Preliminary Diagnosis: Pancreatic Cancer
I. What imaging technique is first-line for this diagnosis?
- Pancreatic protocol CT abdomen and pelvis with and without contrast
II. Describe the advantages and disadvantages of this technique for diagnosis of pancreatic cancer.
Advantages
- Enhancement patterns are often characteristic of different pancreatic neoplastic lesions, which may narrow the diagnosis
- Simultaneously evaluates the liver for metastatic disease and demonstrates intra- or extrahepatic biliary ductal dilation due to tumor mass effect
Disadvantages
- Administration of iodinated contrast may result in worsening renal function (contrast nephropathy) in patients with renal insufficiency. Contrast dose should be reduced or withheld in these patients
- Exposure to ionizing radiation
III. What are the contraindications for the first-line imaging technique?
- History of allergic reaction to IV contrast requires pretreatment for a minimum of 13 hours with steroids and antihistamines
- Pregnant patients should not undergo CT
IV. What alternative imaging techniques are available?
- MRI abdomen with contrast, magnetic resonance cholangiopancreatography (MRCP)
- Abdominal ultrasound
- Endoscopic ultrasound
V. Describe the advantages and disadvantages of the alternative techniques for diagnosis of pancreatic cancer.
MRI/MRCP
Advantages
- Able to show level and degree of ductal obstruction
- Less invasive than ERCP
- Does not require sedation
Disadvantages
- Expensive
- Time consuming
- Requires significant patient cooperation to minimize motion artifact
Abdominal Ultrasound
Advantages
- Does not use ionizing radiation
- Quick and inexpensive exam
Disadvantages
- Does not provide the level of anatomic detail needed for surgical planning (eg, degree of vascular involvement)
- Less sensitive in evaluating the liver for metastatic disease
Endoscopic Ultrasound
Advantages
- Does not use ionizing radiation
- May get better images of pancreas than abdominal ultrasound
Disadvantages
- Invasive procedure
- Requires sedation
VI. What are the contraindications for the alternative imaging techniques?
MRI/MRCP
- Contraindicated in patients with non–MRI-approved metallic devices
- Gadolinium contrast is contraindicated in patients with decreased renal function (GFR <30-40 mL/min/1.73m2) due to risk of nephrogenic systemic fibrosis
Abdominal Ultrasound
- There are no contraindications to ultrasound
Endoscopic Ultrasound
- Contraindicated in patients that are at risk for perforation
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