Ductal adenocarcinoma of pancreas

  • Aggressive 
  • Early advanced local or distant spread
  • Perivascular, perineurial and lymphatic spread
  • Early spread to liver and peritoneum
  • At time of diagnosis, only 10% cases surgically resectable
  • 5 year survival rate <5%
  • Radical pacreaticoduodenectomy – severe morbidity and mortality
  • Weight loss, anorexia common symptoms
  • Obstructive jaundice seen in tumors involving head of pancreas
  • CA 19-9 is associated, but is neither sensitive nor specific
  • USG is first line investigation due to widespread availability. It is very useful to pick up obstructive jaundice. Masses may or may not be seen. 
  • Contrast enhanced oral water CT is the investigation of choice
  • ERCP should not be done prior to any imaging as it reduces the ability of scans to pick up small tumors
  • Endoscopic USG helps in biopsy of equivocal non obstructing lesions 
  • PET has limited role in initial diagnosis, but high accuracy in identifying local recurrence
  • 70% in head or uncinate process
  • Tumor is hypo echoic on US
  • Poorly enhancing area in dynamic contrast enhanced CT. 11% tumors are iso dense. 
  • Earlier fixed delay technique of scanning at 40 sec with 4ml/s flow rate was used. Now it is replaced by bolus tracking and aorta +25 sec. 
  • Upstream main pancreatic duct dilatation and secondary pancreatic atrophy may be seen
  • Uncinate process tumors – often don’t present with jaundice, spread along superior mesenteric artery, perineurial and even obstruct duodenum
Direct sign
  • Hypo attenuating mass lesion
Indirect signs
  • Biliary duct dilatation
  • Pancreatic duct dilatation
  • Double duct sign
  • Focal gland atrophy
  • Distorted contour of gland
  • Loss of pancreatic lobulation
TXPrimary tumor cannot be assessed
T0No evidence of primary tumor
TisCarcinoma in situ
T1Tumor ≤2 cm in greatest dimension
T2Tumor >2 cm, but ≤4 cm in greatest dimension
T3Tumor >4 cm in greatest dimension
T4Tumor involves celiac axis, superior mesenteric artery and/or common hepatic artery
NXRegional lymph nodes cannot be assessed
N0No regional lymph nodes 
N1Regional (peripancreatic) lymph node metastases
M0No distant metastasis
M1Distant metastasis
  • Perineurial spread and perivascular invasion suggest unresectability
  • Tumor-vessel contact >180 degrees indicates venous involvement
  • Tumor-vessel contact >180 degrees AND vessel irregularity or stenosis indicates arterial involvement
  • Tear drop deformity sign: the fibrotic tumor when abutting the superior mesenteric or portal vein deforms the venous contour
  • Stomach and duodenum involvement demonstrated with loss of normal enhancement of their wall
  • Order of lymph node involvement: peripancreas, celiac, common hepatic, mesenteric, para aortic 
  • Tumor recurrence: often around superior mesenteric artery either as a mass or a cuff-like formation