6/5/2011 Pancreatic Adenocarcinoma Imaging

Pancreatic Adenocarcinoma Imaging

Author: Mahesh Kumar Neelala Anand, MBBS, DNB, FRCR; Chief Editor: John Karani, MBBS, FRCR
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Updated: May 27, 2011

Overview
Of all the GI malignancies, pancreatic adenocarcinoma, as shown in the images below, is the second most
common cause of death from cancer. In clinical practice, pancreatic cancer is synonymous with pancreatic ductal
adenocarcinoma, which constitutes 90% of all primary malignant tumors arising from the pancreatic gland.
Radiologic characteristics of pancreatic adenocarcinoma are seen in the images below.

Scan from axial multisection CT in a patient w ith pancreatic cancer show s a low -attenuating mass in the head of the pancreas, adjacent
to the superior mesenteric vein (SMV). Image courtesy of Dr Zahir Amin.

Coronal reconstruction show ing a mass encasing and narrow ing the portal vein. Image courtesy of Dr Zahir Amin.

Tumors may arise from pancreatic ducts (99%) or from acinar cells (1%). More than 90% of pancreatic cancers
appear in the late stage of disease; this observation emphasizes the role of radiology in early detection and
determination of resectability of the tumor. The role of diagnostic imaging is to demonstrate the tumor and its
relationship to surrounding vasculature, and the results determine the possibility of curative resection.

The diagnosis of pancreatic cancer is rarely made at an early stage. This is one of the main reasons for failing to
achieve a cure in most patients.

Preferred examination
There is much debate concerning the sensitivity and specificity of imaging investigations in the diagnosis and
staging of pancreatic carcinoma.

Multisection computed tomography (CT) scanning is generally accepted to be the first line of investigation in a
patient with suspected pancreatic cancer. The best imaging technique is determined by local availability and

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expertise, but this will nearly always be spiral CT (ideally multisection CT). The reasons for this preference include
its wide availability, speed, thin sections, optimal enhancement, high spatial resolution, and consistently good
images.

The importance of good CT technique cannot be overemphasized, and the key elements are the following: oral
water as negative intraluminal contrast, 120-150 mL of iodinated contrast material intravenously administered at a
rate of 3-4 mL/s, and scanning with thin (2- to 3-mm) collimation during pancreatic parenchymal phase (at 25-35 s)
with the liver phase obtained at 60-70 s.

If the patient is clinically jaundiced and when biliary ductal dilatation is demonstrated on ultrasonographic (US)
examination, endoscopic retrograde cholangiopancreatography (ERCP) is the next investigation of choice with a
view to a drainage procedure. ERCP reliably demonstrates the point of obstruction. [1]

US is often the initial test in symptomatic patients. US is used for diagnosis rather than staging, although liver
metastasis and ascites may be seen. Significant technical improvements in US have occurred. It may be used for
problem solving in thin patients. Portal venous involvement may be more apparent on sonograms than on CT
and/or MRI images, and liver lesions can be characterized as cystic or solid.

Magnetic resonance imaging (MRI) has improved considerably in recent years, and it continues to evolve. Studies
comparing CT and MRI found that detection and assessment of resectability to be similar with both modalities.
MRI takes longer, it costs more, it is more complex, and it is limited by artifacts. The current role of MRI is
probably problem solving. That is if the mass is not demonstrable with CT and US, MRI could be used to evaluate
the pancreas in obstructive jaundice. MRI is also helpful in evaluating and characterizing liver lesions in patients
with pancreatic cancer.

In the detection and staging of small tumors, endoscopic US (EUS) can be reliable when it is performed by
experienced imagers. Previous studies have demonstrated a higher sensitivity and specificity with EUS than with
other modalities, but these results probably reflect the use of suboptimal CT and MR techniques. Evidence
suggests that EUS is similar to CT in diagnosis and staging of pancreatic cancer. EUS requires special
endoscopic skills and expertise, and it is less readily available worldwide.

EUS-guided fine-needle aspiration (FNA) is safe and effective, especially for pancreatic head masses. EUS-guided
FNA has sensitivity and specificity similar to that of CT-guided FNA cytology (FNAC).

Kamisawa et al found that diffusion-weighted MRI (DWI) can be used to differentiate autoimmune pancreatitis (AIP)
from pancreatic cancer. In a study of 13 patients with AIP and 40 patients with pancreatic cancer, pancreatic
cancers were detected as high-signal intensity areas, which were diffuse, solitary, or multiple in patients with AIP,
but solitary in patients with pancreatic cancer. Pancreatic cancer more often had a nodular shape, while AIP more
often had a longitudinal shape. Apparent diffusion coefficient (ADC) values were significantly lower in AIP than in
pancreatic cancer, and an optimal ADC cutoff value of 1.075 x 10-3 mm2/s could be used to distinguish AIP from
pancreatic cancer. [2]

Limitations of techniques
The detection of a mass on imaging is nonspecific and 5-15% of pancreatic resections show benign pathology.

Transabdominal US (TAUS) has a relatively poor sensitivity, and its results are not satisfactory for assessment in
approximately 20% of patients because of a poor acoustic window due to bowel gas.

MRI is sensitive in the detection and staging of pancreatic cancer with sensitivity and specificity similar to that of
multisection CT. MRI involves expensive equipment and meticulous attention to the image technique. Other
technical limitations are movement artifacts due to bowel peristalsis and breathing. Because the high sensitivity
and specificity of MRI in detection and staging small tumors has not been achieved consistently and universally,
debate continues about the superiority of MRI over CT.

Multisection CT should be used first in the detection of pancreatic adenocarcinoma. When CT findings are
negative, MRI or EUS should be applied for detection and for the assessment of resectability. Although
conventional angiography is obsolete in primary staging, it is occasionally required to assess peripancreatic
vessels before surgery. Modern multislice CT scanners are capable of excellent depiction of arterial and venous

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branches. The role of MR angiography (MRA) in the assessment of mesenteric vessels prior to surgery is not
firmly established, though some encouraging study results are reported.

Radiography
Plain radiographs have no role in establishing a firm diagnosis of pancreatic carcinoma. Pancreatic calcifications
may be seen concurrently in approximately 2% of patients who have chronic pancreatitis complicated by
pancreatic carcinoma.

Upper GI barium studies may reveal an extrinsic impression of the mass on the posteroinferior aspect of the
antrum of the stomach. This is known as antral pad sign. The medial margin of the descending duodenum may be
pulled medially at the level of the ampulla, forming a reversed-3 appearance. This is known as Frostberg 3 sign.
Infiltration of the duodenal mucosa may cause a spiculated appearance with irregularity and thickening of the
duodenal mucosa. The changes also may represent a desmoplastic response to malignant disease. A nodular
mass with an ampullary carcinoma may be observed.

Barium enema studies may demonstrate loss of normal haustral pattern from haustral padding along the
transverse colon. The studies may show infiltration of the colon with an irregular or serrated contour to the bowel
margin along the transverse colon, up to the level of splenic flexure. Tethering of colonic or small bowel margins
resulting in asymmetry may occur from intraperitoneal seeding of pancreatic carcinoma.

Degree of confidence
In the presence of jaundice, barium studies have reasonably good specificity. The disease is usually advanced by
the time the mass produces the characteristic signs on barium studies.

False positives/negatives
False-positive results may occur from a pseudocyst or other mass lesions producing similar appearances on the
duodenal C-loop. Small masses may produce false-negative results.

Computed Tomography
Features suggestive of underlying pancreatic cancer include the following: alterations in morphology of the gland
with abnormalities of CT attenuation values, obliteration of peripancreatic fat, loss of sharp margins with
surrounding structures, involvement of adjacent vessels and regional lymph nodes, pancreatic ductal dilatation,
pancreatic atrophy, and obstruction of the common bile duct (CBD). See the images below. [3, 4, 5, 6, 7, 8, 9, 10]

Scan from axial multisection CT in a patient w ith pancreatic cancer show s a low -attenuating mass in the head of the pancreas, adjacent
to the superior mesenteric vein (SMV). Image courtesy of Dr Zahir Amin.

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Coronal reconstruction show ing a mass encasing and narrow ing the portal vein. Image courtesy of Dr Zahir Amin.

Abnormal morphology of the gland, such as a change in size, shape, or attenuation values, may include focal or
diffuse enlargement, a focal lobulated eccentric mass, or decreased attenuation of the mass, respectively.

Macari et al determined that at portal venous phase dual-source dual-energy CT, pancreatic malignant-tumor
conspicuity is greater at 80 kVp than with 120-kVp acquisition simulated with a weighted-average acquisition. The
mean difference in attenuation for pancreatic tumors and adjacent normal pancreas was 83.27 +/- 29.56 (SD) HU
at 80 kVp and 49.40 +/- 23.00 HU at weighted-average 120 kVp. At 80 kVp, contrast-to-noise ratio was
significantly higher, as was duct visualization. [11]

Focal enlargement
A change in size is usually focal, and focal enlargement is seen in about 96% of patients with pancreatic
adenocarcinoma. The size is an unreliable indicator of tumor, as a normally sized pancreatic head is consistent
with a carcinoma of pancreas when atrophy of the body and tail is observed. This feature may be seen in
pancreatic carcinoma in as many as 20% of patients. Focal enlargement also can occur in benign disease; thus,
it is a nonspecific finding. Diffuse enlargement is less common and usually suggests pancreatitis.

By the time the mass has grown to produce a focal enlargement, the mass has often progressed to an inoperable
stage. Some small tumors may cause biliary ductal obstruction and appear early. A change in the shape of the
gland in the absence of enlargement is a more important sign and may suggest underlying tumor. Demonstration
of fatty interstices within the mass suggests that the focal lobulation is of normal pancreas. If the fatty interstices
are absent and if the mass is completely solid, it is more likely to be abnormal, and a biopsy is recommended.

The normal pancreas has an attenuation value of 30-50 HU. A central zone of decreased attenuation occurs in
83% of patients. The margins of the low-attenuating mass usually are poorly defined and correspond to a
hypovascular scirrhous tumor. Pancreatic tumor also may undergo central necrosis to produce a low density, and
the tumor then simulates a small pseudocyst.

Needle biopsy is occasionally needed to differentiate necrotic tumor from pseudocyst as a result of focal
pancreatitis. The pancreatic tumors are hypovascular and are best demonstrated with the intravenous
administration of contrast material and by acquiring images across the mass in the parenchymal arterial phase.
The mass is seen as a low-attenuating lesion in the brightly enhancing surrounding parenchyma.

Dilatation
Ductal dilatation occurs in 58% of patients. Among patients with ductal dilatation, 75% have dilation of both the
pancreatic ducts and the biliary ducts. Pancreatic ductal dilatation proximal to the obstructing tumor is detected in
approximately 88% of pancreatic head tumors and 60% of pancreatic body neoplasms. The duct size in
pancreatic cancer is 5-10 mm, and the duct is either smooth or beaded.

The pancreatic duct is dilated to more than 50% of the anteroposterior diameter of the gland in pancreatic cancer
from atrophy of the gland. In chronic pancreatitis, duct dilatation is less than 50% of the anteroposterior (AP)
diameter. Loss of normal peripancreatic fat-plane attenuation is suggestive of extension of tumor beyond the
margins of the gland with invasion. The peripancreatic fat shows an increase in attenuation. Extension to involve
peripancreatic fat and surrounding structures is observed on CT scans in 92% of patients.

Metastasis
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Vascular encasement usually determines unresectability and is seen on CT as narrowing, displacement or
obliteration of the vessel lumen by surrounding tumor. Collateral venous circulation may be observed from venous
occlusion with contrast-enhanced vessels around the stomach and splenic hilum. Arterial encasement is usually
well demonstrated by good-quality CT scans, and angiography is unnecessary.

The arterial involvement, in descending order of frequency, is as follows: superior mesenteric, splenic, celiac,
hepatic, gastroduodenal, and left renal. Spread to surrounding organs may involve the spleen, stomach,
duodenum, splenic flexure of the colon, transverse mesocolon, porta hepatis, kidney, and spine. Local, posterior
tumoral extension into the porta hepatis is seen in approximately 68% of patients. The presence of ascites
indicates peritoneal metastatic disease with implants. Ascites is seen in 13% of patients with pancreatic cancer.
The peritoneal deposits are poorly demonstrated by means of CT.

Regional lymph-node metastasis has been reported to vary from 38-65%. Metastasis to liver is the most common
in pancreatic cancer, occurring in approximately 17-55%. The CBD is displaced anteriorly and medially when the
pancreatic mass causes distal ductal obstruction. Intrahepatic ductal dilatation and gall bladder dilatation can be
demonstrated.

Degree of confidence
At present, CT is the most widely used and most sensitive test for an evaluation of the pancreas for pancreatic
carcinoma. Dynamic CT has a detection rate of approximately 99%. Multisection CT should be the first-line study
for detecting this tumor and for evaluating its resectability.

False positives/negatives
Cysts or focal pancreatitis can occasionally cause problems in diagnosis, and it can produce false-positive and
false-negative results.

Magnetic Resonance Imaging

The role of MRI in the management of pancreatic adenocarcinoma has yet to be firmly established. Compared with
other modalities, MRI appears to be more valuable for staging the extent and spread of pancreatic carcinoma than
for tumor detection of lesions smaller than 2 cm. The ability of MRI to demonstrate pancreatic adenocarcinoma
largely depends on the demonstration of deformity of the gland, as reflected in its size, shape, contour, and signal
intensity characteristics. [12, 13, 14, 15]

The criteria to suspect a mass are similar to those applied with CT, as discussed above. Rarely, nonenhanced
MRI reveals a carcinoma of the pancreas before it deforms the gland. However, when such a feature is
encountered, the dilemma to distinguish the focal abnormality from focal pancreatitis becomes challenging.

An alteration in signal characteristics is less specific for tumor because the tissue relaxation times between
pancreatic cancer, pancreatitis, and controls can overlap significantly. The mean T1 relaxation time of normal
pancreas is 507 ms ± 98, and the T1 relaxation time of pancreatic tumor is about 660 ms ± 115. The T2 relaxation
time of normal pancreas is 59 ms ± 9, and the T2 relaxation time of pancreatic tumor is 67 ms ± 29.

The normal pancreas is of low signal intensity on T1-weighted images and of intermediate signal on T2-weighted
images, with a variable amount of fat in the gland parenchyma.

Newer techniques to obtain images using breath-hold techniques and advances in body coil technology and faster
techniques have made it possible to acquire images with excellent spatial resolution.

T1-weighted fat-suppressed spin-echo and single–breath-hold gradient-echo fast low-angle shot (FLASH)
sequences with gadolinium enhancement are valuable for tumor detection. The mass is demonstrated as a low-
intensity lesion within a homogeneously enhancing normal pancreatic gland. Intravenous Gd-enhanced FLASH
images obtained 10 s after contrast enhancement has proven to be more sensitive in demonstrating tumor than
other techniques.

Gadolinium-based contrast agents have been linked to the development of nephrogenic systemic fibrosis (NSF) or
nephrogenic fibrosing dermopathy (NFD). The disease has occurred in patients with moderate to end-stage renal
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nephrogenic fibrosing dermopathy (NFD). The diseaseAdenocarcinoma
has occurred Imaging
in patients with moderate to end-stage renal
disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans. NSF/NFD is a
debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching,
swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble
moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness.

Magnetic resonance cholangiopancreatography (MRCP) is as sensitive as ERCP and may prevent inappropriate
explorations of the pancreatic and bile ducts in patients with suspected pancreatic carcinoma in whom
interventional endoscopic therapy is unlikely. The sensitivity of MRCP in a study of 124 patients was 84% with a
specificity of 97% for pancreatic cancer. The findings are complimentary to those of ERCP and percutaneous
transhepatic cholangiography (PTC).

Degree of confidence
It has been difficult to prove consistent results using MRI in demonstrating the tumor and its resectability. The
degree of confidence with MRI is less than that with CT at the moment because of the wide variability in MRI
techniques and its limitations from motion artifacts. Recent studies have demonstrated results confirming greater
reliability with MRI performed by using meticulous technique.

Ultrasonography
The lesion may have a variable appearance on US. It may be hypoechoic, isoechoic, or hyperechoic to the normal
pancreas. Pancreatic ductal dilatation and biliary ductal dilatation are easily demonstrated in patients with a tumor
in the head of pancreas that causes an obstruction. [16, 17]

Lymphadenopathy, the relation of the tumor to peripancreatic vessels, and the tumor margins are demonstrated
less reliably with US than with other modalities. The mass appears as an irregular hypoechoic mass that infiltrates
a bright pancreatic parenchyma.

Degree of confidence
The degree of confidence may be improved by using EUS in the detection of tumors smaller than 2 cm.

US equipment has improved considerably, and this is likely to have reflected on the sensitivity for detecting
pancreatic masses. TAUS examination is still less sensitive than other modalities in the detection of pancreatic
malignancy smaller than 2 cm. It has a sensitivity of 70% and a specificity of 95% for the diagnosis of pancreatic
malignancy.

The specificity of EUS for differentiating benign from malignant lesions using US appearance alone remains
unsatisfactory. EUS has a high sensitivity and specificity for pancreatic cancer, with an overall staging accuracy
higher than 80%. The possibility of performing EUS-guided FNA significantly improves both diagnostic and staging
capability of EUS. EUS-guided FNA is safe with a morbidity of less than 2%.

In a review of 63 patients, the assessment of tumor resectability with EUS was compared with an assessment
with MRI. The sensitivity for EUS for resectability was 61% and that of MRI was 73%. When EUS and MRI were
used together, the sensitivity was 89% for resectability.

Nuclear Imaging
The detection of a pancreatic tumor and distinguishing its appearances from those of other focal pancreatic
diseases has remained a challenging diagnostic problem.

Positron emission tomography (PET) is based on functional changes in the pancreatic cancer cells caused by
enhanced glucose utilization as in any other malignant tissue. With 2-[fluorine 18]-fluoro-2-deoxy-D-glucose (FDG),
PET can be used to identify pancreatic cancer and differentiate it from chronic pancreatitis with a sensitivity of 85-
98% and a specificity of 53-93%.[18, 19]

PET maps the metabolic activity at a molecular level; therefore, the uptake of FDG by neoplastic tissue is also
dependent on factors such as tissue oxygenation, regional blood flow, and a peritumoral inflammatory reaction.
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PET is also useful in staging and determination of resectability of the tumor at the time of initial diagnosis. PET
also has been shown to be an effective tool in the follow-up care of patients with pancreatic cancer. In more than
50% of patients in one study, additional information using PET influences the therapeutic procedure. [20, 21, 22]

Degree of confidence
In general, the sensitivity of PET is high in the detection of lesions more than a centimeter in diameter. Early
detection because of increased metabolic activity in cancer usually precedes the structural changes detected with
US, MRI, or CT.

PET has shown some promise in the detection of tumors, with high sensitivity and specificity. PET is dependent
on tumor stage. However, further clinical trials are required to demonstrate the limitations of PET in the
assessment of early pancreatic cancer.

False positives/negatives
PET is not an absolute technique as it fails to demonstrate pancreatic adenocarcinoma smaller than 1 cm. False-
positive results may occur when focal pancreatitis is associated with early pancreatic carcinoma.

Angiography
Angiography is an invasive procedure that demands considerable operator skill and high-quality radiographic
technique. Selective arteriograms obtained with an injection of iodinated contrast through the celiac axis and
superior mesenteric artery with some magnification techniques may be required to demonstrate detail. [23, 10]

Pancreatic carcinoma is relatively avascular and associated with neovascularity in 50% of patients. Pancreatic
malignancy usually demonstrates arterial encasement of peripancreatic vessels or, actually, of vessels within the
pancreas. The vessels involved are the following, in descending order of frequency: superior mesenteric artery
(33%), splenic artery (14%), celiac artery (11%), hepatic artery (11%), gastroduodenal artery (3%), and left renal
artery (0.6%).

When the disease is advanced, venous occlusions and venous encasement with collateral vessels may be
observed. Superior mesenteric vein encasement by tumor is seen in 23%, and the splenic vein is encased by
tumor in 15%, with portal vein infiltration in 4%.

Complete occlusion of the splenic vein is seen in 34%, and complete occlusion of the superior mesenteric vein is
seen in 10%. Pancreatic carcinoma can be distinguished from pancreatitis. The demonstration of hypervascularity
with the typical beaded changes of alternating narrowing with dilatation of internal pancreatic vessels is a feature of
pancreatitis.

The mesenteric circulation has been evaluated by using MRA and compared with conventional angiography.
Excellent agreement was seen between MRA and conventional angiography. Gd-enhanced MRA is useful in the
evaluation of proximal mesenteric arteries and in the evaluation of portal hypertension. Conventional angiography is
needed for the evaluation of intrahepatic arteries and branches of the superior mesenteric artery.

Degree of confidence
Pancreatic carcinoma is a hypovascular lesion; therefore, angiography has rightly been replaced as the method of
choice for evaluation of pancreatic parenchymal disease.

Helical CT angiography shows useful information about the peripancreatic vessels in patients with pancreatic
carcinoma. In a study of 84 patients, the negative predictive value of a resectable tumor was 96% for helical CT
angiography and axial helical CT compared with 70% for helical CT alone. The addition of helical CT angiography
improves the radiologist's ability to predict the resectability of pancreatic tumors.

False positives/negatives
Angiography has an accuracy of only 70% in making a specific diagnosis of pancreatic carcinoma.

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Contributor Information and Disclosures

Author
Mahesh Kumar Neelala Anand, MBBS, DNB, FRCR Consultant Radiologist, Department of Radiology,
Pennine Acute Hospitals NHS Trust, UK

Mahesh Kumar Neelala Anand, MBBS, DNB, FRCR is a member of the following medical societies: British
Medical Association, British Society of Gastroenterology, British Society of Interventional Radiology,
Cardiovascular and Interventional Radiological Society of Europe, European Society of Gastrointestinal and
Abdominal Radiology, Indian Radiology and Imaging Association, Radiological Society of North America, and
Royal College of Radiologists

Disclosure: Nothing to disclose.

Coauthor(s)
Colm Boylan, MB, BCh, MRCP, FRCR Assistant Professor of Radiology, McMaster University; Staff
Radiologist, St Joseph's Hospital, Canada

Colm Boylan, MB, BCh, MRCP, FRCR is a member of the following medical societies: Royal College of
Radiologists

Disclosure: Nothing to disclose.

Narainder Gupta, MBBS, MSc, FRCR, MD Assistant Professor of Cardiothoracic Radiology, Division
Director, Division of Cardiothoracic Radiology, Thomas Jefferson University Hospital

Narainder Gupta, MBBS, MSc, FRCR, MD is a member of the following medical societies: American Roentgen
Ray Society, Radiological Society of North America, Royal College of Radiologists, and Society of Thoracic
Radiology

Disclosure: Nothing to disclose.

Specialty Editor Board

Zahir Amin, MD, MBBS, MRCP, FRCR Consulting Staff, Department of Imaging, University College Hospital,
UK

Zahir Amin, MD, MBBS, MRCP, FRCR is a member of the following medical societies: British Institute of
Radiology, British Medical Association, and Royal College of Radiologists

Disclosure: Nothing to disclose.

Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt
Valley District Health Board, New Zealand

Disclosure: Nothing to disclose.

Udo P Schmiedl, MD, PhD Clinical Professor, Department of Radiology, University of Washington; Consulting
Staff, Swedish Medical Center, University of Washington Medical Center, Seattle Radiologists

Udo P Schmiedl, MD, PhD is a member of the following medical societies: American College of Radiology and
Radiological Society of North America

Disclosure: Nothing to disclose.

Robert M Krasny, MD Resolution Imaging Medical Corporation

Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and
Radiological Society of North America

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Disclosure: Nothing to disclose.

Chief Editor
John Karani, MBBS, FRCR Clinical Director of Radiology and Consultant Radiologist, Department of
Radiology, King's College Hospital, UK

John Karani, MBBS, FRCR is a member of the following medical societies: British Institute of Radiology, British
Society of Interventional Radiology, Cardiovascular and Interventional Radiological Society of Europe, European
Society of Gastrointestinal and Abdominal Radiology, European Society of Radiology, Radiological Society of
North America, and Royal College of Radiologists

Disclosure: Nothing to disclose.

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