disease in Patients With Pancreatic Cancer.
Raman SP, Reddy S, Weiss MJ, Manos LL, Cameron JL, Zheng L, Herman JM, Hruban RH, Fishman EK, Wolfgang CL
AJR Am J Roentgenol. 2015 Jan;204(1):W37-42
- “ Partial regression of tumor-vessel contact indicates suitability for surgical exploration, irrespective of the degree of decrease in tumor size or the degree of residual vascular involvement.”
Locally Advanced Pancreatic Adenocarcinoma: Reassessment of Response with CT after Neoadjuvant Chemotherapy and Radiation Therapy
Cassinotto C et al.
Radiology 2014; 273:108-116 - “ Following neoadjuvant combined chemotherapy and radiation therapy (CRT), reduction of tumor to superior mesenteric vein (SMV) and/or portal vein contact and the reduction of tumor to the superior mesenteric artery (SMA) contact were significantly associated with a complete resection.”
Locally Advanced Pancreatic Adenocarcinoma: Reassessment of Response with CT after Neoadjuvant Chemotherapy and Radiation Therapy
Cassinotto C et al.
Radiology 2014; 273:108-116 - “ Partial regression of tumor contact with the SMV/portal vein was associated in all cases with R0 resection (10 of 10 patients) and partial regression of tumor contact with any peripancreatic vascular axis (SMV/portal vein, SMA, hepatic artery, or celiac trunk) was associated with R0 resection in 91% of cases (20 of 22 patients).”
Locally Advanced Pancreatic Adenocarcinoma: Reassessment of Response with CT after Neoadjuvant Chemotherapy and Radiation Therapy
Cassinotto C et al.
Radiology 2014; 273:108-116 - “ Tumor attenuation values and their change before and after neoadjuvant CRT do not provide any useful information either in the determination of tumor response or the prediction of an R0 resection.”
Locally Advanced Pancreatic Adenocarcinoma: Reassessment of Response with CT after Neoadjuvant Chemotherapy and Radiation Therapy
Cassinotto C et al.
Radiology 2014; 273:108-116 - “ Change in tumor size (large axis or sum of large and small axes) was associated with the histologic grade of tumor response but was not significantly associated with R0 resection.”
Locally Advanced Pancreatic Adenocarcinoma: Reassessment of Response with CT after Neoadjuvant Chemotherapy and Radiation Therapy
Cassinotto C et al.
Radiology 2014; 273:108-116
- “Pancreatic cancer is the deadliest of all solid malignancies. Early detection offers the best hope for a cure, but characteristics of this disease, such as the lack of early clinical symptoms, make the early detection difficult. Recent genetic mapping of the molecular evolution of pancreatic cancer suggests that a large window of opportunity exists for the early detection of pancreatic neoplasia, and developments in cancer genetics offer new, potentially highly specific approaches for screening of curable pancreatic neoplasia. We review the challenges of screening for early pancreatic neoplasia, as well as opportunities presented by incorporating molecular genetics into these efforts.”
The Early Detection of Pancreatic Cancer: What Will It Take to Diagnose and Treat Curable Pancreatic Neoplasia?
Lennon AM, Wolfgang CL, Canto MI, Klein AP, Herman JM, Goggins M, Fishman EK, Kamel I, Weiss MJ, Diaz LA, Papadopoulos N, Kinzler KW, Vogelstein B, Hruban RH
Cancer Res. 2014 Jul 1;74(13):3381-3389 - “Pancreatic cancer is the deadliest of all solid malignancies. Early detection offers the best hope for a cure, but characteristics of this disease, such as the lack of early clinical symptoms, make the early detection difficult. Recent genetic mapping of the molecular evolution of pancreatic cancer suggests that a large window of opportunity exists for the early detection of pancreatic neoplasia, and developments in cancer genetics offer new, potentially highly specific approaches for screening of curable pancreatic neoplasia.”
The Early Detection of Pancreatic Cancer: What Will It Take to Diagnose and Treat Curable Pancreatic Neoplasia?
Lennon AM, Wolfgang CL, Canto MI, Klein AP, Herman JM, Goggins M, Fishman EK, Kamel I, Weiss MJ, Diaz LA, Papadopoulos N, Kinzler KW, Vogelstein B, Hruban RH
Cancer Res. 2014 Jul 1;74(13):3381-3389
- “ During the year 2013 in the United States, an estimated 45,220 people will be diagnosed with pancreatic cancer, and approximately 38,460 people will die of pancreatic cancer. This disease is the fourth most common cause of cancer-related death among U.S. men (after lung, prostate, and colorectal cancer) and women (after lung, breast, and colorectal cancer). Its peak incidence occurs in the seventh and eighth decades of life. Although incidence is roughly equal in both sexes, African Americans have a higher incidence of pancreatic cancer than white Americans. Furthermore, the incidence of pancreatic cancer in the United States increased from 1999 to 2008, possibly because of the increasing prevalence of obesity and other unknown factors. Mortality rates have remained largely unchanged.”
NCCN Guidelines Version 1.2014 Pancreatic Adenocarcinoma - “ During the year 2013 in the United States, an estimated 45,220 people will be diagnosed with pancreatic cancer, and approximately 38,460 people will die of pancreatic cancer. This disease is the fourth most common cause of cancer-related death among U.S. men (after lung, prostate, and colorectal cancer) and women (after lung, breast, and colorectal cancer). Its peak incidence occurs in the seventh and eighth decades of life.”
NCCN Guidelines Version 1.2014 Pancreatic Adenocarcinoma - “As an overall guiding principle of these guidelines, the panel believes that decisions about diagnostic management and resectability of pancreatic cancer should involve multidisciplinary consultation at high- volume centers with reference to appropriate imaging studies. In addition, the panel believes that increasing participation in clinical trials (currently only 4.5% of patients enroll on a pancreatic cancer trial) is critical to making progress in this disease.”
NCCN Guidelines Version 1.2014 Pancreatic Adenocarcinoma - “Although the increase in risk is small, pancreatic cancer is firmly linked to cigarette smoking. There is also some evidence that increased consumption of red/processed meat and dairy products is associated with an elevation in pancreatic cancer risk, although other studies have failed to identify dietary risk factors for the disease. Occupational exposure to chemicals such as beta-naphthylamine and benzidine is associated with increased risk for pancreatic cancer, as is heavy alcohol consumption. Recent data also suggest that low plasma 25-hydroxyvitamin D levels may increase the risk of pancreatic cancer. Chronic pancreatitis has also been identified as a risk factor for pancreatic cancer, and a more recent study demonstrated a 7.2- fold increased risk of pancreatic cancer for patients with a history of pancreatitis.An increased body mass index (BMI) is also associated with an increased risk for pancreatic cancer.”
NCCN Guidelines Version 1.2014 Pancreatic Adenocarcinoma - “Although the increase in risk is small, pancreatic cancer is firmly linked to cigarette smoking. There is also some evidence that increased consumption of red/processed meat and dairy products is associated with an elevation in pancreatic cancer risk, although other studies have failed to identify dietary risk factors for the disease. Occupational exposure to chemicals such as beta-naphthylamine and benzidine is associated with increased risk for pancreatic cancer, as is heavy alcohol consumption.”
NCCN Guidelines Version 1.2014 Pancreatic Adenocarcinoma - “Recent data also suggest that low plasma 25-hydroxyvitamin D levels may increase the risk of pancreatic cancer. Chronic pancreatitis has also been identified as a risk factor for pancreatic cancer, and a more recent study demonstrated a 7.2- fold increased risk of pancreatic cancer for patients with a history of pancreatitis.21 An increased body mass index (BMI) is also associated with an increased risk for pancreatic cancer.”
NCCN Guidelines Version 1.2014 Pancreatic Adenocarcinoma - “In addition, pancreatic cancer is associated with 2 cancer syndromes. Germline mutations in the STK11 gene result in Peutz-Jeghers syndrome, in which individuals have gastrointestinal polyps and an elevated risk for colorectal cancer. These individuals also have a highly elevated risk for developing pancreatic cancer. Lynch syndrome is the most common form of genetically determined colon cancer predisposition and is caused by germline mutations in DNA mismatch repair (MMR) genes (MLH1, MSH2, MSH6, or PMS2). Patients with Lynch syndrome also have an elevated risk for pancreatic cancer.”
NCCN Guidelines Version 1.2014 Pancreatic Adenocarcinoma - “ The association between diabetes mellitus and pancreatic cancer is particularly complicated. Numerous studies have shown an association between new-onset non-insulin-dependent diabetes and the development of pancreatic cancer, especially in those who are elderly, have a lower BMI, experience weight loss, or do not have a family history of diabetes. Some studies also showed an association of pancreatic cancer with diabetes of longer duration, but not with a >8 year history of diabetes. However, certain risk factors such as obesity, associated with both diabetes and pancreatic cancer, may confound these analyses.”
NCCN Guidelines Version 1.2014 Pancreatic Adenocarcinoma
- Do you use templates for radiology reports?
- Advantages
- Disadvantages
- Will there be consensus on structured reporting?
- What do referring physicians prefer?
- What is the potential impact of patients access to reports? - “ Adoption of this standardized imaging reporting template should improve the decision making process for the management of patients with pancreatic ductal adenocarcinoma by providing a complete, pertinent, and accurate reporting of disease staging to optimize treatment recommendations that can be offered to the patient.”
Pancreatic Ductal Adenocarcinoma Radiology Reporting Template: Consensus Statement of the Society of Abdominal Radiology and the American Pancreatic Association
Al-Hawary MH, Francis IR, Chari ST, Fishman EK et al.
Radiology 2014;270:248-260 - “ Given the variability in expertise and definition of pancreatic ductal adenocarcinoma disease extent among different practitioners, adoption of a standardized template for radiology reporting, using universally accepted and agreed upon terminology for solid pancreatic neoplasms is needed.”
Pancreatic Ductal Adenocarcinoma Radiology Reporting Template: Consensus Statement of the Society of Abdominal Radiology and the American Pancreatic Association
Al-Hawary MH, Francis IR, Chari ST, Fishman EK et al.
Radiology 2014;270:248-260 - Pancreatic Adenocarinoma: Facts
- 4th most common cause of cancer related deaths in the US in 2012
- 43920 new cases diagnosed and approximately 37390 deaths
- Tumor incidence seems to be increasing since 1999 by 1.2% a year and by 2020 will become the second most common cause of cancer related deaths in the US
- Only 15-20% of patients have potentially resectable disease at presentation - “ It is therefore essential that these patients undergo repeat imaging with a dedicated pancreatic CT examination that includes biphasic multidetector CT angiography.”
Pancreatic Ductal Adenocarcinoma Radiology Reporting Template: Consensus Statement of the Society of Abdominal Radiology and the American Pancreatic Association
Al-Hawary MH, Francis IR, Chari ST, Fishman EK et al.
Radiology 2014;270:248-260 - “ These factors limit the ability to generate the high quality reformatted images and three dimensional reconstructions that are often necessary for accurate staging. It is therefore essential that these patients undergo repeat imaging with a dedicated pancreatic CT examination that includes biphasic multidetector CT angiography.”
Pancreatic Ductal Adenocarcinoma Radiology Reporting Template: Consensus Statement of the Society of Abdominal Radiology and the American Pancreatic Association
Al-Hawary MH, Francis IR, Chari ST, Fishman EK et al.
Radiology 2014;270:248-260 
- Pancreas Cancer Reporting Template
- http://pubs.rsna.org/doi/suppl/10.1148/radiol.13131184/suppl_file/suppl/131184appendix.pdf 
- “ Visually isoattenuating pancreatic adenocarcinoma represents a small but meaningful subset of pancreatic cancer and has characteristic clinical and pathologic features. MR imaging and PET/CT may be useful as subsequent examinations when the patient is suspected of having the lesion at CT.”
Visually Isoattenuating Pancreatic Adenocarcinoma at Dynamic-Enhanced CT: Frequency, Clinical and Pathologic Characteristics, and Diagnosis at Imaging Examinations
Kim JH et al.
Radiology 2010; 257:87-96 - “ Compared with usual pancreatic adenocarcinoma, visually isoattenuating pancreatic adenocarcinoma was independently associated with better patient survival after curative intent surgery. The adjusted hazard ratio was 0.430.”
Visually Isoattenuating Pancreatic Adenocarcinoma at Dynamic-Enhanced CT: Frequency, Clinical and Pathologic Characteristics, and Diagnosis at Imaging Examinations
Kim JH et al.
Radiology 2010; 257:87-96 - “ The frequency of visually isoattenuating pancreatic adenocarcinoma among pathologically proved pancreatic cancers was 5.4%.”
Visually Isoattenuating Pancreatic Adenocarcinoma at Dynamic-Enhanced CT: Frequency, Clinical and Pathologic Characteristics, and Diagnosis at Imaging Examinations
Kim JH et al.
Radiology 2010; 257:87-96 - Pancreatic Adenocarcinoma
- Over 28,000 cases each year (2% of all cancers)
- Accounts for 95% of all pancreatic exocrine malignancies
- 4th leading case of cancer mortality
- Poor prognosis with < 5% survival at 5 years
- < 20% of patients are candidates for curative surgery - CT Appearance
- Typical features:
- Hypodense
- Poorly marginated with posterior infiltration into the retroperitoneum
- Not “well-circumscribed” and usually difficult to discretely measure
- Tendency to encase vessels and involve CBD and pancreatic duct - CT Appearance
- Secondary Signs:
- Pancreatic ductal dilatation
- Biliary ductal dilatation
- Abrupt cut-off of the dilated pancreatic duct
- Upstream pancreatic atrophy
- Abnormal contour of the pancreas
- Secondary signs are most important in 5-10% of pancreatic cancers which are isoattenuating to the pancreatic parenchyma on both arterial and venous phase - Determining Resectability
- Try not to use the terms “resectable” or “unresectable” in your dictations
- Varies depending on institution, surgeon, patient factors, pancreatic cancer clinic, etc.
- If a tumor is correctly determined to be resectable, survival is 15-20% at 5 years
- If tumor is incorrectly thought to be resectable, survival after Whipple no better than chemoradiation - Sites of metastatic disease
- Liver
- Locoregional lymph nodes
- Carcinomatosis
- Lung - Lymphadenopathy and Distant Metastatic Disease
- Don’t worry so much about locoregional lymph nodes
- Only extensive/bulky or distant lymphadenopathy prevents surgery
- Sensitivity of CT for metastatic nodes is low (~22%), but nodes generally sampled and resected at surgery - Lymphadenopathy and Distant Metastatic Disease
- Distant metastatic disease makes the patient unresectable
- Venous phase images critical
- Use perfusion abnormalities or THADs on arterial phase images as a clue for small liver metastases
- CT is effective for liver lesions > 1 cm (sensitivity of 91%)
- Sensitivity for carcinomatosis only 25-37% - Vascular Involvement
- Five vessels must be evaluated on every study
- SMV
- Portal Vein
- Celiac trunk
- Hepatic artery
- SMA
- Differentiate tumor involving < 180 or >180 degrees of an artery’s circumference
- Look for a preserved fat plane around each of the major arteries
- Distinguish abutment, encasement, narrowing, or occlusion of the portal vein/SMV at the confluence, and allow the surgeon to determine if a venous reconstruction is technically feasible - Lymphoma
- Primary pancreatic lymphoma is quite rare (< 1% of pancreatic tumors)
- Usually diffuse large B-cell lymphoma
- Immunocompromised patients or elderly
- Secondary lymphomatous involvement of the pancreas much more common
- Imaging Features:
- Focal infiltrative mass
- Usually pancreatic head
- No vascular narrowing or occlusion
- Infiltrates without regard to anatomic boundaries
- Anterior and posterior (adenocarcinoma usually extends only posteriorly)
- Lymphadenopathy
- “Although these routine CT examinations may be diagnostic for pancreatic adenocarcinoma, they are inadequate for disease extent assessment given the lack of optimal multi-phasic enhancement and use of thicker slice selection. These factors limit the ability to generate high quality reformatted images and 3D reconstructions that are often necessary for accurate staging. It is therefore essential that these patients undergo MDCT angiogram using a dedicated pancreatic protocol.”
Pancreatic Ductal Adenocarcinoma Radiology Reporting Template: Consensus Statement of the Society of Abdominal Radiology (SAR), and the American Pancreatic Association (APA)
Al-Hawary MM et al
Radiology (in press) - “Pancreatic cancer is currently one of the deadliest of the solid malignancies. However, surgery to resect neoplasms of the pancreas is safer and less invasive than ever, novel drug combinations have been shown to improve survival, advances in radiation therapy have resulted in less toxicity, and enormous strides have been made in the understanding of the fundamental genetics of pancreatic cancer. These advances provide hope but they also increase the complexity of caring for patients. It is clear that multidisciplinary care that provides comprehensive and coordinated evaluation and treatment is the most effective way to manage patients with pancreatic cancer.”
Recent Progress in Pancreatic Cancer
Wolfgang CL, Herman JM, Kaheru DA, Klein AP, Erdek MA, Fishman EK,Hruban RH
CA Cancer J Clin 2013 July 15 (epub ahead of print) - Pancreatic Cancer: Demographics
- 44,000 new cases in 2012
- 10th most common cancer in men, 11th in woman
- 37,400 deaths in the US in 2012
- 4th leading cause of cancer deaths in men and woman
- More common in blacks than whites
- Mean age at diagnosis is 71 years and range is 40 to 80
“ Well known risk factors for pancreatic cancer are advancing age, tobacco smoking, obesity, certain inherited familial disorders, second hand smoke exposure, chronic pancreatitis, and diabetes. Associations with human immunodeficiency virus, ABO blood group, hepatitis B virus, HIV, and H pylori have been identified.”
Demographics and Epidemiology of Pancreatic Cancer
Yeo TP, Lowenfels AB
Cancer J 2012;18:477-484 - Pancreatic Cancer: Risk Factors
- Aging
- Family history of certain inherited disorders
- Tobacco use
- Obesity
- New onset of diabetes
- Pancreatitis
- Certain occupational exposures - Pancreatic Cancer: Risk Factors
- Family history and genetic risk factors ( if 2 or more first degree relatives have pancreatic cancer then risk is two fold increased
- Germ line BRCA2 is most common mutation
- Familial syndromes include hereditary pancreatitis, hereditary nonpolyposis colorectal cancer, hereditary breast and ovarian cancer syndrome, Peutz Jeghers syndrome, Fanconi anemia - Pancreatic Cancer: Environmental Factors
- Tobacco exposure and carcinogens
- Environmental tobacco smoke exposure
- Occupational and job exposures (exposure to asbestos, pesticides, coal products)
- Diabetes (new onset over past 3 years)
- Prior episodes of pancreatitis
- Increased alcohol consumption - “ Appropriate diagnosis of these complications is contingent on an understanding of the surgical anatomy, normal postoperative imaging appearance in both the immediate postoperative and chronic settings, and typical CT appearance of each of these complications.”
CT After Pancreaticoduodenectomy: Spectrum of Normal Findings and Complications
Raman SP, Horton KM, Cameron JC, Fishman EK
AJR 2013;201:2-13 - “ A multidisciplinary approach to the treatment of this disease, combined with an equally diverse approach of targeting different fronts of the pancreatic tumor (i.e. the microenvironment, the epithelial cells, the distant sites, the immune system) might be critical for dramatically changes outcomes of this lethal disease.”
Molecular Based and Alternative Therapies for Pancreatic Cancer
Tholey R et al.
Cancer J 2012;18:665-673
- Pancreatitis versus Malignancy
- Not always so easy!
- May require follow-up
- Pancreatic cancer can cause pancreatitis (~5%)
- Ductal obstruction is rare in pancreatitis
- Pancreatitis infiltrates anteriorly
- Pancreatic cancer infiltrates posteriorly
- “ Neoplastic and inflammatory diseases that can closely simulate pancreatic adenocarcinoma include neuroendocrine tumor, metastasis to the pancreas, lymphoma, groove pancreatitis, autoimmune pancreatitis, and focal chronic pancreatitis.”
Pancreatic Imaging Mimics: Part 1, Imaging Mimics of Pancreatic Adenocarcinoma
Coakley FV et al.
AJR 2012; 199:301-308 - “ Neoplastic and inflammatory diseases that can closely simulate pancreatic adenocarcinoma include neuroendocrine tumor, metastasis to the pancreas, lymphoma, groove pancreatitis, autoimmune pancreatitis, and focal chronic pancreatitis. Aypical imaging findings that should suggest diagnoses other than adenocarcinoma include the absence of significant duct dilatation, incidental detection, hypervascularity, large (>5cm), IV tumor thrombus, and intralesional ducts or cysts.”
Pancreatic Imaging Mimics: Part 1, Imaging Mimics of Pancreatic Adenocarcinoma
Coakley FV et al.
AJR 2012; 199:301-308 - “ Aypical imaging findings that should suggest diagnoses other than adenocarcinoma include the absence of significant duct dilatation, incidental detection, hypervascularity, large (>5cm), IV tumor thrombus, and intralesional ducts or cysts.”
Pancreatic Imaging Mimics: Part 1, Imaging Mimics of Pancreatic Adenocarcinoma
Coakley FV et al.
AJR 2012; 199:301-308 - “ Several lines of evidence suggest that misdiagnosis, either radiologically or pathologically, may be relatively common. Published false-negative rates for the pathologic misdiagnosis of pancreatic adnocarcinoma range from 1.6% to 30%.”
Pancreatic Imaging Mimics: Part 1, Imaging Mimics of Pancreatic Adenocarcinoma
Coakley FV et al.
AJR 2012; 199:301-308 - Pancreatic Adenocarcinoma: Mimics
- Neuroendocrine tumors
- Metastases to the pancreas
- Pancreatic lymphoma
- Adenocarcinoma arising in a IPMN
- Groove pancreatitis
- Autoimmune pancreatitis
- Focal chronic pancreatitis
- “Neoplastic and inflammatory diseases that can closely simulate pancreatic adenocarcinoma include neuroendocrine tumor, metastasis to the pancreas, lymphoma, groove pancreatitis, autoimmune pancreatitis, and focal chronic pancreatitis.”
Pancreatic Imaging Mimics: Part 1, Imaging Mimics of Pancreatic Adenocarcinoma
Coakley FV et al.
AJR 2012; 199:301-308 - Mimics of Pancreatic Adenocarcinoma
- neuroendocrine tumor
- metastasis to the pancreas
- lymphoma
- groove pancreatitis
- autoimmune pancreatitis
- focal chronic pancreatitis
Pancreatic Imaging Mimics: Part 1, Imaging Mimics of Pancreatic Adenocarcinoma
Coakley FV et al.
AJR 2012; 199:301-308 - “Atypical imaging findings that should suggest diagnoses other than adenocarcinoma include the absence of significant duct dilatation, incidental detection, hypervascularity, large size (>5cm), IV tumor thrombus, and intralesional duxts or cysts.”
Pancreatic Imaging Mimics: Part 1, Imaging Mimics of Pancreatic Adenocarcinoma
Coakley FV et al.
AJR 2012; 199:301-308
- “ We found no significant differences in the depiction of pancreatic parenchyma, main pancreatic duct, splanchnic arteries, and most of small splanchnic arterial branches when we compared 320- and 64 detector CT images.”
CT of the Pancreas: Comparison of Anatomic Structure Depiction, Image Quality, and Radiation Exposure between 320-Detector Volumetric Images and 64-Detector Helical Images
Goshima S et al.
Radiology 2011; 260:139-147 - “ Image quality was acceptable in both groups, and it was slightly better in the 64-detector group for pancreatic phase axial images and arterial phase multiplanar reformated images.”
CT of the Pancreas: Comparison of Anatomic Structure Depiction, Image Quality, and Radiation Exposure between 320-Detector Volumetric Images and 64-Detector Helical Images
Goshima S et al.
Radiology 2011; 260:139-147 - “ A 320-detector CT scan facilitates fast volumetric contrast enhanced CT of the entire pancreas with acceptable image quality, even though SNR was significantly lower at 320-detector volumetric scanning.”
CT of the Pancreas: Comparison of Anatomic Structure Depiction, Image Quality, and Radiation Exposure between 320-Detector Volumetric Images and 64-Detector Helical Images
Goshima S et al.
Radiology 2011; 260:139-147 - “The mean sensitivity and specificity of 64-detector row CT and 3.0-T MR imaging in the detection of pancreatic cancer (mean sensitivity, 95% vs 96%, respectively; mean specificity, 96% for both) are not significantly different.”
Gadobenate Dimeglumine-enhanced 3.0-T MR Imaging versus Multiphasic 64-Detector Row CT: Prospective Evaluation in Patients Suspected of Having Pancreatic Cancer
Koelblinger C et al.
Radiology 2011; 259:757-766 - “ Both CT and MR imaging are equally suited for detecting and staging pancreatic cancer.”
Gadobenate Dimeglumine-enhanced 3.0-T MR Imaging versus Multiphasic 64-Detector Row CT: Prospective Evaluation in Patients Suspected of Having Pancreatic Cancer
Koelblinger C et al.
Radiology 2011; 259:757-766 - “ The prevalence of isoattenuating pancreatic cancers was higher among the small (?20 mm) pancreatic adenocarcinomas than among the 21-30 mm cancers ; however, most small isoattenuating pancreatic cancers showed secondary signs, and thus, seeking secondary signs might be a solution to the problems associated with detecting these atypical pancreatic cancers.”
Small (?20 mm) Pancreatic Adenocacinomas: Analysis of Enhancement Patterns and Secondary Signs with Multiphasic Multidetector CT
Yoon SH et al.
Radiology 2011; 259:442-452 - “ The detection of ductal dilatation with an abrupt ending or contour changes on multidetector CT images should be interpreted as an indication for further imaging studies such as MR imaging with cholangiopancreatography, endoscopic ultrasonography, or fluorine 18 fluorodeoxyglucose PET.”
Small (?20 mm) Pancreatic Adenocarcinomas: Analysis of Enhancement Patterns and Secondary Signs with Multiphasic Multidetector CT
Yoon SH et al.
Radiology 2011; 259:442-452 - “ Most (88%) small (?20 mm) isoattenuating pancreatic cancers showed secondary signs such as duct dilatation and contour abnormalities.”
Small (?20 mm) Pancreatic Adenocarcinomas: Analysis of Enhancement Patterns and Secondary Signs with Multiphasic Multidetector CT
Yoon SH et al.
Radiology 2011; 259:442-452 - “ The prevalence of isoattenuating pancreatic cancers was significantly higher among well differentiated tumors (58%) than among moderately differentiated (16%) and poorly differentiated tumors (10%).”
Small (?20 mm) Pancreatic Adenocarcinomas: Analysis of Enhancement Patterns and Secondary Signs with Multiphasic Multidetector CT
Yoon SH et al.
Radiology 2011; 259:442-452 - “ The prevalence of isoattenuating pancreatic cancers at multiphasic multidetector CT among 20-mm or smaller tumors (27%) was higher than that among 21-30 mm tumors (13%).”
Small (?20 mm) Pancreatic Adenocarcinomas: Analysis of Enhancement Patterns and Secondary Signs with Multiphasic Multidetector CT
Yoon SH et al.
Radiology 2011; 259:442-452 - “ The prevalence of isoattenuating pancreatic cancers differed significantly according to tumor size and cellular differentiation. Most small isoattenuating pancreatic cancers showed secondary signs.”
Small (?20 mm) Pancreatic Adenocarcinomas: Analysis of Enhancement Patterns and Secondary Signs with Multiphasic Multidetector CT
Yoon SH et al.
Radiology 2011; 259:442-45 "Sensitivity for prediction of resectability tends to be lower for patients with locally advanced pancreatic cancer that has been downgraded by neoadjuvant therapy, but this trend is not statistically significant. Interobservor variability for determination of resectability is statistically higher than for controls who did not receive preoperative therapy."
Resectability of Pancreatic Adenocarcinoma in Patients with Locally Advanced Disease Downstaged by Preoperative Therapy: A Challenge for MDCT
Morgan DE et al.
AJR 2010; 194,615-622"The perineural plexuses closely follow peripancreatic vessels, which are well depicted by contrast enhanced 3D volume rendered imaging, thus facilitating the diagnosis of extrapancreatic perineural invasion of pancreatic adenocarcinoma."
Pathways of Extrapancreatic Perineural Invasion by Pancreatic Adenocarcinoma: Evaluation With 3D Volume Rendered MDCT Imaging Deshmukh SD, Willmann JK, Jeffrey RB AJR 2010; 194:668-674
"And for subjects with both of these findings, we recommend more frequent checkups after excluding malignancy with a detailed examination."
Slight Dilatation of the Main pancreatic Duct and Presence of Pancreatic Cysts as Predictive Signs of Pancreatic Cancer: A Prospective Study
Tanaka S et al.
Radiology 2010; 254:965-972"For subjects with both findings the 5 year cumulative risk of pancreatic cancer was 5.62%."
Slight Dilatation of the Main pancreatic Duct and Presence of Pancreatic Cysts as Predictive Signs of Pancreatic Cancer: A Prospective Study
Tanaka S et al.
Radiology 2010; 254:965-972"Accuracy in the assessment of vessel invasion in patients with neoadjuvant CCRT was improved by not considering the presence of a perivascular halo (in the absence of solid tissue in contact with vessel) as a sign of vessel invasion."
Effects of Neoadjuvant Combined Chemotherapy and Radiation Therapy on the CT Evaluation of Resectability and Staging in Patients with Pancreatic Head Cancer
Kim YE et al.
Radiology 2009;250:758-765"Accuracy in the assessment of vessel invasion in patients with neoadjuvant CCRT was improved by not considering the presence of a perivascular halo (in the absence of solid tissue in contact with vessel) as a sign of vessel invasion."
Effects of Neoadjuvant Combined Chemotherapy and Radiation Therapy on the CT Evaluation of Resectability and Staging in Patients with Pancreatic Head Cancer
Kim YE et al.
Radiology 2009;250:758-765"Neoadjuvant combined chemotherapy and radiation therapy (CCRT) reduces the accuracy of tumor restaging after treatment of pancreatic head cancer, but this effect is not so great as to affect the determination of resectability."
Effects of Neoadjuvant Combined Chemotherapy and Radiation Therapy on the CT Evaluation of Resectability and Staging in Patients with Pancreatic Head Cancer
Kim YE et al.
Radiology 2009;250:758-765"The purpose was to assess capabilities of the multidetector-row computed tomography (MDCT) with multiplanar reformations (MPR) for predicting of pancreatic adenocarcinoma resectability. Forty-eight patients deemed to have resectable pancreatic adenocarcinoma after assessment using biphasic MDCT with MPRs underwent surgery for potential tumor resection. Imaging findings were retrospectively evaluated for tumor resectability and correlated with surgical and pathological results. Curative resection was successful in 44 of 48 patients. The positive predictive value for tumor resectability made up 91% with four false-negative results. The reasons for unresectability were venous involvement (1), small liver metastases (2) and peritoneal involvement associated with small metastases to lymph nodes (1). MDCT yielded a negative predictive value of 99% (286 of 288 vessels) for detection of vascular invasion. Our results indicate the tendency towards improved prediction of resectability using MDCT compared to single-detector CT."
Resectability of pancreatic adenocarcinoma: assessment using multidetector-row computed tomography with multiplanar reformations.
Manak E et al.
Abdom Imaging. 2009 Jan-Feb;34(1):75-80"Overall, 48 out of 203 (23.6%) patients had a change in their recommended management based on clinical review of their case by the multidisciplinary tumor board."
Evaluating the impact of a single-day multidisciplinary clinic on the management of pancreatic cancer.
Pawlik TM, Laheru D, Hruban RH, Coleman J, Wolfgang CL, Campbell K, Ali S, Fishman EK, Schulick RD, Herman JM
Ann Surg Oncol 2008 Aug; 15(8):2078-80"Review of the histological slides by dedicated pancreatic pathologists resulted in changes in the interpretation for 7 of 203 patients (3.4%)."
Evaluating the impact of a single-day multidisciplinary clinic on the management of pancreatic cancer.
Pawlik TM, Laheru D, Hruban RH, Coleman J, Wolfgang CL, Campbell K, Ali S, Fishman EK, Schulick RD, Herman JM
Ann Surg Oncol 2008 Aug; 15(8):2078-80"On presentation, the outside computed tomography (CT) report described locally advanced/unresectable disease (34.9%), metastatic disease (17.7%), and locally advanced disease with metastasis (1.1%). On review of submitted imaging and imaging performed at Hopkins, 38 out of 203 (18.7%) patients had a change in the status of their clinical stage."
Evaluating the impact of a single-day multidisciplinary clinic on the management of pancreatic cancer.
Pawlik TM, Laheru D, Hruban RH, Coleman J, Wolfgang CL, Campbell K, Ali S, Fishman EK, Schulick RD, Herman JM
Ann Surg Oncol 2008 Aug; 15(8):2078-80"The single-day pancreatic multidisciplinary clinic provided a comprehensive and coordinated evaluation of patients that led to changes in therapeutic recommendations in close to one-quarter of patients."
Evaluating the impact of a single-day multidisciplinary clinic on the management of pancreatic cancer.
Pawlik TM, Laheru D, Hruban RH, Coleman J, Wolfgang CL, Campbell K, Ali S, Fishman EK, Schulick RD, Herman JM
Ann Surg Oncol 2008 Aug; 15(8):2078-80"There has been progress in the imaging, staging, surgical technique, and the use of chemotherapy and chemoradiotherapy in the management of borderline resectable pancreatic cancer. Patients can benefit from multidisciplinary management at high-volume pancreatic cancer treatment centers."
Borderline Resectable Pancreatic Cancer: On The Edge of Survival
Springett GM, Hoffe
SE Cancer Control 2008 Oct; 15(4):295-307"The use of neoadjuvant treatment programs that employ gemcitabine-based chemotherapy regimens followed by chemoradiation increases the likelihood of subsequent margin-negative resection in borderline resectable pancreatic cancer."
Borderline Resectable Pancreatic Cancer: On The Edge of Survival
Springett GM, Hoffe
SE Cancer Control 2008 Oct; 15(4):295-307"Review of the histological slides by dedicated pancreatic pathologists resulted in changes in the interpretation for 7 of 203 patients (3.4%)."
Evaluating the impact of a single-day multidisciplinary clinic on the management of pancreatic cancer.
Pawlik TM, Laheru D, Hruban RH, Coleman J, Wolfgang CL, Campbell K, Ali S, Fishman EK, Schulick RD, Herman JM
Ann Surg Oncol 2008 Aug; 15(8):2078-80"On presentation, the outside computed tomography (CT) report described locally advanced/unresectable disease (34.9%), metastatic disease (17.7%), and locally advanced disease with metastasis (1.1%). On review of submitted imaging and imaging performed at Hopkins, 38 out of 203 (18.7%) patients had a change in the status of their clinical stage."
Evaluating the impact of a single-day multidisciplinary clinic on the management of pancreatic cancer.
Pawlik TM, Laheru D, Hruban RH, Coleman J, Wolfgang CL, Campbell K, Ali S, Fishman EK, Schulick RD, Herman JM
Ann Surg Oncol 2008 Aug; 15(8):2078-80"The single-day pancreatic multidisciplinary clinic provided a comprehensive and coordinated evaluation of patients that led to changes in therapeutic recommendations in close to one-quarter of patients."
Evaluating the impact of a single-day multidisciplinary clinic on the management of pancreatic cancer.
Pawlik TM, Laheru D, Hruban RH, Coleman J, Wolfgang CL, Campbell K, Ali S, Fishman EK, Schulick RD, Herman JM
Ann Surg Oncol 2008 Aug; 15(8):2078-80"With recent advances in pancreatic imaging and surgical techniques, a distinct subset of pancreatic tumors is emerging that blurs the distinction between resectable and locally advanced disease: tumors of "borderline resectability."
Borderline Resectable Pancreatic Cancer: Definitions, Management, and Role of Preoperative Therapy
Varadhachary GR et al.
Ann Surg Oncol 2006 Aug; 13(8):1035-1046- "With currently available surgical techniques, patients with borderline-resectable pancreatic head cancer are at high risk for a margin-positive resection. Therefore, our approach to these patients is to use preoperative systemic therapy and local-regional chemoradiation to maximize the potential for an R0 resection and to avoid R2 resections. In our experience, patients with favorable responses to preoperative therapy (radiographical evidence of tumor regression and improvement in serum tumor marker levels) are the subset of patients who have the best chance for an R0 resection and a favorable long-term outcome."
- What is borderline resectable?
- Encasement of a short segment of the hepatic artery w/o celiac artery involvement
- Tumor abutment of the SMA but <180 degrees
- Short segment occlusion of SMV, portal vein, or their confluence "There has been progress in the imaging, staging, surgical technique, and the use of chemotherapy and chemoradiotherapy in the management of borderline resectable pancreatic cancer. Patients can benefit from multidisciplinary management at high-volume pancreatic cancer treatment centers."
Borderline Resectable Pancreatic Cancer: On The Edge of Survival
Springett GM, Hoffe SE
Cancer Control 2008 Oct; 15(4):295-307"The use of neoadjuvant treatment programs that employ gemcitabine-based chemotherapy regimens followed by chemoradiation increases the likelihood of subsequent margin-negative resection in borderline resectable pancreatic cancer."
Borderline Resectable Pancreatic Cancer: On The Edge of Survival
Springett GM, Hoffe SE
Cancer Control 2008 Oct; 15(4):295-307Pretreatment Assessment of Resectable and Borderline Resectable Pancreatic Cancer: Expert Consensus Statement
Callery MP, Chang KJ, Fishman EK, Talamonti MS, Traverso WL, Linehan DC
Ann Surg Oncol 2009 Jul;16(7):1727-33"Overall, 48 out of 203 (23.6%) patients had a change in their recommended management based on clinical review of their case by the multidisciplinary tumor board."
Evaluating the impact of a single-day multidisciplinary clinic on the management of pancreatic cancer.
Pawlik TM, Laheru D, Hruban RH, Coleman J, Wolfgang CL, Campbell K, Ali S, Fishman EK, Schulick RD, Herman JM
Ann Surg Oncol 2008 Aug; 15(8):2078-80"Major conclusions that can be drawn from these trials in composite are (1) adjuvant chemotherapy is superior to observation following pancreaticoduodenectomy for pancreatic cancer, (2) gemcitabine is superior to 5- FU as adjuvant chemotherapy, and (3) the benefit of adjuvant chemoradiation is uncertain."
Strength of the Evidence: Adjuvant Therapy for Resected Pancreatic Cancer
Picozzi VJ et al
J Gastrointest Surg (2008);12:657-661- Treatment Of Pancreatic Cancer: Options
- Surgery
- Chemotherapy (I.e. gemcitabine)
- Radiation therapy
- A combination of the above in different protocols
"Initial prospective clinical interpretation of all 114 pancreatic CT angiographic scans had 100% overall sensitivity in the detection of resectability and 72% specificity; the blinded retrospective evaluation by expe"”
Pancreatic Adenocarcinoma: value of multidetector CT Angiography in Preoperative Evaluation
Zamboni GA et al
Radiology 2007;245:770-778"Multidetector CT angiography is an effective preoperative tool that reduces the number of aborted pancreatic resections; there is no evidence from this retrospective study suggestive varying results from the various generations of multidetector CT scanners used."
Pancreatic Adenocarcinoma: value of multidetector CT Angiography in Preoperative Evaluation
Zamboni GA et al
Radiology 2007;245:770-778
- "A combination of pancreatic parenchymal phase and PVP imaging is necessary and efficient for the assessment of pancreatic adenocarcinoma. The addition of coronal and sagittal MPR images increased the performance of MDCT, especially in the evaluation of local extension."
MDCT of Pancreatic Adenocarcinoma: Optimal Imaging Phases and Multiplanar Reformatted Imaging
Ichikawa T et al.
AJR 2006; 187:1513-1520
- "The addition of coronal and sagittal MPR images to the MDCT protocol increases the sensitivity of MDCT and improves its agreement with surgical findings regarding local staging factors."
MDCT of Pancreatic Adenocarcinoma: Optimal Imaging Phases and Multiplanar Reformatted Imaging
Ichikawa T et al.
AJR 2006; 187:1513-1520
- "Multidetector (64 section) volumetric CT allows comprehensive preoperative assessment of pancreatic adenocarcinoma. Carefully timed scan acquisition maximizes the difference in attenuation between the neoplasm and the pancreatic parenchyma and allows accurate local and distant staging as well as assessment of local resectability."
Comprehensive Preoperative Assessment of Pancreatic Adenocarcinoma with 64-Section Volumetric CT
Brennan DD et al
RadioGraphics 2007; 27:1653-1666
- "Venous involvement >180° and arterial involvement >90° by CT had a 100% positive predictive value for failure to achieve R0 resection."
Endoscopic Ultrasound and Computed Tomography Predictors of Pancreatic Cancer Resectability
Bao PQ et al
J Gastrointest Surg (2008) 12:10-16
(R0 is margin negative)
- "EUS has become the favorite tool of the gastroenterologist for staging pancreatic cancer, whereas most surgeons still feel that a CT scan is really all we need to determine resectability. I believe your data confirm this opinion."
Published Discussion- Nakeeb A
Endoscopic Ultrasound and Computed Tomography Predictors of Pancreatic Cancer Resectability
Bao PQ et al
J Gastrointest Surg (2008) 12:10-16
- "Pancreas protocol CT imaging appears to be a better predictor of resectability compared with EUS. EUS accuracy is affected by the presence of biliary stents."
Endoscopic Ultrasound and Computed Tomography Predictors of Pancreatic Cancer Resectability
Bao PQ et al
J Gastrointest Surg (2008) 12:10-16
- PATIENTS: Ninety-one consecutive patients (53 men, 38 women; mean age, 61 years) referred to our department with a diagnosis of cancer of the head of the pancreas underwent a preoperative contrast enhanced triphasic 16-slice multi-detector computed tomography. Sixty-three were considered inoperable because of advanced local disease, metastatic disease, or poor surgical risk.
INTERVENTION: Of the remaining 28 patients, 23 underwent a Whipple procedure, whereas 5 patients underwent a palliative procedure.
Predicting resectability of pancreatic head cancer with multidetector CT. Surgical and pathologic correlation Olivie D et al
JOP. 2007 Nov 9;8(6):753-8
- "Of the 91 patients evaluated, 25% had successful resection of pancreatic head carcinoma; while only 5% had a palliative procedure. When compared to surgical outcome, the positive predictive value of multi-detector computed tomography for resectability was 100%. On the basis of pathologic results, the positive predictive value of multi-detector computed tomography for resectability fell to 83%, Four patients deemed resectable following multi-detector computed tomography had positive margins at pathology."
Predicting resectability of pancreatic head cancer with multidetector CT. Surgical and pathologic correlation Olivie D et al
JOP. 2007 Nov 9;8(6):753-8
- "When compared to surgical outcome, the positive predictive value of multi-detector computed tomography for resectability was 100%. On the basis of pathologic results, the positive predictive value of multi-detector computed tomography for resectability fell to 83%, Four patients deemed resectable following multi-detector computed tomography had positive margins at pathology."
Predicting resectability of pancreatic head cancer with multidetector CT. Surgical and pathologic correlation Olivie D et al
JOP. 2007 Nov 9;8(6):753-8
- The initial clinical interpretation of CT angiographic scans in all 114 patients had 100% sensitivity in the detection of resectability, 72% specificity, 89% PPV, and 100% NPV. These parameters did not appear to vary among different types of scanner. With the blinded retrospective evaluation by experienced readers, specificity increased to 94% and PPV to 98%, with no difference in sensitivity and NPV.
Pancreatic adenocarcinoma:value of multidetector CT angiography in preoperative evaluation
Zamboni GA et al Radiology 2007 Dec;245(3):770-778
- "Multidetector CT angiography is an effective preoperative tool that reduces the number of aborted pancreatic resections; there is no evidence from this retrospective study suggesting varying results from the various generations of multidetector CT scanners used."
Pancreatic adenocarcinoma:value of multidetector CT angiography in preoperative evaluation
Zamboni GA et al Radiology 2007 Dec;245(3):770-778
- "Our results suggest that by combining data from both CT and EUS, a clinically relevant scoring system can be utilized to help select appropriate interventions and therapy for patients with pancreatic cancer."
Predicting Unresectability in Pancreatic Cancer Patients: The Additive Effects of CT and Endoscopic Ultrasound
Yovino S et al.
J Gastrointest Surg (2007) 11:36-42
- "In conclusion, based on the high sensitivity estimate for diagnosis of helical CT compared with MRI and US and the high specificity value for resectability compared with US, helical CT is preferable as an imaging modality for the diagnosis and assessment of resectability of pancreatic adenocarcinoma."
Ultrasonography, Computed Tomography and Magnetic Resonance Imaging for Diagnosis and Determining Resectability of Pancreatic Adenocarcinoma: A Meta Analysis
Bipat S et al.
J Comput Assist Tomogr 2005;29:438-445
- "Helical CT is preferable as an imaging modality for the diagnosis and determination of resectability of pancreatic adenocarcinoma."
Ultrasonography, Computed Tomography and Magnetic Resonance Imaging for Diagnosis and Determining Resectability of Pancreatic Adenocarcinoma
A Meta-Analysis
Bipat S et al.
J Comput Assist Tomogr 2005;29:438-445
- "For diagnosis, sensitivities of helical CT, conventional CT, MRI and US were 91%, 86%, 84%, and 76% and specificities were 85%, 79%, 82%, and 75% respectively."
Ultrasonography, Computed Tomography and Magnetic Resonance Imaging for Diagnosis and Determining Resectability of Pancreatic Adenocarcinoma
A Meta-Analysis
Bipat S et al.
J Comput Assist Tomogr 2005;29:438-445
- "For determining resectability, sensitivities of helical CT, conventional CT, MRI and US were 81%, 82%, 82%, and 83% and specificities were 82%, 76%, 78%, and 63% respectively."
Ultrasonography, Computed Tomography and Magnetic Resonance Imaging for Diagnosis and Determining Resectability of Pancreatic Adenocarcinoma
A Meta-Analysis
Bipat S et al.
J Comput Assist Tomogr 2005;29:438-445
- Ultrasonography, Computed Tomography and Magnetic Resonance Imaging for Diagnosis and Determining Resectability of Pancreatic Adenocarcinoma
A Meta-Analysis
Bipat S et al.
J Comput Assist Tomogr 2005;29:438-445
literature search:the studied reviewed articles published between January 1990 and December 2003
- "Vascular resection as an adjunct to pancreaticoduodenectomy is increasingly used in pancreatic head surgery. As a result, the imaging criteria to determine which patients are candidates for potentially curative resection are evolving."
New Concepts in Staging and Treatment of Locally Advanced Pancreatic Head Cancer
Lall CG et al.
AJR 2007; 189:1044-1050
- "Noncircumferential involvement of the superior mesenteric vein downstream (toward the liver) from its jejunal branches is no longer considered unresectable for cure. Multiphasic isotropic CT of the abdomen and use of reformations help in determining the exact site and extent of venous invasion."
New Concepts in Staging and Treatment of Locally Advanced Pancreatic Head Cancer
Lall CG et al.
AJR 2007; 189:1044-1050
- Pylorus Preserving Pancreaticoduodenectomy (Whipple Procedure): Facts
Radical resection of
- Pancreatic head
- Duodenum
- Regional lymph nodes
- Gallbladder
- Distal common bile duct
- Pancreatic Ductal Carcinoma
- Accounts for 75% of all pancreatic tumors
- 4th leading cause of cancer death in the US
11th most common cancer
- Represents only 2-3% of all cancers
- Demographics
- Mean age of onset 55
- Peak age, 7th decade
- M:F 2:1
- B > W
- Pancreatic Ductal Carcinoma
- Heritable syndrome
- Familial aggregation of pancreatic cancer
- Familial colon cancer, Gardner’s syndrome, hereditary pancreatitis, ataxia telangiectasisa
- Risk Factors
- Cigarette smoking
- Diabetes Mellitus
- Chronic pancreatitis
- High fat diet
- Elevated CEA, Ca19-9
- Pancreatic Ductal Carcinoma
- Presentation
- 65% advanced local disease or metastases
- 21% localized disease with spread to regional nodes
- 14% confined to the pancreas
- Pancreatic Ductal Carcinoma
- Contraindications to surgical resection*
- Metastases - usually liver or peritoneal
- Distant lymph node metastases
- Arterial encasement
- Greater than 50% encasement of major venous structures.
- **Alexakis et al. Br J Surg 2004;91:1410-1427.
- Vascular Involvement
- Lu AJR 1997;168:1439-1443.
- When greater than 50%of the vessel circumference (arteries and veins) is in contact with the tumor, it is unresectable
- Using this criteria, the sensitivity for resectability was 84% with 98% specificity
- Nakayama JCAT 2001;25:337-342.
- Same criteria as Lu
- Lu’s criteria worked well for veins but not for arteries because sometimes arteries surrounded by fibrous tissue or inflammatory stranding
- Vascular Involvement
- Horton Radiol Clin North Am 2002;40: 1263-1272.
- Changes in vessel caliber or presence of collaterals are also helpful signs to determine vascular involvement
- Arslan Eur J Radiol 2000;38:151-159
- CT showed accuracy rate of 90% for determining vascular invasion
- House Gastrointestinal Surg 2004;8:280-288.
- 3D CT was 95% accurate in determining cancer invasion of the superior mesenteric vessels
- Vascular Involvement
- CT Appearance
- Tumor encases >50% vessel diameter
- If tumor involved 25-50% of vessel diameter, some will still be resectable
- Narrowing of involved vessel
- Loss of fat plane
- Collateral vessels
- Peripancreatic veins, gastroepiploic veins
- Nodal Staging
- Roche. AJR 2003;180:475-480.
- Using short axis > 10mm
- Sensitivity 14%
- Specificity 85%
- Positive predictive value 17%
- Negative predictive value 82%
- Ovoid shape, clustering of nodes and absence of fatty hilum were not useful predictors or malignancy
- "Helical CT is preferable as an imaging modality for the diagnosis and determination of resectability of pancreatic adenocarcinoma."
Ultrasonography, Computed Tomography and Magnetic Resonance Imaging for Diagnosis and Determining Resectability of Pancreatic Adenocarcinoma
Bipat S et al J Comput Assist Tomogr 2005; 29:438-445
- "It is recommended that the CT diagnostic criteria for arterial and venous invasion should be dealt with differently."
Pancreatic Adenocarcinoma:The Different CT Criteria for Peripancreatic major Arterial and Venous Invasion Li H et al. J Comput Assist Tomogr 2005; 29:170-175
- "Multidetector row CT with 3-dimensional volume rendering allows for accurate delineation of the portal venous system and collaterals that develop in cases of portal hypertension.Whereas the direction of blood flow cannot be determined on axial images the pattern of collateral circulation that develops can predict the flow direction to bypass a point of obstruction along the portal venous system."
Patterns of Collateral Pathways in Extrahepatic Portal Hypertension as Demonstrated by Multidetector Row Computed Tomography and Advanced Image Processing
Kamel IR, Lawler LP, Corl FM, Fishman EK J Comput Assist Tomogr 2004;28:469-477
- "Preoperative multidetector CT can help predict the presence of invasive carcinoma associated with IPMN."
Intraductal Papillary Mucinous Neoplasm of the Pancreas: Can Benign Lesions Be Differentiated from Malignant Lesions with MDCT?
Kawamoto S, Horton KM, Lawler LP, Hruban RH, Fishman EK
RadioGraphics 2005; 25:1451-1470
- "Among the patients with periampullary cancer, the extent of local tumor burden involving the pancreas and peripancreatic tissues was accurately depicted by 3D-CT in 93% of the patients. 3D-CT was 95% accurate in determining cancer invasion of the superior mesenteric vessels. Preoperative 3D-CT accurately predicted periampullary cancer resectability and a margin-negative resection in 98% and 86% of patients, respectively."
Predicting resectability of periampullary cancer with three-dimensional computed tomography
House MG et al
J Gastrointest Surg. 2004 Mar-Apr;8(3):280-8.
- "In resectable pancreatic ductal carcinoma, CT is not accurate overall for the prediction of nodal involvement. In a patient with presumed pancreatic adenocarcinoma that is considered to be resectable, the depiction on CT of peripancreatic nodes should not prevent attempted curative resection."
CT and Pathologic Assessment of Prospective Nodal Staging in Patients with Ductal Adenocarcinoma of the Head of the Pancreas
Roche CJ et al.
AJR 2003;180:475-480
- "Dual phase helical CT is a useful technique for preoperative staging of pancreatic cancer. The main limitation of CT is that it may not reveal small hepatic metastases."
Dual-Phase Helical CT of Pancreatic Adenocarcinoma: Assessment of Resectability before Surgery
Valls C et al.
AJR 2002; 178:821-826
- Pancreatic Resection of Adenocarcinoma: What were the errors on CT?
- Positive predictive value was 73.5% (25 of 34 cases)
- Errors in 9 of 34 cases were
- Liver metastases (5)
- Vascular encasement (2)
- Adenopathy (2)
- Dual-Phase Helical CT of Pancreatic Adenocarcinoma: Assessment of Resectability before Surgery
Valls C et al.
AJR 2002; 178:821-826
- "Portal vein/SMV resection during pancreaticoduodenectomy increases operative time, estimated blood loss, length of intensive care unit stay, and overall hospital stay but does not significantly add to the operative mortality rates, mortality rates or incidence of positive histologic margins."
Efficacy of Venous Reconstructions in Patients with Adenocarcinoma of the Pancreatic Head
Howard TJ et al.
J Gastrointest Surg 2003;7:1089-1095
- "Our preliminary data on MDCT shows that the technique has excellent negative predictive value for vascular invasion and good negative predictive value for overall tumor resectability in patients with pancreatic adenocarcinoma, suggesting an improvement over previous results reported using single detector CT."
- "For detection of vascular invasion, MDCT yielded a negative predictive value of 100% with no false negative findings and an accuracy of 99% with one false positive finding."
MDCT in Pancreatic Adenocarcinoma: Prediction of Vascular Invasion and Resectability Using a Multiplasic Technique with Curved Planar Reformations
Vargas R et al.
AJR 2004; 182:419-425
- "Pure acinar cell carcinoma of the pancreas is usually an exophytic, oval or round, well marginated, and hypovascular mass on CT and MRI. It typically is completely solid when small and contains cystic areas due to necrosis when large."
CT and MRI Features of Pure Acinar Cell Carcinoma of the Pancreas in Adults
tatli et al.
AJR 2005; 184:511-519
- Acinar Cell Carcinoma of the Pancreas
- 1% of pancreatic cells are acinar cells
- 5th thru 7th decade of life
- Tumor cells may produce pancreatic enzymes that circulate systemically and cause polyarthritis and subcutaneous fat necrosis
- Aggressive tumor with mortality less than adenocarcinoma
- Acinar Cell Carcinoma of the Pancreas
- Pancreatic head is most common site
- Lesions are usually solid and exophytic
- Mean size around 7 cm
- Presentaion may be palpable mass, abdominal pain or weight loss
- Pancreatic Pseudocysts:Complications
- Infection
- Hemorrhage
- Rupture
- Obstruction of other organs
- Cystic Pancreatic Mass: Differential Diagnosis
- Pseudocyst
- Serous cystadenoma
- Mucinous cystic tumor
- IMPN (intraductal mucinous tumor)
- SPEN (solid and papillary neoplasm)
- Cystic islet cell tumor
- Serous Cystadenoma: Facts
- AKA microcystic cystadenoma
- Usually woman over age 60
- Multiple 0.2-2.0 cm cysts
- Central calcified stellate scar classic
- May seem cystic or even solid on CT
- Mucinous Cystic Tumor: Facts
- Enhancing septations and nodules are common
- Peripheral calcification is seen in up to 25% of cases
- Malignant potential and should be removed
- IPMN: facts
- Main or side branch duct dilatation common
- Most common in uncinate
- Can be multiple throughout the pancreatic gland
- "In conclusion, based on the high sensitivity estimate for diagnosis of helical CT compared with MRI and US and the high specifciity value for resectability compared with US, helical CT is preferable as an imaging modality for the diagnosis and assessment of resectability of pancreatic adenocarcinoma.
Ultrasonography, Computed Tomography and Magnetic Resonance Imaging for Diagnosis and Determining Resectability of Pancreatic Adenocarcinoma
Bipat S et al J Comput Assist Tomogr 2005; 29:438-445
- "Helical CT is preferable as an imaging modality for the diagnosis and determination of resectability of pancreatic adenocarcinoma."
Ultrasonography, Computed Tomography and Magnetic Resonance Imaging for Diagnosis and Determining Resectability of Pancreatic Adenocarcinoma
Bipat S et al J Comput Assist Tomogr 2005; 29:438-445
- "It is recommended that the CT diagnostic criteria for arterial and venous invasion should be dealt with differently."
Pancreatic Adenocarcinoma:The Different CT Criteria for Peripancreatic major Arterial and Venous Invasion Li H et al. J Comput Assist Tomogr 2005; 29:170-175
- Pancreatic Tumors in Children
- Pancreatoblastoma
- Pseudopapillary tumor (SPEN)
- Islet cell tumor (insulinoma)
- Pancreatoblastoma: Facts
- Most common pancreatic tumor in young children
- Mean age is 4.5 years
- Slight male predominance
- More common in Asians
- Pancreatoblastoma: CT Findings
- Large mass (5 cm or greater)
- Smooth and multiloculated
- Calcifications not uncommon
- Liver metastases not uncommon and hypovascular
- Islet Cell Tumors
- Functioning or hyperfunctioning:
- Insulinoma most common (47%)
- Gastrinoma 2nd most common
- Nonfunctioning
- Gastrinomas
- Found in the "gastrinoma triangle" bounded by the porta hepatis and the second and third portions of the duodenum
- Nearly all gastrinomas are solitary
- MEN 1 or Wermer Syndrome
- Synchronous or metachronous tumors of the:
- Parathyroid glands
- Anterior pituitary
- Pancreas
- GI Tract
- Multiple True Pancreatic Cysts: Differential Diagnosis
- Von Hippel-Lindau disease
- Beckwith-Wiedermann syndrome
- Autosomal dominant PCK
- Pancreas
- Meckel-Gruber syndrome
- "Single phase helical CT is effective for the diagnosis and assessment of resectability of patients with suspected pancreatic cancer. Advantages are the lower radiation dose and fewer images to film and store."
Dual Phase Versus Single Phase Helical CT to Detect and Assess Resectability of Pancreatic Carcinoma
Imbriaco M, Megibow AJ et al.
AJR 2002; 178:1473-1479
(single detector scanner).