Harris GE Siemens
CTisUS Sponsers
Pancreas

Pancreatic Adenocarcinoma

  • “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
  • 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
  • “ 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):295-307

  • Pretreatment 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).
All images on this site are © 2013 Elliot K. Fishman, MD.