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Carcinoma of the pancreas: detection and staging using CT and MRI

Carcinoma of the pancreas: detection and staging using CT and MRI Multidisciplinary Symposium — carcinoma of the pancreas 19 Laparoscopic examination of the abdominal cavity will, Key points at most, improve this yield by 10%. The effect of (1) Incidence of disease far more common in the elderly endoscopic ultrasound, peritoneal washings, bone mar- (2) Histological type of great importance prognostically row biopsy and PET scanning have yet to be fully (3) Early diagnosis essential evaluated. It is cost-effective to limit the investigations to (4) Operability determined by high quality imaging state-of-the-art CT scanning and accept a slightly higher (5) Resection associated with a <5% mortality and a rate of inoperable cases which can be managed by 20% 5-year survival surgical palliation. With selection the surgical outcome should be a mortality of under 5% and a 5-year survival of 20% for duct cell carcinomas. The quality of life for patients Further reading undergoing pancreatoduodenectomy is good and their [1] Kloppel G, Solcia E, Longnecker DS, Capella C, Sobin LH. initial recovery period is no longer than 3 months before Histological typing of tumours of the exocrine pancreas. achieving an acceptable normalization of life. Adjuvant International Histological Classification of Tumours, 2nd chemotherapy improves survival by 10%. Radio- Edition. Berlin: Springer. World Health Organisation, 1998: therapy does not improve survival and it may even be 1–61. harmful. [2] Lillemoe KD, Cameron JL, Yeo CJ, Sohn TA, Nakeeb A, Sauter PK, Hruban RH, Abrams RA, Pitt HA. Pancreaticoduodenectomy. Does it have a role in the palliation of pancreatic cancer? Ann Surg 1996; 223: 718–25. [3] Krech RL, Walsh D. Symptoms of pancreatic cancer. J Pain Conclusion Symptom Management 1991; 6: 360–7. [4] Yeo CJ, Cameron JL, Sohn TA, Coleman J, Sauter PK, The surgeons’ view of pancreatic carcinoma is that the Hruban RH, Pitt HA, Lillemoe KD. Pancreaticoduo- diagnosis should be made early, the investigations denectomy with or without extended retroperitoneal lym- phadenectomy for periampullary adenocarcinoma: comparison should be undertaken expeditiously and the investiga- of morbidity and mortality and short-term outcome. Ann Surg tions limited to helical CT scanning. For those patients 1999; 229: 613–22. with an inoperable tumour a biopsy is appropriate. Operative mortality should be low and the quality of life The digital object identifier for this article is: 10.1102/ following recovery from resection good. 1470-7330.2001.010 Carcinoma of the pancreas: detection and staging using CT and MRI Jay P Heiken Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri, USA Our ability to diagnose pancreatic carcinoma has improved reduce the percentage of patients who are unnecessarily substantially over the past 20 years, owing to major subjected to laparotomy. advances in pancreatic imaging, including the development CT has become established as the primary initial imaging of US, CT and MRI. Despite these advances, however, the method for both detection and staging of suspected pancre- prognosis of patients with pancreatic cancer remains dis- atic carcinoma. Most studies have found that CT is highly [1] mal. The overall 5-year survival rate is only 3% , although reliable when it demonstrates features indicating that a [5,6] the 5-year survival rate for patients who undergo pancreatic tumor is unresectable . The positive predictive value [2–4] resection is reported to be approximately 20% . Because (PPV) of a diagnosis of unresectability with helical CT has [7–11] of the very poor prognosis of patients with pancreatic ranged from 92% to 100% . Helical CT is less reliable, carcinoma, many physicians take a nihilistic approach to its however, for predicting that a tumor is resectable [7–11] diagnosis and staging. It is important to keep in mind, (PPV = 76–90%) . Nevertheless, this represents a sub- however, that a large percentage of patients with pancreatic stantial improvement over prediction of resectability with [12–14] cancer who undergo laparotomy for possible curative resec- conventional CT (PPV = 45–72%) . Limitations of CT tion are found to have unresectable disease. Thus, optimi- include: poor ability to demonstrate small hepatic or peri- zation of pre-operative imaging is important in order to toneal metastases; inability to demonstrate microscopic 20 Multidisciplinary Symposium — carcinoma of the pancreas lymph node metastases; and inability to differentiate in the diagnosis of pancreatic carcinoma in patients inflammatory from neoplastic lymph node enlargement. with an indeterminate pancreatic mass, but currently Optimized technique is essential to achieve the highest does not play a significant role in pancreatic carcinoma predictive values for resectability and unresectability. The staging. CT data should be acquired helically using a rapid IV Although criteria for unresectability vary among sur- [15,16] contrast medium injection rate (e.g. 4–5 ml/s) and geons, imaging features that generally indicate unresectabil- appropriate scan timing during the pancreatic parenchymal ity include vascular invasion, lymph node metastases [17,18] phase of enhancement . Images should be acquired beyond those in the immediate vicinity of the pancreas, and with thin collimation (3 mm) to optimize in-plane spatial distant metastases. Metastases most commonly involve the resolution, and overlapping reconstructions are recom- liver or peritoneum. mended for producing high quality multiplanar and Several recent studies have evaluated the accuracy of CT 3-dimensional images when needed. Curved planar refor- findings of vascular invasion (of the portal vein, superior mations through the pancreatic duct or peripancreatic mesenteric vein, superior mesenteric artery, celiac axis and vessels can be useful for displaying the imaging findings hepatic artery) in predicting the resectability of pancreatic [19] [31–34] [32–34] to the surgeon . Two-dimensional and 3-dimensional carcinoma . In three of these studies the pro- volume-rendered images of the peripancreatic vessels are portion of the vessel circumference in contact with the not routinely necessary for staging but can provide useful tumor was assessed. All three studies found that when the [20,21] information in some cases . Such CT angiographic tumor is not contiguous with the vessel (i.e. when an images can be useful in pre-operative planning, especially if intervening fat plane is present), vascular invasion is almost variant celiac axis, hepatic artery or superior mesenteric never present. When the tumor is contiguous with less than artery anatomy is present. one-quarter of the vessel circumference, it is resectable in State-of-the-art MRI using breath-hold imaging the majority of cases, but when the tumor is contiguous sequences, a phased-array torso coil and dynamic gadolin- with one-quarter to one-half the vessel circumference, it is ium enhancement is equivalent to CT for demonstrating unresectable in the majority of cases. It is in the group of small pancreatic carcinomas and providing accurate staging patients in which the tumor contacts up to one-half the [22] information . A recent study found dynamic gadolinium- vessel circumference that EUS may be of value to better enhanced MR imaging to be superior to dual-phase helical assess vascular invasion. Otherwise, surgical exploration is CT in the pre-operative assessment of resectability of needed to determine resectability. Tumors contacting more [9] pancreatic carcinoma . However, in that study, the helical than one-half the circumference of the vessel are nearly [31] CT imaging technique was not optimized. As with CT, the always unresectable. Another study assessed the contour MR imaging technique must be optimized in order for MR of the tumor at its point of contact with the vessel as a to provide accurate pre-operative staging information. The predictor of resectability. Tumors that were inseparable limitations of MR imaging are similar to those of CT. A from the vessel but had a convex contour with the vessel potential advantage of MR is its superior tissue contrast wall were resectable in 55% of cases (an additional 34% compared with CT. In addition, heavily T2-weighted pulse could be resected but required venous resection). Tumors sequences can be used to perform MR cholangiopancrea- that were inseparable from the vessel and had a concave [23,24] tography (MRCP) . Although its spatial resolution is contour with the vessel were resectable in only 7% of cases less than that of endoscopic retrograde cholangiopancrea- (an additional 40% could be resected but required venous tography (ERCP), an advantage of MRCP over ERCP, in resection). The proportion of vessel circumference involved addition to its noninvasiveness, is its ability to demonstrate by tumor is a more reliable predictor of resectability than the tumor contour at its point of contact with the vessel. the portions of the pancreatic and bile ducts proximal to obstructions and high-grade strictures. In addition, Another sign of unresectability of adenocarcinoma of the MRCP is useful for the demonstration and evaluation of head of the pancreas is a teardrop shape of the superior [25–27] mucin-producing pancreatic tumors . mesenteric vein (SMV), which represents either direct In the hands of some investigators, transabdominal color tumor infiltration of the vein or peritumoral fibrosis [35] Doppler ultrasonography has been shown to have an adherent to the vessel . accuracy similar to those of CT and angiography for Assessment of the peripancreatic veins can also provide diagnosing arterial and portal venous invasion by pancre- information regarding the likelihood of vascular invasion [28,29] atic carcinoma . Nevertheless, ultrasonography contin- by pancreatic carcinoma. In patients with pancreatic carci- ues to play a secondary role in the detection and staging noma, dilatation of the posterior superior pancreatico- of pancreatic carcinoma at most institutions. Endoscopic duodenal vein or the gastrocolic trunk is a sign of portal or [36–39] ultrasound (EUS) is also highly accurate for predicting superior mesenteric vein invasion . However, a dilated portal venous invasion and is considered by some gastrocolic trunk should not be used as an independent sign [34] investigators to be the most accurate test for imaging of surgical unresectability . [30] pancreatic cancer . EUS is particularly useful for detect- Our ability to detect and stage pancreatic carcinoma is ing small masses in the head and body of the pancreas currently better than it has ever been, and it is very likely and for directing transluminal biopsies of these masses. that continued technological advances in CT and MR Limitations of EUS are that it is not widely available imaging will further improve our diagnostic and staging and that it provides inconsistent visualization of the capabilities. Improvements in pre-operative staging will pancreatic tail. FDG-PET may have a potential role further minimize the number of patients with unresectable Multidisciplinary Symposium — carcinoma of the pancreas 21 tumors who undergo needless laparotomy and may help in window for evaluation of pancreatic adenocarcinoma. Am J Radiol 1999; 172: 605–8. directing patients to appropriate nonoperative or combined [19] Nino-Murcia M, Jeffrey RB, Beaulieu CF, Li KCP, Rubin operative and nonoperative forms of therapy, if improved GD. Multidetector CT of the pancreas and bile duct system: treatment methods become available. Finally, imaging for value of curved planar reformations. Am J Radiol 2001; 176: early detection of pancreatic carcinoma may take on 689–93. [20] Raptopoulos V, Steer ML, Sheiman RG, Vrachliotis TG, greater importance if genetic screening methods allow Gougoutas CA, Movson JS. The use of helical CT and CT identification of individuals who are at high risk for angiography to predict vascular involvement from pancreatic developing this insidious and deadly disease. cancer: correlation with findings at surgery. Am J Radiol 1997; 168: 971–7. [21] Baek SY, Sheafor DH, Keogan MT, DeLong DM, Nelson RC. Two-dimensional multiplanar and three-dimensional References volume-rendered vascular CT in pancreatic carcinoma: inter- observer agreement and comparison with standard helical [1] National Cancer Institute. Annual Cancer Statistics Review techniques. Am J Radiol 2001; 176: 1467–3. 1973–1988. NIH Publication No. 91-1789. Bethesda, MD: [22] Ichikawa T, Haradome H, Hachiya J et al. Pancreatic ductal Department of Health and Human Services, 1991. adenocarcinoma: preoperative assessment with helical CT [2] Ferna ´ ndez-del Castillo C, Rattner DW, Warshaw AL. versus dynamic MR imaging. Radiology 1997; 202: 655–62. Standards for pancreatic resection in the 1990s. Arch Surg [23] Lamanto D, Pavone P, Laghi A et al. Magnetic resonance 1995; 130: 295–300. cholangiopancreatography in the diagnosis of biliopancreatic [3] Geer RJ, Brennan MF. Prognostic indicators for survival after diseases. Am J Surg 1997; 174: 33–8. resection of pancreatic adenocarcinoma. Am J Surg 1993; 165: [24] Yamaguchi K, Chijiiwa K, Shimizu S, Yokohata K, Morisaki 68–73. T, Tanaka M. Comparison of endoscopic retrograde and [4] Cameron JL, Crist DW, Sitzmann JV et al. Factors influenc- magnetic resonance cholangiopancreatography in the ing survival after pancreatoduodenectomy for pancreatic surgical diagnosis of pancreatic diseases. Am J Surg 1998; 175: cancer. Am J Surg 1991; 161: 120–5. 203–8. [5] Andre ´n-Sandberg A r , Lindberg CG, Lundstedt C, Ihse I. [25] Sugiyama M, Atomi Y, Hachiya J. Intraductal papillary Computed tomography and laparoscopy in the assessment of tumors of the pancreas: evaluation with magnetic resonance the patient with pancreatic cancer. J Am Coll Surg 1998; 186: cholangiopancreatography. Am J Gastroenterol 1998; 93: 35–40. 156–9. [6] Freeny PC, Traverso LW, Ryan JA. Diagnosis and staging [26] Onaya H, Itai Y, Niitsu M et al. Ductectatic mucinous of pancreatic adenocarcinoma with dynamic computed cystic neoplasms of the pancreas: evaluation with MR tomography. Am J Surg 1993; 165: 600–5. cholangiopancreatography. Am J Radiol 1998; 171: 171–7. [7] Zeman RK, Cooper C, Zeiberg AS et al. TNM staging of [27] Koito K, Namieno T, Ichimura T et al. Mucin-producing pancreatic carcinoma using helical CT. Am J Radiol 1997; pancreatic tumors: comparison of MR cholangiopancreatog- 169: 459–64. raphy with endoscopic retrograde cholangiopancreatography. [8] Diehl SJ, Lehmann KJ, Sadick M, Lachmann R, Georgi M. Radiology 1998; 208: 231–7. Pancreatic cancer: value of dual-phase helical CT in assessing [28] Tomiyama T, Ueno N, Tano S, Wada S, Kimura K. resectability. Radiology 1998; 206: 373–8. Assessment of arterial invasion in pancreatic cancer using [9] Sheridan MB, Ward J, Guthrie JA et al. Dynamic contrast- color Doppler ultrasonography. Am J Gastroenterol 1996; 91: enhanced MR imaging and dual-phase helical CT in the 1410–6. preoperative assessment of suspected pancreatic cancer: a [29] Ueno N, Tomiyama T, Tano S, Wada S, Miyata T. Color comparative study with receiver operating characteristic Doppler ultrasonography in the diagnosis of portal vein analysis. Am J Radiol 1999; 173: 583–90. invasion in patients with pancreatic cancer. J Ultrasound Med [10] Legmann P, Vignaux O, Dousset B et al. Pancreatic tumors: 1997; 16: 825–30. comparison of dual-phase helical CT and endoscopic [30] Sugiyama M, Hagi H, Atomi Y, Saito M. Diagnosis of portal sonography. Am J Radiol 1998; 170: 1315–22. venous invasion by pancreatobiliary carcinoma: value of [11] Coley SC, Strickland NH, Walker JD, Williamson RCN. endoscopic ultrasonography. Abdom Imaging 1997; 22: Spiral CT and the pre-operative assessment of pancreatic 434–8. adenocarcinoma. Clin Radiol 1997; 52: 24–30. [31] Loyer EM, David CL, Dubrow RA, Charnsangave C. [12] Warshaw AL. Implications of peritoneal cytology for staging Vascular involvement in pancreatic adenocarcinoma: of early pancreatic cancer. Am J Surg 1991; 161: 26–30. reassessment by thin-section CT. Abdom Imaging 1996; 21: [13] Freeny PC, Traverso LW, Ryan JA. Diagnosis and staging 202–6. of pancreatic adenocarcinoma with dynamic computed [32] Lu DSK, Reber HA, Krasny RM, Kadell BM, Sayre J. Local tomography. Am J Surg 1993; 165: 600–6. staging of pancreatic cancer: criteria for unresectability of [14] Andersen HB, Effersoe H, Tjalve E et al. CT for assessment of major vessels as revealed by pancreatic-phase, thin-section pancreatic and periampullary cancer. Acta Radiol 1993; 34: helical CT. Am J Radiol 1997; 168: 1439–43. 569–72. [33] Furukawa H, Kosuge T, Mukai K et al. Helical computed [15] Tublin ME, Tessler FN, Cheng SL et al.Effect of injection tomography in the diagnosis of portal vein invasion by pancreatic head carcinoma. Arch Surg 1998; 133: 61–5. rate of contrast medium on pancreatic and hepatic helical CT. Radiology 1999; 210: 97–101. [34] O’Malley ME, Boland GWL, Wood BJ, Ferna ´ ndez-del- [16] Kim T, Murakami T, Takahashi S, Okada A, Hori M, Castillo C, Warshaw AL, Mueller PR. Adenocarcinoma of the Narumi Y, Nakamura H. Pancreatic CT imaging: effects of head of the pancreas: determination of surgical unresectability different injection rates and doses of contrast material. with thin-section pancreatic-phase helical CT. Am J Radiol Radiology 1999; 212: 219–25. 1999; 173: 1513–8. [17] Lu DS, Vandantham S, Krasny RM et al. Two-phase helical [35] Hough TJ, Raptopoulos V, Siewert B, Matthews JB. CT for pancreatic tumors: pancreatic versus hepatic phase Teardrop superior mesenteric vein: CT sign for unresectable enhancement of tumor, pancreas, and vascular structures. carcinoma of the pancreas. Am J Radiol 1999; 173: 1509–12. Radiology 1996; 199: 697–701. [36] Mori H, Miyake H, Aikawa H et al. Dilated posterior [18] Boland GW, O’Malley ME, Saez M, Ferna ´ ndez-del-Castillo superior pancreaticoduodenal vein: recognition with CT and C, Warshaw AL, Mueller PR. Pancreatic-phase versus portal clinical significance in patients with pancreaticobiliary vein-phase helical CT of the pancreas: optimal temporal carcinomas. Radiology 1991; 181: 793–800. 22 Multidisciplinary Symposium — carcinoma of the pancreas [37] Mori H, McGrath FP, Malone DE, Stevenson GW. [39] Yamada Y, Mori H, Kiyosue H, Matsumoto S, Hori Y, The gastrocolic trunk and its tributaries: CT evaluation. Maeda T. CT assessment of the inferior peripancreatic veins: Radiology 1992; 182: 871–7. clinical significance. Am J Radiol 2000; 174: 677–84. [38] Hommeyer SC, Freeny PC, Crabo LG. Carcinoma of the head of the pancreas: evaluation of the pancreaticoduodenal veins The digital object identifier for this article is: 10.1102/ with dynamic CT — potential for improved accuracy in staging. Radiology 1995; 196: 233–8. 1470-7330.2001.013 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Cancer Imaging Springer Journals

Carcinoma of the pancreas: detection and staging using CT and MRI

Heiken, Jay
Cancer Imaging , Volume 2 (1) – May 5, 2015
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Springer Journals
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Copyright © 2001 by International Cancer Imaging Society
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Medicine & Public Health; Imaging / Radiology; Cancer Research; Oncology
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Abstract

Multidisciplinary Symposium — carcinoma of the pancreas 19 Laparoscopic examination of the abdominal cavity will, Key points at most, improve this yield by 10%. The effect of (1) Incidence of disease far more common in the elderly endoscopic ultrasound, peritoneal washings, bone mar- (2) Histological type of great importance prognostically row biopsy and PET scanning have yet to be fully (3) Early diagnosis essential evaluated. It is cost-effective to limit the investigations to (4) Operability determined by high quality imaging state-of-the-art CT scanning and accept a slightly higher (5) Resection associated with a <5% mortality and a rate of inoperable cases which can be managed by 20% 5-year survival surgical palliation. With selection the surgical outcome should be a mortality of under 5% and a 5-year survival of 20% for duct cell carcinomas. The quality of life for patients Further reading undergoing pancreatoduodenectomy is good and their [1] Kloppel G, Solcia E, Longnecker DS, Capella C, Sobin LH. initial recovery period is no longer than 3 months before Histological typing of tumours of the exocrine pancreas. achieving an acceptable normalization of life. Adjuvant International Histological Classification of Tumours, 2nd chemotherapy improves survival by 10%. Radio- Edition. Berlin: Springer. World Health Organisation, 1998: therapy does not improve survival and it may even be 1–61. harmful. [2] Lillemoe KD, Cameron JL, Yeo CJ, Sohn TA, Nakeeb A, Sauter PK, Hruban RH, Abrams RA, Pitt HA. Pancreaticoduodenectomy. Does it have a role in the palliation of pancreatic cancer? Ann Surg 1996; 223: 718–25. [3] Krech RL, Walsh D. Symptoms of pancreatic cancer. J Pain Conclusion Symptom Management 1991; 6: 360–7. [4] Yeo CJ, Cameron JL, Sohn TA, Coleman J, Sauter PK, The surgeons’ view of pancreatic carcinoma is that the Hruban RH, Pitt HA, Lillemoe KD. Pancreaticoduo- diagnosis should be made early, the investigations denectomy with or without extended retroperitoneal lym- phadenectomy for periampullary adenocarcinoma: comparison should be undertaken expeditiously and the investiga- of morbidity and mortality and short-term outcome. Ann Surg tions limited to helical CT scanning. For those patients 1999; 229: 613–22. with an inoperable tumour a biopsy is appropriate. Operative mortality should be low and the quality of life The digital object identifier for this article is: 10.1102/ following recovery from resection good. 1470-7330.2001.010 Carcinoma of the pancreas: detection and staging using CT and MRI Jay P Heiken Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri, USA Our ability to diagnose pancreatic carcinoma has improved reduce the percentage of patients who are unnecessarily substantially over the past 20 years, owing to major subjected to laparotomy. advances in pancreatic imaging, including the development CT has become established as the primary initial imaging of US, CT and MRI. Despite these advances, however, the method for both detection and staging of suspected pancre- prognosis of patients with pancreatic cancer remains dis- atic carcinoma. Most studies have found that CT is highly [1] mal. The overall 5-year survival rate is only 3% , although reliable when it demonstrates features indicating that a [5,6] the 5-year survival rate for patients who undergo pancreatic tumor is unresectable . The positive predictive value [2–4] resection is reported to be approximately 20% . Because (PPV) of a diagnosis of unresectability with helical CT has [7–11] of the very poor prognosis of patients with pancreatic ranged from 92% to 100% . Helical CT is less reliable, carcinoma, many physicians take a nihilistic approach to its however, for predicting that a tumor is resectable [7–11] diagnosis and staging. It is important to keep in mind, (PPV = 76–90%) . Nevertheless, this represents a sub- however, that a large percentage of patients with pancreatic stantial improvement over prediction of resectability with [12–14] cancer who undergo laparotomy for possible curative resec- conventional CT (PPV = 45–72%) . Limitations of CT tion are found to have unresectable disease. Thus, optimi- include: poor ability to demonstrate small hepatic or peri- zation of pre-operative imaging is important in order to toneal metastases; inability to demonstrate microscopic 20 Multidisciplinary Symposium — carcinoma of the pancreas lymph node metastases; and inability to differentiate in the diagnosis of pancreatic carcinoma in patients inflammatory from neoplastic lymph node enlargement. with an indeterminate pancreatic mass, but currently Optimized technique is essential to achieve the highest does not play a significant role in pancreatic carcinoma predictive values for resectability and unresectability. The staging. CT data should be acquired helically using a rapid IV Although criteria for unresectability vary among sur- [15,16] contrast medium injection rate (e.g. 4–5 ml/s) and geons, imaging features that generally indicate unresectabil- appropriate scan timing during the pancreatic parenchymal ity include vascular invasion, lymph node metastases [17,18] phase of enhancement . Images should be acquired beyond those in the immediate vicinity of the pancreas, and with thin collimation (3 mm) to optimize in-plane spatial distant metastases. Metastases most commonly involve the resolution, and overlapping reconstructions are recom- liver or peritoneum. mended for producing high quality multiplanar and Several recent studies have evaluated the accuracy of CT 3-dimensional images when needed. Curved planar refor- findings of vascular invasion (of the portal vein, superior mations through the pancreatic duct or peripancreatic mesenteric vein, superior mesenteric artery, celiac axis and vessels can be useful for displaying the imaging findings hepatic artery) in predicting the resectability of pancreatic [19] [31–34] [32–34] to the surgeon . Two-dimensional and 3-dimensional carcinoma . In three of these studies the pro- volume-rendered images of the peripancreatic vessels are portion of the vessel circumference in contact with the not routinely necessary for staging but can provide useful tumor was assessed. All three studies found that when the [20,21] information in some cases . Such CT angiographic tumor is not contiguous with the vessel (i.e. when an images can be useful in pre-operative planning, especially if intervening fat plane is present), vascular invasion is almost variant celiac axis, hepatic artery or superior mesenteric never present. When the tumor is contiguous with less than artery anatomy is present. one-quarter of the vessel circumference, it is resectable in State-of-the-art MRI using breath-hold imaging the majority of cases, but when the tumor is contiguous sequences, a phased-array torso coil and dynamic gadolin- with one-quarter to one-half the vessel circumference, it is ium enhancement is equivalent to CT for demonstrating unresectable in the majority of cases. It is in the group of small pancreatic carcinomas and providing accurate staging patients in which the tumor contacts up to one-half the [22] information . A recent study found dynamic gadolinium- vessel circumference that EUS may be of value to better enhanced MR imaging to be superior to dual-phase helical assess vascular invasion. Otherwise, surgical exploration is CT in the pre-operative assessment of resectability of needed to determine resectability. Tumors contacting more [9] pancreatic carcinoma . However, in that study, the helical than one-half the circumference of the vessel are nearly [31] CT imaging technique was not optimized. As with CT, the always unresectable. Another study assessed the contour MR imaging technique must be optimized in order for MR of the tumor at its point of contact with the vessel as a to provide accurate pre-operative staging information. The predictor of resectability. Tumors that were inseparable limitations of MR imaging are similar to those of CT. A from the vessel but had a convex contour with the vessel potential advantage of MR is its superior tissue contrast wall were resectable in 55% of cases (an additional 34% compared with CT. In addition, heavily T2-weighted pulse could be resected but required venous resection). Tumors sequences can be used to perform MR cholangiopancrea- that were inseparable from the vessel and had a concave [23,24] tography (MRCP) . Although its spatial resolution is contour with the vessel were resectable in only 7% of cases less than that of endoscopic retrograde cholangiopancrea- (an additional 40% could be resected but required venous tography (ERCP), an advantage of MRCP over ERCP, in resection). The proportion of vessel circumference involved addition to its noninvasiveness, is its ability to demonstrate by tumor is a more reliable predictor of resectability than the tumor contour at its point of contact with the vessel. the portions of the pancreatic and bile ducts proximal to obstructions and high-grade strictures. In addition, Another sign of unresectability of adenocarcinoma of the MRCP is useful for the demonstration and evaluation of head of the pancreas is a teardrop shape of the superior [25–27] mucin-producing pancreatic tumors . mesenteric vein (SMV), which represents either direct In the hands of some investigators, transabdominal color tumor infiltration of the vein or peritumoral fibrosis [35] Doppler ultrasonography has been shown to have an adherent to the vessel . accuracy similar to those of CT and angiography for Assessment of the peripancreatic veins can also provide diagnosing arterial and portal venous invasion by pancre- information regarding the likelihood of vascular invasion [28,29] atic carcinoma . Nevertheless, ultrasonography contin- by pancreatic carcinoma. In patients with pancreatic carci- ues to play a secondary role in the detection and staging noma, dilatation of the posterior superior pancreatico- of pancreatic carcinoma at most institutions. Endoscopic duodenal vein or the gastrocolic trunk is a sign of portal or [36–39] ultrasound (EUS) is also highly accurate for predicting superior mesenteric vein invasion . However, a dilated portal venous invasion and is considered by some gastrocolic trunk should not be used as an independent sign [34] investigators to be the most accurate test for imaging of surgical unresectability . [30] pancreatic cancer . EUS is particularly useful for detect- Our ability to detect and stage pancreatic carcinoma is ing small masses in the head and body of the pancreas currently better than it has ever been, and it is very likely and for directing transluminal biopsies of these masses. that continued technological advances in CT and MR Limitations of EUS are that it is not widely available imaging will further improve our diagnostic and staging and that it provides inconsistent visualization of the capabilities. Improvements in pre-operative staging will pancreatic tail. FDG-PET may have a potential role further minimize the number of patients with unresectable Multidisciplinary Symposium — carcinoma of the pancreas 21 tumors who undergo needless laparotomy and may help in window for evaluation of pancreatic adenocarcinoma. Am J Radiol 1999; 172: 605–8. directing patients to appropriate nonoperative or combined [19] Nino-Murcia M, Jeffrey RB, Beaulieu CF, Li KCP, Rubin operative and nonoperative forms of therapy, if improved GD. Multidetector CT of the pancreas and bile duct system: treatment methods become available. Finally, imaging for value of curved planar reformations. Am J Radiol 2001; 176: early detection of pancreatic carcinoma may take on 689–93. [20] Raptopoulos V, Steer ML, Sheiman RG, Vrachliotis TG, greater importance if genetic screening methods allow Gougoutas CA, Movson JS. The use of helical CT and CT identification of individuals who are at high risk for angiography to predict vascular involvement from pancreatic developing this insidious and deadly disease. cancer: correlation with findings at surgery. Am J Radiol 1997; 168: 971–7. [21] Baek SY, Sheafor DH, Keogan MT, DeLong DM, Nelson RC. Two-dimensional multiplanar and three-dimensional References volume-rendered vascular CT in pancreatic carcinoma: inter- observer agreement and comparison with standard helical [1] National Cancer Institute. Annual Cancer Statistics Review techniques. Am J Radiol 2001; 176: 1467–3. 1973–1988. NIH Publication No. 91-1789. Bethesda, MD: [22] Ichikawa T, Haradome H, Hachiya J et al. Pancreatic ductal Department of Health and Human Services, 1991. adenocarcinoma: preoperative assessment with helical CT [2] Ferna ´ ndez-del Castillo C, Rattner DW, Warshaw AL. versus dynamic MR imaging. Radiology 1997; 202: 655–62. Standards for pancreatic resection in the 1990s. Arch Surg [23] Lamanto D, Pavone P, Laghi A et al. Magnetic resonance 1995; 130: 295–300. cholangiopancreatography in the diagnosis of biliopancreatic [3] Geer RJ, Brennan MF. Prognostic indicators for survival after diseases. Am J Surg 1997; 174: 33–8. resection of pancreatic adenocarcinoma. Am J Surg 1993; 165: [24] Yamaguchi K, Chijiiwa K, Shimizu S, Yokohata K, Morisaki 68–73. T, Tanaka M. Comparison of endoscopic retrograde and [4] Cameron JL, Crist DW, Sitzmann JV et al. Factors influenc- magnetic resonance cholangiopancreatography in the ing survival after pancreatoduodenectomy for pancreatic surgical diagnosis of pancreatic diseases. Am J Surg 1998; 175: cancer. Am J Surg 1991; 161: 120–5. 203–8. [5] Andre ´n-Sandberg A r , Lindberg CG, Lundstedt C, Ihse I. [25] Sugiyama M, Atomi Y, Hachiya J. Intraductal papillary Computed tomography and laparoscopy in the assessment of tumors of the pancreas: evaluation with magnetic resonance the patient with pancreatic cancer. 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Cancer Imaging – Springer Journals

Published: May 5, 2015

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