Pancreatic adenocarcinoma with preoperative staging and postoperative Whipple images
Presentation
Staging for abdominal cancer.
Patient Data
Ill-defined relatively hypoenhancing/low-attenuation mass in the pancreas head resulting in upstream dilation of the pancreas duct and mild atrophy. Mild dilation of the intrahepatic bile ducts and moderate dilation of the common bile duct and gallbladder, with rapid tapering at the level of the pancreas head mass. Mild focal narrowing of the superior mesenteric vein and portal splenic confluence the level of the mass. Very subtle strandy soft tissue contacting the leftward aspect of the SMA. Soft tissue thickening about the distal common hepatic and proper hepatic artery and hepatic hilum (at least abutment, may encase in some areas), and also encasement of the gastroduodenal artery (easiest to see on coronal arterial images). Few borderline regional lymph nodes including porta hepatis/portacaval. No liver metastases.
Post SBRT and Whipple
Patient is now post SBRT and Whipple surgery. Normal pancreaticojejunostomy. Small regional lymph nodes and stranding related to treatment. Hepaticojejunostomy with small amount of pneumobilia. Focal fat without suspicious liver lesion. Mild right and proximal transverse colon thickening may be inflammatory/infectious.
Case Discussion
Staging teaching case for pancreas adenocarcinoma, highlighting the relatively subtle low-attenuation appearance the primary tumor which is often easiest to see on late arterial phase imaging as it enhances less than the normal pancreas. Characteristic vascular findings include narrowing of adjacent superior mesenteric vein/portal splenic confluence and subtle findings of arterial involvement, including soft tissue abutment of the hepatic and encasement of the gastroduodenal arteries. There is also equivocal stranding adjacent to the SMA which should be reported.
This patient underwent preoperative chemotherapy and SBRT and eventually the Whipple procedure with the typical post-operative and post-treatment appearance on the second CT where the pancreaticojejunostomy and hepaticojejunostomy can be clearly seen, and without evidence of recurrent disease.