Evidence-Based Imaging of Pancreatic Malignancies

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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

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