Diagnostic Imaging Pathways - Pancreatic Cancer (Suspected and Staging)
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This pathway provides guidance on imaging patients with suspected pancreatic cancer to confirm the diagnosis and to aid in determining the subsequent course of treatment.
Date reviewed: October 2011
Date of next review: 2017/2018
Published: October 2011
Quick User Guide
Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
Clicking on the PINK text box will bring up the full text.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
 | None | 0 |
 | Minimal | < 1 millisieverts |
 | Low | 1-5 mSv |
 | Medium | 5-10 mSv |
 | High | >10 mSv |
Images
Image GalleryNote: These images open in a new page | ||
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| 1a |  |
Pancreatic Carcinoma Image 1a, 1b, and 1c (Computed Tomography): Dilated common bile duct, pancreatic duct, and gallbladder. There is a mass located in the head of pancreas with involvement of the mesenteric vessels. |
| 1b |  |
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| 1c |  |
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| 2 |  |
Pancreatic Carcinoma Image 2 (ERCP): "Double-duct" sign - strictures are seen in the common bile duct (yellow arrow) and pancreatic duct (grey arrow) with dilatation of the pancreatic duct. |
| 3a |  |
Pancreatic Cancer Image 3a (H&E, x2.5) and 3b (H&E, x10): Histological sections of a pancreatic adenocarcinoma showing the typical appearance of irregular malignant glands set in abundant desmoplastic stroma. Note, the residual normal pancreatic parenchyma (blue arrow). Image 3b shows the predisposition of this cancer for perineural invasion.
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| 3b |  |
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Teaching Points
Teaching Points
- The role of imaging in the patient newly diagnosed with pancreatic cancer, is the selection of appropriate candidates for potentially curative surgical resection
- If for any reason, the patient is not suitable for surgery palliative options are recommended
- Staging begins with a tri-phasic CT scan of the abdomen
- Further evaluation is with PET scan or Endoscopic US (EUS) depending on local resources and expertise
ct
Computed Tomography (CT) Abdomen
- Involves the use of intravenous contrast and timed image sequences that enable the evaluation of vascular structures around the pancreas
- Features
- Very accurate at determining unresectable disease with positive predictive values for unresectability varying from approximately 89% to 100% 2,3,4,6
- For determining resectability, the sensitivity of spiral CT is 81-90% and specificity is 82%. This is comparable to conventional CT and MRI. However, spiral CT has the added benefit of superior sensivity (91-98%) for the initial diagnosis of pancreatic carcinoma compared to conventional CT (86%) and MRI (84%) 23,25
- Multidetector CT (MDCT) with multiplanar reformatted images offers improved evaluation of vascular involvement and liver metastases and is more accurate in assessing tumour resectability compared to single detector CT. The positive predictive value for detemining resectability is 91% 26,27,28
- Demonstration of tumour involvement of more than one half of the circumference of major vessels is highly specific for unresectable tumour 5
- Limitations
eus
Endoscopic Ultrasound (EUS)
- Not available at all centres but is useful for identifying unresectable pancreatic tumours
- Patients are given conscious sedation usually with fentanyl and midazolam and an echo-endoscope is passed to the second part of the duodenum to view the pancreas
- The results of studies looking at the accuracy of EUS in the staging of pancreatic cancer have been highly variable due to various factors 11
- Seems to most useful in staging small tumours less than 2-3cm in size 12,13
- The accuracy of EUS for determining unresectable disease has varied from approximately 71-96% 11,15,16,17,18,19
- As the accuracy of CT improves with the introduction of faster, higher resolution helical scanners, the future role of endoscopic ultrasound may change
pan
Suspected Pancreatic Cancer
- This pathway outlines the diagnostic and staging investigations used to confirm the diagnosis of pancreatic cancer and to determine if a patient is suitable for potentially curative surgery
- Surgical resection involving pancreaticoduodenectomy is the only potentially curative treatment for patients but it does have a significant risk of morbidity 1
- Accurate staging of patients is therefore very important for determining those patients who will benefit from surgery
pet
Positron Emission Tomography (PET)
- Benefit of FDG-PET in staging pancreatic cancer has not been conclusively proven and it is currently not rebatable under Medicare for this indication
- There have been conflicting studies as to the usefulness of PET and its cost effectiveness 21,22
- However PET has several potential advantages
- Non invasive means of determining if a patient has metastatic disease.
- The findings on PET scan can lead to a reduction in unnecessary laparotomies in patients with incurable disease 7,22
- In another study, the addition of PET to CT altered surgical management in 43% of patients with suspected pancreatic carcinoma 8
- In patients with pancreatic carcinoma, PET has been shown to be better than CT at detecting hepatic metastases greater than 1cm in size 9
- Has an approximately 61% sensitivity for detecting lymph node metastases in patients with pancreatic cancer 10
tissue
Tissue Diagnosis
- For potentially resectable tumours on imaging, it is controversial whether preoperative biopsy should be performed and is highly dependent on the institution. 29 Advantages include avoiding unnecessary surgery in patients with an unexpected benign diagnosis and confirmation of pathology prior to surgery and initiation of neoadjuvant therapy. Disadvantages include potential needle tract tumour seeding, risk of bleeding and acute pancreatitis which may render the tumour unresectable
- However, there is general consensus that histological confirmation is necessary for inoperable tumours and patients who are not medically fit for surgery but who are candidates for chemoradiation 30
- Extrapancreatic metastases should be targeted preferentially due to easier accessibility, higher cell retrieval and lower complication rates 30
- Options for tissue sampling of the primary tumour include
Percutaneous Biopsy
- The sensitivity of percutaneous fine needle aspiration (FNA) under ultrasound or CT guidance ranges from 45 to 100% and the specificity, from 91 to 100%. 31 The false negative rate is reported at approximately 20% 30
- There are no large studies comparing percutaneous core biopsy and FNA for pancreatic cancers
Endoscopic Ultrasound (EUS) Guided Biopsy
- Compared to percutaneous biopsy, EUS-guided biopsy has greater sensitivity for smaller lesions with reduced risk of needle tract tumour seeding. Regional lymph nodes may also be easily sampled 32
- The sensitivity of EUS guided FNA ranges from 54 to 95% and the specificity, from 71-100%. 3 Early trials suggest a superior accuracy of EUS guided FNA compared to ultrasound and CT guided procedures 33,34
References
References
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Trede M, Schwall G, Saeger HD. Survival after pancreatoduodenectomy: 118 consecutive resections without an operative mortality. Ann Surg. 1990;211:447-58. (Level IV evidence)
- Megibow AJ, Zhou XH, Rotterdam H, et al. Pancreatic adenocarcinoma: CT versus MR imaging in the evaluation of resectability - report of the Radiology Diagnostic Oncology Group. Radiology. 1995;195:327-32. (Level II evidence). View the reference
- Freeny PC, Traverso LW, Ryan JA. Diagnosis and staging of pancreatic adenocarcinoma with dynamic computed tomography. Am J Surg. 1993;165:600-6. (Level III evidence)
- Valls C, Andia E, Sanchez A, et al. Dual phase helical CT of pancreatic adenocarcinoma: assessment of resectability before surgery. AJR Am J Roentgenol. 2002;178:821-6. (Level II evidence). View the reference
- Lu DS, Reber HA, Krasny RM, et al. Local staging of pancreatic cancer: criteria for unresectability of major vessels as revealed by pancreatic-phase, thin section helical CT. AJR Am J Roentgenol. 1997;168:1439-43. (Level II evidence). View the reference
- Bluemke DA, Cameron JL, Hruban RH, et al. Potentially resectable pancreatic adenocarcinoma: spiral CT assessment and surgical and pathological correlation. Radiology. 1995;197:381-5. (Level III evidence)
- Bares R, Dohman BM, Cremerius U, Fass J, Teusch M, Bull U et al. Results of positron emission tomography with fluorine-18 labeled fluorodeoxyglucose in differential diagnosis and staging of pancratic carcinoma. Radiology. 1996;36:435-40 (Level III evidence)
- Delbeke D, Rose DM, Chapman WC, et al. Optimal interpretation of FDG PET in the diagnosis, staging and management of pancreatic carcinoma. J Nucl Med. 1999;40:1784-91. (Level III evidence)
- Fröhlich A, Diederichs CG, Staib L, et al. Detection of liver metastases from pancreatic cancer using FDG PET. J Nucl Med. 1999;40:250-5. (Level III evidence)
- Zimny M, Bares R, Fass J, et al. Fluorine-18 fluoro-deoxyglucose positron emission tomography in the differential diagnosis of pancreatic carcinoma: a report of 106 cases. Eur J Nucl Med. 1997;24:678-82. (Level III evidence)
- Yusoff IF, Mendelson RM, Edmunds SEJ, et al. Preoperative assessment of pancreatic malignancy using endoscopic ultrasound. Abdom Imaging 28;556-62. (Level III evidence)
- Nakaizumi A, Uehara H, Iishi H, et al. Endoscopic ultrasonography in diagnosis and staging of pancreatic cancer. Dig Dis Sci. 1995;40:696-700. (Level II evidence). View the reference
- Yasuda K, Mukai H, Fujimoto S, et al. The diagnosis of pancreatic cancer by endoscopic ultrasonography. Gastrointest Endosc. 1988;34:1-8. (Level III evidence)
- Brügel M, Rummeny EJ, Dobritz M. Vascular invasion in pancreatic cancer: value of multislice CT. Abdom Imaging. 2004;29:239-45. (Pictorial Essay)
- Ramsay D, Marshall M, Song S, et al. Identification and staging of pancreatic tumours using computed tomography, endoscopic ultrasound and mangafodipir trisodium-enhanced magnetic resonance imaging. Australas Radiol. 2004;48:154-61. (Level III evidence)
- Palazzo L, Roseau G, Gayet B, et al. Endoscopic ultrasonograph in the diagnosis and staging of pancreatic adenocarcinoma. Results of a prospective study with comparison to ultrasonography and CT scan. Endoscopy. 1993;25:143-50. (Level III evidence)
- Tio TL, Sie LH, Kallimanis G, et al. Staging of ampullary and pancreatic carcinoma: comparison between endosonography and surgery. Gastrointest Endosc. 1996;44:706-13. (Level III evidence)
- Grimm H, Maydeo A, Soehendra N. Endoluminal ultrasound for the diagnosis and staging of pancreatic cancer. Baillieres Clin Gastroenterol. 1990;4:869-88. (Review article)
- Müller MF, Meyenberger C, Bertschinger P, Schaer R, Marincek B. Pancreatic tumors: evaluation with endoscopic US, CT, and MR imaging. Radiology. 1994;190:745-51. (Level II evidence). View the reference
- Prokesch RW, Chow LC, Beaulieu CF, et al. Local staging of pancreatic carcinoma with multi-detector row CT: use of curved planar reformations - initial experience. Radiology. 2002;225:759-65. (Level II evidence). View the reference
- Lyrtas D, Connor S, Bosonnet L et al. Positron emission tomography does not add to computed tomography for the diagnosis and staging of pancreatic cancer. Dig Surg. 2005; 22:55-62. (Level III evidence)
- Heinrich S, Goerres GW, Schafer M et al. Positron emission tomography/computed tomography influences on the management of resectable pancreatic cancer and its cost effectiveness. Ann Surg. 2005;242:235-43. (Level III evidence)
- Bipat S, Phoa SS, van Delden OM et al. Ultrasonography, computed tomography and magnetic resonance imaging for diagnosis and determining resectability of pancreatic adenocarcinoma: a meta-analysis. J Comput Assist Tomogr. 2005;29(4):438-45. (Level I/II evidence)
- Diehl SJ, Lehmann KJ, Sadick M, Lachmann R, Georgi M. Pancreatic cancer: value of dual-phase helical CT in assessing resectability. Radiology. 1998;206(2):373-8. (Level III evidence)
- Lee JK, Kim AY, Kim PN, Lee MG, Ha HK. Prediction of vascular involvement and resectability by multidetector-row CT versus MR imaging with MR angiography in patients who underwent surgery for resection of pancreatic ductal adenocarcinoma. Eur J Radiol. 2010;73(2):310-6. (Level III evidence)
- Manak E, Merkel S, Klein P, Papadopoulos T, Bautz WA, Baum U. Resectability of pancreatic adenocarcinoma: assessment using multidetector-row computed tomography with multiplanar reformations. Abdom Imaging. 2009;34(1):75-80. (Level III evidence)
- Vargas R, Nino-Murcia M, Trueblood W, Jeffrey RB, Jr. MDCT in Pancreatic adenocarcinoma: prediction of vascular invasion and resectability using a multiphasic technique with curved planar reformations. AJR Am J Roentgenol. 2004;182(2):419-25. (Level III evidence)
- Ichikawa T, Erturk SM, Sou H et al. MDCT of pancreatic adenocarcinoma: optimal imaging phases and multiplanar reformatted imaging. AJR Am J Roentgenol. 2006;187(6):1513-20. (Level III evidence)
- Itani KM, Taylor TV, Green LK. Needle biopsy for suspicious lesions of the head of the pancreas: pitfalls and implications for therapy. J Gastrointest Surg. 1997;1(4):337-41. (Level II/III evidence)
- Hartwig W, Schneider L, Diener MK, Bergmann F, Bchler MW, Werner J. Preoperative tissue diagnosis for tumours of the pancreas. Br J Surg. 2009;96(1):5-20. (Level I/II evidence)
- Bret PM, Nicolet V, Labadie M. Percutaneous fine-needle aspiration biopsy of the pancreas. Diagn Cytopathol. 1986;2:221-7. (Review)
- Micames C, Jowell PS,White R et al. Lower frequency of peritoneal carcinomatosis in patients with pancreatic cancer diagnosed by EUS-guided FNA vs. percutaneous FNA. Gastrointest Endosc. 2003;58:690-5. (Level III evidence)
- Horwhat JD, Paulson EK, McGrath K et al. A randomized comparison of EUS-guided FNA versus CT or US-guided FNA for the evaluation of pancreatic mass lesions. Gastrointest Endosc. 2006;63:966-75. (Level II evidence)
- Volmar KE, Vollmer RT, Jowell PS, Nelson RC, Xie HB. Pancreatic FNA in 1000 cases: a comparison of imaging modalities. Gastrointest Endosc. 2005;61:854-61. (Level III evidence)
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