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Pancreas: Pancreatic Adenocarcinoma Imaging Pearls - Educational Tools | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ Pancreas ❯ Pancreatic Adenocarcinoma

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  • “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):295-307

  • 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).
© 1999-2018 Elliot K. Fishman, MD, FACR. All rights reserved.