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Pancreatic Ductal Carcinoma

Published on 18/07/2015 by admin

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 Strong tendency to obstruct pancreatic and common bile ducts with abrupt ductal cutoff at site of obstruction

image Pancreatic parenchymal atrophy upstream from mass
image Soft tissue infiltration to involve adjacent vessels and organs (e.g., duodenum, bowel, stomach, and adrenals)
image Most common sites of distant metastatic disease are liver, peritoneum, and lungs
image Arterial involvement quantified as < 180° or ≥ 180° tumoral involvement of vessel circumference
image Venous involvement may involve abutment, encasement, narrowing, or occlusion
• MR: Tumor conspicuous on T1WI, appearing low signal and juxtaposed against high signal pancreatic parenchyma

image T2WI less useful, as tumors isointense to pancreas
image Conspicuity on T1WI C+ similar to CT, with tumors demonstrating progressive delayed enhancement

CLINICAL ISSUES

• Most common malignant tumor of exocrine pancreas and accounts for > 95% of pancreatic malignancies
• Most common symptoms are jaundice, weight loss, abdominal pain, and back pain

image Often asymptomatic until late in course, particularly body/tail tumors that do not cause jaundice
• Only potentially curative treatment is complete surgical resection with negative surgical margins
• Only 15-20% of patients candidates for surgery at presentation, with 5-year survival of ∼ 20% after surgery
• 5-year survival rate is < 5% without surgery with median survival of 3.5 months
image
(Left) Graphic shows pancreatic head carcinoma image encasing and obstructing the pancreatic and distal bile ducts. There is encasement of the superior mesenteric vessels image and spread to celiac nodes image. Note the atrophy of the distal body-tail segments image.

image
(Right) Axial CECT in the venous phase demonstrates a poorly marginated hypodense mass image in the pancreatic body, typical for pancreatic adenocarcinoma. The mass abuts the distal celiac trunk image and the hepatic artery image, with < 180° involvement of each.
image
(Left) Coronal CECT demonstrates a subtle hypodense mass image in the pancreatic head resulting in obstruction and upstream dilatation of the pancreatic duct image. The presence of pancreatic ductal dilatation and abrupt cut-off should always prompt careful search for a pancreatic mass.

image
(Right) Sagittal CECT demonstrates a poorly marginated pancreatic cancer image encasing the SMA, with 360° involvement. This degree of encasement almost certainly makes this tumor unresectable.

TERMINOLOGY

Synonyms

• Pancreatic adenocarcinoma, pancreatic cancer

Definitions

• Malignancy arising from ductal epithelium of exocrine pancreas

IMAGING

General Features

• Best diagnostic clue

image Poorly marginated, hypoenhancing mass with abrupt obstruction of pancreatic duct ± common bile duct
• Location

image Head (60%), body (20%), diffuse (15%), tail (5%)
• Size

image Variable; average size 2-3 cm
• Morphology

image  

CT Findings

• CT sensitivity for pancreatic cancer is excellent (∼ 97%)

image Excellent modality for determining unresectability (positive predictive value for unresectability of 89-100%)
image Less effective in determining resectability, as only 60-91% of tumors found to be resectable on CT are actually resectable at surgery
• Poorly marginated, hypodense mass with tendency to infiltrate posteriorly into retroperitoneum

image Tumor most conspicuous in portal venous (∼ 70 seconds) and pancreatic (∼ 40 seconds) contrast phases
image 5% of tumors isodense to pancreas on all phases, requiring attention to secondary signs of tumor
image Tumor virtually never calcifies in absence of treatment
• Secondary signs of tumor

image Strong tendency to obstruct pancreatic and common bile ducts with abrupt ductal cutoff at site of obstruction
image Pancreatic parenchymal atrophy upstream from mass
image Abnormal contour of pancreas with loss of normal fatty lobulation and texture
image Soft tissue infiltration to involve adjacent vessels and organs (e.g., duodenum, bowel, stomach, and adrenals)
• Distant metastatic disease

image Most common sites are liver, peritoneum, and lungs
image Regional lymph nodes frequently involved, but CT inaccurate for involvement (sensitivity < 20%)
image Adrenals, bones, and pleura (uncommon)
• CT best modality for determining vascular invasion

image Arterial involvement quantified as < 180° or ≥ 180° tumoral involvement of vessel circumference
image Venous involvement determined based on degree of contact between tumor and vessel, and described as abutment, encasement, narrowing, or occlusion

– Distinction between < 180° or ≥ 180° involvement of veins no longer as important with advent of venous reconstruction
– SMV or splenic vein narrowing often results in mesenteric or gastroepiploic collateral veins
image Tumor thrombus in mesenteric veins very uncommon, and much more common with neuroendocrine tumors
• Pancreatic adenocarcinoma classically causes hypercoagulability: Look for evidence of incidental pulmonary emboli or deep venous thrombosis

MR Findings

• Normal pancreas

image Diffusely high signal intensity on T1WI (≥ liver)
image Parenchyma variable in signal on T2WI
image Pancreas enhances avidly and homogeneously on T1WI C+ (hyperintense to liver on arterial phase and isointense on delayed phase)
• MR particularly helpful in identifying small group of tumors that are isodense to normal pancreas on CT
• Tumor conspicuous on T1WI, appearing low signal and juxtaposed against high signal pancreatic parenchyma

image Atrophic pancreas upstream from tumor often abnormally low signal on T1WI
• T2WI generally not useful for tumor detection, as tumors often isointense to pancreas
• Conspicuity on T1WI C+ similar to CT, with hypovascular tumors often demonstrating progressive delayed enhancement
• Tumors often demonstrate restricted diffusion with lower ADC values than adjacent normal pancreas 

image DWI not helpful in differentiating tumors from other entities (such as autoimmune pancreatitis)
• MRCP and T2WI can nicely demonstrate abrupt cutoff and obstruction of pancreatic and common bile ducts
• MR generally 2nd choice (behind CT) for evaluating vascular involvement

Ultrasonographic Findings

• Hypoechoic mass with only minimal internal color Doppler flow vascularity
• Biliary dilatation and pancreatic ductal dilatation upstream from tumor
• Endoscopic ultrasound: Similar to conventional US findings, with inferior accuracy compared to CECT for locoregional staging or determining vascular involvement

image Helpful in excluding  malignancy in patients with indeterminate CT findings (↑ negative predictive value)
image Can help guide biopsy of pancreatic masses

Nuclear Medicine Findings

• PET/CT

image PET alone (without diagnostic CT) not effective for diagnosis of primary tumor (sensitivity as low as 72%)

– Possible role in differentiating malignant from benign lesions, as FDG-avid lesions have ↑ risk of malignancy

image May help differentiate pancreatic adenocarcinoma, which shows avid focal uptake in mass, from focal autoimmune pancreatitis, which shows diffuse uptake throughout pancreas and within salivary glands
– Effective in judging response to treatment (chemoradiation), whereas CT may not differentiate post-treatment fibrosis from residual tumor
image PET not helpful for vascular involvement or locoregional staging (e.g., lymph nodes) due to poor spatial resolution
image Helpful for distant staging, and may change resectability status of ∼ 20% of patients compared to CECT

Radiographic Findings

• Barium (upper GI) study

image Frostberg 3 sign: “Inverted 3” contour to medial part of duodenal sweep
image Spiculated duodenal wall with traction, fixation, and widening of duodenal sweep
image Antral padding: Extrinsic indentation by tumor of posteroinferior margin of antrum
• ERCP

image Irregular, abrupt, nodular, rat-tailed, eccentric obstruction of pancreatic and common bile ducts
image Double duct sign: Obstruction of pancreatic and common bile duct at same level
image Localized encasement with prestenotic dilatation

Angiographic Findings

•  

Imaging Recommendations

• Best imaging tool

image Dual-phase CECT with arterial and portal venous phases
• Protocol advice

image Best phase for identifying pancreatic cancers is pancreatic phase at ∼ 40 seconds after contrast
image Portal venous phase nearly equivalent for tumor detection and allows optimal evaluation of liver metastases and central mesenteric veins
image Arterial phase critical for evaluating relationship of tumor to mesenteric arteries
image Most institutions no longer acquire 3 phases, as arterial and portal venous phases are sufficient
image Multiplanar views improve detection and depiction of ductal obstruction, vascular encasement, nodes
• CT and MR

image High predictive value (near 100%) for tumor nonresectability
image Less predictive value (75-85%) for resectable tumor
• Endoscopic US

image Excellent for detection and staging of small tumor
image Facilitates biopsy for tissue confirmation

DIFFERENTIAL DIAGNOSIS

Pancreatic Neuroendocrine Tumors

• Well-circumscribed mass that is typically markedly hypervascular on arterial phase images
• Usually no ductal obstruction or parenchymal atrophy
• Frequently calcify and may invade mesenteric veins with tumor thrombus (unusual features for pancreatic adenocarcinoma)

Focal Autoimmune Pancreatitis

• Classic appearance is sausage-like diffuse enlargement of pancreas with peripheral peripancreatic “halo”
• Can rarely manifest as focal hypodense pancreatic mass that may appear identical to adenocarcinoma
• Upstream pancreas usually enlarged, rather than atrophic, and pancreatic duct usually not dilated
• Typically responds dramatically to steroid therapy

Chronic Pancreatitis

• May be associated with focal fibroinflammatory mass that can be indistinguishable from pancreatic cancer
• Usually other stigmata of chronic pancreatitis, including diffuse atrophy of gland, dilated/beaded pancreatic duct with ductal calculi, and parenchymal calcifications
• May obstruct both pancreatic and common bile ducts, producing double duct sign (similar to adenocarcinoma)
• Given that chronic pancreatitis is a major risk factor, chronic pancreatitis and pancreatic adenocarcinoma may coexist

Pancreatic Metastases and Lymphoma

• Hypovascular metastases (e.g., lung, colon) to pancreas may mimic pancreatic adenocarcinoma, but typically evidence of widespread metastatic disease elsewhere

image Less commonly obstruct pancreatic duct or CBD
• Lymphoma presents as homogeneous, hypoenhancing soft tissue mass 

image Almost never causes ductal obstruction/dilatation or parenchymal atrophy
image Usually occurs in setting of disseminated disease, with significant surrounding lymphadenopathy
image Encases peripancreatic vessels without narrowing or occlusion

Asymmetric Fatty Infiltration of Pancreatic Head

• May superficially mimic tumor, but no mass effect, ductal dilatation, or other secondary signs of malignancy
• MR with in- and out-of-phase imaging can easily make distinction between fatty infiltration and tumor

Mucinous Cystic Pancreatic Tumor

• Cystic component may not be recognized on NECT
• Usually does not obstruct pancreatic or bile duct

Tumors From Adjacent Organs

• Duodenal adenocarcinoma or GI stromal tumors (GIST) involving distal stomach or duodenum may be difficult to distinguish from primary pancreatic mass

Groove Pancreatitis

• Form of chronic pancreatitis affecting pancreaticoduodenal groove
• Sheet-like, curvilinear soft tissue mass between pancreatic head and duodenum
• Prospective diagnosis is very uncommon, and surgery often performed due to difficulty in differentiating from pancreatic or duodenal carcinoma

PATHOLOGY

General Features

• Etiology

image Risk factors: Cigarette smoking, alcohol, obesity, diabetes mellitus, chronic pancreatitis, high-fat diet
• Genetics

image Family history is strong risk factor, as ∼ 10% of patients have 1st degree relative with pancreatic cancer
image Activated  KRAS  oncogene in ∼ 95% of cases
image BRCA2 mutations (10% of patients), cholecystokinin B gene variant (35%), and several other genes associated
image Abnormal high levels of p53 gene
• Associated abnormalities

image Heritable syndromes associated with ↑ risk include

– Hereditary pancreatitis, hereditary breast and ovarian cancer syndrome, Peutz-Jeghers, ataxia telangiectasia, familial colon cancer, Gardner syndrome, and familial aggregation of pancreatic cancer
image High-risk groups may benefit from screening with CT, MR, or EUS

Staging, Grading, & Classification

• Local staging

image T1 tumor limited to pancreas ≤ 2 cm
image T2 tumor limited to pancreas ≥ 2 cm
image T3 tumor beyond pancreas but no celiac or SMA involvement
image T4 tumor involves celiac or SMA
• Determination of locoregional resectability (MD Anderson criteria)

image Unequivocally resectable

– No metastatic disease, suspicious lymphadenopathy distant from tumor, or vascular involvement of SMV, portal vein, celiac, hepatic artery, or SMA
– Local lymph nodes immediately around tumor do not generally preclude surgical resection
image Unresectable

– Distant metastatic disease or bulky lymphadenopathy distant from mass
– > 180° involvement of SMA or > 180° involvement of celiac/hepatic artery without options for reconstruction
– Occlusion of SMV or portal vein without options for reconstruction
image Borderline resectable (definition may vary depending on author and institution)

– ≤ 180° involvement of SMA
– Short segment encasement or abutment of common hepatic artery near its origin with possibility of reconstruction at surgery
– Short segment occlusion of SMV/portal vein with possibility of venous reconstruction

Gross Pathologic & Surgical Features

• Hard, nodular mass obstructing pancreatic duct/CBD
• Hypovascular and locally invasive with prominent desmoplastic response
• Produces mucin and dense, collagenous desmoplastic stroma
• Spread: Local, peripancreatic, perivascular, perineural, and lymphatic invasion

Microscopic Features

• White, fibrous lesion; dense cellularity; nuclear atypia
• Most ductal cancers are mucinous adenocarcinomas

CLINICAL ISSUES

Presentation

• Most common signs/symptoms

image Most common symptoms are jaundice, weight loss (often severe), abdominal pain (usually epigastric pain radiating to back), and back pain

– Jaundice ↑ common in pancreatic head tumors
– Patients may present with Courvoisier gallbladder (distended palpable gallbladder due to obstruction)
– Commonly asymptomatic until late in course, particularly body/tail tumors that do not cause jaundice
– Rarely presents with unexplained migratory superficial thrombophlebitis (Trousseau syndrome) due to tumor induced hypercoagulability or bleeding from varices, which result from SMV or splenic vein occlusion
image At presentation

– Advanced local disease &/or metastases (65%)
– Localized disease with spread to regional lymph nodes (21%)
– Tumor confined to pancreas (14%)
image Lab data

– Elevated tumor markers: CA 19-9 (most important), CEA, CA 242 

image CA 19-9 levels often followed after surgery or therapy as marker of potential disease progression

Demographics

• Age

image Median age at onset: 71 years 

– Almost always after age 45
image Peak: 7th-8th decade
• Gender

image M:F = 1.3:1
• Ethnicity

image African Americans > Caucasians
• Epidemiology

image 12th most common cancer and 4th leading cause of cancer deaths in USA

– Lifetime risk of ∼ 1.5% with 46,000 new cases each year
image Accounts for 2-3% of all cancers
image Most common malignant tumor of exocrine pancreas

– Accounts for > 95% of pancreatic malignancies

Natural History & Prognosis

• Complications: Venous thrombosis, GI hemorrhage
• Only 15-20% of patients are candidates for surgery at time of presentation
• 5-year survival rate is ∼ 20% after surgery

image Survival no better than chemoradiation alone if surgery performed for tumor found to be locally advanced at surgery
image Surgical margins and node status at surgery are major prognostic indicators

– Surgeon required to sample minimum number of nodes during surgery
– Survival in node-negative disease after surgery may be as high as 30%
• 5-year survival rate is < 5% without surgery with median survival of 3.5 months
• Overall survival is poor, with only 6.7% surviving 5 years

Treatment

• Only potentially curative treatment for resectable tumor is complete surgical resection with negative surgical margins (R0 resection)

image Pancreaticoduodenectomy (Whipple resection) for tumors of pancreatic head/uncinate, distal pancreatectomy for tumors of body/tail, and very rarely total pancreatectomy
• Chemotherapy and radiation (external beam) utilized for resectable, borderline, and unresectable cancers

image Gemcitabine and FOLFIRINOX are chemotherapy mainstays
image Neoadjuvant chemoradiation often utilized prior to surgery in borderline resectable tumors
• Palliative procedures include endoscopic biliary stenting (for jaundice), enteric stents or diverting gastrojejunostomy (for gastric/duodenal obstruction), and chemical splanchnicectomy or celiac nerve block to palliate abdominal pain

DIAGNOSTIC CHECKLIST

Consider

• Differentiate from other solid pancreatic masses ± main pancreatic duct dilatation

Image Interpretation Pearls

• Dilated pancreatic duct with abrupt cutoff and upstream atrophy, even in absence of visible mass, should be considered tumor until proven otherwise and requires further investigation (usually with endoscopic ultrasound)

Reporting Tips

• Provide information that determines resectability, including presence of metastatic disease and involvement of major central mesenteric vasculature (portal vein, SMV, celiac, hepatic artery, and SMA)
image
(Left) Coronal CECT demonstrates a poorly marginated hypodense mass image in the pancreatic head/neck, typical of pancreatic adenocarcinoma. Note that the tumor involves the distal portal vein image, portal/SMV confluence, and superior SMV.

image
(Right) Coronal volume-rendered CECT in the same patient demonstrates that the mass image has occluded the SMV over several centimeters extending from the confluence, with development of multiple collaterals and reconstitution of the SMV more inferiorly image.
image
(Left) Coronal volume-rendered CECT demonstrates a hypoenhancing mass image in the pancreatic head, found to be a pancreatic cancer at resection. The lack of parenchymal atrophy or ductal dilatation is unusual for pancreatic cancer.

image
(Right) Axial CECT demonstrates hypodense enlargement of the entire pancreas image, representing infiltration by pancreatic adenocarcinoma. Although uncommon, pancreatic cancer can rarely diffusely involve the entire gland, and may be confused for autoimmune pancreatitis.
image
(Left) Coronal CECT demonstrates a pancreatic cancer image involving the adjacent duodenum, resulting in duodenal obstruction and dilatation image. Note that the tumor involves roughly a 180° circumference of the SMA image.

image
(Right) Coronal CECT demonstrates a pancreatic cancer image obstructing the pancreatic duct image and causing upstream parenchymal atrophy. Note that the mass directly invades the adjacent duodenum image. Multiple liver metastases image are present, precluding resection.
image
(Left) Transverse ultrasound demonstrates a hypoechoic mass image in the pancreatic body, representing a pancreatic adenocarcinoma. Ultrasound is generally quite limited in assessment of the pancreas due to overlying bowel gas.

image
(Right) Color Doppler ultrasound of the pancreatic head demonstrates a hypoechoic, poorly marginated pancreatic adenocarcinoma image. Note the relatively minimal internal color flow vascularity within the mass, typical of these lesions on ultrasound.
image
(Left) ERCP in a patient with a pancreatic head adenocarcinoma demonstrates an irregular stricture image of the common bile duct. The abrupt, irregular narrowing of the duct at the stricture certainly is a highly suspicious feature for malignancy.

image
(Right) Coronal MRCP with MIP reconstruction demonstrates the typical double duct sign associated with pancreatic cancer, with abrupt occlusion of the pancreatic duct and common bile duct at the level of the patient’s pancreatic head mass.
image
(Left) Axial T1WI C+ FS MR demonstrates a hypoenhancing mass image in the pancreatic head, compatible with pancreatic adenocarcinoma. The appearance of pancreatic cancer on post-gadolinium MR images is comparable to its appearance on CECT.

image
(Right) Axial ADC map in the same patient demonstrates significant restricted diffusion image within the mass. Restricted diffusion can be a valuable tool to help increase the conspicuity of subtle pancreatic cancers.
image
(Left) Axial CECT in a patient with pancreatic cancer demonstrates peripherally enhancing metastases throughout the liver. The liver is almost always the 1st site of distant metastasis for pancreatic adenocarcinoma.

image
(Right) Axial CECT demonstrates an infiltrative, hypodense mass image in the pancreatic tail, in keeping with pancreatic adenocarcinoma. Pancreatic tail cancers typically do not involve vital vasculature and often come to attention later than pancreatic head cancers due to lack of jaundice.
image
(Left) Coronal CECT demonstrates an infiltrative hypodense mass image in the pancreatic head with upstream pancreatic ductal dilatation image. The mass encases and severely narrows the SMV image.

image
(Right) Coronal volume-rendered CECT in the same patient demonstrates severe narrowing image of the SMV, with the development of large venous collaterals image. The presence of venous collaterals in a pancreatic cancer patient should always suggest the presence of venous narrowing or occlusion.
image
(Left) Axial curved MINIP display shows upstream dilatation of the pancreatic duct image proximal to a focal structure image in the pancreatic duct.

image
(Right) Endoscopic ultrasound of the strictured area reveals a solid mass image that was biopsied and shown to be adenocarcinoma. Any focal stricture of the main pancreatic duct should be considered as an isodense carcinoma until proven otherwise, and should lead to EUS interrogation and biopsy.
image
(Left) Axial T1 noncontrast MR demonstrates a hypointense uncinate process mass image nicely juxtaposed against the T1 hyperintense normal pancreatic parenchyma image. Noncontrast T1 images tend to be more helpful than T2WI for pancreatic adenocarcinoma identification.

image
(Right) Coronal T2 MR demonstrates the relative lack of conspicuity of the same tumor image on T2WI. The lesion is relatively hypointense, and is difficult to differentiate from the adjacent hypointense normal pancreatic parenchyma image.
image
(Left) Axial T1 C+ FS MR demonstrates a poorly marginated, hypoenhancing mass image in the pancreatic tail extending into the splenic hilum and invading the spleen.

image
(Right) Axial T2 MR in the same patient demonstrates that the mass image is mildly T2 hyperintense. In general, pancreatic adenocarcinoma is often isointense or only mildly hyperintense on T2WI, making this pulse sequence unreliable for tumor detection.
image
(Left) Axial T1 FS C+ MR in the arterial phase demonstrates a hypodense mass image in the pancreatic tail, compatible with pancreatic adenocarcinoma. Several metastases image are present in the liver.

image
(Right) Axial FS T1 C+ MR in the delayed phase from the same patient shows that the mass image now demonstrates considerable delayed enhancement. Delayed enhancement, which is much easier to appreciate on MR compared to CT, is a fairly common feature of pancreatic adenocarcinoma.
image
Axial CECT during the venous phase shows a hypodense mass image in the pancreatic head that encases the splenoportal confluence and SMA image and occludes the SMV. The body and tail are atrophic and the duct is dilated.

image
Axial CECT shows cancer arising from pancreatic head/uncinate with extensive encasement of the SMA image and splenoportal confluence. Perigastric collaterals image indicate splenic vein occlusion.
image
Axial CECT shows a hypovascular mass in the pancreatic body image that occludes the splenic artery and vein, with perigastric varices image. Note the liver metastases.
image
Transverse abdominal ultrasound shows a hypoechoic mass (calipers) within the pancreatic head image. Note the gastric antrum image.
image
Axial T1WI C+ MR shows a hypointense mass image within the pancreatic head. Note the “teardrop” shape of the SMV image, indicating tumor invasion.
image
Axial arterial phase CECT show a poorly defined mass image in the head of the pancreas.
image
Axial portal venous phase image in the same patient again shows a poorly defined mass in the head of the pancreas image. Note also the enlarged mesenteric lymph nodes image.
image
Endoscopic ultrasound performed in the same patient clearly outlines a solid mass image in the head of the pancreas.
image
Endoscopic ultrasound in the same patient shows a liver metastasis image. A biopsy was performed of the metastatic lesion by EUS image. This case illustrates the value of EUS in both diagnosing and staging pancreatic carcinoma.
image
Axial CECT shows upstream dilatation of the pancreatic duct image by a hypodense mass image in the neck of the pancreas.
image
A more caudal image shows the hypodense tumor image encasing the splenoportal confluence image. Note that the tumor extends posterior to the portal vein image along a known perineural pathway that leads to the right celiac ganglion. Early extrapancreatic perineural spread of adenocarcinoma is a major contributing factor to the poor prognosis of this disease.
image
Axial CECT shows a centrally necrotic adenocarcinoma image in the head of the pancreas. Note that the lesion infiltrates the fat plane contiguous with the SMA image, but there is less than 180 degree involvement by tumor.
image
A more caudal axial image in the same patient again shows the tumor image and extension adjacent to the SMA image, making this a borderline resectable lesion. A Whipple resection was attempted but the lesion could not be dissected from the SMA.
image
Axial CECT of the celiac artery demonstrates soft tissue encasement image of the celiac and common hepatic arteries. Note the irregular luminal contour image of the common hepatic artery that results in a “saw-toothed” appearance.
image
A curved planar reformation along the common hepatic artery in the same patient shows soft tissue encasement image and irregular saw-toothing of its arterial contour image. This luminal irregularity, or saw-toothing, is a direct sign of adventitial invasion.
image
Axial MINIP display from a CECT shows a locally advanced carcinoma image arising from the tail of the pancreas, directly invading into the retroperitoneum image and into the left adrenal gland.
image
Coronal view in the same patient shows celiac artery encasement image as well as encasement of the left gastric artery image. As is evident in this patient, tail of pancreas lesions often present clinically at such an advanced stage that they are rarely curable by resection.
image
A more anterior coronal view in the same patient shows soft tissue tumor encasement image along the posterior inferior pancreaticoduodenal artery, which is the 1st branch off the SMA image. This is a common perineural pathway for extrapancreatic spread, a very characteristic feature of uncinate adenocarcinomas.
image
Coronal CECT shows a locally advanced pancreatic carcinoma image arising from the uncinate process. Note the extensive soft tissue encasement image of the SMA.
image
A more anterior coronal image in the same patient shows direct extension of the tumor image into the root of the mesentery adjacent to mesenteric veins image. Arterial encasement and mesenteric invasion make this an unresectable lesion.
image
A curved planar reformation along the splenic artery from a CECT shows extensive soft tissue encasement image of the artery with irregular areas of luminal narrowing image.
image
Craniocaudal MIP in the same patient shows an irregular contour of the artery image as well as luminal narrowing image. The arterial encasement in this patient makes it unresectable.
image
Coronal curved planar reformation along the pancreatic duct shows dilated duct image obstructed by a hypodense mass image in the head of the pancreas. Note the cuff of soft tissue around the common hepatic artery image, indicating arterial encasement.
image
Coronal reformation (same patient) shows encasement image of the celiac image and SMA image. Arterial encasement is a universally accepted criterion for nonresectability and the patient was treated with chemoradiation.
image
Axial MINIP display shows an isodense mass image causing abrupt obstruction of the dilatated pancreatic duct image. Note that the mass extends posteriorly and obliterates the fat plane around the IVC image.
image
A more caudal MINIP image in the same patient again shows the mass image invading the anterior margin of the IVC image and the dilated pancreatic duct image. At surgery, the mass was adherent to the IVC and could not be resected.
image
Coronal CECT shows a small, hypodense carcinoma image obstructing both the common bile duct image and the pancreatic duct image.
image
A more posterior coronal image shows an irregular, enlarged lymph node image adjacent to the celiac artery image. At surgery, the celiac node was positive for metastatic adenocarcinoma and the surgery was abandoned. An enlarged lymph node outside the anatomic boundary of a Whipple resection should prompt biopsy of the node to avoid unnecessary surgery.
image
Axial CECT shows a small, hypodense carcinoma arising from the uncinate process image. Note that the superior mesenteric vein has a pointed or “teardrop” configuration image rather than its normal rounded appearance.
image
A more caudal axial image again shows the carcinoma image and the “teardrop” sign image, indicating adventitial invasion of the wall of the superior mesenteric vein. In these cases, surgical resection with negative margins can only be accomplished with a venous bypass graft.
image
Axial CECT shows a hypodense carcinoma image causing focal flattening image of the superior mesenteric vein and splenoportal confluence. Note upstream pancreatic ductal dilatation image.
image
A more caudal axial image in the same patient shows focal compression of the SMV image without circumferential encasement. This tumor was considered to be borderline for resectability. At surgery, the tumor was not able to be dissected free of the splenoportal confluence.
image
Axial CECT shows a hypodense carcinoma image in the uncinate process. Note that the mass abuts the posterior margin image of the superior mesenteric artery but does not encase or exceed 1/2 of the circumference of the SMA.
image
Curved planar reformation of the SMA image in the same patient shows the carcinoma image with 2 cm length of contact image with the lateral margin of the SMA, indicating a borderline resectable lesion. At surgery, the lesion was adherent to the SMA and was unresectable.
image
Axial arterial phase image from a gadolinium-enhanced MR shows a hypointense mass image in the head of the pancreas.
image
A more caudal axial image in the same patient shows that the mass image does not involve the fat planes image around the superior mesenteric vein, indicating a resectable lesion. The patient underwent a successful Whipple resection with negative margins (R0 resection).
image
Axial CECT shows a large, hypodense carcinoma image arising from the body/tail segment of the pancreas.
image
A more caudal plane in the same patient shows that the mass invades posteriorly to encase the left renal vein image and the left kidney, resulting in hydronephrosis image and a delayed nephrogram. Posterior invasion into the retroperitoneum is a characteristic pattern of spread for locally invasive ductal adenocarcinoma.
image
Axial CECT demonstrates a poorly marginated pancreatic tail adenocarcinoma image. The mass involves no major vasculature and would be theoretically resectable.
image
Axial CECT in the same patient demonstrates a nodular soft tissue focus image in the right omentum. The nodule was biopsied and found to be a tumor implant, thus precluding resection. Other than the liver, the peritoneum is one of the more common sites of distant metastatic disease.
image
Coronal CECT demonstrates a hypodense mass image in the pancreatic head resulting in abrupt occlusion and upstream dilatation of the pancreatic duct image. A biliary stent image has been placed to relieve the patient’s jaundice.
image
Axial CECT demonstrates a poorly defined, hypodense mass image in the pancreatic head, typical for pancreatic adenocarcinoma. Note that the mass completely encases the adjacent SMA image, precluding this patient from undergoing resection.

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