Pancreatic ductal adenocarcinoma

Last revised by Mostafa El-Feky on 15 Sep 2023

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

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:

There is only a weak association, if at all, with heavy alcohol consumption alone, though chronic pancreatitis is a risk factor 1.

The serum levels of these antigens are frequently raised in people with pancreatic cancer and can be used to track a patient's response to treatment. However, these markers cannot be used for population screening due to a lack of sensitivity and specificity 12.

Three precursor lesions for pancreatic adenocarcinoma have been identified 8:

Cancerous cells arise from the pancreatic ductal epithelium. As the majority of tumors (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 superior mesenteric artery and celiac 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

Histological subtypes include:

The most prevalent molecular changes responsible for pancreatic carcinoma are:

  • KRAS: the most commonly mutated oncogene (>90%) 

  • TP53: alterations in 70-75%

  • SMAD4: inactivated in 55%

  • CKN2A: altered in 30% 12

Please see pancreatic ductal adenocarcinoma staging.

Recurrence is probably better estimated by a risk score than by staging 10.

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 workhorse 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 hypoattenuating on arterial phase scans in 75-90% of cases, but may become isoattenuating on delayed scans 1 (thus the need for multiple phase scanning when pancreatic cancer is the clinical question). The double duct sign may be seen. Calcifications are very rare in adenocarcinoma and when present are more likely due to a pre-existing condition such as chronic pancreatitis 11.

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 tumor to surrounding vessels (superior mesenteric artery and celiac axis). If the tumor 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 the 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 tumors 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 of pancreatic head tumors 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:

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Cases and figures

  • Figure 1: gross pathology
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  • Case 1
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  • Case 2: MRI
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  • Case 3
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  • Case 4: with biliary obstruction
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  • Case 5: with ultrasound
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  • Case 5: ultrasound
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  • Case 6
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  • Case 8
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  • Case 7: MRI
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  • Case 9
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  • Case 11: vascular encasement
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  • Case 12: with biliary drain
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  • Case 13: ultrasound; with post resection CT
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  • Case 14: background chronic pancreatitis
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  • Case 15
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  • Case 16: double duct sign
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  • Case 17
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  • Case 18
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  • Case 19
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  • Case 20: pancreatic duct dilatation
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  • Case 21
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  • Case 22
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  • Case 23
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  • Case 10
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  • Case 24: metastatic
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  • Case 25: with vascular involvement
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  • Case 26
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