HYUN-JUNG JANG, MD & TAE KYOUNG KIM, MD
UNIVERSITY OF TORONTO, CANADA
UNIVERSITY HEALTH NETWORK/MSH/WCH
Pancreatic neoplasms in multidisciplinary settings:
What is the role of radiologists and how to navigate efficiently prior to surgery?
Surgical resection only offers potentially curative treatment
🡪 Detailed vascular assessment is often required even for locally advanced appearing PDAC
Staging of Pancreatic Ductal Adenocarcinoma (PDAC)
Start staging: Primary focus on RESECTABILITY
YES
Resectable
Borderline resectable
Locally Advanced
(Unresectable)
Metastatic
Consider Neoadjuvant ChemoTx :
High CA 19-9, large tumor, Regional LAP
Neoadjuvant ChemoTx
+/- Chemoradiation
Remain Resectable
Converts to Resectable
Neoadjuvant ChemoTx
+/- Chemoradiation
Surgery
Adapted from Grainne M. CMAJ 2021;193
Standardized Reporting
A] SMA, CT (celiac trunk), CHA
V] PV, SMV
CHA bifurcation, origin of CT/SMA
Reconstructive patent vessels at both ends
Key Points
Whipple, Distal or Total pancreatectomy
*Aortocaval/paraaortic
Liver, lung, peritoneum…
What to assess for vessels
Arterial
Venous
Neither
Borderline Resectable
Resectable
Unresectable
Encasement
Tumoral contact >180°
Abutment
Tumoral contact ≤ 180°
Deformity
[Summarized from NCCN V2.2025 Resectability Criteria]
Understand Evolving nature of resectability criteria
*First branch of SMA: now borderline
Illustration by Connie Choi
Tumor
Vessel
62F. Infiltrative pancreatic neck cancer
Case 1: How do surgeons plan vascular reconstruction based on imaging?
Involving 1st jejunal branch of SMA (red) & SMV (green)
Pancreaticoduodenectomy
(Whipple Procedure)
Reconstruction of SMA w saph v. jump graft
Reconstruction of SMV
Reconstruction of Splenic V w LRV graft
https://pie.med.utoronto.ca/TVASurg
Dividing Duodenum
Tumor
SMA
SMV
Posteriorly situated tumor
Encasing long segment of SMA
Porto-mesenteric vein draping over the tumor & narrowed
Dividing SMA
Dividing MPV/SMV
Dividing Spl v.
En bloc removal of specimen
https://pie.med.utoronto.ca/TVASurg
https://pie.med.utoronto.ca/TVASurg
Reconstruction of SMA
(aorta to distal remnant SMA)
using saphenous v. jump graft
Anastomose MPV – distal SMV
Reconnect Splenic V to MPV using left renal vein graft
MPV
SMV
LRV graft
SMA jump graft
Spl V
https://pie.med.utoronto.ca/TVASurg
https://pie.med.utoronto.ca/TVASurg
Pancreaticojejunostomy
Choledochojejunostomy
Gastrojejunostomy
https://pie.med.utoronto.ca/TVASurg
62M
Infiltrative cancer head to body
Tumor
PV collaterals
Occluded SMV
SMV occlusion
Patent distal V
https://pie.med.utoronto.ca/TVASurg
Case 2: How do surgeons plan vascular reconstruction based on imaging?
Tumor encasing long segment of distal PV/Splenic V (red), inferiorly occluding SMV w collaterals (green)
Reconstructible, patent distal SMV
62M
Celiac
CHA
GDA
Spl A
LGA
View from above
Encasing CT & Spl A
Encasing CHA but origin of CT free
No extension to HA bifurcation
LHA
RHA
https://pie.med.utoronto.ca/TVASurg
Tumor encasing celiac T & its branches
CT origin
CT
Intact LHA & RHA
Tumor
Total Pancreatectomy
Reconstruction of CT w saph v. graft
Reconstruction of SMV w LRV graft
(includes splenectomy)
Dividing Celiac T
CHA
PV
SMV
Celiac:
Saph. v graft
PV-SMV: LRV graft
SMA free of tumor
CHA
https://pie.med.utoronto.ca/TVASurg
Dividing CHA proximal to tumor
Dividing MPV proximally & SMV distally
New Celiac T connecting
Aorta - remaining CHA
Long venous gap: graft reconstruction
Splenectomy (no need for spl v. recon)
CHALLENGES IN PREOPERATIVE IMAGING OF PDAC
Imaging Assessment in Post-neoadjuvant Therapy (NAT)
Attenuation: Post Tx necrosis/edema cannot be differentiated from residual tumor tissue
⁇
Tumor size: Tend to be overestimated on CT due to Tx-related necrosis/edema
⁇
Reduction of tumor-vessel contiguity compared with pre-NAT:
most significant predictor of R0 (margin negative) resection
regardless of tumor size reduction or current extent of tumor-vessel contact
✓
(* Do not count perivascular reactive halo without solid tissue)
Response to NAT: Do not classify by NCCN/RECIST criteria
No progression of tumor size & CA 19-9
✓
Do not apply RECIST: Reduction of tumor-vessel contact – R0 resection
Restored calibers of A & V (Sure sign of improved vascular involvement)
Pre NAT
Post NAT
Post NAT Response
Pancreatic body cancer
Encasing Celiac T with severe narrowing
Encasing MPV with severe narrowing
Tumor size reduction, not significant by RECIST
Still encasing Celiac T & its branches
Abutting MPV superiorly
Successful Whipple op. with arterial reconstruction.
RHA from SMA (free of tumor)
Spared origin of CT
Arterial Variant & its relation to tumor may open up or deny the opportunity for surgery
Long segment of CHA encasement (red arrow: normally beyond HA bifurcation) but RHA arising from SMA (yellow) free from the tumor
(click cine)
(click cine)
44F. Lynch syndrome. History of ovarian ca 8 YA
NAT 2 mo FU
NAT 13 mo FU
Whipple procedure
No residual tumor Complete Response
Small but measurable residual tumor on CT
Decreased tumor size with improved MPV narrowing
Long segment MPV narrowing
Bulky exophytic pancreatic tumor extending up to hepatic hilum (Biopsy: Acinar cell ca)
(click cine)
(click cine)
Post NAT
What we measure on imaging may not all reflect a tumor
M61. Outside CT small head PDAC without vascular invasion, underlying IPMN
In 2 months: progression of both primary and now obvious liver metastases
Outside: upfront surgery attempted
Aborted Whipple
Early Small Liver Metastasis
(click cine)
Even in retrospect only 1 lesion visible
🡪 Advocates to incorporate in routine preoperative work-ups
65/M. Potentially resectable pancreatic tail cancer.
Atypical hypervascular metastasis? Hemangioma?
T1
T2
DWI
AP
PVP
DP
Hyperintense
Hypervascular
Persistent enhancement
What next?
Defect on HB phase (not shown)
Challenges for characterizing tiny lesions continue with MRI
Metastatic adenocarcinoma
Prevent futile surgery for metastatic PDAC
CEUS-guided biopsy
Gray-scale occult
Tiny washout lesion
Biopsy targeting the washout lesion
CEUS-guided biopsy: useful tool to solve this preoperative dilemma
2 month FU
68M. US for epigastric pain.
Still isoattenuating
Duct 2 mm
Duct 4 mm
CT: No lesion 🡪 recommend FU
Staging CT (proven PDAC on EUS Bx)
EUS +/- biopsy
MRI (or US)
Abrupt MPD cut-off
CT Isoattenuating PDAC
5-10% [30% in ≤2 cm]
Further Work-up, not FU!
Possible nodule
Obstructing mass
Abrupt MPD cut-off: red flag!
Depending on the level of suspicion
Small head PDAC. No vascular invasion. No metastasis on w/u
Successful Whipple op. after stenting
Celiac trunk - checklist on Sagittal!
Whipple terminates current collaterals from SMA to CT ➤ at risk of hepatic ischemia
Pre stent
Post stent
Anything else to check before Whipple?
Sagittal: Severe Celiac stenosis
Why did they correct this asymptomatic celiac stenosis preoperatively?
Horn your skills with the following quiz-format case illustrations 🡪
*Different surgical or non-surgical options
Neoplasms other than PDAC
Non-neoplastic Mimickers
For Non-PDAC or Indeterminate cases, How should we navigate?
Non-PDAC vs PDAC
Non-surgical vs Surgical
Essential priority of imaging
PDAC or Non-PDAC?
70F. Jaundice
44M. RUQ discomfort. Abnormal LFT.
A
B
Both patients have an Ill-defined hypoattenuation in the pancreatic head.
Biliary dilatation
Mild MPD dilatation
Some halo around the tail
Whipple op.
Focal IgG4-RD (AIP)
70F. Jaundice
A
Non-surgical disease
PDAC or Non-PDAC?
AP
T1
Whipple op: Pancreatic adenoca
44M. RUQ discomfort. Abnormal LFT.
B
IgG4??
2ndary inflammatory stranding in cancer may mimic halo sign!
76M. Pain, weight loss, jaundice. CA 19-9 normal.
55M. Pain, weight loss. CA 19-9 normal.
Cystic change, no BD dilatation
Smooth PD groove widening
Infiltrative isoattenuating head lesion causing biliary obstruction
DWI
Paraduodenal (Groove) Pancreatitis
MRI: AP
Discrete head mass infiltrating into the groove
Pancreatic head ca
Peripancreatic & duodenal invasion
small cystic change
Surgical or Non-surgical?
A
B
Both: Soft tissue lesion in the pancreaticoduodenal groove
What would you recommend first?
T1
AP
DP
T2
DWI
ADC
Response to steroid Tx
Focal IgG4-RD (AIP)
61M. Abdominal pain
Serum IgG4
Surgical or Non-surgical
* IgG4-RD generally show strong restricted diffusion, not useful in DDx from PDAC
Helpful sign
Elevated
58M. Abdominal pain.
AP
PVP
Biopsy 🡪 distal pancreatectomy
Pancreatic adenocarcinoma
What would you recommend first?
Surgical or Non-surgical
(click cine)
(click cine)
Diffuse hypoattenuation following the contour of pancreatic tail
Biopsy
Next step?
PP
PVP
43F. Incidental pancreatic head mass
Surgical or Non-surgical?
Well-circumscribed, heterogeneous, predominantly hypervascular mass
What additional information did you get from MRI?� �Now what would you recommend?
Serous cystadenoma
(Whipple op. based on MR report of neuroendocrine tumor)
T1
AP
3m
T2
T2
Careful look on T2WI is important!
🡪 strong sign of its cystic nature
* On histopathology, septations of SCN are very rich in vascularity, therefore they can mimic hypervascular solid mass.
Hypervascular
✓
✓
67F. Pancreatic mass found on w/u for endometrial ca
7mo later, Jaundice
Whipple op:
Adenoca arising from IPMN
T2
DWI
T1
AP
DP
Reported as serous cystadenoma
🡪 Leading GYN team to hold further w/u & follow this lesion.
Invasive soft tissue
What would YOU recommend?
Surgical or Non-surgical?
MRCP: reminiscent of lobulated microcystic mass
Central solid enhancing area
(click cine)
(click cine)
Keep in mind PDAC is an aggressive malignancy
Any suspicious solid area? 🡪 Prioritize W/U NOT F/U!
52F. Nonspecific abdominal pain
Cystic PNET
AP
DP
CT PVP
T2
Rim-enhancing cystic mass
Your recommendation?
68Gd-DOTATATE PET
AP
DP
DP
61M. Melena. Duodenal mass found on endoscopy
Duodenal Bx
Metastatic RCC
(Right nephrectomy 11 YA)
Liver & pancreas
invading into the duodenum
Your top differential dagnosis?
Empty RT renal fossa
Rt. RCC resected 6 YA
US: New pancreatic masses in 1Yr
Metastatic RCC
Remote RCC & recent LMSa
AP
AP
AP
PVP
Metastatic Leiomyosarcoma
EUS Biopsy
RCC 2.5YA on 6m surveillance
Resectable PDAC
Duct Obstructing mass, new in 6 mo
EUS Biopsy
B.
C.
A.
Three different patients with prior history of RCC
Multiple, new, hypervascular
Hypovascular mass
Pancreatic neoplasms in multidisciplinary settings
Knowledge of surgical relevance as well as imaging spectrum required!
Toronto General Hospital
Thank you!