Pancreatic Ductal Adenocarcinoma Radiology Reporting Template: Consensus Statement of the Society of Abdominal Radiology and the American Pancreatic Association

Radiology (Impact Factor: 6.87). 01/2014; 270(1):248-60. DOI: 10.1148/radiol.13131184
Source: PubMed
ABSTRACT
Pancreatic ductal adenocarcinoma is an aggressive malignancy with a high mortality rate. Proper determination of the extent of disease on imaging studies at the time of staging is one of the most important steps in optimal patient management. Given the variability in expertise and definition of disease extent among different practitioners as well as frequent lack of complete reporting of pertinent imaging findings at radiologic examinations, adoption of a standardized template for radiology reporting, using universally accepted and agreed on terminology for solid pancreatic neoplasms, is needed. A consensus statement describing a standardized reporting template authored by a multi-institutional group of experts in pancreatic ductal adenocarcinoma that included radiologists, gastroenterologists, and hepatopancreatobiliary surgeons was developed under the joint sponsorship of the Society of Abdominal Radiologists and the American Pancreatic Association. Adoption of this standardized imaging reporting template should improve the decision-making process for the management of patients with pancreatic ductal adenocarcinoma by providing a complete, pertinent, and accurate reporting of disease staging to optimize treatment recommendations that can be offered to the patient. Standardization can also help to facilitate research and clinical trial design by using appropriate and consistent staging by means of resectability status, thus allowing for comparison of results among different institutions. © RSNA and the AGA Institute, 2014 Online supplemental material is available for this article.

Full-text

Available from: Dushyant V Sahani, Apr 28, 2015
ORIGINAL RESEARCH
n
Special RepoRt
248 radiology.rsna.org
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Radiology: Volume 270: Number 1—January 2014
Pancreatic Ductal
Adenocarcinoma Radiology
Reporting Template: Consensus
Statement of the Society of
Abdominal Radiology and the
American Pancreatic Association
1
Mahmoud M. Al-Hawary, MD
Isaac R. Francis, MD
Suresh T. Chari, MD
Elliot K. Fishman, MD
David M. Hough, MD
David S. Lu, MD
Michael Macari, MD
Alec J. Megibow, MD
Frank H. Miller, MD
Koenraad J. Mortele, MD
Nipun B. Merchant, MD
Rebecca M. Minter, MD
Eric P. Tamm, MD
Dushyant V. Sahani, MD
Diane M. Simeone, MD
Pancreatic ductal adenocarcinoma is an aggressive malig-
nancy with a high mortality rate. Proper determination
of the extent of disease on imaging studies at the time of
staging is one of the most important steps in optimal pa-
tient management. Given the variability in expertise and
definition of disease extent among different practitioners
as well as frequent lack of complete reporting of perti-
nent imaging findings at radiologic examinations, adoption
of a standardized template for radiology reporting, using
universally accepted and agreed on terminology for solid
pancreatic neoplasms, is needed. A consensus statement
describing a standardized reporting template authored by
a multi-institutional group of experts in pancreatic duc-
tal adenocarcinoma that included radiologists, gastro-
enterologists, and hepatopancreatobiliary surgeons was
developed under the joint sponsorship of the Society of
Abdominal Radiologists and the American Pancreatic As-
sociation. Adoption of this standardized imaging reporting
template should improve the decision-making process for
the management of patients with pancreatic ductal ade-
nocarcinoma by providing a complete, pertinent, and ac-
curate reporting of disease staging to optimize treatment
recommendations that can be offered to the patient. Stan-
dardization can also help to facilitate research and clinical
trial design by using appropriate and consistent staging by
means of resectability status, thus allowing for compari-
son of results among different institutions.
q
RSNA and the AGA Institute, 2014
Online supplemental material is available for this article.
1
From the Departments of Radiology (M.M.A., I.R.F.), Surgery
(R.M.M., D.M.S.), and Molecular and Integrative Physiology
(D.M.S.), University of Michigan Health System, 1500 E Medi-
cal Center Dr, University Hospital, Room B1 D502, Ann Arbor,
MI 48109; Departments of Internal Medicine (S.T.C.) and
Radiology (D.M.H.), Mayo Clinic, Rochester, Minn; Russell H.
Morgan Department of Radiology and Radiological Sciences,
Johns Hopkins University School of Medicine, Baltimore,
Md (E.K.F.); Department of Radiology, David Geffen School
of Medicine at UCLA, University of California–Los Angeles,
Los Angeles, Calif (D.S.L.); Department of Radiology, New
York University Medical Center, New York, NY (M.M., A.J.M.);
Department of Radiology, Feinberg School of Medicine,
Northwestern University, Chicago, Ill (F.H.M.); Department of
Radiology, Beth Israel Deaconess Medical Center, Harvard
Medical School, Boston, Mass (K.J.M.); Department of
Surgery, Vanderbilt University, Nashville, Tenn (N.B.M.);
Department of Radiology, University of Texas–MD Anderson
Cancer Center, Houston, Tex (E.P.T.); and Department of
Radiology, Massachusetts General Hospital, Boston, Mass
(D.V.S.). Received June 4, 2013; revision requested June
28; revision received August 10; accepted August 20; final
version accepted September 5. Address correspondence
to M.M.A. (e-mail: alhawary@med.umich.edu).
Deceased.
This article is being simultaneously published in
Gastroenterology.
q
RSNA and the AGA Institute, 2014
Note: This copy is for your personal non-commercial use only. To order presentation-ready
copies for distribution to your colleagues or clients, contact us at www.rsna.org/rsnarights.
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SPECIAL REPORTS: Pancreatic Ductal Adenocarcinoma Radiology Reporting Template Al-Hawary et al
gastroenterologists. To develop a tem-
plate that can be used for uniform,
comprehensive, and reproducible re-
porting of imaging findings in patients
with PDA, a multi-institutional group
of 15 experts that included radiolo-
gists, hepatopancreatobiliary surgeons,
and gastroenterologists, composed of
members of the Society of Abdominal
Radiology and the American Pancre-
atic Association, convened a consensus
conference during the annual American
Pancreatic Association meeting (Chi-
cago, November 2011). Existing tem-
plates at each member institution were
provided to the group at the meeting.
A draft template including the most
appropriate findings chosen from the
available templates based on the state
of knowledge and available pertinent
literature was developed by consensus
during the meeting. After the confer-
ence, a final draft was prepared by
the lead author (M.M.A.) and sent to
all participants for review, comments,
and approval. This consensus state-
ment addresses the integration of the
appropriate descriptive terms defining
the stage based on the disease extent,
suggests a lexicon to be used in the re-
porting of the imaging findings to avoid
with complete, incomplete, or margin-
positive resection (R0 no residual or
R1 residual microscopic or R2 resid-
ual macroscopic disease, respectively)
have progressively decreasing survival
rates. Patients with R2 resections have
survival rates similar to patients with
comparable stage and performance
status who have not undergone resec-
tion. Accordingly, these patients do not
benefit from surgical resection (7,8).
Therefore, accurate staging of PDA at
the time of presentation carries sub-
stantial implications for appropriate
recommendation to patients of the
most suitable treatment option, thus
maximizing the survival benefit for pa-
tients in whom complete resection can
be achieved and minimizing the mor-
bidity from unnecessary laparotomy or
major surgery in patients with high risk
of residual disease following resection.
Finally, proper and uniform staging fa-
cilitates more accurate enrollment in
clinical trials, aiding in the analysis of
clinical trials results and comparison to
other studies.
Imaging evaluation plays a central
and primary role in the initial decision-
making process of patients with PDA
(9). There are, however, limitations in
the current reporting of these imaging
studies. These include variability of the
descriptive terminology that attempts
to define disease extent and incomplete
documentation of disease sites which
may affect prognosis and adversely af-
fect treatment planning by surgeons,
medical and radiation oncologists, and
P
ancreatic ductal adenocarcinoma
(PDA) is the second most com-
mon gastrointestinal malignancy
after colorectal cancer. It is a highly
aggressive tumor that carries a high
mortality rate and is the fourth most
common cause of cancer-related death
in the United States in both men and
women, with an estimated 43 920 new
cases diagnosed and approximately
37 390 deaths in 2012 (1,2). The high
mortality rate is due to the aggressive
disease biology and the delayed diag-
nosis of most cases at an unresectable
stage. Owing to the high percentage
of advanced disease at the time of di-
agnosis and limited efficacy of current
treatment options, mortality rates have
remained the same over the past 2
decades. Furthermore, the incidence
of PDA is increasing, with a reported
annual percentage change of 1.2% be-
tween the years 1999 and 2010, com-
pared with a negative change in the
preceding years (3). A recent report
predicts that, based on current trends,
PDA will become the second most com-
mon cause of cancer-related deaths in
the United States by 2020 (4).
With limited advances in the treat-
ment of advanced PDA, the main hope
for improved patient survival and po-
tential cure lies in early detection of the
disease when complete surgical resec-
tion is feasible and in supplementation
with more effective therapeutic agents.
Currently only 15%–20% of patients
have potentially resectable disease at
the time of presentation (5,6). Patients
Implications for Patient Care
n
Adoption of a standardized im-
aging reporting template should
improve the decision-making
process for the management of
patients with PDA.
n Standardization of radiology
reports in PDA can also help to
facilitate research and clinical
trial design by using appropriate
consistent staging of patients by
means of resectability status,
thus allowing for comparison of
results among different
institutions.
Advances in Knowledge
n
Given the variability in expertise
and definition of pancreatic
ductal adenocarcinoma (PDA)
disease extent among different
practitioners, adoption of a stan-
dardized template for radiology
reporting, using universally ac-
cepted and agreed on termi-
nology for solid pancreatic neo-
plasms, is needed.
n A consensus statement by a mul-
ti-institutional group of experts
in treating patients with PDA is
presented.
Published online
10.1148/radiol.13131184 Content codes:
Radiology 2014; 270:248–260
Abbreviations:
CHA = common hepatic artery
MPV = main portal vein
NCCN = National Comprehensive Cancer Network
PDA = pancreatic ductal adenocarcinoma
SMA = superior mesenteric artery
SMV = superior mesenteric vein
Author contributions:
Guarantors of integrity of entire study, M.M.A., S.T.C.,
R.M.M., D.M.S.; study concepts/study design or data
acquisition or data analysis/interpretation, all authors;
manuscript drafting or manuscript revision for important
intellectual content, all authors; approval of final version
of submitted manuscript, all authors; literature research,
M.M.A., S.T.C., E.K.F., D.S.L., M.M., F.H.M., K.J.M., N.B.M.,
D.V.S., D.M.S.; clinical studies, I.R.F., M.M., F.H.M., N.B.M.,
R.M.M.; experimental studies, F.H.M., N.B.M.; statistical
analysis, N.B.M.; and manuscript editing, M.M.A., I.R.F.,
S.T.C., E.K.F., D.M.H., D.S.L., A.J.M., F.H.M., K.J.M., N.B.M.,
R.M.M., E.P.T., D.V.S., D.M.S.
Conflicts of interest are listed at the end of this article.
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PDA in patients according to the latest
NCCN guidelines (16) is summarized in
Table 1.
There are, however, several addi-
tional imaging findings not explicitly de-
scribed in the NCCN guidelines criteria
defining resectability that are pertinent
for surgical planning and should be in-
cluded in the radiology template:
1. The presence of tumor or bland
venous thrombosis;
2. Extension of tumor contact with
the common hepatic artery (CHA) to
the level of the origins of right and left
hepatic arteries;
3. Extension of tumor contact to
first superior mesenteric artery (SMA)
confusion in terminology, and provides
a structured template to improve the
completeness of radiology reporting in
cases of PDA.
PDA Staging
PDA staging is based on the determina-
tion of tumor size, location within the
pancreas, local extent which may involve
surrounding vessels, and the presence
of metastatic lesions. The reported
imaging data must allow clinicians to
translate the information in the imaging
report into established clinical staging
systems thereby facilitating appropriate
treatment selection, eligibility for clinical
trials, and prognosis. Commonly used
staging systems in the United States are
from the American Joint Committee on
Cancer and the National Comprehensive
Cancer Network (NCCN).
The American Joint Committee on
Cancer staging system, which is based
on the TNM staging system, is used to
assess the immediate and long-term
clinical prognosis and to generate sur-
vival data for patients on the basis of
the stage of disease (10,11). The T
stage is based on the size of the tu-
mor and whether the lesion extends
beyond the pancreas with or without
contact with the adjacent vessels. The
regional lymph node (N) and distant
metastasis (M) stages are based on
the absence or presence of metastasis
to the regional lymph nodes or other
distant sites, respectively. Of note,
only the regional lymph nodes located
along the lymphatic drainage path-
ways that would be included in the
surgical field and will be resected with
the primary tumor are included in the
N categories. Metastases to lymph
nodes outside the normal drainage
pathways or the ones not routinely
included in the surgical resection are
classified as M1 stage.
The NCCN consensus report
guidelines define a staging system
based on tumor extent and offer treat-
ment recommendations accordingly
(12,13). The NCCN criteria defining
resectability status are based on the
American Hepato-Pancreatico-Biliary
Association consensus report (14,15).
In the absence of metastatic disease,
pancreatic cancer cases are classified
into three main categories—resect-
able, borderline resectable, or locally
advanced/unresectable disease. The
disease category selection depends
on tumor location within the pancreas
(Fig 1) and the arterial or venous
involvement (Figs 2 and 3). In the
guidelines, less than or equal to 180°
tumor contact of the vessel circumfer-
ence is described as “abutment” and
more than 180° tumor contact of the
vessel circumference is referred to as
“encasement.”
According to the location and ex-
tent of vascular involvement, staging of
Figure 1
Figure 1: Tumor location. Tumor located to the right of the superior mesenteric vein (SMV) in the
(a) pancreatic head or (b) uncinate process is potentially suitable for a Whipple procedure or pancreati-
coduodenectomy procedure. Tumor located to the left of the SMV in the (c) pancreatic body or (d) tail is
potentially suitable for distal pancreatectomy. T = tumor.
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Figure 2
Figure 2: Arterial tumor contact. (a) Less than or equal to 180° tumor contact without deformity. (b) More than 180° tumor contact without deformity. (c) Tumor
contact with deformity (arrow). A = artery, T = tumor. Dashed line = 180° of lumen circumference.
Figure 3
Figure 3: Venous tumor contact. (a) Less than or
equal to 180° tumor contact without deformity.
(b) More than 180° tumor contact without defor-
mity. (c) Less than or equal to 180° tumor contact
with deformity (arrows). (d) Tear drop deformity
(arrows). T = tumor, V = vein. Dashed line = 180°
of lumen circumference.
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Standardized template reporting can
also simplify the process, perhaps even
in an automated fashion, of organiz-
ing the structured reports to create a
database that can be used for clinical
outcomes analysis or to assist in clinical
decision making (23). The adoption of
structured reporting has been shown to
be acceptable by radiologists, particu-
larly in academic tertiary centers (24).
Imaging Evaluation
Pancreatic CT Protocol
Multidetector computed tomography
(CT) angiography, performed by using
a dedicated dual-phase pancreatic pro-
tocol, is the preferred method for initial
imaging evaluation in patients in whom
PDA is suspected (9,25,26). Magnetic
resonance (MR) imaging has been
shown to be equally sensitive and spe-
cific in staging pancreatic cancer and
can be used interchangeably (27); how-
ever, it is not as widely used as the pri-
mary imaging modality in most centers
because of cost and availability. In most
centers, MR imaging is predominantly
utilized for problem solving in patients
with isoattenuating pancreatic lesions
or to better characterize indeterminate
liver lesions identified at prior CT ex-
aminations. Endoscopic ultrasonogra-
phy (US) can assist in the detection of
small tumors and in patients when the
primary tumor is not visualized or is
showed a preference for structured or
template radiology reporting, as used
in other medical specialties such as pa-
thology, over the current predominantly
prevailing mode of radiologic reporting
using freestyle dictation (18). Freestyle
dictation can potentially be confusing to
the referring clinicians because informa-
tion that is critical to treatment planning
may be buried in excessively verbose
text, may not be presented concisely in
a manner that makes the information
easily interpretable by everyone on the
patient care team (physicians, nurses,
data managers, and social workers),
or may not even have been included in
the report. This can be avoided by using
systematic and standardized template
reporting (19–21).
In recent years, several professional
radiology organizations have attempted
to introduce standardized structured
template form reporting into radiology
practice (eg, the Radiological Society
of North America’s radiology reporting
initiative [22], among others). The goal
of structured radiology reporting is to
improve the completeness, accessibil-
ity, and interpretability of radiologic re-
ports to the referring physician. These
structured templates utilize a standard-
ized lexicon developed by radiologists
in conjunction with other medical spe-
cialties to reach mutually understand-
able and agreed on nonambiguous
terminology which avoids the use of
vague and imprecise nomenclature.
branch and to most proximal draining
vein into SMV;
4. Presence of increased hazy at-
tenuation/stranding contact with the
vessel, particularly in patients who re-
ceived prior radiation therapy; and
5. Arterial variants, in particular
origin of the right hepatic artery from
the SMA.
Structured Reporting
To accurately stage the disease in pa-
tients to guide appropriate treatment,
the radiology report should include all
the criteria outlined above in the com-
monly used staging systems, as well as
any additional findings that may affect
surgical planning. The radiology report
must document the lesion size, location,
presence and detailed extent of vascular
involvement, presence of arterial vari-
ants with or without tumor contact, and
presence of nodal or metastatic disease.
The imaging features that define disease
extent, in particular the definition of
vascular involvement and extension,
should be based on established criteria
that have appropriate levels of sensitiv-
ity and specificity. These criteria should
provide the basis for consistent image
interpretation within and between prac-
tices or departments. There is a growing
expectation by oncologists and surgeons
for standardized radiology reports that
are reproducible and easily understood
(17). A study of referring clinicians
Table 1
NCCN Criteria for PDA Staging
Stage Arterial Venous
Resectable Clear fat planes around CA, SMA, and HA No SMV/portal vein distortion
Borderline resectable Gastroduodenal artery encasement up to the hepatic artery with either short
segment encasement or direct abutment of the hepatic artery without
extension to the CA. Tumor abutment of the SMA not to exceed greater
than 180° of the circumference of the vessel wall
Venous involvement of the SMV or portal vein with distortion
or narrowing of the vein or occlusion of the vein with
suitable vessel proximal and distal, allowing for safe
resection and replacement
Unresectable*
Aortic invasion or encasement. Based on tumor location: Pancreatic
head—More than 180° SMA encasement, any CA abutment, IVC
Pancreatic body/tail—SMA or CA encasement greater than 180°
Unreconstructible SMV/portal vein occlusion
Note.—CA = celiac axis, HA = hepatic artery, IVC = inferior vena cava.
* The presence of distant metastasis, including metastases to lymph nodes beyond the field of resection, renders the patient unresectable irrespective of the type of vascular involvement.
Extension to adjacent structures such as transverse colon or mesocolon, stomach, spleen, adrenal gland, or kidney is not a definite contraindication to surgical resection, since these structures can
be resected along with the primary tumor.
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Table 2
Multidetector CT Dedicated Pancreatic Protocol Parameters
Parameter Details
Scan type Helical
Section thickness (detector configuration) Preferably submillimeter (0.5–1 mm)
Interval Same as section thickness
Oral contrast agent Neutral or low-Hounsfield units oral agent
Intravenous contrast agent Preferably high iodine concentration [. 300 mg I/mL] at an
injection rate of 3–5 mL/sec
Scan acquisition Pancreatic parenchymal phase at 40–50 sec; portal venous
phase at 65–70 sec
Image reconstruction
Axial 2–5 mm thickness
Multiplanar reformats in the coronal plane at 2–3 mm
thickness, and per institutional preference, the
sagittal plane
Maximum intensity projections or three-dimensional
volumetric thick sections for vascular evaluation
Table 3
Morphologic Evaluation
Parameter Finding
Appearance (in the pancreatic parenchymal phase) Hypo-, iso-, or hyperattenuating
Size (maximal axial dimension in centimeters) Measurable or nonmeasurable (isoattenuating tumors)
Location (head right of SMV, body left of SMV) Head/uncinate or body/tail
Pancreatic duct narrowing/abrupt cut-off with or
without upstream dilatation
Present or absent
Biliary tree abrupt cut-off with or without
upstream dilatation
Present or absent
isoattenuating on CT images (28). En-
doscopic US with fine-needle aspiration
has an established role in cytohistologic
confirmation before treatment initi-
ation and in negative cross-sectional
evaluation with CT or MR imaging
and persistent strong clinical suspicion
of PDA (28). The availability of high-
quality pancreatic multidetector CT
angiography (preferably 16–detector
row or greater) combined with exper-
tise in interpreting these studies has
been shown to improve preoperative
staging and alter management in a sig-
nificant proportion of patients (29,30).
Multidetector CT angiography protocol
for pancreatic imaging consists of a
biphasic examination (Table 2) (9). In
the pancreatic parenchymal phase (ac-
quisition time is shortly after the arte-
rial phase and before the portal venous
phase), there is maximal pancreatic
parenchymal enhancement, producing
optimal visual contrast differences be-
tween the enhanced pancreatic paren-
chyma and the usually hypoattenuat-
ing tumor. The peripancreatic arteries
are usually well opacified during this
phase, allowing for their concomitant
evaluation. In the second portal venous
phase acquisition, the portomesenteric
venous system is well opacified, allow-
ing for better evaluation of the portal
venous system; furthermore, the liver
is maximally enhanced, improving de-
tection of hepatic metastases which are
usually hypoattenuating compared with
the enhanced hepatic parenchyma. The
smallest available section thickness or
detector configuration should be used
to enable the production of high-fidel-
ity reformatted and volumetric images
from the nearly isotropic voxels ac-
quisition (31,32). The nearly isotropic
acquired data set will allow high-quality
reformatted images in any plane, either
as maximum intensity projections or
three-dimensional volumetric images,
which may be necessary to allow full
assessment of the circumferential and
longitudinal vascular contact, detection
of change in vessel caliber, or the pres-
ence of contour deformity secondary to
tumor, which may not be appreciated
on the axial images alone. These re-
formats also help in assessing vascular
anatomic variants and potentially signif-
icant vascular disease or collaterals if
present.
Accurate imaging assessment is criti-
cal for optimal treatment selection; how-
ever, frequently the diagnosis of PDA is
made on routine single-phase CT studies
obtained in the portal venous phase. Al-
though these routine CT studies may be
sufficient to diagnose pancreatic adeno-
carcinoma, they are inadequate in some
cases for the assessment of the local
tumor extent because of the absence of
multiphasic contrast enhancement and
thicker-section images that are com-
monly obtained in these examinations.
These factors limit the ability to gener-
ate the high-quality reformatted images
and three-dimensional reconstructions
that are often necessary for accurate
staging. It is therefore essential that
these patients undergo repeat imaging
with a dedicated pancreatic CT exami-
nation that includes biphasic multidetec-
tor CT angiography.
Morphologic Evaluation
Morphologic evaluation of PDA includes
documentation of tumor size (longest
diameter in the axial plane), appear-
ance, location, and associated biliary or
pancreatic duct dilatation/abrupt inter-
ruption (Table 3).
In the majority of cases, PDA is usu-
ally hypoattenuating when compared to
the pancreatic parenchyma, in partic-
ular during the pancreatic parenchy-
mal phase of enhancement. In a small
percentage of cases the tumor is isoat-
tenuating to the surrounding pancreatic
parenchyma and is difficult to visualize;
however, the presence of tumor can
frequently be inferred from associated
secondary findings, including a focal
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can be difficult to differentiate from solid
tumor.
Arterial evaluation.—The evalua-
tion of the celiac axis, SMA, CHA, and
arterial variants, if present, is an im-
portant component of the assessment
of the patient’s imaging study (Table 4).
The analysis of arterial contact (less
than or equal to 180° versus more than
180°) as well as the presence of change
in the vessel caliber (focal narrowing)
or contour irregularity should be noted
and documented in sufficient detail in
the standardized report (Figs 4–6).
or change in caliber is also considered
a sign of vascular invasion regardless of
the degree of contact between tumor and
vessel (37). The positive predictive value
of CT for determining nonresectability
is very high (89%–100%); however, it is
lower for predicting resectability (45%–
79%) since the diagnostic criteria for vas-
cular invasion that have been developed
are more specific than sensitive, to mini-
mize the number of patients inappropri-
ately denied surgery and potential cure.
Following neoadjuvant chemotherapy and
radiation therapy, the solid tumor vascu-
lar contact may be replaced by perivas-
cular haziness or fat stranding that can
be due to posttreatment fibrosis or viable
tumor, making assessment of tumor re-
sectability on cross-sectional images dif-
ficult (38–40). Occasionally inflammatory
stranding from pancreatitis secondary to
ductal obstruction due to the tumor or
from recent procedures such as endo-
scopic retrograde cholangiopancreatog-
raphy or endoscopic US with biopsy may
also produce perivascular haziness that
bulge in the pancreatic contour, abrupt
interruption of the biliary or pancre-
atic duct (with or without upstream
dilatation), and proximal (upstream)
pancreatic atrophy (33–35). PDA rarely
contains calcifications, which are more
frequently seen in other types of solid
pancreatic neoplasms, such as neuroen-
docrine tumors.
Vascular Evaluation
In the absence of distant metastasis,
the presence and degree of contact be-
tween the tumor and the peripancreatic
vessels is of paramount importance in
determining surgical resectability.
Lu et al (36) initially described a
system for determining the likelihood of
vascular involvement by the pancreatic
tumor based on the percentage of cir-
cumferential surface contact between the
tumor and the adjacent vessel, and they
concluded that more than 180° of tumor-
vessel contact is highly specific for tumor
unresectability. Irregularity of the vessel
contour (including “tear drop” deformity)
Table 4
Arterial Evaluation
Parameter Finding
SMA Present or absent
Degree of solid soft-tissue contact 180° or .180°
Degree of increased hazy attenuation/stranding contact 180° or .180°
Focal vessel narrowing or contour irregularity Present or absent
Extension to first SMA branch Present or absent
Celiac axis Present or absent
Degree of solid soft-tissue contact 180° or .180°
Degree of increased hazy attenuation/stranding contact 180° or .180°
Focal vessel narrowing or contour irregularity Present or absent
CHA Present or absent
Degree of solid soft-tissue contact 180° or .180°
Degree of increased hazy attenuation/stranding contact 180° or .180°
Focal vessel narrowing or contour irregularity Present or absent
Extension to celiac axis Present or absent
Extension to bifurcation of right/left hepatic artery Present or absent
Arterial variant Present or absent
Variant anatomy Accessory right hepatic artery, replaced right
hepatic artery, replaced CHA, others
(origin of replaced or accessory artery)
Variant vessel contact Present or absent
Degree of solid soft-tissue contact 180° or .180°
Degree of increased hazy attenuation/stranding contact 180° or .180°
Focal vessel narrowing or contour irregularity Present or absent
Figure 4
Figure 4: Images in a 60-year-old man with less
than 180° of circumferential tumor contact with the
SMA. (a) Axial contrast-enhanced biphasic multi-
detector CT angiogram demonstrates a pancreatic
body mass (T) directly contacting less than 180° of
the SMA circumference without contour deformity
(short arrow). (b) On the sagittal reformatted image,
the length of tumor contact and vessel caliber are
better delineated (short arrow). Finding less than
180° of tumor contact with the SMA places the
patient in the borderline resectable category.
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the presence or absence and degree of
vascular tumor contact or surrounding
haziness with the variant vessel should
be described. In addition, relevant arte-
rial disease such as median arcuate lig-
ament compression or significant SMA
stenosis should be described, as it may
affect surgical planning.
Venous evaluation.—The most im-
portant veins that can affect tumor
resectability include the portal vein
and SMV. The circumferential degree
of tumor-vessel contact (less than or
equal to 180° versus more than 180°)
(Figs 9–11), or the presence of in-
creased hazy attenuation/stranding at
presentation or following neoadjuvant
chemotherapy and radiation ther-
apy treatment, should be described
2. CHA: in pancreatic head lesions,
tumor extension that can affect the
staging and the type of vascular recon-
struction performed includes tumor
contact with the gastroduodenal artery
extending to involve the hepatic artery,
which would change the staging from re-
sectable to borderline resectable, CHA
tumor contact extension to involve the
celiac axis and extension to involve the
proper hepatic artery division into the
right or left hepatic arteries, which will
render the tumor unresectable (Fig 8).
3. Arterial variants: reporting of ar-
terial variants involving the celiac axis
or SMA, particularly the presence of
a replaced right hepatic artery from
the SMA, can assist in surgical plan-
ning. Similarly, reporting regarding
On posttreatment staging scans
following neoadjuvant chemotherapy
and radiation therapy, where the solid
tumor contact can be replaced by in-
creased hazy attenuation or stranding,
the degree of contact of the haziness
or stranding with the vessel should be
noted. Additional pertinent information
includes:
1. SMA: tumor extension to first
SMA branch, since involvement of the
proximal SMA branches such as the
jejunal or colic arteries can affect the
decision to resect (Fig 7).
Figure 5
Figure 5: Images in a 73-year-old woman with
more than 180° of circumferential tumor contact
with the SMA. (a) Axial contrast-enhanced biphasic
multidetector CT angiogram demonstrates a pancre-
atic head mass (T) contacting more than 180° of the
SMA circumference (short arrows). (b) Extension and
involvement of the first SMA branch (short arrow) is
better delineated on the coronal reformatted image.
The presence of greater than 180° of tumor in
contact with the SMA and tumor in contact with the
SMA branch places the patient in the unresectable
category.
Figure 6
Figure 6: Images in a 71-year-old woman with
tumor involvement of the celiac axis (CA). (a) Axial
contrast-enhanced biphasic multidetector CT angio-
gram demonstrates a mass in the pancreatic body
(T) that is in contact with less than 180° of the celiac
axis circumference (short arrow). (b) On the sagittal
reformatted image, the contact with the celiac axis is
better delineated (short arrow). The presence of less
than 180° of tumor contact with the celiac axis places
the patient in the borderline resectable category.
Figure 7
Figure 7: Images in a 58-year-old man show
tumor contact with several SMA branches. (a) Axial
contrast-enhanced biphasic multidetector CT
angiogram demonstrates a pancreatic head mass
(T) in contact with the adjacent SMA branches.
(b) The SMA branches involvement on the coronal
reformatted image. The tumor involvement of the
SMA branches places the patient in the unresect-
able category.
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underlying systemic conditions) sug-
gest disseminated disease that would
render the patient unsuitable for a cu-
rative resection.
The presence of enlarged lymph
nodes can also affect surgical resect-
ability and indicate need for additional
therapy. The presence and location of
suspicious lymph nodes (defined as
short axis . 1 cm, abnormal round
morphology, heterogeneity, or cen-
tral necrosis) should be noted. This
is especially true for enlarged lymph
nodes which are outside the immedi-
ate local drainage pathways based on
tumor location (ie, aortocaval or para-
aortic lymph nodes), as these can alter
kidneys, adrenal glands, inferior vena
cava, aorta, or spleen should be noted
as it can affect the surgical decision
making.
If focal hepatic lesions are present
that demonstrate suspicious features
concerning for metastasis (poorly de-
fined margins, rim enhancement) or
are indeterminate if the lesion is too
small to characterize by means of CT,
then further imaging or tissue sampling
to arrive at a final diagnosis may be
warranted (Fig 14).
Peritoneal nodules or the pres-
ence of ascites (in the absence of
other potential causes of ascites
such as mesenteric venous occlusion,
(Fig 12). Additional features includ-
ing the presence of tumor or bland
thrombus, focal caliber narrowing,
contour irregularity, or tear drop de-
formity should be described (Fig 13).
Similar to the SMA contact, extension
of the tumor to the most proximal veins
draining into the SMV should be re-
corded (Table 5).
Extrapancreatic Evaluation
The presence of extrapancreatic tu-
mor extension, either local or distant,
should also be described (Table 6).
Direct local extension into surround-
ing adjacent structures such as stom-
ach, small bowel or colon/mesocolon,
Figure 8
Figure 8: Images in a 70-year-old man with
tumor in contact with the CHA. (a) Axial contrast-
enhanced biphasic multidetector CT angiogram
demonstrates a mass in the pancreatic head
mass (T) in contact with the CHA (short arrow).
(b) The length of contact is better delineated on
the curved planar reformatted image through the
length of the vessel, which shows that the tumor
contact extends to the hepatic artery bifurcation
(short white arrow) and the celiac axis (short
black arrow). The extension to the celiac axis
places the patient in the unresectable category.
HA = hepatic artery.
Figure 9
Figure 9: Images in a 55-year-old women with
tumor with less than 180° of contact with the SMV.
(a) Axial contrast-enhanced biphasic multidetector CT
angiogram demonstrates a pancreatic head mass (T)
contacting less than 180° of the SMV circumference
without contour deformity or focal narrowing (short
arrow). (b) The length of contact and vessel caliber is
better delineated on the coronal reformatted image
(short arrow). The limited tumor contact with the
SMV and the identification of suitable vessel proximal
and distal to the lesion, which allows safe resection
and venous replacement, places the patient in the
borderline resectable category.
Figure 10
Figure 10: Images in a 76-year-old man with tu-
mor with more than 180° contact with the main por-
tal vein (MPV). (a) Axial contrast-enhanced biphasic
multidetector CT angiogram demonstrates a pan-
creatic head mass (T) with tumor contact extending
more than 180° around the MPV (short arrows). (b)
The focal vessel narrowing and length of contact is
better delineated on the coronal view (short arrow).
Despite the degree of tumor contact with the MPV,
the presence of suitable vessel proximal and distal
to the narrowing potentially allows for safe resection
and venous replacement, which places the patient in
the borderline resectable category.
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Figure 11
Figure 12
Figure 12: Images in a 68-year-old woman with
pancreatic head mass and perivascular increased
haziness or stranding. (a, b) Axial contrast-
enhanced biphasic multidetector CT angiogram
shows a mass in the pancreatic head (T). Tumor
contacts less than 180° of the SMV circumfer-
ence and there is extension to the first draining
vein (short arrow). The tumor involvement of the
SMV and draining vein places the patient in the
unresectable category. (c, d) Following chemother-
apy and radiation therapy, there is shrinkage of the
tumor and replacement of the solid tumor contact
with the SMV and the draining branch by increased
haziness, likely representing fibrosis rather than
tumor (short arrows). The tumor was resected with
negative margins.
Figure 11: Three-dimensional volume rendered
display of multivessel tumor involvement. (a–c)
Axial contrast-enhanced biphasic multidetector CT
angiograms demonstrate a mass in the body of
the pancreas (T) with more than 180° of contact
with the MPV, splenic vein, and SMV and narrow-
ing of the vessels (short arrow). (d) The multifocal
narrowing and the length of tumor contact, as well
as the presence of collaterals, are better delineated
on the three-dimensional volume rendered display
(short arrow). This degree of tumor contact with the
MPV and SMV places the patient in the borderline
resectable category. SV = splenic vein.
Page 10
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standardized imaging reporting tem-
plate using universally accepted and
agreed on terms should improve the
preoperative staging and surgical
decision making for the management
of patients with PDA. The imaging re-
porting template should summarize all
the pertinent findings; however, the
decision regarding resectability status
should be decided in consensus at
multidisciplinary meetings/discussions.
Standardized reporting can also help
facilitate research and clinical trial de-
sign by classifying patients’ resectability
status based on precise imaging param-
eters and can also facilitate comparison
of results among different institutions.
The full, standardized template is avail-
able in Appendix E1 (online).
Disclosures of Conflicts of Interest: M.M.A. No
relevant conflicts of interest to disclose. I.R.F. No
relevant conflicts of interest to disclose. S.T.C.
No relevant conflicts of interest to disclose.
E.K.F. No relevant conflicts of interest to dis-
close. D.M.H. No relevant conflicts of interest to
disclose. D.S.L. No relevant conflicts of interest
to disclose. M.M. No relevant conflicts of inter-
est to disclose. AJ.M. Financial activities related
to the present article: none to disclose. Financial
activities not related to the present article: con-
sultant, Bracco Diagnostics. Other relationships:
none to disclose. F.H.M. No relevant conflicts of
interest to disclose. K.J.M. No relevant conflicts
of interest to disclose. N.B.M. No relevant con-
flicts of interest to disclose. R.M.M. No relevant
conflicts of interest to disclose. E.P.T. Financial
activities related to the present article: none to
disclose. Financial activities not related to the
present article: Consultant 10/2010 to 10/2011
on Advantage workstation, General Electric.
Other relationships: none to disclose. F.H.M.
disease staging, the panel recom-
mends that all patients who have no
obvious metastatic disease or exten-
sive local invasion at initial routine
abdominal CT examinations undergo
a repeat examination with dedicated
pancreas protocol multidetector CT
angiography.
A standardized template for PDA
staging created by consensus and en-
dorsed by two major national orga-
nizations (the Society of Abdominal
Radiology and the American Pancre-
atic Association) is presented in this
article. The adoption of this suggested
staging from local node involvement to
metastatic disease.
Conclusion
The central role of high-quality im-
aging for the diagnosis and proper
description of the extent of tumor at
the time of tumor staging is of great
importance for optimal therapeu-
tic decision making and for ongoing
management in patients with PDA.
Complete, accurate, and reproducible
radiology reporting of disease extent
is therefore essential. For accurate
Figure 13
Figure 13: Images in a 55-year-old man with venous thrombosis. (a) Axial contrast-enhanced biphasic multidetector CT angiogram demonstrates a pancreatic
body mass (T). Note the upstream dilatation of the pancreatic duct (short arrow). (b) Image at a lower level shows bland intraluminal thrombus in the SMV (short
arrow). (c) Coronal reformatted CT image displays the extent of the thrombosis (short arrows).
Table 5
Venous Evaluation
Parameter Finding
MPV Present, absent, or complete occlusion
Degree of solid soft-tissue contact 180° or .180°
Degree of increased hazy attenuation/stranding contact 180° or .180°
Focal vessel narrowing or contour irregularity
(tethering or tear drop)
Present or absent
SMV Present, absent, or complete occlusion
Degree of solid soft-tissue contact 180° or .180°
Degree of increased hazy attenuation/stranding contact 180° or .180°
Focal vessel narrowing or contour irregularity
(tethering or tear drop)
Present or absent
Extension to first draining vein Present or absent
Thrombus within vein Present or absent (MPV, SMV, or splenic vein),
(tumor, bland)
Venous collaterals
Present or absent (around pancreatic head,
porta hepatis, root of the mesentery, or left
upper quadrant)
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Author stated no relevant conflicts of interest
to disclose. D.V.S. Financial activities related to
the present article: none to disclose. Financial
activities not related to the present article: re-
search agreements, GE Healthcare and Siemens
Medical Systems; textbook royalties, Elsevier
Publishing. Other relationships: none to dis-
close. D.M.S. Author stated no relevant conflicts
of interest to disclose.
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Liver lesions* Present or absent
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Figure 14
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Page 13
    • "A precise report and captured images are critical to determine the patient resectability status [7,10] and should include: -Tumour characteristics: size, appearance (hypo-, iso-, hyperattenuating compared with normal pancreatic parenchyma ), location (uncinate process, head, body, tail) and biliary or pancreatic duct narrowing. Most cases of PC are slightly hypoattenuating but in some cases the only sign of tumour is an abrupt interruption of the pancreatic or biliary duct. "
    [Show abstract] [Hide abstract] ABSTRACT: Pancreatic adenocarcinoma remains a devastating disease with a 5-year survival rate not exceeding 6%. Treatment of this disease remains a major challenge. This article reviews the state-of-the-art in the management of this disease and the new innovative approaches that may help to accelerate progress in treating its victims. After careful pre-therapeutic evaluation, only 15-20% of patients diagnosed with a pancreatic cancer (PC) are eligible for upfront radical surgery. After R0 or R1 resection in such patients, evidence suggests a significantly positive impact on survival of adjuvant chemotherapy comprising 6 months of gemcitabine or fluorouracil/folinic acid. Delayed adjuvant chemoradiation is considered as an option in cases of positive margins. Borderline resectable pancreatic cancer (BRPC) is defined as a tumour involving the mesenteric vasculature to a limited extend. Resection of these tumours is technically feasible, yet runs the high risk of a R1 resection. Neoadjuvant treatment probably offers the best chance of achieving successful R0 resection and long-term survival, but the best treatment options should be determined in prospective randomised studies. Gemcitabine has for 15 years been the only validated therapy for advanced PC. Following decades of negative phase III studies, increasing evidence now suggests that further significant improvements to overall survival can be achieved via either Folfirinox or gemcitabine + nab-paclitaxel regimens. Progress in systemic therapy may improve the chances of resection in borderline resectable pancreatic cancer (BRPC) or locally advanced PC. This requires first enhancing knowledge of the genetic events driving carcinogenesis, which may then be translated into clinical studies.
    No preview · Article · Apr 2016 · European journal of cancer (Oxford, England: 1990)
  • Source
    • "Radiological studies should include computed tomography (CT) angiography at the pancreatic arterial (40–50 s) and portal venous (65–70 s) phases. A consensus statement, describing a standardised reporting template, was recently developed to provide a precise reporting of disease staging and to improve the decision-making process for patients with pancreatic cancer [12]. When assessing vessel involvement, the use of magnetic resonance imaging (MRI) is left to expert discretion. "
    Full-text · Article · Sep 2015 · Annals of Oncology
  • Source
    • "Of these, nearly 80% develop local or distant recurrence within 2 years, reflecting the need for better prognostic and predictive biomarkers to dictate adjuvant therapy [4]. Clinical and pathological characteristics have limited value in predicting prognosis in PDAC patients with metastatic , locally advanced or resectable sub-groups [8,9]. There are no established diagnostic, prognostic or predictive biomarkers for PDAC [10]. "
    [Show abstract] [Hide abstract] ABSTRACT: Improved usage of the repertoires of pancreatic ductal adenocarcinoma (PDAC) profiles is crucially needed to guide the development of predictive and prognostic tools that could inform the selection of treatment options. Using publicly available mRNA abundance datasets, we performed a large retrospective meta-analysis on 466 PDAC patients to discover prognostic gene signatures. These signatures were trained on two clinical cohorts (n = 70), and validated on four independent clinical cohorts (n = 246). Further validation of the identified gene signature was performed using quantitative real-time RT-PCR. We identified 225 candidate prognostic genes. Using these, a 36-gene signature was discovered and validated on fully independent clinical cohorts (hazard ratio (HR) = 2.06, 95% confidence interval (CI) = 1.51 to 2.81, P = 3.62 × 10(-6), n = 246). This signature serves as a good alternative prognostic stratification marker compared to tumour grade (HR = 2.05, 95% CI = 1.45 to 2.88, P = 3.18 × 10(-5)) and tumour node metastasis (TNM) stage (HR = 1.13, 95% CI = 0.66 to 1.94, P = 0.67). Upon multivariate analysis with adjustment for TNM stage and tumour grade, the 36-gene signature remained an independent prognostic predictor of clinical outcome (HR = 2.21, 95% CI = 1.17 to 4.16, P = 0.01). Univariate assessment revealed higher expression of ITGA5, SEMA3A, KIF4A, IL20RB, SLC20A1, CDC45, PXN, SSX3 and TMEM26 was correlated with shorter survival while B3GNT1, NOSTRIN and CADPS down-regulation was associated with poor outcome. Our 36-gene classifier is able to prognosticate PDAC independent of patient cohort and microarray platforms. Further work on the functional roles, downstream events and interactions of the signature genes is likely to reveal true molecular candidates for PDAC therapeutics.
    Full-text · Article · Dec 2014 · Genome Medicine
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