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Pancreatic Malignancy: Value of Arterial, Pancreatic, and Hepatic Phase Imaging with Multi–Detector Row CT¹

¹ From the Department of Radiology (J.G.F., M.A.F., J.L.F., T.K., C.D.J., D.H.S., E.M.W.), Division of Gastroenterology and Hepatology, Departments of Internal Medicine (M.J.W.) and Laboratory Medicine and Pathology (L.J.B.), and Division of Biostatistics (W.S.H.), Mayo Clinic Rochester, 200 First St SW, Mayo E-2 B, Rochester, MN 55905. From the 2001 RSNA scientific assembly. Received May 15, 2002; revision requested July 12; final revision received January 2, 2003; accepted February 24. Address correspondence to J.G.F. (e-mail: fletcher.joel@mayo.edu).

View larger version (18K): [in a new window]   Figure 1. Graph shows timing of different phases in pancreatic CT protocols used by investigators. Assumptions include 9 cm of craniocaudal coverage for the pancreas (during the arterial and pancreatic phases) and 16 cm for the abdomen (during the hepatic phase). When a range of table speeds was available, the median table speed was used, with the assumption of a 4 mL/sec contrast material injection (*). In this study, during the hepatic phase only the pancreas (**) was imaged. Gray rectangles represent arterial phase; white rectangles, pancreatic phase; black rectangles, hepatic phase.

View larger version (27K): [in a new window]   Figure 2. Graph shows average enhancement of the pancreas and tumor in 29 patients with pancreatic adenocarcinoma. = pancreas, = tumor, = mean tumor-to-gland attenuation difference.

View larger version (140K): [in a new window]   Figure 3a. Transverse CT images in 65-year-old man with pancreatic ductal adenocarcinoma in the pancreatic head, which was detected by readers on images obtained in arterial, pancreatic, and hepatic phases. (a) Image of tumor (arrow) obtained in arterial phase, with tumor-to-gland attenuation difference of 16 HU. (b) Image of tumor (arrow) obtained in pancreatic phase, with tumor-to-gland attenuation difference of 64 HU. (c) Image of tumor (arrow) obtained in hepatic phase, with tumor-to-gland attenuation difference of 46 HU. (d) Image obtained in pancreatic phase slightly cephalad to the tumor demonstrates flow artifact (arrow) in the superior mesenteric vein. (e) Image obtained in hepatic phase at same level as in d demonstrates homogeneous distribution of contrast material in the superior mesenteric vein (arrow), which is hyperattenuating, compared with the adjacent pancreas.

View larger version (138K): [in a new window]   Figure 3b. Transverse CT images in 65-year-old man with pancreatic ductal adenocarcinoma in the pancreatic head, which was detected by readers on images obtained in arterial, pancreatic, and hepatic phases. (a) Image of tumor (arrow) obtained in arterial phase, with tumor-to-gland attenuation difference of 16 HU. (b) Image of tumor (arrow) obtained in pancreatic phase, with tumor-to-gland attenuation difference of 64 HU. (c) Image of tumor (arrow) obtained in hepatic phase, with tumor-to-gland attenuation difference of 46 HU. (d) Image obtained in pancreatic phase slightly cephalad to the tumor demonstrates flow artifact (arrow) in the superior mesenteric vein. (e) Image obtained in hepatic phase at same level as in d demonstrates homogeneous distribution of contrast material in the superior mesenteric vein (arrow), which is hyperattenuating, compared with the adjacent pancreas.

View larger version (140K): [in a new window]   Figure 3c. Transverse CT images in 65-year-old man with pancreatic ductal adenocarcinoma in the pancreatic head, which was detected by readers on images obtained in arterial, pancreatic, and hepatic phases. (a) Image of tumor (arrow) obtained in arterial phase, with tumor-to-gland attenuation difference of 16 HU. (b) Image of tumor (arrow) obtained in pancreatic phase, with tumor-to-gland attenuation difference of 64 HU. (c) Image of tumor (arrow) obtained in hepatic phase, with tumor-to-gland attenuation difference of 46 HU. (d) Image obtained in pancreatic phase slightly cephalad to the tumor demonstrates flow artifact (arrow) in the superior mesenteric vein. (e) Image obtained in hepatic phase at same level as in d demonstrates homogeneous distribution of contrast material in the superior mesenteric vein (arrow), which is hyperattenuating, compared with the adjacent pancreas.

View larger version (141K): [in a new window]   Figure 3d. Transverse CT images in 65-year-old man with pancreatic ductal adenocarcinoma in the pancreatic head, which was detected by readers on images obtained in arterial, pancreatic, and hepatic phases. (a) Image of tumor (arrow) obtained in arterial phase, with tumor-to-gland attenuation difference of 16 HU. (b) Image of tumor (arrow) obtained in pancreatic phase, with tumor-to-gland attenuation difference of 64 HU. (c) Image of tumor (arrow) obtained in hepatic phase, with tumor-to-gland attenuation difference of 46 HU. (d) Image obtained in pancreatic phase slightly cephalad to the tumor demonstrates flow artifact (arrow) in the superior mesenteric vein. (e) Image obtained in hepatic phase at same level as in d demonstrates homogeneous distribution of contrast material in the superior mesenteric vein (arrow), which is hyperattenuating, compared with the adjacent pancreas.

View larger version (145K): [in a new window]   Figure 3e. Transverse CT images in 65-year-old man with pancreatic ductal adenocarcinoma in the pancreatic head, which was detected by readers on images obtained in arterial, pancreatic, and hepatic phases. (a) Image of tumor (arrow) obtained in arterial phase, with tumor-to-gland attenuation difference of 16 HU. (b) Image of tumor (arrow) obtained in pancreatic phase, with tumor-to-gland attenuation difference of 64 HU. (c) Image of tumor (arrow) obtained in hepatic phase, with tumor-to-gland attenuation difference of 46 HU. (d) Image obtained in pancreatic phase slightly cephalad to the tumor demonstrates flow artifact (arrow) in the superior mesenteric vein. (e) Image obtained in hepatic phase at same level as in d demonstrates homogeneous distribution of contrast material in the superior mesenteric vein (arrow), which is hyperattenuating, compared with the adjacent pancreas.

View larger version (161K): [in a new window]   Figure 4a. Transverse CT images in 68-year-old man with replaced right hepatic artery in juxtaposition to pancreatic adenocarcinoma in the posterior aspect of the pancreatic head, which indicates arterial invasion. (a) Image obtained in arterial phase on which the tumor was not identified with certainty, which likely led to misdiagnosis of lack of vascular invasion. Replaced right hepatic artery (arrow) and tumor (arrowheads) are seen. (b) Image obtained in pancreatic phase on which vascular invasion was correctly identified. Note increased conspicuity of the tumor (arrowheads) compared with the normal gland (black arrow). The low-attenuation tumor is clearly depicted adjacent to the artery (white arrow). (c) Image obtained in hepatic phase on which arterial invasion was correctly diagnosed shows tumor (arrowheads) and artery (arrow).

View larger version (161K): [in a new window]   Figure 4b. Transverse CT images in 68-year-old man with replaced right hepatic artery in juxtaposition to pancreatic adenocarcinoma in the posterior aspect of the pancreatic head, which indicates arterial invasion. (a) Image obtained in arterial phase on which the tumor was not identified with certainty, which likely led to misdiagnosis of lack of vascular invasion. Replaced right hepatic artery (arrow) and tumor (arrowheads) are seen. (b) Image obtained in pancreatic phase on which vascular invasion was correctly identified. Note increased conspicuity of the tumor (arrowheads) compared with the normal gland (black arrow). The low-attenuation tumor is clearly depicted adjacent to the artery (white arrow). (c) Image obtained in hepatic phase on which arterial invasion was correctly diagnosed shows tumor (arrowheads) and artery (arrow).

View larger version (158K): [in a new window]   Figure 4c. Transverse CT images in 68-year-old man with replaced right hepatic artery in juxtaposition to pancreatic adenocarcinoma in the posterior aspect of the pancreatic head, which indicates arterial invasion. (a) Image obtained in arterial phase on which the tumor was not identified with certainty, which likely led to misdiagnosis of lack of vascular invasion. Replaced right hepatic artery (arrow) and tumor (arrowheads) are seen. (b) Image obtained in pancreatic phase on which vascular invasion was correctly identified. Note increased conspicuity of the tumor (arrowheads) compared with the normal gland (black arrow). The low-attenuation tumor is clearly depicted adjacent to the artery (white arrow). (c) Image obtained in hepatic phase on which arterial invasion was correctly diagnosed shows tumor (arrowheads) and artery (arrow).

View larger version (114K): [in a new window]   Figure 5a. Transverse CT images in 76-year-old man with vascular invasion of the superior mesenteric vein from pancreatic adenocarcinoma. (a) Image obtained in hepatic phase above region of narrowing shows normal-caliber portal vein (arrow). (b) Image obtained in hepatic phase shows focal narrowing and flattening of the superior mesenteric vein (arrows). (c) Image obtained in hepatic phase below narrowing demonstrates normal-caliber superior mesenteric vein (large arrow) and tumor (arrowhead) adjacent to common bile duct stent. Note inferior mesenteric vein (small arrows). (d, e) Images obtained in pancreatic phase at a level corresponding to b and c, respectively, fail to demonstrate convincing narrowing of the superior mesenteric vein (arrow), and contrast enhancement of the superior mesenteric vein is suboptimal. Note inferior mesenteric vein (small arrows) on e.

View larger version (116K): [in a new window]   Figure 5b. Transverse CT images in 76-year-old man with vascular invasion of the superior mesenteric vein from pancreatic adenocarcinoma. (a) Image obtained in hepatic phase above region of narrowing shows normal-caliber portal vein (arrow). (b) Image obtained in hepatic phase shows focal narrowing and flattening of the superior mesenteric vein (arrows). (c) Image obtained in hepatic phase below narrowing demonstrates normal-caliber superior mesenteric vein (large arrow) and tumor (arrowhead) adjacent to common bile duct stent. Note inferior mesenteric vein (small arrows). (d, e) Images obtained in pancreatic phase at a level corresponding to b and c, respectively, fail to demonstrate convincing narrowing of the superior mesenteric vein (arrow), and contrast enhancement of the superior mesenteric vein is suboptimal. Note inferior mesenteric vein (small arrows) on e.

View larger version (112K): [in a new window]   Figure 5c. Transverse CT images in 76-year-old man with vascular invasion of the superior mesenteric vein from pancreatic adenocarcinoma. (a) Image obtained in hepatic phase above region of narrowing shows normal-caliber portal vein (arrow). (b) Image obtained in hepatic phase shows focal narrowing and flattening of the superior mesenteric vein (arrows). (c) Image obtained in hepatic phase below narrowing demonstrates normal-caliber superior mesenteric vein (large arrow) and tumor (arrowhead) adjacent to common bile duct stent. Note inferior mesenteric vein (small arrows). (d, e) Images obtained in pancreatic phase at a level corresponding to b and c, respectively, fail to demonstrate convincing narrowing of the superior mesenteric vein (arrow), and contrast enhancement of the superior mesenteric vein is suboptimal. Note inferior mesenteric vein (small arrows) on e.

View larger version (132K): [in a new window]   Figure 5d. Transverse CT images in 76-year-old man with vascular invasion of the superior mesenteric vein from pancreatic adenocarcinoma. (a) Image obtained in hepatic phase above region of narrowing shows normal-caliber portal vein (arrow). (b) Image obtained in hepatic phase shows focal narrowing and flattening of the superior mesenteric vein (arrows). (c) Image obtained in hepatic phase below narrowing demonstrates normal-caliber superior mesenteric vein (large arrow) and tumor (arrowhead) adjacent to common bile duct stent. Note inferior mesenteric vein (small arrows). (d, e) Images obtained in pancreatic phase at a level corresponding to b and c, respectively, fail to demonstrate convincing narrowing of the superior mesenteric vein (arrow), and contrast enhancement of the superior mesenteric vein is suboptimal. Note inferior mesenteric vein (small arrows) on e.

View larger version (125K): [in a new window]   Figure 5e. Transverse CT images in 76-year-old man with vascular invasion of the superior mesenteric vein from pancreatic adenocarcinoma. (a) Image obtained in hepatic phase above region of narrowing shows normal-caliber portal vein (arrow). (b) Image obtained in hepatic phase shows focal narrowing and flattening of the superior mesenteric vein (arrows). (c) Image obtained in hepatic phase below narrowing demonstrates normal-caliber superior mesenteric vein (large arrow) and tumor (arrowhead) adjacent to common bile duct stent. Note inferior mesenteric vein (small arrows). (d, e) Images obtained in pancreatic phase at a level corresponding to b and c, respectively, fail to demonstrate convincing narrowing of the superior mesenteric vein (arrow), and contrast enhancement of the superior mesenteric vein is suboptimal. Note inferior mesenteric vein (small arrows) on e.