Staging of pancreatic cancer: resectable, borderline resectable, and unresectable disease

Currently Debated Topics on Surgical Treatment of Pancreatic Ductal Adenocarcinoma: A Narrative Review on Surgical Treatment of Borderline Resectable, Locally Advanced, and Synchronous or Metachronous Oligometastatic Tumor

BACKGROUND

Previously considered inoperable patients (borderline resectable, locally advanced, synchronous oligometastatic or metachronous pancreatic adenocarcinoma (PDAC)) are starting to become resectable thanks to advances in chemo/radiotherapy and the reduction in operative mortality.

METHODS

This narrative review presents a chosen literature selection, giving a picture of the current state of treatment of these patients.

RESULTS

Neoadjuvant therapy (NAT) is generally recognized as the treatment of choice before surgery. However, despite the increased efficacy, the best pathological response is still limited to 10.9-27.9% of patients. There are still limited data on the selection of possible NAT responders and how to diagnose non-responders early. Multidetector computed tomography has high sensitivity and low specificity in evaluating resectability after NAT, limiting the resection rate of resectable patients. Ca 19-9 and Positron emission tomography are giving promising results. The prediction of early recurrence after a radical resection of synchronous or metachronous metastatic PDAC, thus identifying patients with poor prognosis and saving them from a resection of little benefit, is still ongoing, although some promising data are available.

CONCLUSION

In conclusion, high-level evidence demonstrating the benefit of the surgical treatment of such patients is still lacking and should not be performed outside of high-volume centers with interdisciplinary teams of surgeons and oncologists.

Exosomes: Emerging Modulators of Pancreatic Cancer Drug Resistance

Pancreatic cancer (PaC) is one of the most lethal tumors worldwide, difficult to diagnose, and with inadequate therapeutical chances. The most used therapy is gemcitabine, alone or in combination with nanoparticle albumin-bound paclitaxel (nab-paclitaxel), and the multidrug FOLFIRINOX. Unfortunately, PaC develops resistance early, thus reducing the already poor life expectancy of patients. The mechanisms responsible for drug resistance are not fully elucidated, and exosomes seem to be actively involved in this phenomenon, thanks to their ability to transfer molecules regulating this process from drug-resistant to drug-sensitive PaC cells. These extracellular vesicles are released by both normal and cancer cells and seem to be essential mediators of intercellular communications, especially in cancer, where they are secreted at very high numbers. This review illustrates the role of exosomes in PaC drug resistance. This manuscript first provides an overview of the pharmacological approaches used in PaC and, in the last part, focuses on the mechanisms exploited by the exosomes released by cancer cells to induce drug resistance.

Home Care Use and Out-of-Hospital Death in Pancreatic Cancer Patients: A Retrospective Cohort Study

Objective: This study aimed to determine the factors associated with usage of home care, including palliative home care, in patients with pancreatic cancer in Ontario. In addition, this study attempted to investigate factors associated with early-onset palliative home care as well as the impact of home care services on survival and out-of-hospital death. Methods: The Ontario Cancer Registry (OCR) was used to identify and capture basic patient/cancer characteristics of index cases of pancreatic cancer diagnosed between April first, 2010 and March 31st, 2016. Patients that received home care were identified using the Home Care Database (HCD) and stratified into general, transition-to-palliative, and early-onset palliative home care. Logistic regressions were used to describe determinants of home care use and determinants of out-of-hospital death. Results: A total of 6888 pancreatic cancer patients met eligibility criteria for this study. A high proportion of patients (83.7%) received home care, including palliative home care (56.8%). In general, older patients (OR = 3.07) and those with more advanced malignancy (OR = 4.98) for stage 4 versus stage 1) had greater odds of receiving palliative home care. Patients receiving home care (P < .01) and those residing in rural regions (P < .01) had greater odds of out-of-hospital death. Conclusion: A large proportion of patients with pancreatic cancer are directed to home care and those that do are more likely to die outside of hospital. Age and stage at diagnosis are significant predictors of home care use. Differences exist in the healthcare experience of patients depending on if they receive home care services and the type of home care.

Imaging Assessment of Pancreatic Cancer Resectability After Neoadjuvant Therapy: AJR Expert Panel Narrative Review

Despite important innovations in the treatment of pancreatic ductal adenocarcinoma (PDAC), PDAC remains a disease with poor prognosis and high mortality. A key area for potential improvement in the management of PDAC, aside from earlier detection in patients with treatable disease, is the improved ability of imaging techniques to differentiate treatment response after neoadjuvant therapy (NAT) from worsening disease. It is well established that current imaging techniques cannot reliably make this distinction. This narrative review provides an update on the imaging assessment of pancreatic cancer resectability after NAT. Current definitions of borderline resectable PDAC, as well as implications for determining likely patient benefit from NAT, are described. Challenges associated with PDAC pathologic evaluation and surgical decision making that are of relevance to radiologists are discussed. Also explored are the specific limitations of imaging in differentiating the response after NAT from stable or worsening disease, including issues relating to protocol optimization, tumor size assessment, vascular assessment, and liver metastasis detection. The roles of MRI as well as PET and/or hybrid imaging are considered. Finally, a short PDAC reporting template is provided for use after NAT. The highlighted methods seek to improve radiologists' assessment of PDAC treatment response after NAT.

Identifying optimal candidates for tumor resection among borderline and locally advanced pancreatic cancer: A population-based predictive model

BACKGROUND

Whether patients with borderline resectable and locally advanced pancreatic cancer (BR/LAPC) benefit from resection of the primary cancer is controversial. We developed a nomogram to screen who would benefit from surgery for the primary tumor.

METHODS

We identified patients from the Surveillance, Epidemiology, and End Results (SEER) database and then divided them into surgical and non-surgical groups. A 1:1 propensity score matching (PSM) was used to mitigate the bias. We hypothesized that patients who underwent surgery would benefit from surgery by having a longer median overall survival (OS) than patients who did not undergo surgery. Univariate and multivariate logistic regression analyses were used to determine the variables affecting surgical outcomes, and a nomogram was created based on the multivariate logistic results. Finally, we verified the discrimination and calibration of the nomogram with receiver operator characteristic (ROC) curve and calibration plots.

RESULTS

A total of 518 pairs of surgical and non-surgical pancreatic cancer patients were matched after PSM. Survival curves showed longer OS in the surgical group than in the non-surgical group, median survival times were 14 months versus 8 months. In the surgical group, 340 (65.63%) patients have a longer survival time than 8 months (beneficial group). Multifactorial logit regression results showed that including age, tumor size, degree of differentiation, and chemotherapy were significant influences on the benefit of surgery for primary tumors and were used as predictors to construct a nomogram. The area under the ROC curve (AUC) reached 0.747 and 0.706 in the training and validation sets.

CONCLUSION

We developed a practical predictive model to support clinical decision-making that can be used to help clinicians determine if there is a benefit to surgical resection of the primary tumor in patients with BR/LAPC.

Nanocarriers targeting the diseases of the pancreas

Diseases of the pancreas include acute and chronic pancreatitis, exocrine pancreatic insufficiency, diabetes and pancreatic cancer. These pathologies can be difficult to treat due to the innate properties of the pancreas, its structure and localization. The need for effective targeting of the pancreatic tissue by means of nanoparticles delivering therapeutics is a major focus area covered and discussed in this review. Most common diseases of the pancreas do not have specific and direct medical treatment option, and existing treatment options are generally aimed at relieving symptoms. Diabetes has different treatment options for different subtypes based on insulin having stability problems and requiring injections reducing patient compliance. Pancreatic cancer progresses silently and can only be diagnosed in advanced stages. Therefore, survival rate of patients is very low. Gemcitabine and FOLFIRINOX treatment regimens, the most commonly used clinical standard treatments, are generally insufficient due to the chemoresistance that develops in cancer cells and also various side effects. Therefore new treatment options for pancreatic cancer are also under focus. Overcoming drug resistance and pancreatic targeting can be achieved with active and passive targeting methods, and a more effective and safer treatment regimen can be provided at lower drug doses. This review covers the current literature and clinical trials concerning pancreatic drug delivery systems in the nanoscale focusing on the challenges and opportunities provided by these smart delivery systems.

Long-term survival after pancreaticoduodenectomy in patients with ductal adenocarcinoma of the pancreatic head

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) has the worst prognosis of all malignant tumors due to unavailable screening methods, late diagnosis with a low proportion of resectable tumors and resistance to systemic treatment. Complete tumor resection remains the cornerstone of modern multimodal strategies aiming at long-term survival. This study was performed to investigate the overall rate of long-term survival (LTS) and its contributing factors.

METHODS

This was a retrospective single-center analysis of consecutive patients undergoing pancreaticoduodenectomy (PD) for PDAC between 2007 and 2014 at the St. Josef Hospital, Ruhr University Bochum, Germany. Clinical and laboratory parameters were assessed and evaluated for prediction of LTS with Cox regression analysis.

RESULTS

The overall rate of LTS after PD for PDAC was 20.4% (34/167). Median survival was 24 months regardless of adjuvant treatment. Carbohydrate antigen 19-9 levels, tumor grade, lymph vessel invasion, perineural invasion and reduced general condition were significantly associated with LTS in univariate analysis (P < 0.05). Serum levels of carbohydrate antigen 19-9, American Joint Committee on Cancer stage, tumor grade, abdominal pain, male, exocrine pancreatic insufficiency and duration of postoperative hospital stay were independent predictors of cancer survival in multivariable analysis.

CONCLUSIONS

Cancer related characteristics are associated with LTS in multimodally treated patients after curative PDAC surgery.

European Cancer Organisation Essential Requirements for Quality Cancer Care (ERQCC): Pancreatic Cancer

European Cancer Organisation Essential Requirements for Quality Cancer Care (ERQCC) are written by experts representing all disciplines involved in cancer care in Europe. They give patients, health professionals, managers and policymakers a guide to essential care throughout the patient journey. Pancreatic cancer is an increasing cause of cancer mortality and has wide variation in treatment and care in Europe. It is a major healthcare burden and has complex diagnosis and treatment challenges. Care must be carried out only in pancreatic cancer units or centres that have a core multidisciplinary team (MDT) and an extended team of health professionals detailed here. Such units are far from universal in European countries. To meet European aspirations for comprehensive cancer control, healthcare organisations must consider the requirements in this paper, paying particular attention to multidisciplinarity and patient-centred pathways from diagnosis, to treatment, to survivorship.

Distal Pancreatectomy with Celiac Axis Resection: Systematic Review and Meta-Analysis

Simple Summary

The literature is conflicting regarding the feasibility and survival outcomes of distal pancreatectomy with celiac axis resection (DP-CAR), although this procedure, in selected cases, represents the only therapeutical option for patients with locally advanced pancreatic cancer. The available studies often include small surgical populations, and there are important variations in the inclusion criteria and pre- and post-operative treatment. The purpose of this study was to provide an overview of the literature of the last 15 years, to evaluate the efficacy and the clinical safety of this procedure. This could help physicians in the choice of a multidisciplinary targeted therapeutical plan for patients. The combination of neoadjuvant chemo/radiochemotherapy and demolitive surgeries such as DP-CAR could have a role in changing the survival outcomes of patients with locally advanced pancreatic adenocarcinoma.

Abstract

Background: Major vascular invasion represents one of the most frequent reasons to consider pancreatic adenocarcinomas unresectable, although in the last decades, demolitive surgeries such as distal pancreatectomy with celiac axis resection (DP-CAR) have become a therapeutical option. Methods: A meta-analysis of studies comparing DP-CAR and standard DP in patients with pancreatic adenocarcinoma was conducted. Moreover, a systematic review of studies analyzing oncological, postoperative and survival outcomes of DP-CAR was conducted. Results: Twenty-four articles were selected for the systematic review, whereas eleven were selected for the meta-analysis, for a total of 1077 patients. Survival outcomes between the two groups were similar in terms of 1 year overall survival (OS) (odds ratio (OR) 0.67, 95% confidence interval (CI) 0.34 to 1.31, p = 0.24). Patients who received DP-CAR were more likely to have T4 tumors (OR 28.45, 95% CI 10.46 to 77.37, p < 0.00001) and positive margins (R+) (OR 2.28, 95% CI 1.24 to 4.17, p = 0.008). Overall complications (OR, 1.72, 95% CI, 1.15 to 2.58, p = 0.008) were more frequent in the DP-CAR group, whereas rates of pancreatic fistula (OR 1.16, 95% CI 0.81 to 1.65, p = 0.41) were similar. Conclusions: DP-CAR was not associated with higher mortality compared to standard DP; however, overall morbidity was higher. Celiac axis involvement should no longer be considered a strict contraindication to surgery in patients with locally advanced pancreatic adenocarcinoma. Considering the different baseline tumor characteristics, DP-CAR may need to be compared with palliative therapies instead of standard DP.

CT Simplified Radiomic Approach to Assess the Metastatic Ductal Adenocarcinoma of the Pancreas

The aim of this study was to perform a simplified radiomic analysis of pancreatic ductal adenocarcinoma based on qualitative and quantitative tumor features and to compare the results between metastatic and non-metastatic patients. A search of our radiological, surgical, and pathological databases identified 1218 patients with a newly diagnosed pancreatic ductal adenocarcinoma who were referred to our Institution between January 2014 and December 2018. Computed Tomography (CT) examinations were reviewed analyzing qualitative and quantitative features. Two hundred eighty-eight patients fulfilled the inclusion criteria and were included in this study. Overall, metastases were present at diagnosis in 86/288 patients, while no metastases were identified in 202/288 patients. Ill-defined margins and a hypodense appearance on portal-phase images were significantly more common among patients with metastases compared to non-metastatic patients (p < 0.05). Metastatic tumors showed a significantly larger size and significantly lower arterial index, perfusion index, and permeability index compared to non-metastatic tumors (p < 0.05). In the management of pancreatic ductal adenocarcinoma, early detection and correct staging are key elements. The study of computerized tomography characteristics of pancreatic ductal adenocarcinoma showed substantial differences, both qualitative and quantitative, between metastatic and non-metastatic disease.

The Latest Advancement in Pancreatic Ductal Adenocarcinoma Therapy: A Review Article for the Latest Guidelines and Novel Therapies

Pancreatic ductal adenocarcinoma (PDAC) is the fourth leading cause of cancer deaths in the US, and it is expected to be the second leading cause of cancer deaths by 2030. The lack of effective early screening tests and alarming symptoms with early undetectable micro-metastasis at the time of presentation play a vital role in the high death rate from pancreatic cancer. In addition to this, the low mutation burden in pancreatic cancer, low immunological profile, dense tumorigenesis stroma, and decreased tumor sensitivity to cytotoxic drugs contribute to the low survival rates in PDAC patients. Despite breakthroughs in chemotherapeutic and immunotherapeutic drugs, pancreatic cancer remains one of the solid tumors that exhibit meager curative rates. Therefore, researchers must dedicate more effort to understanding the pathology and immunological behavior of PDAC, in addition to properly utilizing more advanced screening modalities and new therapeutic agents. In our review, we focus mainly on the latest updates from clinical guidelines and novel therapies that have been recently investigated or are under investigation for PDAC. We used PubMed as a search tool for finding original research articles addressing the latest developments in diagnosing and treating PDAC. Additionally, we also used the clinical trials published on clinicaltrialsgov as sources for our data.

A nomogram of preoperative predictors for occult metastasis in patients with PDAC during laparoscopic exploration

Background

Surgical resection is the only potentially curative treatment for pancreatic ductal adenocarcinoma (PDAC). However, most of patients lose the chance of surgery due to the unresectable disease at the time of diagnosis. Despite the improvement of radiological imaging, a portion of patients intended for radical resection were proven to be unresectable at surgical exploration due to occult metastasis.

Methods

Patients who were aimed to undergo radical pancreatectomy for PDAC from 2010 to 2019 were reviewed retrospectively. All patients included underwent diagnostic laparoscopic exploration. Patients were divided into two groups depending on whether distant metastasis were encountered during exploration. Univariate and multivariate logistic regression analyses were used to identify risk factors for occult metastasis. A nomogram to predict occult metastasis of PDAC on exploration was developed and evaluated.

Results

A total of 273 patients who underwent diagnostic laparoscopic exploration were included in this study. Nineteen (7.0%) patients were found with distant metastasis during exploration. Multivariate logistic regression analysis showed that ALT>40U/L, CA19-9, CA125 and regional nodes enlargement were independent predictors for occult metastasis. Incorporating these four factors, the nomogram achieved concordance index of 0.799, with a well-fitted calibration curve.

Conclusions

Occult metastasis is not unusual during surgical exploration in patients with resectable or borderline resectable PDAC. The nomogram could achieve a personal prediction of unexpected distant metastasis on exploration. It may help to sift through patients with PDAC who would benefit from laparoscopic exploration.

Targets (Metabolic Mediators) of Therapeutic Importance in Pancreatic Ductal Adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC), an extremely aggressive invasive cancer, is the fourth most common cause of cancer-related death in the United States. The higher mortality in PDAC is often attributed to the inability to detect it until it has reached advanced stages. The major challenge in tackling PDAC is due to its elusive pathology, minimal effectiveness, and resistance to existing therapeutics. The aggressiveness of PDAC is due to the capacity of tumor cells to alter their metabolism, utilize the diverse available fuel sources to adapt and grow in a hypoxic and harsh environment. Therapeutic resistance is due to the presence of thick stroma with poor angiogenesis, thus making drug delivery to tumor cells difficult. Investigating the metabolic mediators and enzymes involved in metabolic reprogramming may lead to the identification of novel therapeutic targets. The metabolic mediators of glucose, glutamine, lipids, nucleotides, amino acids and mitochondrial metabolism have emerged as novel therapeutic targets. Additionally, the role of autophagy, macropinocytosis, lysosomal transport, recycling, amino acid transport, lipid transport, and the role of reactive oxygen species has also been discussed. The role of various pro-inflammatory cytokines and immune cells in the pathogenesis of PDAC and the metabolites involved in the signaling pathways as therapeutic targets have been previously discussed. This review focuses on the therapeutic potential of metabolic mediators in PDAC along with stemness due to metabolic alterations and their therapeutic importance.

B lymphocytes contribute to stromal reaction in pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) is characterized by a prominent stromal reaction that has been variably implicated in both tumor growth and tumor suppression. B-lymphocytes have been recently implicated in PDAC progression but their contribution to the characteristic stromal desmoplasia has never been assessed before. In the present work, we aimed to verify whether B-lymphocytes contribute to stromal cell activation in PDAC. CD19⁺ B-lymphocytes purified from peripheral blood of patients with PDAC were cultivated in the presence of human pancreatic fibroblasts and cancer-associated fibroblasts. Released pro-fibrotic soluble factors and collagen production were assessed by ELISA and Luminex assays. Quantitative RT-PCR was used to assess fibroblast activation in the presence of B cells. The expression of selected pro-fibrotic and inflammatory molecules was confirmed on PDAC tissue sections by multi-color immunofluorescence studies. We herein demonstrate that B-cells from PDAC patients (i) produce the pro-fibrotic molecule PDGF-B and stimulate collagen production by fibroblasts; (ii) express enzymes implicated in extracellular matrix remodeling including LOXL2; and (iii) produce the chemotactic factors CCL-4, CCL-5, and CCL-11. In addition we demonstrate that circulating plasmablasts are expanded in the peripheral blood of patients with PDAC, stimulate collagen production by fibroblasts, and infiltrate pancreatic lesions. Our results indicate that PDAC is characterized by perturbations of the B-cell compartment with expansion of B-lymphocyte subsets that directly contribute to the stromal reaction observed at disease site. These findings provide an additional rationale for modulating B-cell activity in patients with pancreatic cancer.

Role of yttrium-90 selective internal radiation therapy in the treatment of liver-dominant metastatic colorectal cancer: an evidence-based expert consensus algorithm

Surgical resection of colorectal liver metastases is associated with greater survival compared with non-surgical treatment, and a meaningful possibility of cure. However, the majority of patients are not eligible for resection and may require other non-surgical interventions, such as liver-directed therapies, to be converted to surgical eligibility. Given the number of available therapies, a general framework is needed that outlines the specific roles of chemotherapy, surgery, and locoregional treatments [including selective internal radiation therapy (SIRT) with Y-90 microspheres]. Using a data-driven, modified Delphi process, an expert panel of surgical oncologists, transplant surgeons, and hepatopancreatobiliary (HPB) surgeons convened to create a comprehensive, evidence-based treatment algorithm that includes appropriate treatment options for patients stratified by their eligibility for surgical treatment. The group coined a novel, more inclusive phrase for targeted locoregional tumor treatment (a blanket term for resection, ablation, and other emerging locoregional treatments): local parenchymal tumor destruction therapy. The expert panel proposed new nomenclature for 3 distinct disease categories of liver-dominant metastatic colorectal cancer that is consistent with other tumor types: (I) surgically treatable (resectable); (II) surgically untreatable (borderline resectable); (III) advanced surgically untreatable (unresectable) disease. Patients may present at any point in the algorithm and move between categories depending on their response to therapy. The broad intent of therapy is to transition patients toward individualized treatments where possible, given the survival advantage that resection offers in the context of a comprehensive treatment plan. This article reviews what is known about the role of SIRT with Y-90 as neoadjuvant, definitive, or palliative therapy in these different clinical situations and provides insight into when treatment with SIRT with Y-90 may be appropriate and useful, organized into distinct treatment algorithm steps.

White paper on pancreatic ductal adenocarcinoma from society of abdominal radiology's disease-focused panel for pancreatic ductal adenocarcinoma: Part I, AJCC staging system, NCCN guidelines, and borderline resectable disease

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive gastrointestinal malignancy with a poor 5-year survival rate. Accurate staging of PDAC is an important initial step in the development of a stage-specific treatment plan. Different staging systems/consensus statements convened by different societies and academic practices are currently used. The most recent version of the American Joint Committee on Cancer (AJCC) tumor/node/metastases (TNM) staging system for PDAC has shifted its focus from guiding management to assessing prognosis. In order to preoperatively define the resectability of PDAC and to guide management, additional classification systems have been developed. The National Comprehensive Cancer Network (NCCN) guidelines, one of the most commonly used systems, provide recommendations on the management and the determination of resectability for PDAC. The NCCN divides PDAC into three categories of resectability based on tumor-vessel relationship: 'resectable,' 'borderline resectable,' and 'unresectable'. Among these, the borderline disease category is of special interest given its evolution over time and the resulting variations in the definition and the associated recommendations for management between different societies. It is important to be familiar with the evolving criteria, and treatment and follow-up recommendations for PDAC. In this article, the most current AJCC staging (8th edition), NCCN guidelines (version 2.2019-April 9, 2019), and challenges and controversies in borderline resectable PDAC are reviewed.

Quantitative dynamic contrast-enhanced MR imaging for the preliminary prediction of the response to gemcitabine-based chemotherapy in advanced pancreatic ductal carcinoma

PURPOSE

To investigate the role of the quantitative parameters of dynamic contrast-enhanced MR imaging (DCE-MRI) in the prediction of the response to chemotherapy in pancreatic ductal carcinoma (PDC).

METHOD

Forty patients with histologically confirmed PDC who underwent quantitative DCE-MRI were retrospectively analyzed. All patients were divided into groups of responders and nonresponders. DCE-MRI parameters, including the volume transfer constant (K^trans), the extracellular extravascular volume fraction (v_e), the rate constant (k_ep) and the initial area under the concentration curve in 60 s (iAUC60), were measured and compared. DCE-MRI parameters were obtained from different ROIs.

RESULTS

The values of K^trans in responders with peripheral, whole tumor slice, and adjacent non-tumorous region ROIs were significantly higher than those in nonresponders (P = 0.015, 0.043, and 0.025, respectively). Responders showed a significantly higher k_ep with peripheral area ROI compared with nonresponders (P =  0.013). Ve and iAUC60 with all ROIs were not significantly different between responders and nonresponders (P = 0.140-0.968). Kep with periphery ROI showed the highest area under the ROC curve (AUC) of 0.806, but there were no statistical differences when compared with values of K^trans.There were statistically significant differences for DCE-MRI parameters among four ROIs (all P <  0.05). All parameters showed good to excellent intra and interobserver agreement.

CONCLUSIONS

Quantitative parameters derived from DCE-MRI might be a potential predictor of response to gemcitabine in patients with PDC. Perfusion parameters were diverse depending on the location of the ROI on different tumoral and peritumoral areas.

MRI evaluation of pancreatic ductal adenocarcinoma: diagnosis, mimics, and staging

The radiologist's role in the evaluation of pancreatic ductal adenocarcinoma remains critical in the management of this deadly disease. Imaging plays a vital role in the diagnosis and staging of pancreatic cancer. Although CT is more commonly used for staging pancreatic cancer, MR is increasingly playing an important role in this regard. In our institution, all pancreatic malignancies undergo staging with MRI. In this pictoral essay, we illustrate the MR imaging features of pancreatic ductal adenocarcinoma and its mimics, and we also discuss pearls and pitfalls in MR staging of pancreatic carcinoma.