Staging of Pancreatic Adenocarcinoma by Imaging Studies Jimmie C. Wong, David S.K. Lu  Clinical Gastroenterology and Hepatology  Volume 6, Issue 12, Pages 1301-1308 (December 2008) DOI: 10.1016/j.cgh.2008.09.014 Copyright © 2008 AGA Institute Terms and Conditions

Figure 1 A 70-year-old woman with resectable pancreatic adenocarcinoma. (A) Axial CT image shows a circumscribed hypovascular mass in the head of the pancreas (black arrow). It is separated from the adjacent superior mesenteric vein (white arrow) by a fat plane. (B) Coronal CT image shows the mass (black arrow) to be separate from the superior mesenteric vein (white arrow) and portal vein (arrowhead). The patient underwent successful pancreaticoduodenectomy and is well at the time this article was written (2 years after surgery). Clinical Gastroenterology and Hepatology 2008 6, 1301-1308DOI: (10.1016/j.cgh.2008.09.014) Copyright © 2008 AGA Institute Terms and Conditions

Figure 2 A 41-year-old man with locally advanced pancreatic adenocarcinoma. (A) Axial CT image shows tumor (large arrows) on both sides of the superior mesenteric artery (small arrow). (B) Coronal CT image shows circumferential encasement of the celiac artery (large arrow) and superior mesenteric artery (small arrow). Clinical Gastroenterology and Hepatology 2008 6, 1301-1308DOI: (10.1016/j.cgh.2008.09.014) Copyright © 2008 AGA Institute Terms and Conditions

Figure 3 Coronal reformatted CT image shows constriction of the superior mesenteric vein (arrow). Using the grading system proposed by Lu et al, this finding is considered to be indicative of vascular invasion regardless of the degree of tumor contact between the tumor and the vessel. As an isolated finding, this represents T3 disease, which may be resectable with venous resection and reconstruction. Clinical Gastroenterology and Hepatology 2008 6, 1301-1308DOI: (10.1016/j.cgh.2008.09.014) Copyright © 2008 AGA Institute Terms and Conditions

Figure 4 A 59-year-old man with unresectable pancreatic adenocarcinoma. (A) Axial CT image shows a large hypovascular mass in the tail of the pancreas (arrow). (B) Axial CT image shows a hypovascular mass in the periphery of the right lobe of the liver (arrow), with imaging features similar to the pancreatic mass. Hepatic metastasis was confirmed by percutaneous biopsy. Clinical Gastroenterology and Hepatology 2008 6, 1301-1308DOI: (10.1016/j.cgh.2008.09.014) Copyright © 2008 AGA Institute Terms and Conditions

Figure 5 A 69-year-old woman with unresectable pancreatic adenocarcinoma. Axial CT image shows soft-tissue infiltration of the greater omentum (large arrow), nodular bowel wall thickening (small arrow), and thickening of the parietal peritoneum (arrowhead) consistent with peritoneal carcinomatosis. Clinical Gastroenterology and Hepatology 2008 6, 1301-1308DOI: (10.1016/j.cgh.2008.09.014) Copyright © 2008 AGA Institute Terms and Conditions

Figure 6 A 73-year-old woman with pancreatic adenocarcinoma. Axial CT image shows a hypovascular mass in the pancreatic head (arrow) that abuts the right posterolateral aspect of the superior mesenteric vein, contacting 25% to 50% of the circumference of the vessel, without deformity of the vessel (arrowheads denote zone of contact). The patient was appropriately deemed to have potentially resectable disease, with the understanding that the tumor ultimately may be found to be unresectable. At surgery, tumor invasion of the right posterolateral aspect of the superior mesenteric vein was identified and resection was aborted. Clinical Gastroenterology and Hepatology 2008 6, 1301-1308DOI: (10.1016/j.cgh.2008.09.014) Copyright © 2008 AGA Institute Terms and Conditions