Pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma makes up the vast majority (~90%) of all pancreatic neoplasms and remains a disease with a very poor prognosis and high morbidity.

On imaging, it usually presents as a hypodense mass on CT that is poorly marginated, which may encase vessels and the common biliary duct.

Pancreatic cancer accounts for 22% of all deaths due to gastrointestinal malignancy, and 5% of all cancer deaths 1. In general, it is a malignancy of the elderly with over 80% of cases occurring after the age of 60 1.

Risk factors include:

Perhaps surprisingly there is only a weak if at all present association with heavy alcohol consumption 1.

  • pain (most common)
  • Courvoisier’s gallbladder: painless jaundice and enlarged gallbladder
  • Trousseau’s syndrome: migratory thrombophlebitis 
  • new onset diabetes mellitus
  • lipase hypersecretion syndrome (10-15%) 9
    • polyarthralgia and subcutaneous fat necrosis +/- lytic bone lesions
    • elevated serum lipase and eosinophilia

Three precursor lesions for pancreatic adenocarcinoma have been identified 8:

Cancerous cells arise from the pancreatic ductal epithelium. As the majority of tumours (90%) 1 are not resectable, diagnosis is usually achieved with imaging (typically CT scan) although laparoscopy is often required to confirm resectability 1-2. The key to accurate staging is the assessment of the SMA and coeliac axis, which if involved exclude the patient from any attempted resection 1-2.

  • head and uncinate process: two-thirds of cases
  • body and tail: one-third of cases 1

Please see pancreatic ductal adenocarcinoma staging

If large enough may demonstrate a reverse impression on the duodenum: Frostburg inverted 3 sign or a wide duodenal sweep

Findings are non-specific and include:

CT is the work-horse of pancreatic imaging. Typically ductal adenocarcinomas appear as poorly defined masses with extensive surrounding desmoplastic reaction. They enhance poorly compared to adjacent normal pancreatic tissue and thus appear hypodense on arterial phase scans in 75-90% of cases, but may become isodense on delayed scans 1 (thus the need for multiple phase scanning when pancreatic cancer is the clinical question). Double duct sign may be seen.

CT correlates well with surgical findings in predicting unresectability (positive predictive value of 89-100% 3). The most important feature to assess locally is the relationship of the tumour to surrounding vessels (SMA and coeliac axis). If the tumour surrounds a vessel by more than 180 degrees, then it is deemed T4 disease and is unresectable 3.

Signal characteristics include:

  • T1: hypointense cf. normal pancreas 5
  • T1 FS: hypointense cf. normal pancreas 5 
  • T1 + C (Gd): slower enhancement than normal pancreas, therefore dynamic injection with fat saturation with arterial phase imaging is ideal
  • T2/FLAIR: variable (therefore not very useful), depending on the amount of reactive desmoplastic reaction 1,5
  • MRCP: double duct sign may be seen

Most tumours are not resectable at diagnosis.

Surgery for stage I and II (see staging of pancreatic cancer) does offer the chance of cure, though with high morbidity (20-30%) and mortality (5%) 3. Resection is performed with a Whipple operation.

Even when resection is possible, the majority of patients succumb to recurrence, with only a doubling of survival in operated patients 1, from 5% to 10% at 5 years 4. At 12 months following the diagnosis, almost a quarter of the patients will have died 4.

General imaging differential considerations include:

Pancreatic pathology
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Article information

rID: 6736
Synonyms or Alternate Spellings:
  • Pancreatic carcinoma
  • Pancreatic ductal cancer
  • Pancreatic adenocarcinoma
  • Ductal carcinoma of pancreas
  • Carcinoma of pancreas
  • Ductal carcinoma of the pancreas

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Cases and figures

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    Figure 1: gross pathology
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    Case 1
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    Case 2
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    Case 3: with double duct sign
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    Case 4: with portal vein invasion
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    Case 5
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    Case 6: adenocarcinoma
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    Case 7
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    Case 8: unicinate process carcinoma
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    Case 9
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    Case 10: with mass effect shown on upper GI study
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    Case 11: pancreatic head adenocarcinoma
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    Case 12
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    Case 13: biopsy proven adenocarcinoma
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    Case 14
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