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Diagnosis, Staging, and Surveillance of Pancreatic Cancer

¹ Department of Diagnostic Radiology, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd., Box 57, Houston, TX 77030.
² Department of Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030.

View larger version (71K): [in a new window]   Fig. 1A. —T1 and T2 tumors. Drawing shows T1 tumor, which is defined as being equal to or smaller than 2 cm in maximum diameter and confined to pancreas, and T2 tumor, larger than 2 cm and confined to pancreas.

View larger version (186K): [in a new window]   Fig. 1B. —T1 and T2 tumors. Axial CT image shows stage T1 pancreatic ductal adenocarcinoma (arrow) in 52-year-old woman with history of T1 N0 M0 pancreatic ductal adenocarcinoma.

View larger version (78K): [in a new window]   Fig. 2A. —T3 tumor. Drawing shows T3 tumor, defined as tumor that may extend beyond pancreas but without involvement of celiac axis or superior mesenteric artery.

View larger version (150K): [in a new window]   Fig. 2B. —T3 tumor. 68-year-old man with history of T3 N0 M0 pancreatic ductal adenocarcinoma. Contrast-enhanced axial CT image shows T3 tumor (medium-length arrows) that has involved common bile duct, requiring a stent (curved arrow), and that extends medially beyond confines of pancreatic head. Tumor is separated from superior mesenteric vein (long arrow) and superior mesenteric artery (short arrow) by fat plane (type A relationship). Note that tumor involves duodenum (arrowhead).

View larger version (70K): [in a new window]   Fig. 3A. —T4 tumor. Drawing shows T4 tumor, defined as primary tumor involving either superior mesenteric artery (as shown here) or celiac axis.

View larger version (162K): [in a new window]   Fig. 3B. —T4 tumor. 69-year-old woman with T4 NX M0 disease. Contrast-enhanced axial CT image shows pancreatic tumor (white arrows) engulfing celiac axis. Short black arrow = splenic artery, long black arrow = common hepatic artery.

View larger version (77K): [in a new window]   Fig. 4. —Drawing shows lymph node groups that can be involved by local spread of tumor: 1, superior to pancreatic head; 2, superior to pancreatic body; 3, near pancreatic tail; 4, splenic hilum; 5, anterior pancreaticoduodenal; 6, inferior to pancreatic head and body; 7, near common bile duct; 8, near pancreaticoduodenal groove and pylorus. Proximal mesenteric nodes (9) are hidden posteriorly.

View larger version (160K): [in a new window]   Fig. 5A. —60-year-old man with history of T3 N1 MO pancreatic ductal adenocarcinoma. Contrast-enhanced axial CT image shows pancreatic carcinoma (thin arrows) in uncinate process that involves duodenal wall. Gastrocolic trunk (thick arrow) is enlarged.

View larger version (178K): [in a new window]   Fig. 5B. —60-year-old man with history of T3 N1 MO pancreatic ductal adenocarcinoma. Contrast-enhanced axial CT image acquired at level superior relative to A shows portacaval nodal disease (arrows), identified as separate from primary mass.

View larger version (127K): [in a new window]   Fig. 6A. —54-year-old woman with history of T4 N1 M1 pancreatic ductal adenocarcinoma. Contrast-enhanced axial CT image shows ductal carcinoma (white arrows) of pancreatic body and tail. Liver metastasis is present (black arrow). Prominent local varices are seen (arrowheads). Superior mesenteric vein (S) is involved by tumor.

View larger version (116K): [in a new window]   Fig. 6B. —54-year-old woman with history of T4 N1 M1 pancreatic ductal adenocarcinoma. Contrast-enhanced axial CT image obtained in portal venous phase shows multiple liver metastases (black arrows) and left gastric adenopathy (white arrow).

View larger version (152K): [in a new window]   Fig. 7A. —59-year-old man with history of T4 NX M0 pancreatic ductal adenocarcinoma. Contrast-enhanced axial CT image shows tumor in pancreatic head (long white arrows) that has concave point of contact with superior mesenteric artery (short white arrow), type D relationship. Inferior pancreaticoduodenal artery (arrowhead) is encased by tumor. Stent (black arrow) is present.

View larger version (137K): [in a new window]   Fig. 7B. —59-year-old man with history of T4 NX M0 pancreatic ductal adenocarcinoma. Coronal oblique reformatted CT image shows tumor (white arrows) involving superior mesenteric artery (arrowhead). Stent (black arrow) is also seen.

View larger version (162K): [in a new window]   Fig. 8A. —59-year-old man with history of T3 NX M0 pancreatic ductal adenocarcinoma. T1-weighted axial MR image shows pancreatic carcinoma (black arrows) involving superior mesenteric vein (white arrow).

View larger version (134K): [in a new window]   Fig. 8B. —59-year-old man with history of T3 NX M0 pancreatic ductal adenocarcinoma. T2-weighted axial MR image acquired at same level as T1-weighted image (A) shows diffuse increased signal in pancreatic head (arrows). Differentiation between normal pancreatic parenchyma and tumor is limited. Patient was placed on neoadjuvant therapy in preparation for surgery; subsequent imaging (not shown) revealed development of liver metastases.

View larger version (133K): [in a new window]   Fig. 9. —54-year-old woman with history of T4 NX M0 pancreatic ductal adenocarcinoma. Fat suppressed spin-echo T1-weighted MR image of pancreas shows tumor (thin white arrows) surrounding and narrowing superior mesenteric vein (black arrow) and in contact with superior mesenteric artery (thick white arrow).

View larger version (157K): [in a new window]   Fig. 10A. —68-year-old man with history of T4 NX M0 pancreatic ductal adenocarcinoma. Contrast-enhanced axial CT image shows pancreatic head mass (medium-sized arrows) involving superior mesenteric vein (large arrow). Superior mesenteric artery (small arrow) was not definitely shown to be involved on this image, but other images (not shown) revealed involvement.

View larger version (152K): [in a new window]   Fig. 10B. —68-year-old man with history of T4 NX M0 pancreatic ductal adenocarcinoma. Contrast-enhanced axial CT image acquired at level superior to A shows dilated biliary tree (arrows) associated with obstruction by mass in pancreatic head.

View larger version (109K): [in a new window]   Fig. 10C. —68-year-old man with history of T4 NX M0 pancreatic ductal adenocarcinoma. ERCP image shows dilated biliary tree (white arrows) and obstruction of common bile duct (black arrow) associated with tumor in pancreatic head.

View larger version (123K): [in a new window]   Fig. 11A. —64-year-old man with T3 NX M1 pancreatic ductal adenocarcinoma. Contrast-enhanced axial CT image obtained in portal venous phase shows tumor (arrowheads) surrounding stent within common bile duct (thick white arrow). Dilated pancreatic duct (thin white arrow) is partially seen. Liver metastasis is present (black arrow). Superior mesenteric vein (S) is involved by tumor.

View larger version (169K): [in a new window]   Fig. 11B. —64-year-old man with T3 NX M1 pancreatic ductal adenocarcinoma. Contrast-enhanced axial CT image obtained in pancreatic parenchymal phase shows dilated pancreatic duct (arrowheads).

View larger version (105K): [in a new window]   Fig. 11C. —64-year-old man with T3 NX M1 pancreatic ductal adenocarcinoma. Left posterior oblique image from ERCP shows common bile duct narrowed by tumor and crossed by stent (arrowheads). Proximal common bile duct (thick arrow) is dilated, and dilated pancreatic duct (thin arrows) is partially opacified.

View larger version (82K): [in a new window]   Fig. 12. —72-year-old man with T4 NX M0 pancreatic ductal adenocarcinoma. Coronal thick-slab (50-mm) image from MR cholangiopancreatography shows double-duct sign caused by obstruction by tumor. Dilated common bile duct (thick arrows) and dilated pancreatic duct (thin arrows) are seen proximal to abrupt cutoff (arrowheads).

View larger version (109K): [in a new window]   Fig. 13A. —48-year-old woman with T3 N0 M0 pancreatic ductal adenocarcinoma. Positron emission tomography (PET) scan obtained in coronal plane shows activity in pancreatic head (arrow) and in right lobe of thyroid gland (arrowhead). Sonogram of thyroid (not shown) revealed multinodular goiter.

View larger version (95K): [in a new window]   Fig. 13B. —48-year-old woman with T3 N0 M0 pancreatic ductal adenocarcinoma. Follow-up PET scan obtained 3 months later than A, after patient had undergone chemotherapy and radiation therapy, no longer shows pancreatic head activity. Thyroid gland activity (arrowhead) persists.

View larger version (102K): [in a new window]   Fig. 14. —Contrast-enhanced axial CT image shows low-attenuation mass (arrow) in pancreatic head in 45-year-old man. Endoscopic sonographically guided fine-needle aspiration biopsy (not shown) revealed chronic pancreatitis.

View larger version (138K): [in a new window]   Fig. 15. —68-year-old man with history of T3 N1 M0 pancreatic ductal adenocarcinoma. Pancreatic tumor (thin white arrows) is separated from superior mesenteric vein (V) by normal pancreatic parenchyma (type B relationship). Tumor (thick white arrow) has convex point of contact with superior mesenteric artery (A) in type C relationship. Stent is also seen (black arrow). Given this relationship, tumor involvement of superior mesenteric artery cannot be reliably predicted. At time of surgery, superior mesenteric artery was found not to be involved by tumor.

View larger version (155K): [in a new window]   Fig. 16. —76-year-old man with history of T3 NX M0 pancreatic ductal adenocarcinoma. Contrast-enhanced axial CT image shows type F relationship of tumor to vasculature. Portal vein (medium-sized arrow) is thrombosed. On more inferior axial images (not shown) portal and superior mesenteric veins were occluded by tumor. Numerous collaterals (small arrow) are seen between pancreatic head and duodenum. Although this image shows stranding surrounding common hepatic artery (large arrow), with anomalous origin from the aorta, artery is not definitely involved by tumor.

View larger version (130K): [in a new window]   Fig. 17A. —63-year-old man with history of T4 NX M0 pancreatic ductal adenocarcinoma confirmed by biopsy. Contrast-enhanced axial CT image shows large mass (thick arrow) in pancreatic head involving superior mesenteric artery (short thin arrow) and superior mesenteric vein (arrowhead). Stent (long thin arrow) is present in common bile duct.

View larger version (130K): [in a new window]   Fig. 17B. —63-year-old man with history of T4 NX M0 pancreatic ductal adenocarcinoma confirmed by biopsy. Contrast-enhanced axial CT image obtained 6 months later than A, after patient had undergone treatment with radiation therapy and gemcitabine, shows residual soft tissue representing site of tumor (large arrows). Tumor is posterior relative to both superior mesenteric artery and superior mesenteric vein (small arrows).

View larger version (140K): [in a new window]   Fig. 18. —50-year-old woman with history of T3 N1 M0 pancreatic ductal adenocarcinoma. Patient had undergone pancreaticoduodenectomy 15 months earlier for ductal adenocarcinoma. Contrast-enhanced axial CT image shows tumor (medium-length arrows) has recurred near superior mesenteric artery (large arrow). Surgical clip (small arrow) is seen.

View larger version (154K): [in a new window]   Fig. 19A. —77-year-old woman with history of T4 N0 M0 pancreatic ductal adenocarcinoma that has been treated with chemotherapy and radiation therapy. Surveillance imaging obtained during a 6-year period revealed stable residual disease involving superior mesenteric artery. Contrast-enhanced axial CT image obtained 7 years after initial diagnosis shows new irregular narrowing of superior mesenteric artery (thick arrow) by tumor (thin arrows).

View larger version (154K): [in a new window]   Fig. 19B. —77-year-old woman with history of T4 N0 M0 pancreatic ductal adenocarcinoma that has been treated with chemotherapy and radiation therapy. Surveillance imaging obtained during a 6-year period revealed stable residual disease involving superior mesenteric artery. Contrast-enhanced axial CT image acquired at level superior relative to A shows new fistula (medium-length arrows) between stomach (thick arrow) and recurrent tumor (small arrow).

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