Peripancreatic Vessels Research Articles

PD-0032 Preoperative Chemoradiation for Resectable Adenocarcinoma of the Pancreas (ISRCTN 78805636): Pattern of Recurrence.

ABSTRACT Introduction Standard treatment for resectable pancreatic carcinoma is primary surgery, and most patients die of recurrent cancer. Chemoradiation is used to treat locally unresectable pancreatic cancer which is meant to stop local progress at least for a while. Neoadjuvant chemoradiation was introduced prior to surgery in locally resectable cancer in this trial. The local effect of chemoradiation and its influence on resection rates and recurrence patterns after tumor resection is examined now. Methods Patients with histologically proven ductal adenocarcinoma of the pancreatic head encircling peripancreatic vessels for Results Between 01.06.2003 and 31.12.2009, 73 patients were randomised in 8 centres (A n = 37, B n = 36). Due to slow recruitment the trial was closed early (planned n = 254). By 09.03.2012 data of 68 patients (A/B n = 34) could be evaluated, 3 patients withdrew consent (A/B n = 2/1), 1 centre did not sent data (A/B n = 1). Tumor resection was performed in 24 patients (A) and in 20 patients (B) by intention-to-treat-analysis. Explorative laparotomy revealed locally unresectable tumor in 6 patients (A/B n = 4/2) and distant metastasis in 13 patients (A/B n = 5/8). By now 20 patients (A) and 16 patients (B) had recurrence of cancer: 3 patients (A) had residual tumor and/or residual filiae and died within 7 months, 1 patient (B) had residual tumor and died 5 months after randomization. 6 patients (A/B n = 5/1) had local recurrence first, whereas 15 patients (A/B n = 7/8) had distant metastases as primary recurrence localization. 9 patients (A/B n = 4/5) had local recurrence and distant metastases diagnosed simultaneously. The localization of cancer recurrence was not known in 2 patients (A/B n = 1/1). There was no significant difference in median time from randomization until tumor progression with 10 months in group A and 9 months in group B (p = 0.4) after tumor resection. Even though median time to local recurrence was delayed after chemoradiation with 7 months in group A and 10 months in group B. Conclusion In this trial the pattern of local and distant recurrence of pancreatic cancer after tumor resection was not significantly different with and without preoperative chemoradiation treatment. But this might be due to low patient numbers because of early stopping the trial for slow recruitment.

Peripancreatic Arterial Anatomy Analyzed by 3-Dimensional Multidetector-Row Computed Tomography

Since the anatomy of the peripancreatic vessel system is complex, it is important to preoperatively clarify the running aspects of such vessels, especially when pancreatoduodenectomy is performed. In 166 patients undergoing multidetector-row computed tomography, peripancreatic vessels were three-dimensionally reconstructed using computer software. The dorsal pancreatic artery branched from the splenic artery (45.4%), common hepatic artery (24.8%), superior mesenteric artery (SMA, 15.6%), celiac axis (9.9%) and other arteries such as the middle colic artery (4.3%). Branching of the inferior pancreatoduodenal artery (IPDA) was categorized into two types: a single main IPDA branching from one artery, such as the first jejunal artery (J1a, 55.2%) and SMA (25.1%) and two IPDAs branching from one artery (J1a, 7.0% or SMA, 2.8%) or separately from two arteries (3.5%). Most IPDAs (129 of identified 168 IPDAs) ran behind the SMA at the right edge of the SMA. In 52 patients, superior mesenteric vein tributaries ran above the SMA and mask the IPDA's ramification. Peripancreatic vessel anatomy is very complex. The preoperative 3D arteriography and portography enables us to obtain precise information about peripancreatic vessels.

Robotic Extended Pancreatectomy With Vascular Resection for Locally Advanced Pancreatic Tumors

Limited involvement of the major peripancreatic vessels is no longer considered a contraindication for resection in cases of locally advanced pancreatic cancer. Extended open pancreatectomies associated with vascular resection are performed in experienced centers with mortality and morbidity rates comparable to standard pancreatic resection. We evaluate the safety, feasibility, and outcomes of robotic extended pancreatectomy with vascular resection. We reviewed data of 5 patients with a median age of 60 years (range, 52-74 years) who underwent robotic surgery for pancreatic tumors with vascular involvement between May 2007 and March 2010 at our institution. The types of resection included 2 left-sided splenopancreatectomy with celiac axis resection, 1 left-sided splenopancreatectomy with portal vein resection, and 2 pancreaticoduodenectomy with portal vein resection. No conversions occurred. The overall mean operating time was 392 ± 66 minutes (range, 310-460 min). The overall mean blood loss was 200 ± 61 mL (range, 150-300 mL) with no transfusions. No mortalities occurred. At a median follow-up of 6 months (range, 3-20 months), 4 patients were alive and disease free. This early series by a single surgeon supports the feasibility and safety of robotic pancreatectomy with vascular resection for selected patients with locally advanced pancreatic tumor.

Autoimmunpankreatitis assoziiert mit rheumatoider Arthritis

MEDICAL HISTORY AND CLINICAL FINDINGS: A 70-year-old female patient suffered from steatorrhea and upper abdominal discomfort for 8 weeks combined with new onset of arthralgia in both hands. Additionally she reported elevated fasting blood glucose levels. The physical examination was without pathological findings except for mild upper abdominal pressure pain. Imaging studies, including MRI and ultrasound examinations showed diffuse pancreatic enlargement without peripancreatic vessel involvement. Serological examinations showed elevated Cancer Associated Antigen 19 - 9 (1289 U/ml) and hyperglobulinemia with an IgG level of 170 mg/dl. The inflammatory markers were within normal ranges other than a slightly elevated erythrocyte sedimentation rate (35mm/1 h). Subsequent pancreatic biopsy showed lymphoplasmocellular, neutrophile and eosinophile granulocyte infiltration causing damage of the acinar pancreatic cells, typical for autoimmune pancreatitis (AIP). Magnetic resonance imaging (MRI) confirmed arthritis of both hands. Medical treatment was started with oral prednisolone (50 mg/day) for one week, tapered to 25 mg/day for another 2 weeks, followed by dose reductions of 5 mg/day every 2 weeks with a final maintenance dose of 5 mg/day for 8 months. After the first week of steroid therapy methotrexate (MTX) was started with an initial dose of 10 mg/week. Dose was raised until a final dosage of 30 mg/week. After 8 months without relapse, the maintenance therapy was reduced to 20 mg/week MTX and corticosteroids were stopped. With this treatment regimen the patient has showed complete remission of AIP and arthritis for 36 months. MTX may be successful as an initial basic treatment to reach better control of autoimmune-related extrapancreatic manifestations.

Upper gastrointestinal bleeding in chronic pancreatitis

Pseudoaneurysm of peripancreatic vessels is a rare complication of chronic pancreatitis. Being close to the pancreas, splenic artery is the most frequently affected vessel whereas right gastroepiploic artery pseudoaneurysm is very rare. Rupture of such pseudoaneurysm is a rare cause of upper gastrointestinal (GI) bleeding. We report a patient of chronic pancreatitis with past history of pancreatic duct stenting who presented with massive upper GI bleeding and stent migration. Bleeding from pseudoaneurysm of right gastroepiploic artery was detected in angiography. Coil embolization was done but later rebleeding occurred and was managed with laparotomy and ligation of the pseudoaneurysm. Patient improved during postoperative period. Keywords: chronic pancreatitis; embolization; pseudoaneurysm DOI: http://dx.doi.org/10.3126/joim.v32i2.4946 Journal of Institute of Medicine, August, 2010; 32: 47-50

CT diagnosis of recurrence after pancreatic cancer: Is there a pattern?

To investigate predilection sites of recurrence of pancreatic cancer by computed tomography (CT) in follow-up after surgery. Seventy seven patients with recurrence after pancreatic cancer surgery were retrospectively identified. The operative technique, R-status, T-stage and development of tumor markers were evaluated. Two radiologists analyzed CT scans with consensus readings. Location of local recurrence, lymph node recurrence and organ metastases were noted. Surgery and progression of findings on follow-up CT were considered as reference standard. The mean follow-up interval was 3.9 ± 1.8 mo, with a mean relapse-free interval of 12.9 ± 10.4 mo. The predominant site of recurrence was local (65%), followed by lymph node (17%), liver metastasis (11%) and peritoneal carcinosis (7%). Local recurrence emerged at the superior mesenteric artery (n = 28), the hepatic artery (n = 8), in an area defined by the surrounding vessels: celiac trunk, portal vein, inferior vena cava (n = 22), and in a space limited by the mesenteric artery, portal vein and inferior vena cava (n = 17). Lymph node recurrence occurred in the mesenteric root and left lateral to the aorta. Recurrence was confirmed by surgery (n = 22) and follow-up CT (n = 55). Tumor markers [carbohydrate antigen 19-9 (CA19-9), carcinoembryonic antigen (CEA)] increased in accordance with signs of recurrence in most cases (86% CA19-9; 79.2% CEA). Specific changes of local and lymph node recurrence can be found in the course of the cardinal peripancreatic vessels. The superior mesenteric artery is the leading structure for recurrence.

Recent advances and limitations of surgical treatment for pancreatic cancer

Recent advances in surgical treatment for pancreatic cancer have been remarkable. Pancreatoduodenectomy is a standard surgical procedure for cancer of the pancreatic head, and is now indicated even for elderly patients over 80 years of age. Pancreatoduodenectomy with combined resection of the peripancreatic vessels has improved survival, but extended resection including lymph nodes is considered to have no extra survival benefit. Furthermore, laparoscopic resection procedures including pancreatoduodenectomy, distal pancreatectomy, enucleation and central pancreatectomy can now be performed safely. Neoadjuvant or adjuvant chemotherapy using gemcitabine may further improve the surgical outcome. An understanding of the oncological aspects of pancreatic cancer and the development of surgical techniques and chemotherapy may further contribute to improving the outcome of surgery for pancreatic cancer.

Pathways of Extrapancreatic Perineural Invasion by Pancreatic Adenocarcinoma: Evaluation With 3D Volume-Rendered MDCT Imaging

The purpose of this article is to familiarize radiologists with the common pathways of extrapancreatic perineural invasion of pancreatic adenocarcinoma and to highlight the potential value of 3D volume-rendered MDCT in its diagnosis. The perineural plexuses closely follow peripancreatic vessels, which are well depicted by contrast-enhanced 3D volume-rendered imaging, thus facilitating the diagnosis of extrapancreatic perineural invasion of pancreatic adenocarcinoma.

Surgical design and outcome of duodenum‐preserving pancreatic head resection for benign or low‐grade malignant tumors

To apply duodenum-preserving pancreatic head resection (DPPHR) as radical procedure for benign or low-grade malignant tumors, it needs the reconciliation of complete pancreatic head resection and preservation of the bile duct and peripancreatic vessels. Several modifications have been introduced and applied to remove these lesions, however, the techniques have not been made clear in the management of the peripancreatic vessels and the bile duct. The long-term outcomes of the DPPHR have been reported as extremely rare in comparison with pylorus preserving pancreatoduodenectomy (PPPD) in these pancreatic head tumors. The angiograms by multi-detector row CT (MD-CT) can be reconstructed more physiologically than selective angiography. The anterior arcade is predominant in 43% of 64 patients. Therefore, we modified the DPPHR to include a complete resection of the pancreatic head and the preservation of both anterior and posterior arterial arcades. The bile duct is covered by the pancreatic parenchyma in various ways. The techniques of the preservation of the bile duct are also introduced. We performed 21 DPPHRs and 19 PPPDs in the patients with benign or low-grade malignant pancreatic head tumor. There was no significant difference in operative factors. The postoperative death was one patient in PPPD, but none in DPPHR. The postoperative complications of PPPD were more often than that of DPPHR. There is no postoperative recurrence in DPPHR in the follow-up period from 2 to 216 months. Both exocrine and endocrine function and the long-term results following DPPHR were superior to those following PPPD. The DPPHR should be favored over the PPPD in benign or low-grade malignant tumors of the head of the pancreas if there is no compromise with oncologic radicality.

Prognostic implications of tumor invasion or adhesion to peripancreatic vessels in resected pancreatic cancer

The purpose of this study was to evaluate the operative risk and the prognostic implications of pancreatectomy plus resection and reconstruction of peripancreatic vessels (PPV) in patients with pancreatic adenocarcinoma. One hundred ten patients who underwent pancreatectomy with PPV resection and reconstruction (Study Group; SG) were retrospectively compared with 62 patients without distant metastasis who were palliated, (Control Group 1; CG-1), as well as 197 patients who underwent "conventional"pancreatectomy (Control Group 2; CG-2). Postoperative morbidity and mortality were similar in SG (33% and 3%), in CG-1 (26% and 3%), and in CG-2 (40% and 6%) patients. Median survival time (MST) of SG patients (15 months) was longer than that of CG-1 patients (6 months; P < .0001) and similar to that of CG-2 patients (18 months). Patients undergoing isolated venous resection (n = 84) had the best outcome (MST: 15 months) ( P < .0001 vs CG-1 patients), while patients undergoing resection of multiple PPV (n = 14) had the worst outcome (MST: 8 months). PPV infiltration, histologically proven in 64 patients (65%), was associated with decreased MST only if the tunica intima was infiltrated (26%) (11 months; P < .001). Multivariate analysis showed that no adjuvant therapy, intimal invasion, and poorly differentiated histology were associated with a higher hazard of death by 2.2, 2.2, and 2.5-fold, respectively. In properly selected patients, pancreatectomy plus resection and reconstruction of PPV was performed as safely as palliation or "conventional" pancreatectomy and was associated with better survival when compared to palliation.

Value of three-dimensional reconstructions in pancreaticcarcinoma using multidetector CT: Initial results

To evaluate the use of three-dimensional imaging of pancreatic carcinoma using multidetector computed tomography (CT) in a prospective study. Ten patients with suspected pancreatic tumors were examined prospectively using multidetector CT (Somatom Sensation 16, Siemens, Erlangen, Germany). The images were evaluated for the presence of a pancreatic carcinoma and invasion of the peripancreatic vessels and surrounding organs. Using the isotropic CT data sets, a three-dimensional image was created with automatic vascular analysis and semi-automatic segmentation of the organs and pancreatic tumor by a radiologist. The CT examinations and the three-dimensional images were presented to the surgeon directly before and during the patient's operation using the Medical Imaging Interaction Toolkit-based software "ReLiver". Immediately after surgery, the value of the two images was judged by the surgeon. The operation and the histological results served as the gold standard. Nine patients had a pancreatic carcinoma (all pT3), and one patient had a serous cystadenoma. One tumor infiltrated the superior mesenteric vein. The infiltration was correctly evaluated. All carcinomas were resectable. In comparison to the CT image with axial and coronal reconstructions, the three-dimensional image was judged by the surgeons as better for operation planning and consistently described as useful. A 3D-image of the pancreas represents an invaluable aid to the surgeon. However, the 3D-software must be further developed in order to be integrated into daily clinical routine.

Assessment of Pancreatic Tumor Resectability with Multidetector Computed Tomography: Semiautomated Console-generated Images Versus Dedicated Workstation-generated Images

The purpose of this retrospective study was to compare the maximum intensity projection (MIP) images generated at a multidetector computed tomography (MDCT) scanner console using advanced tools at a three-dimensional (3D) workstation for assessment of pancreatic tumor resectability. Institutional review board approval and informed consent wavier were obtained for this retrospective study. The intraoperative findings were used as reference standard. Two radiologists assessed console MIPs that were created using computed tomographic (CT) data sets of 30 patients (17 men and 13 women; age range, 35-79 years; mean age, 58 years) operated for pancreatic tumors. Semi-automated MIP images were created on a separate MDCT console. Two blinded radiologist (R1, R2) and surgeons (S1, S2) evaluated the image data independently for vascular involvement and tumor resectability. The image quality and diagnostic confidence for MIPs were graded on a 5-point scale (1 = poor, 2 = suboptimal, 3 = intermediate, 4 = good; 5 = excellent) and comparison was made with 3D workstation image scores. The findings revealed greater than 90% sensitivity, specificity, and accuracy for detecting involvement of peripancreatic vessels by pancreatic tumor with an excellent interobserver agreement (kappa = 0.87-1.00). The findings of console-generated MIPs were same as the findings of 3D workstation images. The mean of image quality and diagnostic confidence grading for console MIPs by assessors were 4.4 and 4.2, respectively. The average time to generate simple MIPs at the console was 3.4 minutes (range, 2.3-4.4) compared to 26 minutes (range, 18-33) to create images at the 3D workstation. Semi-automated MIPs generated from an MDCT scanner console is an excellent alternative to 3D workstation images for assessing resectability of pancreatic tumor based on vascular involvement. Console MIPs can be quickly generated during the time of scan and thus can improve CT workflow.

Vascular involvement in periampullary tumors: MDCT, EUS, and CDU

In patients affected by periampullary tumors, surgical resection represents the only treatment with curative intent. Preoperative evaluation of vascular involvement is necessary to avoid surgical treatments unable of curative intent resection. The aim of our update article is to assess the performance of multidetector computed tomography (MDCT), endoscopic ultrasonography (EUS), and color Doppler ultrasonography (CDU) in the evaluation of vascular involvement of major peripancreatic vessels, in periampullary tumors, analyzing the current and past literature.

Relationship between changes of serum concentrations of antiangiogenic factors and disease progression in patients of pancreatic carcinoma

To investigate the relationship between TSP-1, Angiostatin and Endostatin serum concentrations and progression of pancreatic adenocarcinoma. Fifty-six patients with suspected pancreatic cancer were enrolled in the study and divided into resectable group (n = 32) and unresectable group (n = 24) according to evaluation and staging with dual phase helical CT. Histopathologic examinations included postoperative final pathology and preoperative fine needle biopsies. Peripheral blood concentrations of antiangiogenic factors Angiostatin, Endostatin and TSP-1 were detected by using ELISA methods, selecting samples of health people as a control. Serum concentrations of antiangiogenic factors in pancreatic cancer group were significantly higher than those in health group (P < 0.01). Serum concentrations of Endostatin, Angiostatin and TSP-1 were significantly increased in unresectable group, and highly expressed in patients whom tumor sizes were greater than 2 cm and tumor invaded peripancreatic great vessels (P < 0.05). After operation, serum concentrations of Endostatin, Angiostatin and TSP-1 significantly decreased (P < 0.05). There were no significant difference between I, II stage group and III, IV group. Detection of serum concentrations of antiangiogenic factors may be used to evaluate the resectability of pancreatic cancer and may play important roles in growth, invasion and metastasis of pancreatic cancer.

Laparoscopy-assisted Distal Pancreatectomy With Mobilization of the Distal Pancreas and the Spleen Outside the Abdominal Cavity

Laparoscopic ligation of the peripancreatic vessels or duct requires a particularly skillful technique. If the pancreatic tail and the spleen can be mobilized outside of the abdominal cavity, surgeons can perform these procedures as easily as ordinary open surgery. We developed a novel approach to laparoscopy-assisted distal pancreatectomy without hand-assist. In brief, the pancreatic tail and the spleen were mobilized laparoscopically from the retroperitoneum until the celiac axis was exposed, then the pancreatic tail and the spleen were laparoscopically mobilized outside the peritoneal cavity from a small incision at the upper abdomen. After mobilization, the distal pancreatectomy was performed as usual open method. This approach offers better results in coping with organs, which seem to be difficult to resect through laparoscopic surgery alone.

High operative risk of cool‐tip radiofrequency ablation for unresectable pancreatic head cancer

To report and discuss the effect, complications and mortality of cool-tip radiofrequency ablation (RFA) for unresectable pancreatic cancer. During October 2003 to July 2004, sixteen patients with unresectable pancreatic cancer were treated by open cool-tip RFA. One-half of the 16 patients had tumors located in the pancreatic head. A 5-mm minimum safe distance between RFA site and major peripancreatic vessels was kept to avoid injury to the vessels. Six of twelve patients with back pain got pain relief postoperatively. Pancreatic fistula occurred in three patients (18.8%) and healed smoothly in 7-10 days with routine abdominal drainage. The mortality was 25% (4/16). In the four death cases, tumors were all located in the pancreatic head; three patients with tumor close to portal vein died suddenly of massive gastrointestinal hemorrhage on the 4th, 30th, 40th postoperative day respectively and a 79-year-old patient died of acute renal failure on the 2nd postoperative day. Standard use of cool-tip RFA was dangerous for pancreatic head cancer close to portal vein, in which a 5-mm minimum safe distance between RFA site and major peripancreatic vessels might not be enough to avoid injury to the vessels.

Ultrasonography of the pancreas. 3. Doppler imaging

Ultrasonography is probably the most widely used medical imaging technique. In fact, its non-invasivity, portability, widespread distribution and good clinical results have made it the preferred method for a first imaging approach to patients in a large variety of clinical settings. Ultrasound technology is advancing rapidly, aimed to increase image quality. In particular, increased color-Doppler sensitivity is contributing to the diagnosis and staging of pancreatic disease. Doppler studies are in fact integral part of ultrasound examination of the pancreas evaluating the peripancreatic vascular structures enclose portal vein, splenic artery and vein, superior mesenteric artery and vein, aorta, and inferior vena cava. While flows in all peri-pancreatic vessels are well recognized, only few parenchymal vessels are usually appreciable in normal conditions. Anyway the increased Doppler sensitivity allows the visualization of smaller peri-pancreatic and intra-pancreatic vessels. This article will review the technical background underlying the clinical application of Doppler ultrasonography in pancreatic imaging, with particular emphasis to normal vascular anatomy of the pancreas, and to the main applications of Doppler techniques in the different pancreatic pathologies.

Contrast-Enhanced Endoscopic Ultrasonography (CE-EUS) Improves Visualization of Pancreatic Vasculature

Neovascularization in neoplasms may enable improved visualization with EUS if a contrast agent is used. Lipid microspheres are an established diagnostic tool for increasing contrast of vascular structures in echocardiography. Aim: To evaluate the potential utility of contrast enhanced EUS (CE-EUS) in the characterization of pancreatic lesions in a porcine model. Methods: 3 anesthesized 50kg pigs underwent EUS. For optimal visualization, the ultrasound mechanical index was decreased to 0.3. 2 mL of Perflutren lipid microspheres (5uL/kg) (Definity®) were administered by peripheral IV. The pancreas and peri-pancreatic vessels were re-imaged. To create an animal model of pancreatic microvascular disruption, 0.5 mL of 50% ethanol plus purified carbon particle solution (GI Spot®) was injected with an Olympus® 22g EUS-FNA needle into the body of the pancreas. 24–48 hours post ethanol-injection, the pancreas was re-evaluated. Standard and CE-EUS imaging of the pancreas were compared. Post-mortem examination was performed. Results: With conventional EUS, there was minimal color flow within the pancreatic parenchyma. Within 30 seconds of injection of microspheres, the microvasculature of the pancreas was well visualized with increased color flow. The microspheres were also well seen in the peri-pancreatic vessels. The mean duration CE-EUS visualization was 2.29 minutes. Standard EUS imaging showed a subtle 1cm hypoechoic region in the ethanol-treated area. Color and power doppler EUS of this region did not reveal any signal or blood flow. After microsphere injection, color Doppler EUS revealed marked contrast enhancement of normal pancreatic parenchyma from the alcohol-treated area, which on groß examination corresponded to the marked necrotic area. Conclusions: CE-EUS with microspheres improves EUS visualization of the pancreatic microvasculature and delineation of altered vascular perfusion.

Haemorrhagic complication of acute necrotizing pancreatitis presenting with sudden death

Certain complications of acute pancreatitis may lead to death, and of these, haemorrhage caused by rupture of a peri-pancreatic vessel is among the most dangerous. The case reported here was remarkable because the onset of acute necrotizing pancreatitis was completely asymptomatic and the severe haemorrhage of the portal vein that caused the patient’s death was only discovered at autopsy. The onset of abdominal pain was immediately followed by death.

MRI of the pancreas: tumours and tumour-simulating processes

The most important issues in pancreatic imaging are the detection and staging of pancreatic cancer, differentiation between cancer and focal pancreatitis, the characterization of cystic lesions and the search for neuroendocrine tumours. Magnetic resonance (MR) units (1.5 T) with strong gradients and a phased-array torso coil should be used, making breath-hold imaging possible in order to avoid motion artifacts. Standard imaging sequences are T1-weighted (T1w) gradient recalled-echo (GRE) with and without fat saturation. For T2-weighted (T2w) imaging, axial single-shot turbo spin-echo (TSE) and coronal/oblique MR cholangio-pancreatography (MRCP) pulse sequences are preferable. As contrast agents either gadolinium agents or mangafodipir trisodium are used. Dynamic gadolinium-enhanced T1w fatsat 3D GRE images are helpful to delineate vessel infiltration by adenocarcinoma and to assess the aetiology of cystic masses. Mangafodipir-enhanced MRI has been found to be superior to helical computed tomography (CT) in the detection of small cancers and in the delineation of liver metastases. In cases of an equivocal pancreatic mass the presence of the “duct penetrating sign” at MRCP (i.e., the duct traversing the mass) is suggestive of an inflammatory pseudotumour. Hypoattenuation due to focal fatty infiltration may mimic a tumour at CT, but in-phase and opposed-phased T1w imaging readily depicts the fat. Multi-detector CT has gained increasing popularity for pancreatic imaging because of the 3D visualization of the peripancreatic vessels. However, MR imaging is excellent in the delineation of small pancreatic tumours. Due to its superior soft tissue contrast, MR imaging is also the method of choice in the differential diagnosis between tumours and tumour-simulating conditions in patients with equivocal CT and to assess cystic lesions.