Diagnostic Ultrasound - Abdomen and Pelvis

Pancreatic Ductal Carcinoma
Diagnoses: Pancreas
• Thickening of peripancreatic fascia and fat necrosis
• Focal pancreatitis may be mass-like and difficult to
distinguish from carcinoma
Mucinous Cystic Pancreatic Tumor
• Septated cystic mass, more commonly in pancreatic tail;
may have peripheral calcification; no pancreatic duct
dilation
Lymphoma
• Focal or diffuse glandular enlargement of pancreas, rarely
obstructs pancreatic or biliary ducts
• Associated intraabdominal lymphadenopathy, splenic
involvement
Neuroendocrine Tumor of Pancreas
• Hypervascular primary and secondary tumors without
pancreatic duct dilation
Metastases
• Solitary/multiple pancreatic masses, usually with disease
elsewhere (e.g., liver, adrenals, lymph nodes)
• Rarely obstruct pancreatic or biliary ducts
Serous Cystadenoma
• Mixed cystic/solid pancreatic head lesion; may have central
stellate calcification; no pancreatic duct dilation
PATHOLOGY
General Features
• Etiology
○ Risk factors: Cigarette smoking, obesity, diabetes
mellitus, chronic pancreatitis, family history
Staging, Grading, & Classification
• Staging based on tumor size, location, vessel involvement,
and presence of metastatic disease (TMN staging system)
• NCCN criteria: Describes resectability
○ Resectable (stage I, II): Clear fat planes around celiac
artery (CA), SMA, HA (hepatic artery); no superior
mesenteric vein (SMV), portal vein (PV) distortion
Gross Pathologic & Surgical Features
• Poorly defined, firm, solid, infiltrative soft tissue mass
Microscopic Features
• Densely cellular neoplastic cells from ductal epithelium,
with nuclear atypia
• Vascular and perineural invasion commonly seen,
associated with desmoplastic stroma
Demographics
• Age
○ Mean at onset: 55 years; peak: 7th decade
• Gender
○ M:F = 2:1
• Epidemiology
○ 2nd most common gastrointestinal malignancy after
colorectal cancer
Natural History & Prognosis
• Generally poor prognosis due to advanced stage at
presentation
○ Without surgery: 5-year survival rate ~ 5%
○ With surgery: 5-year survival rate 15-20%
Treatment
• Pancreaticoduodenectomy (Whipple procedure) followed
by adjuvant therapy, for resectable tumor (< 15%)
• Neoadjuvant therapy for stage III borderline resectable
cancers, to downstage prior to resection
• Stage III locally advanced disease treated with
chemotherapy &/or chemoradiation
○ Palliative therapy including biliary stent placement,
gastric bypass (for duodenal obstruction), celiac nerve
block (for chronic abdominal pain)
DIAGNOSTIC CHECKLIST
Consider
• Differentiate from other solid pancreatic masses by
presence of main pancreatic duct dilatation
Image Interpretation Pearls
• Infiltrative mass in head of pancreas with ductal
obstruction/dilation and often extensive local invasion and
regional metastases at time of presentation
Reporting Tips
• Follow NCCN criteria to assess resectability
SELECTED REFERENCES
1. Al-Hawary MM et al: Pancreatic ductal adenocarcinoma radiology reporting
template: consensus statement of the Society of Abdominal Radiology and
the American Pancreatic Association. Radiology. 270(1):248-60, 2014
2. Wolfgang CL et al: Recent progress in pancreatic cancer. CA Cancer J Clin.
63(5):318-48, 2013
3. Estrella JS et al: Post-therapy pathologic stage and survival in patients with
pancreatic ductal adenocarcinoma treated with neoadjuvant
chemoradiation. Cancer. 118(1):268-77, 2012
4. Săftoiu A et al: Role of endoscopic ultrasound in the diagnosis and staging of
pancreatic cancer. J Clin Ultrasound. 37(1):1-17, 2009
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CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Usually asymptomatic until late in course
○ Clinical presentation depends on site of primary tumor
– Pancreatic head: Obstructive jaundice
– Body or tail: Weight loss, likely metastases to liver
○ Most commonly presents with distant metastases (~
65%); least likely to present with tumor confined to
pancreas (~ 15%)
○ Serum biomarker: CA 19-9