In general, MRI offers no significant advantages over CT because of a low signal-to-noise ratio,

motion artifacts, lack of bowel opacification, and low spatial resolution. MRI can be considered an

alternative preoperative staging examination in patients with allergies to iodinated contrast agents and

in patients with renal insufficiency. On MRI, a typical pancreatic adenocarcinoma appears hypointense

on T1-weighted, unenhanced images, and has a variable appearance on T2-weighted sequences. The T2

signal of the tumor is often dependent on the amount of desmoplastic response associated with the

tumor. On dynamic imaging following a gadolinium contrast injection, an adenocarcinoma enhances

relatively less than the background pancreatic parenchyma in the early phase and then reveals

progressive enhancement in the subsequent phases. Magnetic resonance imaging with MRCP is currently

indicated for noninvasive diagnostic imaging to evaluate the biliary and pancreatic ducts and may be

the optimal method to survey patients with IPMN and the pancreatic remnant after surgery.

Traditionally, the next step in the evaluation of the jaundiced patient has been cholangiography,

either by the endoscopic or by the percutaneous route. If the endoscopic approach is used, the

duodenum and ampulla can be visualized and biopsy specimens obtained if necessary. In addition, ERCP

allows for direct imaging of the pancreatic duct. The sensitivity of ERCP for the diagnosis of pancreatic

cancer approaches 90%. The finding of a long, irregular stricture in an otherwise normal pancreatic duct

is highly suggestive of a pancreatic cancer (Fig. 55-4). Often, the pancreatic duct will be obstructed with

no distal filling. Although ERCP is reliable in confirming the presence of a clinically suspected

pancreatic cancer, it should not be used routinely. Diagnostic ERCP should be reserved for patients with

presumed pancreatic cancer and obstructive jaundice in whom no mass is demonstrated on CT,

symptomatic but nonjaundiced patients without an obvious pancreatic mass, and patients with chronic

pancreatitis who develop jaundice.

EUS is a minimally invasive technique in which a high-frequency ultrasonographic probe is placed

into the stomach and duodenum endoscopically and the pancreas is imaged. Tumors appear as

hypoechoic areas in the pancreatic substance (Fig. 55-5). The strengths of EUS techniques for pancreatic

cancer are the clarification of small lesions (<2 cm) when CT findings are questionable or negative,

detection of malignant lymphadenopathy, detection of vascular involvement, and the ability to perform

EUS-guided FNA for definitive diagnosis and staging. EUS is not effective in assessing metastatic disease

to the liver. In patients for whom a tissue diagnosis is required (poor operative candidates or

undergoing neoadjuvant therapy), EUS-guided FNA has been used to acquire tissue samples for cytologic

analysis. This approach may avoid the risks of tumor seeding from percutaneous biopsy. The accuracy of

EUS without FNA averages 85% for determining T-stage and 70% for determining N-stage diseases. The

combination of EUS and FNA has a sensitivity of 93% and a specificity of 100% for T stage and an

accuracy of 88% for N stage.13 At the time of diagnosis, only 10% of patients have tumors confined to

the pancreas, 40% have locally advanced disease, and more than 50% have distant spread.

Figure 55-4. Endoscopic retrograde cholangiopancreatography in a patient with adenocarcinoma of the pancreas demonstrates a

stricture of both the distal common bile duct and the pancreatic duct (arrow).

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Figure 55-5. Endoscopic ultrasonogram of a 2.2-cm mass in the head of the pancreas. The transducer tip is located in the

duodenum. The dilated common bile duct and gallbladder (GB) can be seen at the top of the image. The pancreatic duct (PD) is

also dilated. The mass involves the portal vein (PV).

Percutaneous FNA of pancreatic masses is helpful in selected patients. The technique is safe and

generally reliable but is of limited use in patients in whom surgical exploration for attempted resection

or palliation is planned. The reasons for not using FNA or percutaneous biopsy in potentially resectable

lesions are twofold. First, even after repeated sampling, a negative result does not exclude malignancy;

in fact, it is the smaller and likely more curable tumors that are likely to be missed by the needle. The

second concern is the potential for seeding of the tumor, either along the needle tract or with

intraperitoneal spread. Percutaneous biopsy is primarily indicated in patients with unresectable cancers

based on preoperative staging to direct palliative chemoradiation therapy or in patients with cancer in

the head of the pancreas in whom neoadjuvant protocols are being considered. Currently, however, EUS

is the preferred technique when possible in either situation.

PREOPERATIVE STAGING

The goal of preoperative staging of pancreatic cancer is to determine the feasibility of surgery and the

optimal treatment for each individual patient. Specific anatomy-based CT criteria can stratify patients

into four distinct groups (Table 55-9): (1) Resectable, (2) Borderline, (3) Locally advanced, or (4)

Metastatic. The extent of further staging to be performed depends on the individual patient and the

surgeon’s preference. Historically, patients with resectable CT criteria were offered operation as the

first modality of therapy followed by adjuvant chemotherapy or chemoradiotherapy. Recent advances in

the efficacy of systemic chemotherapy agents have further supported the hypothetical benefits of

preoperative neoadjuvant chemotherapy even for resectable tumors. Patients with borderline or locally

advanced pancreatic cancer based on CT criteria should receive preoperative chemotherapy or

chemoradiotherapy. Ideally, patients in these high-risk categories of disease should be offered

enrollment in clinical trials investigating novel treatment agents. Algorithm 55-2 outlines an algorithm

for approaching patients with pancreatic cancer after complete staging and determination of

resectability based on local vascular involvement according to CT findings.

STAGING LAPAROSCOPY

The use of diagnostic laparoscopy in pancreatic cancer remains controversial. Proponents believe that

laparoscopy can identify a substantial number of unresectable patients with advanced disease and,

therefore, should be uniformly applied to all patients with potentially resectable tumors.14 On the other

hand, opponents believe that the inherent cost of such a practice far outweighs the benefit to the small

number of patients in whom diagnostic laparoscopy is useful. The liver and peritoneum are the most

common sites of distant spread of pancreatic carcinoma. Once distant metastases have developed,

survival is so limited that a conservative approach is usually indicated. Liver metastases larger than 1

cm in diameter can usually be detected by CT, but approximately 30% of these metastases are smaller

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