Evidence-Based Imaging of Pancreatic Malignancies
Section snippets
Ultrasound
In most centers, ultrasound is used only as an initial screening test for evaluating suspected pancreaticobiliary disease. Ultrasound is universally available, inexpensive, and noninvasive, and does not carry any risk of iodinated contrast used with CT. Ultrasound is useful for detecting biliary dilation and characterizing cystic lesions of the pancreas when not obscured by body habitus or overlying gas.
Transabdominal ultrasound can provide extraordinary detail for diagnosis and staging of
Computed tomography
CT remains the most important and useful imaging modality for evaluating pancreatic malignancies. Although other imaging modalities can offer important complementary information, CT provides the most comprehensive evaluation for diagnosis and surgical staging for pancreatic malignancies. CT offers highly accurate T staging, including local invasion and vascular involvement. As with other modalities, CT is less accurate at diagnosing early nodal involvement and metastatic disease. CT technology
Endoscopic ultrasound
EUS was developed in the 1980s as a minimally invasive method for imaging and obtaining tissue from the deep-seated organs such as the pancreas and biliary tree. Whereas pancreatic imaging via transabdominal ultrasound can be obstructed by overlying bowel gas and adipose tissue, EUS allows for placement of the ultrasound transducer within close proximity to the pancreas. Very high resolution imaging of the pancreas and associated vascular structures can be obtained, and tissue can be readily
Magnetic resonance imaging
Although most surgeons are not as comfortable interpreting MR images as they are with CT, MR can be used both to assess the pancreatic parenchyma and to provide high-quality images of fluid-filled structures such as the pancreatic ductal systems and pancreatic cysts. MR can be useful in patients with poor renal function who may be poor candidates for contrast CT. As with CT imaging, adenocarcinoma of the pancreas appears hypointense on T1-weighted images both pre- and postcontrast injection.
MR
Positron emission tomography
18F-fluorodeoxyglucose (FDG) is a positron-emitting radiotracer that accumulates and is expressed in cancer cells to a much higher degree than in normal tissue. FDG-PET can be used to diagnose local or metastatic disease, although the limited spacial resolution of FDG-PET makes it a poor test for staging (Fig. 8). Like CT, FDG-PET scans have limited sensitivity for lesions smaller than 1 cm. A study by Frolich and colleagues47 showed 97% detection of lesions greater than 1 cm whereas lesions
Imaging cystic neoplasms of the pancreas
Small cystic lesions of the pancreas are often asymptomatic and are found incidentally on cross-sectional imaging. Cystic lesions of the pancreas can represent either benign disease (serous cystadenomas, pseudocysts) or premalignant/malignant mucinous neoplasms. While mucinous neoplasms can present at advanced stages and act as aggressively as any solid pancreatic adenocarcinoma, cystic neoplasms can also have a more indolent course, taking several years before degenerating into invasive
Summary
A high-quality pancreatic protocol CT is the primary imaging modality for diagnosing and staging pancreatic malignancy. The main limitation of CT is the lack of sensitivity for early pancreatic lesions. EUS provides an excellent complement to CT for both diagnosis and staging of pancreatic cancer, and allows easy access for needle aspiration and tissue diagnosis. MR can be helpful for evaluating small hepatic nodules or cystic lesions of the pancreas, but in general, the role of MR and PET
References (74)
- et al.
Radiologic diagnosis and staging of pancreatic ductal adenocarcinoma
Eur J Radiol
(2001) - et al.
Staging of pancreatic adenocarcinoma by imaging studies
Clin Gastroenterol Hepatol
(2008) - et al.
Assessment of EUS for diagnosing, staging, and determining resectability of pancreatic cancer: a review
Gastrointest Endosc
(2002) - et al.
Endoscopic ultrasound in pancreatic tumor diagnosis
Gastrointest Endosc
(1991) - et al.
Role of EUS in the preoperative staging of pancreatic cancer: a large single-center experience
Gastrointest Endosc
(1999) - et al.
Endoluminal ultrasound for the diagnosis and staging of pancreatic cancer
Baillieres Clin Gastroenterol
(1990) - et al.
Endoscopic ultrasonography diagnosis of pancreatic cancer
Gastrointest Endosc Clin N Am
(1995) - et al.
The use of EUS to diagnose malignant portal venous system invasion by pancreatic cancer
Gastrointest Endosc
(1996) - et al.
Endoscopic ultrasonographic criteria of vascular invasion by potentially resectable pancreatic tumors
Gastrointest Endosc
(1994) - et al.
Computed tomography and magnetic resonance imaging of hepatic metastases
Clin Liver Dis
(2002)
Surgical management of intraductal papillary mucinous neoplasm (IPMN) of the pancreas
J Gastrointest Surg
Cystic lesions and intraductal neoplasms of the pancreas
Best Pract Res Clin Gastroenterol
International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas
Pancreatology
The utility of F-18 fluorodeoxyglucose whole body PET imaging for determining malignancy in cystic lesions of the pancreas
J Gastrointest Surg
Intraductal papillary mucinous tumor of the pancreas
Gastrointest Endosc
The incidence of intraductal papillary mucinous tumors of the pancreas(1)
Curr Surg
Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study
Gastroenterology
Evaluation and management of cystic pancreatic tumors: emphasis on the role of EUS FNA
Clin Gastroenterol Hepatol
Cyst fluid analysis in the differential diagnosis of pancreatic cystic lesions: a pooled analysis
Gastrointest Endosc
Performance of endosonography-guided fine needle aspiration and biopsy in the diagnosis of pancreatic cystic lesions
Am J Gastroenterol
EUS in the evaluation of pancreatic cystic lesions
Gastrointest Endosc
Improving results of pancreaticoduodenectomy for pancreatic cancer
World J Surg
State-of-the-art ultrasonography is as accurate as helical computed tomography and computed tomographic angiography for detecting unresectable periampullary cancer
J Ultrasound Med
Recent advances and novel methods in pancreatic imaging
Minerva Gastroenterol Dietol
Pancreatic and ampullary carcinoma. Ultrasound, computed tomography, magnetic resonance imaging and angiography
Endoscopy
Ultrasound elastography. A possible improvement into the paraphernalia of pancreatic imaging
JOP
Phase-inversion tissue harmonic imaging compared with conventional B-mode ultrasound in the evaluation of pancreatic lesions
Eur Radiol
Inflammatory pancreatic masses: differentiation from ductal carcinomas with contrast-enhanced sonography using carbon dioxide microbubbles
AJR Am J Roentgenol
Two-phase helical CT for pancreatic tumors: pancreatic versus hepatic phase enhancement of tumor, pancreas, and vascular structures
Radiology
Isoattenuating pancreatic adenocarcinoma at multi-detector row CT: secondary signs
Radiology
MR pancreatography: a useful tool for evaluating pancreatic disorders
Radiographics
Pancreatic tumors: comparison of dual-phase helical CT and endoscopic sonography
AJR Am J Roentgenol
Detection of small pancreatic tumors with multiphasic helical CT
AJR Am J Roentgenol
Pancreatic head cancer: accuracy of CT in determination of resectability
Abdom Imaging
Local staging of pancreatic cancer: criteria for unresectability of major vessels as revealed by pancreatic-phase, thin-section helical CT
AJR Am J Roentgenol
Adenocarcinoma of the head of the pancreas: determination of surgical unresectability with thin-section pancreatic-phase helical CT
AJR Am J Roentgenol
Teardrop superior mesenteric vein: CT sign for unresectable carcinoma of the pancreas
AJR Am J Roentgenol
Cited by (60)
Diagnostic strategy with a solid pancreatic mass
2019, Presse MedicaleCitation Excerpt :The reported positive predictive value, sensitivity, and specificity for predicting the resectability of pancreatic cancer are 89%, 100%, and 72%, respectively [38]. In terms of treatment monitoring following chemotherapy or surgery, MDCT is the primary imaging modality, and it is used in conjunction with PET/CT [65]. Nonetheless, some lesions are still difficult to find, in particular small tumour (< 2 cm), absence of biliary dilatation, vascular involvement and mass effect, and little attenuation difference compared to normal pancreatic parenchyma [66].
Imaging and Radiologic Intervention in the Pancreas
2019, Shackelford's Surgery of the Alimentary Tract: 2 Volume SetPET/MRI in the upper abdomen
2015, Seminars in Nuclear MedicineCitation Excerpt :MDCT of the pancreas is complemented by endoscopic ultrasonography (EUS), which is more sensitive for the early detection of lesions. EUS also allows relatively easy access to the pancreas for tissue diagnosis using fine-needle aspiration and provides further important information relevant to tumor staging.42 18F-FDG-PET is more sensitive than MDCT is for treatment monitoring following chemoradiotherapy and for depicting tumor recurrence after resection.43,44
Endoscopic Ultrasound for Diagnosis of Chronic Pancreatitis Versus Pancreatic Cancer
2023, The Pancreas: an Integrated Textbook of Basic Science, Medicine, and Surgery, Fourth EditionDiagnostic applications of nuclear medicine: Pancreatic cancer
2022, Nuclear Oncology: From Pathophysiology to Clinical Applications