Current status of imaging in pancreatic diseases

Clinical value of contrast-enhanced ultrasound enhancement patterns for differentiating solid pancreatic lesions

OBJECTIVES

To explore the diagnostic value of contrast-enhanced ultrasound (CEUS) enhancement patterns for differentiating solid pancreatic lesions and compare them with conventional ultrasound (US) and enhanced computed tomography (CT).

METHODS

A total of 210 patients with solid pancreatic lesions who had definite pathological or clinical diagnoses were enrolled. Six CEUS enhancement patterns were proposed for solid pancreatic lesions. Two US doctors blindly observed the CEUS patterns of solid pancreatic lesions and the interrater agreement was analyzed. The diagnostic value of CEUS enhancement patterns for differentiating solid pancreatic lesions was evaluated, and the diagnostic accuracy was compared with that of US and enhanced CT.

RESULTS

There was good concordance for six CEUS enhancement patterns of solid pancreatic lesions between the two doctors, with a kappa value of 0.767. Hypo-enhancement (Hypo-E) or centripetal enhancement (Centri-E) as the diagnostic criteria for pancreatic carcinoma had an accuracy of 87.62%; hyper-enhancement (Hyper-E) for neuroendocrine tumors had an accuracy of 92.89%; capsular enhancement with low or uneven enhancement inside the tumor (Capsular-E) for solid pseudopapillary tumors had an accuracy of 97.63%; and iso-enhancement (Iso-E) or iso-enhancement with focal hypo-enhancement (Iso-fhypo-E) for focal pancreatitis had an accuracy of 89.10%. The diagnostic accuracy of CEUS was significantly different from that of US for 210 cases of solid pancreatic lesions (p < 0.05) and was not significantly different from that of enhanced CT for 146 cases of solid pancreatic lesions (p > 0.05).

CONCLUSIONS

The different enhancement patterns of solid pancreatic lesions on CEUS were clinically valuable for differentiation.

KEY POINTS

• Six CEUS enhancement (E) patterns, including Hyper-E, Iso-E, Iso-fhypo-E, Hypo-E, Centri-E, and Capsular-E, are proposed for the characterization of solid pancreatic lesions. • Using Hypo-E or Centri-E as the diagnostic criteria for pancreatic carcinoma, Hyper-E for neuroendocrine tumors, Capsular-E for solid pseudopapillary tumors, and Iso-E or Iso-fhypo-E for focal pancreatitis on CEUS had relatively high diagnostic accuracy. • The diagnostic accuracy of CEUS was greatly increased over that of US and was not different from that of enhanced CT.

The Role of Positron Emission Tomography in Clinical Management of Intraductal Papillary Mucinous Neoplasms of the Pancreas

Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas represent a heterogeneous group of tumors, increasingly diagnosed in clinical practice. An early differential diagnosis between malignant and benign lesions is crucial to patient management and the choice of surgery or observation. The therapeutic approach is currently based on a patient’s clinical, biochemical, and morphological characteristics. The latest published International Consensus Guidelines (ICG) make no mention of the role of metabolic assessments of IPMNs. The aim of this study was to review the current literature, examining the role of 18-fluorodeoxyglucose (FDG) positron emission tomography (PET) in IPMN management. An extensive literature review was conducted according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and 10 articles were analyzed in detail, focusing on the value of PET as opposed to other standard imaging criteria. Data were retrieved on 419 patients. The 18-FDG-PET proved more sensitive, specific, and accurate than the ICG criteria in detecting malignant IPMNs (reaching 80%, 95%, and 87% vs. 67%, 58%, and 63%, respectively). Metabolic assessments may be used as an additional tool for the appropriate management of patients with doubtful imaging findings.

Pancreatic intraductal papillary mucinous neoplasm--where is the challenge?

Cystic lesions of the pancreas are increasingly recognized due to the widespread use of modern abdominal imaging technologies. The majority of these lesions display pseudocysts and mucinous cystic neoplasms. In contrast to pseudocysts, it is well established that mucinous cystic neoplasms of the pancreas exhibit a significant potential for malignant transformation over time. Among mucinous cystic tumors, the most frequently observed entity is pancreatic intraductal papillary mucinous neoplasm (IPMN). IPMNs are characterized by cystic dilation of pancreatic ducts and the production of mucus and by an adenoma-carcinoma sequence eventually culminating in invasive carcinoma in some patients. Due to the high risk of harboring malignancy, there is international consensus that IPMNs with involvement of the main pancreatic duct should be recommended for surgical resection. To date, the indication for surgery of branch-duct IPMNs is controversially discussed because of the overall lower risk of malignant transformation compared to main-duct IPMNs. Particularly for small and asymptomatic side-branch IPMNs, the indication for surgical resection remains challenging. In addition to the international consensus guidelines, a number of potential preoperative features predicting malignant transformation have been discussed recently. Moreover, novel surgical pancreatic parenchyma-sparing techniques such as enucleations or segmental pancreatic resections have been reported in order to treat IPMNs. The present article aims to demonstrate the current scientific knowledge in this field and to highlight the current controversy.

Association of acute pancreatitis or high level of serum pancreatic enzymes in patients with acute spinal cord injury: a prospective study

BACKGROUND

Spinal cord injuries has increased together with urban violence and show a high rates of incidence. Besides the onus to patient and society, it can also cause other serious complications to victims. Acute pancreatitis has an important impact on this disease and has been underdiagnosed in several patients.

OBJECTIVES

The aim of this study was investigate the association of acute pancreatitis in acute spinal cord injuries. The secondary aim was to propose an investigation protocol to early diagnose and prevent it.

METHODS

A prospective observational study was conducted in 78 patients who presented acute spinal cord injury (SCI) at our emergency department, confirmed by clinical and imaging examination, in according to the American Spinal Injury Association (ASIA) Classification. Exclusion criteria were chronic or associate diseases in spinal cord, pancreatic direct trauma, alcoholism and chronic pancreatic disease.

RESULTS

The association of acute pancreatitis in patients with SCI was 11.53%. The occurrence of pancreatitis or high levels of serum pancreatic enzymes in patients with ASIA A was 41.7% and only 4.17% in patients with ASIA E. In all, 55.2% of patients who presented pancreatitis or high levels of serum pancreatic enzymes had cervical level of SCI and 34.5% had thoracic level. Adynamic ileus was observed in 68.96% of this group.

CONCLUSION

We concluded that, in acute spinal cord injuries, the occurrence of acute pancreatitis or high serum levels of pancreatic enzymes are more frequent in patients with ASIA A Classification, cervical/thoracic level of spinal injury and adynamic ileus.

Intraductal papillary mucinous neoplasms of the pancreas--a surgical disease

Cystic pancreatic neoplasms are increasingly recognized, with intraductal papillary mucinous neoplasms of the pancreas (IPMNs) being the most frequently observed type. IPMNs are characterized by mucin production and epithelial growth within the pancreatic ducts, and are generally differentiated according to location: main pancreatic duct, its major side branches, or both (mixed type). IPMNs vary from benign to malignant and are considered precursor lesions of pancreatic adenocarcinoma. However, the exact time to neoplastic transformation and whether all IPMNs progress to malignant tumors is unclear. Surgical resection is warranted for all main-duct and mixed-type IPMNs (they harbor a high risk of malignancy of ~70%). By contrast, branch-duct IPMNs progress to cancer in only ~30% of cases. Thus, according to current guidelines (Sendai criteria), asymptomatic side-branch IPMNs <3 cm in size without suspicious radiological features (such as size progression) can be treated conservatively. Lately, even this approach has become controversial, owing to a number of Sendai-negative IPMNs showing malignant transformation. Although most IPMNs should be resected by standard oncological procedures (including lymphadenectomy), small Sendai-negative IPMNs can be treated with limited resections. This Review summarizes current knowledge of the treatment of IPMNs, with a particular focus on surgical approaches to this disease.

Italian consensus guidelines for chronic pancreatitis

This paper gives practical guidelines for diagnosis and treatment of chronic pancreatitis. Statements have been elaborated by working teams of experts, by searching for and analysing the literature, and submitted to a consensus process by using a Delphi modified procedure. The statements report recommendations on clinical and nutritional approach, assessment of pancreatic function, treatment of exocrine pancreatic failure and of secondary diabetes, treatment of pain and prevention of painful relapses. Moreover, the role of endoscopy in approaching pancreatic pain, pancreatic stones, duct narrowing and dilation, and complications was considered. Recommendations for most appropriate use of various imaging techniques and of ultrasound endoscopy are reported. Finally, a group of recommendations are addressed to the surgical treatment, with definition of right indications, timing, most appropriate procedures and techniques in different clinical conditions and targets, and clinical and functional outcomes following surgery.

Identification and validation of specific methylation profile in bile for differential diagnosis of malignant biliary stricture

OBJECTIVE

This study was aimed to identify the specific methylation profile in bile specimens of pancreaticobillary diseases for differential diagnosis of malignant biliary stricture.

DESIGN AND METHODS

In a total of 80 bile specimens from pancreaticobillary diseases, the methylation status of 19 tumor suppressor genes were analyzed by methylation-specific PCR and the methylation index (MI) were compared between the malignant and benign groups.

RESULTS

Methylation of DKK3, p16, SFRP2, DKK2, NPTX2 and ppENK were more frequently detected in the bile of malignant biliary strictures than benign patients. When setting MI 0.5 as the threshold, this 6-gene panel could distinguish the malignant biliary stricture with a high sensitivity, specificity and accuracy (77.27%, 77.78% and 77.50%, respectively).

CONCLUSION

The methylation profile including 6 specific genes in bile may be a promising biomarker for differential diagnosis between malignant and benign biliary strictures.

Role of fat-suppressed t1-weighted magnetic resonance imaging in predicting severity and prognosis of acute pancreatitis: an intraindividual comparison with multidetector computed tomography

OBJECTIVE

To determine the diagnostic value of magnetic resonance (MR) grading focusing on elevated signal on T1-weighted images in the prediction of severity and prognosis of acute pancreatitis as compared with the Balthazar computed tomography (CT) grading.

MATERIALS

Thirty-one patients with acute pancreatitis who underwent CT and MR imaging including fat-suppressed T1-weighted images within a 48-hour interval were included in this study. The severity of pancreatitis was evaluated by 2 observers using the Balthazar CT grading system and an MR grading system that is focused on an elevated signal on T1-weighted images. The MR grading was correlated with the CT grading, and each MR or CT grade was compared with patient outcome parameters, including the duration of hospitalization, local and systemic complications, and clinical outcome grading.

RESULTS

There was a significant correlation between CT and MR gradings for pancreatic or peripancreatic inflammation (r = 0.688, P < 0.01). However, for all of the outcome parameters and outcome grading, a stronger correlation was seen with the MR grading than with the CT grading. No significant correlation was found between CT grading and infected necrosis (r = 0.316, P = 0.083).

CONCLUSIONS

Magnetic resonance imaging including fat-suppressed T1-weighted images is more accurate to predict the severity and prognosis of acute pancreatitis in comparison with CT.

Resectability of pancreatic adenocarcinoma: assessment using multidetector-row computed tomography with multiplanar reformations

The purpose was to assess capabilities of the multidetector-row computed tomography (MDCT) with multiplanar reformations (MPR) for predicting of pancreatic adenocarcinoma resectability. Forty-eight patients deemed to have resectable pancreatic adenocarcinoma after assessment using biphasic MDCT with MPRs underwent surgery for potential tumor resection. Imaging findings were retrospectively evaluated for tumor resectability and correlated with surgical and pathological results. Curative resection was successful in 44 of 48 patients. The positive predictive value for tumor resectability made up 91% with four false-negative results. The reasons for unresectability were venous involvement (1), small liver metastases (2) and peritoneal involvement associated with small metastases to lymph nodes (1). MDCT yielded a negative predictive value of 99% (286 of 288 vessels) for detection of vascular invasion. Our results indicate the tendency towards improved prediction of resectability using MDCT compared to single-detector CT.

Management of mucin-producing cystic neoplasms of the pancreas

During the last decade small lesions of the pancreas have been increasingly recognized in clinical practice. Among these lesions, mucin-producing cystic neoplasms represent a recently described and unique entity among pancreatic tumors. In 1996, the World Health Organization distinguished two different types of mucinous cystic tumors: intraductal papillary mucinous neoplasms (IPMNs) of the pancreas, which are characterized by mucin production, cystic dilation of the pancreatic ducts, and intrapapillary growth, and mucinous cystic neoplasms (MCNs), which are defined by ovarian-like stroma and in most cases do not communicate with pancreatic ducts. Further, IPMNs can be subdivided into main-duct type, mixed-type, and branch-duct type tumors. Older data did not distinguish among different subsets of cystic neoplasms of the pancreas, and consequently many databases were inconsistent. Histopathologically, both IPMNs and MCNs demonstrate a wide spectrum of cellular atypia ranging from mild mucinous hyperplasia to invasive adenocarcinoma. Because mucinous cystic neoplasms of the pancreas show significant differences in clinical behavior from patient to patient, knowledge of the clinicopathologic characteristics and natural history of specific subtypes of IPMNs and MCNs has become crucial for physicians working in the field of gastroenterology. The present work offers an overview of current and generally accepted clinical guidelines for the diagnosis and treatment of IPMNs and MCNs.

Ultrasonography of the pancreas. 1. Conventional imaging

Ultrasound imaging has made significant advances in recent years and plays an important role in the detection, characterization and staging of pancreatic diseases. Conventional ultrasonography (US) is a noninvasive imaging modality, which continues to be the first diagnostic step in the evaluation of the pancreas. Over its various decades of application, US have detected pancreatic pathology of great diversity. This article reviews the wide utility of US and the many examinations techniques, such as filling the stomach with water, changing the patient's position or suspending inspiration or expiration, allowing us to visualize all portions of the pancreas in a high percentage of patients.

Positron emission tomography: clinical applications in oncology. Part 2

This review continues from a previous review on this topic, which was published in the December issue. In that review, the role of positron emission tomography in lung cancer, lymphoma, breast cancer, head and neck cancer, gastroesophageal cancer, colorectal cancer, malignant melanoma, bone tumors and ovarian cancer was discussed. In this review, the role of positron emission tomography in other malignancies, such as gynecological malignancies other than ovary, pancreatic cancer, hepatocellular cancer, gastrointestinal tumors, urological malignancies, neuroendocrine tumors, adrenocortical tumors, soft-tissue sarcomas, pituitary and brain tumors, is discussed.

HELICAL COMPUTED TOMOGRAPHIC ANGIOGRAPHY OF THE NORMAL CANINE PANCREAS

Helical abdominal computed tomography (CT) was performed in nine normal beagle-mix dogs. Following cephalic vein injection of ionic iodinated contrast medium via power injector (rate 5 ml/s) dual-phase CT was performed in all dogs. A delayed scan was performed in five dogs between 5 and 13 min after the contrast medium injection. The median time of appearance of contrast medium in the aorta and gastroduodenal artery was 6.3 and 7 s, post start injection and 12 and 12.2 s in the gastroduodenal and portal vein, resulting in a purely arterial pancreatic time window of 5-6s. Pancreatic veins and parenchyma remained enhanced until the end of the dynamic scan (40s). The pancreatic parenchyma showed heterogeneous arterial and homogenous venous contrast enhancement which was slightly hypoattenuating compared to the liver. Delayed scans provided best delineation of the pancreas from the liver. The common bile duct could be identified ventral and to the right of the portal vein joining the dorsomedial aspect of proximal duodenum. Because of the very short time window and variable onset of pure arterial enhancement careful planning of dual-phase studies with previous dynamic CT is recommended. Dual-phase CT angiography enables assessment of the arterial supply, parenchymal perfusion and venous drainage of the canine pancreas.

Pancreatic and peripancreatic diseases mimicking primary pancreatic neoplasia

A variety of anatomic variants and pathologic conditions in and around the pancreas may simulate primary pancreatic neoplasia at routine abdominal cross-sectional imaging. An ambiguous lesion whose appearance suggests a pancreatic origin requires a broad differential diagnosis that can subsequently be narrowed on the basis of both clinical history and features at optimal computed tomography (CT) and magnetic resonance (MR) imaging. Pancreas-specific multidetector CT and MR imaging techniques with thin collimation, multiplanar and multiphasic scans, and newly introduced curved planar reformation may help avoid potential diagnostic pitfalls. These techniques can help identify and characterize a mass in multiple viewing planes, thereby helping distinguish a true pancreatic neoplasm from peripancreatic adenopathy or from a tumor of the adjacent duodenum or small bowel. They can also help determine the cause of a tumor. It is important that the radiologist be familiar with the wide spectrum of anatomic variants and disease entities that can mimic primary pancreatic neoplasia in order to initiate the appropriate lesion-specific work-up and treatment and avoid unnecessary tests or procedures, including surgery.

Evaluation of delayed additional FDG PET imaging in patients with pancreatic tumour

AIM

To evaluate whether delayed fluorodeoxyglucose (FDG) positron emission tomography (PET) imaging is more helpful in differentiating between malignant and benign lesions and whether delayed FDG PET imaging can identify more lesions in patients in whom pancreatic cancer is suspected.

METHODS

The study evaluated 86 patients who were suspected of having pancreatic tumours. FDG PET imaging (whole body) was performed at 1 h (early) post-injection and repeated 2 h (delayed) after injection only in the abdominal region. Qualitative and semi-quantitative evaluation was performed. The semi-quantitative analysis was performed using the standardized uptake value (SUV), obtained from early and delayed images (SUVearly and SUVdelayed, respectively). Retention index (RI) was calculated according to the equation: (SUVdelayed-SUVearly)x100/SUVearly.

RESULTS

The final diagnosis was pancreatic cancer in 55 and benign disease in 31 patients. On visual and semi-quantitative analysis, the diagnostic accuracy of RI was the highest (88%). The differences between the SUVearly, SUVdelayed and RI value in both pancreatic cancer and benign disease were significant (P<0.01). The mean value of SUVdelayed was significantly higher than that of SUVearly (P<0.01) in pancreatic cancer. Furthermore, new foci of metastasis were seen in the liver in two patients and in the lymph node in one patient only on delayed images.

CONCLUSIONS

The RI values obtained using early and delayed FDG PET may help in evaluating pancreatic cancer. Furthermore, addition of delayed FDG PET imaging is helpful to identify more lesions in patients with pancreatic cancer.

[Surgical treatment of pancreatic and periampullary carcinoma in a specialized unit: a decade later]

INTRODUCTION

Results of surgical treatment for pancreatic and periampullary carcinoma have improved in recent years owing to several factors, particularly the concentration of these patients in specialised surgical units.

MATERIAL AND METHODS

Retrospective-prospective comparative study of results in 2 groups of patients treated over 2 different periods of time and with different surgical policy: group A, which included 80 patients treated from 1982 to 1992 in a general surgery unit, and group B, which comprised 151 patients treated from 1998 to 2003 in a specialised hepato-biliary-pancreatic surgery unit.

RESULTS

Surgical treatment in patients of groups A and B, respectively, was: resection in 20% and 53.6% and by-pass in 62.5% and 36.4%. Postoperative morbidity after resection was similar (75% vs 74.1%) but higher after by-pass in group B (41.8% vs 34%). Postoperative mortality after surgical resection and by-pass was 25% and 14.1%, respectively, for group A and 3.7% and 16.3%, respectively, for group B. Mean survival for all patients was 7.0 +/- 7.1 months for group A and 14.1 +/- 15.3 months for group B. Mean survival for patients with surgical resection was 11.8 +/- 9.8 months and 18.7 +/- 15.8 months for groups A and B, respectively.

CONCLUSIONS

Pancreatic and periampullary carcinoma should be surgically treated in specialised pancreatic surgery units in order to offer the best outcome to patients.

Preoperative evaluation of pancreaticobiliary tumor using MR multi-imaging techniques

AIM: To evaluate the clinical value of MR multi-imaging techniques in diagnosing and preoperative assessment of pancreaticobiliary tumor.

METHODS: MR multi-imaging techniques, including MR cross-sectional imaging, MR cholangiopancreatography (MRCP) and 3D dynamic contrast-enhanced MR angiography (3D DCE MRA), were performed to make prospective diagnosis and preoperative evaluation in 28 patients with suspected pancreaticobiliary tumors. There were 17 cases of pancreatic adenocarcinoma, 8 cases of biliary system carcinoma and 3 cases of non-neoplastic lesions.

RESULTS: Using MR multi-imaging techniques, the accuracy in diagnosing the patients with pancreaticobiliary tumors was 89.3% (25/28). The accuracy in detecting the range of tumor invasion was 80.3% (57/71). The sensitivity, specificity, accuracy, positive and negative predictive value of MR multi-imaging techniques in preoperative assessment of the resectability of pancreaticobiliary tumor were 83.3%, 89.5%, 88.0%, 71.4%, and 94.4%, respectively. There was well diagnostic consistency between MR multi-imaging techniques and CT (κ = 0.64, P<0.01). The fusion image could be made from MRCP and 3D DCE MRA images.

CONCLUSION: MR multi-imaging techniques can integrate the advantages of various MR images. The non-invasive “all-in-one” MR imaging protocol is the efficient method in diagnosing, staging and preoperative assessment of pancreaticobiliary tumor.

Pancreatic Injury in the Athlete

Pancreatic injuries in the athlete are seldom reported in the literature. These injuries can result from atraumatic etiologies and blunt abdominal trauma. Atraumatic pancreatic injuries in the athlete are diagnosed and treated in a similar manner to the nonathletic patient. Fluid replacement, analgesic support, metabolic stabilization, and minimization of gastric stimulation are the primary management methods for this type of pancreatic injury. Athletically related traumatic pancreatic injury is associated with a high morbidity and mortality. The consequences of a delayed diagnosis make this type of injury an important diagnostic consideration in an athlete with abdominal pain. Initial clinical, radiologic, and laboratory findings of direct injury to the pancreas are often equivocal, and require clinical suspicion and further investigation. Current evidence suggests that pancreatic duct injury is the primary cause of the morbidity and mortality associated with the direct trauma. A conservative or surgical management plan should be based on a combination of serial clinical examinations, pancreatic enzyme levels, and either magnetic resonance retrograde choleopancreatogram or endoscopic retrograde chloangiopancreatography investigations to rule out ductal injury. The prevention of pancreatic and other intra-abdominal injuries is an evolving area of sports medicine research. Sports specific epidemiologic data collection and analysis are important elements in the development of evidence-based interventions.

EUS findings in patients with autoimmune pancreatitis

BACKGROUND

Autoimmune pancreatitis is an increasingly recognized benign condition with a presentation similar to pancreatic neoplasia but responds to corticosteroid therapy. Clinical features, ERCP, and CT findings have been described. This study assessed the EUS and EUS-guided FNA features of proven autoimmune pancreatitis.

METHODS

The diagnosis of autoimmune pancreatitis was based on examination of surgical resection specimens or typical clinical findings (elevated immunoglobulin G level, no evidence of malignancy, characteristic non-EUS imaging studies, and clinical improvement, especially in response to treatment with a corticosteroid).

RESULTS

Presenting manifestations in 14 patients included obstructive jaundice, abdominal pain, and weight loss. Ten patients underwent surgery (including exploratory surgery). Six were successfully treated with corticosteroid. EUS revealed diffuse hypoechoic pancreatic enlargement (8/14) or a focal irregular hypoechoic mass (6/14). Features of chronic pancreatitis were not noted. EUS-guided FNA of the pancreas was suggestive of chronic inflammatory pancreatitis in 9 of 12 patients. Celiac and peripancreatic lymphadenopathy (up to 3 cm in diameter) was present in 6 patients. EUS-guided FNA of lymph nodes (3/4) did not reveal evidence of malignancy. Vascular involvement was noted in 3 patients.

CONCLUSIONS

The EUS features of autoimmune pancreatitis are easily mistaken for malignancy. However, a diffusely hypoechoic, enlarged pancreas, together with chronic inflammatory cells in aspirated cytologic specimens, is supportive of the diagnosis of autoimmune pancreatitis. When combined with clinical data, EUS and EUS-guided FNA may support a diagnosis of autoimmune pancreatitis, may warrant a trial of corticosteroid, and thereby may prevent unnecessary surgery.

Molecular analysis of pancreatic juice: a helpful tool to differentiate benign and malignant pancreatic tumors?

Chronic pancreatitis is an important predisposing condition leading to pancreatic carcinoma. As the differential diagnosis between these diseases may be difficult in 1 patient, the detection of specific tumor markers in pancreatic juice is an attractive diagnostic tool. Many studies have investigated tumor-mediated molecular alterations of the pancreatic juice, as k-ras mutations, telomerase reactivation, or promoter methylation of the tumor-suppressor genes p16INK4a and p14ARF. In this overview, we summarize these studies and conclude that molecular analysis of pancreatic juice is not useful for everyday care today. The high specificity of molecular alterations in pancreatic cancer in some pilot studies is waiting to be reproduced in large prospective trials, and has the potential to be a strong complementary marker of malignancy in patients with a pancreatic mass of uncertain dignity.

Role of CT and MR in detection and staging of pancreatic adenocarcinoma

In this review article, the roles of imaging with CT and MRI in the detection and staging of pancreatic carcinoma will be discussed. The frequently employed techniques using these modalities, the common imaging appearances of this tumor, and the limitations of imaging will be addressed.