Multidetector Computed Tomography During Combined Therapy for Pancreatic Adenocarcinoma  Desiree E. Morgan, John C. Texada, Cheri L. Canon, Mark E. Lockhart, James A. Posey, Selwyn M. Vickers  Clinical Gastroenterology and Hepatology  Volume 6, Issue 8, Pages 842-848.e3 (August 2008) DOI: 10.1016/j.cgh.2008.03.023 Copyright © 2008 AGA Institute Terms and Conditions

Figure 1 A 53-year-old man with biopsy-proven locally advanced pancreatic adenocarcinoma. (A) A 2.5-mm pancreatic parenchymal phase axial MDCT image through the superior pancreatic head shows a focal 1.2-cm hypoattenuating mass (arrow) adjacent to the plastic biliary stent. Note soft tissue extending beyond pancreatic margin toward aorta. (B) Slightly inferior to the mass, the extrapancreatic extension of tumor focally narrows the superior mesenteric artery (arrow). (C) Three-dimensional CT angiogram shows the focal narrowing of proximal superior mesenteric artery indicating locally advanced (nonresectable) tumor at present. Clinical Gastroenterology and Hepatology 2008 6, 842-848.e3DOI: (10.1016/j.cgh.2008.03.023) Copyright © 2008 AGA Institute Terms and Conditions

Figure 2 A 58-year-old woman who presented with obstructive jaundice and biopsy-proven pancreatic ductal adenocarcinoma successfully downstaged by neoadjuvant chemoradiation therapy. (A) A 5-mm portal venous phase axial MDCT image shows abnormal narrowing of the portal confluence (arrow) by the superior margin of a pancreatic head mass. (B) Six months after combined chemoradiation, the portal confluence is patent and has a normal caliber (arrow). The mass in the head of the pancreas decreased (not shown), but the mass still was deemed nonresectable. Note the metallic biliary stent placed for long-term palliation. (C) After 4 additional months of chemotherapy, portal venous phase 5-mm axial MDCT image reveals the portal confluence appearing normal (arrow). (D) Portal venous phase 5-mm multiplanar reformatted coronal image reveals the normal portal confluence and no residual mass discernible along the course of the metallic stent in the pancreatic head (arrow). (E) Three-dimensional CT venogram image shows normal contour and caliber of the entire portomesenteric venous system, with no evidence of vascular involvement by tumor. The patient went to surgery after the successful downstaging and had no residual tumor identified in the specimen. Clinical Gastroenterology and Hepatology 2008 6, 842-848.e3DOI: (10.1016/j.cgh.2008.03.023) Copyright © 2008 AGA Institute Terms and Conditions

Figure 3 A 76-year-old woman with long-term partial response/stable disease during chemoradiation followed by chemotherapy alone. (A) Pancreatic parenchymal phase 2.5-mm MDCT axial image shows a 4.2 × 3.6 cm heterogeneous mass replacing the pancreatic head, deemed unresectable because of superior mesenteric vein occlusion (not shown). (B and C) Twenty weeks later after initiation of chemoradiotherapy, follow-up pancreatic parenchymal phase 2.5-mm axial MDCT images reveal a marked decrease in the size of the mass (B, arrow), now measuring 1.9 × 1.2 cm with persistent superior mesenteric vein occlusion and collaterals (C, arrows). Erosion of the mass into the duodenal wall (C, curved arrow) is present. (D) Restaging MDCT 1 year later reveals progression of local and distant disease. *There is enlargement of the primary tumor with further extension into the duodenum, involvement of vascular structures, as well as new liver metastasis (not shown). The duodenal involvement necessitated palliative gastrojejunostomy and a PEG tube placement. This patient underwent 17 cycles of chemotherapy and died 18 months after the original diagnosis. Clinical Gastroenterology and Hepatology 2008 6, 842-848.e3DOI: (10.1016/j.cgh.2008.03.023) Copyright © 2008 AGA Institute Terms and Conditions

Figure 4 A 64-year-old woman with good local response but development of distant (liver) metastases at 6 months during maintenance chemotherapy after chemoradiation. (A) Pancreatic parenchymal phase 2.5-mm MDCT axial image reveals a 3.5 × 3.3 cm mass involving the superior mesenteric artery (arrow) and obliterating the superior mesenteric vein. (B) Twelve weeks after chemoradiation initiation, portal venous phase 5-mm MDCT axial image shows a decrease in size of the pancreatic head mass (arrow), now 1.9 × 1.8 cm with superior mesenteric artery and superior mesenteric vein abutment of less than 90° each. (C and D) Twelve additional weeks later, the pancreatic mass decreased to 1.2 × 1.5 cm (C, arrow), however, (D) new liver lesions developed, indicating good local control but distant tumor progression. Clinical Gastroenterology and Hepatology 2008 6, 842-848.e3DOI: (10.1016/j.cgh.2008.03.023) Copyright © 2008 AGA Institute Terms and Conditions

Figure 5 A 58-year-old woman with extensive acute portal vein thrombosis 1 month after starting chemoradiation. (A) Pretreatment portal venous phase 5-mm axial MDCT image shows patent splenoportal confluence (arrow). (B) Four weeks later during therapy, the patient complained of abdominal pain and distension. MDCT image reveals a new large thrombus within the main portal vein (arrow) and altered liver enhancement caused by the nearly occlusive thrombus; the linear demarcation also suggests alteration owing to local radiation field. Note also the bowel wall and gallbladder wall edema. Clinical Gastroenterology and Hepatology 2008 6, 842-848.e3DOI: (10.1016/j.cgh.2008.03.023) Copyright © 2008 AGA Institute Terms and Conditions

Supplementary Figure 1 A 57-year-old woman with locally advanced pancreatic ductal adenocarcinoma downstaged by neoadjuvant chemoradiation therapy. (A and B) Initial pancreatic parenchymal phase 2.5-mm MDCT axial images show a poorly defined hypodense mass in the head of the pancreas, abutting the superior mesenteric vein in the uncinate process (B, arrowheads), and extending superiorly to the portal confluence where there is a straight right margin of the vein (A, arrow), indicating vessel involvement. (C and D) Fourteen weeks later, the caliber of the superior mesenteric and portal veins is increased with normal convex margin (C, arrow) and (D) improved fat plane surrounding the vessel inferiorly. The patient underwent Whipple procedure with R0 resection 1 week later. Clinical Gastroenterology and Hepatology 2008 6, 842-848.e3DOI: (10.1016/j.cgh.2008.03.023) Copyright © 2008 AGA Institute Terms and Conditions

Supplementary Figure 2 A 68-year-old man with peripancreatic inflammatory changes after chemoradiation. (A) Pancreatic parenchymal phase 2.5-mm MDCT axial image shows an ill-defined mass (arrow) in the pancreatic head surrounding the metallic distal common bile duct stent, with abutment of the common hepatic artery (open arrowhead). (B and C) Six weeks after initiation of therapy, there is lower attenuation within the mass as well as inflammatory stranding surrounding the pancreatic head (C, arrowheads). Note inflammatory fluid adjacent to the gallbladder and duodenum, with moderate irregularity of the duodenal mucosa (B, curved arrow). Clinical Gastroenterology and Hepatology 2008 6, 842-848.e3DOI: (10.1016/j.cgh.2008.03.023) Copyright © 2008 AGA Institute Terms and Conditions

Supplementary Figure 3 A 76-year-old woman with superior mesenteric vein thrombosis during chemoradiation. (A) Pretreatment portal venous phase 5-mm axial MDCT image shows a hypovascular mass in the inferior aspect of the pancreatic body (arrow). Note marked main pancreatic duct dilation and pre-existing gland atrophy. (B) Ten weeks after chemoradiation, portal venous phase 5-mm axial MDCT image at the same level shows increased soft-tissue stranding surrounding the superior mesenteric artery and partial thrombosis of the superior mesenteric vein (arrow) by direct tumor extension. Clinical Gastroenterology and Hepatology 2008 6, 842-848.e3DOI: (10.1016/j.cgh.2008.03.023) Copyright © 2008 AGA Institute Terms and Conditions

Supplementary Figure 4 A 71-year-old man with pancreatic gland atrophy after chemoradiation. (A) Pretreatment pancreatic parenchymal phase 2.5-mm MDCT axial image reveals normal thickness tissue in the pancreatic body and tail. The locally advanced tumor (not shown) was located more inferiorly. Note metallic biliary stent (arrow) in place. (B) Eight weeks after starting chemoradiation, there is extensive interval pancreatic gland atrophy. This patient went on to successful Whipple with R0 margin 6 weeks later. Clinical Gastroenterology and Hepatology 2008 6, 842-848.e3DOI: (10.1016/j.cgh.2008.03.023) Copyright © 2008 AGA Institute Terms and Conditions