Pancreatitis and PDAC: association and differentiation

  • Sherif B. ElsherifEmail author
  • Mayur Virarkar
  • Sanaz Javadi
  • Juan J. Ibarra-Rovira
  • Eric P. Tamm
  • Priya R. Bhosale
Special Section: Pancreatitis


The discrimination of mass-forming chronic pancreatitis (MFCP) from pancreatic ductal adenocarcinoma (PDAC) is a central diagnostic dilemma. It is important to differentiate these entities since they have markedly different prognoses and management. Importantly, the appearance of these two entities significantly overlaps on a variety of imaging modalities. However, there are imaging features that may be suggestive of one entity more than the other. MFCP and PDAC may show different enhancement patterns on perfusion computed tomography (CT) and/or dynamic contrast-enhanced MRI (DCE-MRI). The duct-penetrating sign on magnetic resonance cholangiopancreatography (MRCP) is more often associated with MFCP, whereas abrupt cutoff with upstream dilatation of the main pancreatic duct and the double-duct sign (obstruction/cutoff of both the common bile duct and pancreatic duct) are more often associated with PDAC. Nevertheless, tissue sampling is the most reliable method to differentiate between these entities and is currently generally necessary for management.


Pancreatitis Pancreatic cancer Mass-forming chronic pancreatitis Pancreatic ductal adenocarcinoma MRCP 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Raimondi S, Lowenfels AB, Morselli-Labate AM, Maisonneuve P, Pezzilli R (2010) Pancreatic cancer in chronic pancreatitis; aetiology, incidence, and early detection. Best Pract Res Clin Gastroenterol 24 (3):349-358. CrossRefPubMedGoogle Scholar
  2. 2.
    Harmsen FR, Domagk D, Dietrich CF, Hocke M (2018) Discriminating chronic pancreatitis from pancreatic cancer: Contrast-enhanced EUS and multidetector computed tomography in direct comparison. Endoscopic ultrasound 7 (6):395-403. CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Tajima Y, Kuroki T, Tsutsumi R, Isomoto I, Uetani M, Kanematsu T (2007) Pancreatic carcinoma coexisting with chronic pancreatitis versus tumor-forming pancreatitis: diagnostic utility of the time-signal intensity curve from dynamic contrast-enhanced MR imaging. World J Gastroenterol 13 (6):858-865CrossRefGoogle Scholar
  4. 4.
    Yin Q, Zou X, Zai X, Wu Z, Wu Q, Jiang X, Chen H, Miao F (2015) Pancreatic ductal adenocarcinoma and chronic mass-forming pancreatitis: Differentiation with dual-energy MDCT in spectral imaging mode. Eur J Radiol 84 (12):2470-2476. CrossRefPubMedGoogle Scholar
  5. 5.
    Kennedy T, Preczewski L, Stocker SJ, Rao SM, Parsons WG, Wayne JD, Bell RH, Talamonti MS (2006) Incidence of benign inflammatory disease in patients undergoing Whipple procedure for clinically suspected carcinoma: a single-institution experience. Am J Surg 191 (3):437-441. CrossRefPubMedGoogle Scholar
  6. 6.
    Ichikawa T, Sou H, Araki T, Arbab AS, Yoshikawa T, Ishigame K, Haradome H, Hachiya J (2001) Duct-penetrating sign at MRCP: usefulness for differentiating inflammatory pancreatic mass from pancreatic carcinomas. Radiology 221 (1):107-116. CrossRefPubMedGoogle Scholar
  7. 7.
    van Gulik TM, Moojen TM, van Geenen R, Rauws EA, Obertop H, Gouma DJ (1999) Differential diagnosis of focal pancreatitis and pancreatic cancer. Ann Oncol 10 Suppl 4:85-88CrossRefGoogle Scholar
  8. 8.
    Cho SG, Lee DH, Lee KY, Ji H, Lee KH, Ros PR, Suh CH (2005) Differentiation of chronic focal pancreatitis from pancreatic carcinoma by in vivo proton magnetic resonance spectroscopy. J Comput Assist Tomogr 29 (2):163-169CrossRefGoogle Scholar
  9. 9.
    Niederau C, Grendell JH (1992) Diagnosis of pancreatic carcinoma. Imaging techniques and tumor markers. Pancreas 7 (1):66-86PubMedGoogle Scholar
  10. 10.
    Kim T, Murakami T, Takamura M, Hori M, Takahashi S, Nakamori S, Sakon M, Tanji Y, Wakasa K, Nakamura H (2001) Pancreatic mass due to chronic pancreatitis: correlation of CT and MR imaging features with pathologic findings. AJR Am J Roentgenol 177 (2):367-371. CrossRefPubMedGoogle Scholar
  11. 11.
    Neff CC, Simeone JF, Wittenberg J, Mueller PR, Ferrucci JT, Jr. (1984) Inflammatory pancreatic masses. Problems in differentiating focal pancreatitis from carcinoma. Radiology 150 (1):35-38. CrossRefGoogle Scholar
  12. 12.
    Yadav AK, Sharma R, Kandasamy D, Pradhan RK, Garg PK, Bhalla AS, Gamanagatti S, Srivastava DN, Sahni P, Upadhyay AD (2016) Perfusion CT - Can it resolve the pancreatic carcinoma versus mass forming chronic pancreatitis conundrum? Pancreatology 16 (6):979-987. CrossRefPubMedGoogle Scholar
  13. 13.
    Levy MJ, Wiersema MJ (2002) Endoscopic ultrasound in the diagnosis and staging of pancreatic cancer. Oncology (Williston Park) 16 (1):29-38, 43; discussion 44, 47-29, 53-26Google Scholar
  14. 14.
    Gonçalves B, Soares JB, Bastos P (2015) Endoscopic Ultrasound in the Diagnosis and Staging of Pancreatic Cancer. GE Portuguese journal of gastroenterology 22 (4):161-171. CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Bollen TL, van Santvoort HC, Besselink MG, van Es WH, Gooszen HG, van Leeuwen MS (2007) Update on acute pancreatitis: ultrasound, computed tomography, and magnetic resonance imaging features. Semin Ultrasound CT MR 28 (5):371-383CrossRefGoogle Scholar
  16. 16.
    Manikkavasakar S, AlObaidy M, Busireddy KK, Ramalho M, Nilmini V, Alagiyawanna M, Semelka RC (2014) Magnetic resonance imaging of pancreatitis: an update. World J Gastroenterol 20 (40):14760-14777. CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Balci NC, Bieneman BK, Bilgin M, Akduman IE, Fattahi R, Burton FR (2009) Magnetic resonance imaging in pancreatitis. Top Magn Reson Imaging 20 (1):25-30. CrossRefPubMedGoogle Scholar
  18. 18.
    Thoeni RF (2015) Imaging of Acute Pancreatitis. Radiol Clin North Am 53 (6):1189-1208. CrossRefPubMedGoogle Scholar
  19. 19.
    Porter KK, Cason DE, Morgan DE (2018) Acute Pancreatitis: How Can MR Imaging Help. Magn Reson Imaging Clin N Am 26 (3):439-450. CrossRefPubMedGoogle Scholar
  20. 20.
    Walling A, Freelove R (2017) Pancreatitis and Pancreatic Cancer. Prim Care 44 (4):609-620. CrossRefPubMedGoogle Scholar
  21. 21.
    Jee KN (2018) Mass forming chronic pancreatitis mimicking pancreatic cystic neoplasm: A case report. World J Gastroenterol 24 (2):297-302. CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Guarneri G, Gasparini G, Crippa S, Andreasi V, Falconi M (2019) Diagnostic strategy with a solid pancreatic mass. Presse Med 48 (3 Pt 2):e125-e145. CrossRefPubMedGoogle Scholar
  23. 23.
    Conwell DL, Lee LS, Yadav D, Longnecker DS, Miller FH, Mortele KJ, Levy MJ, Kwon R, Lieb JG, Stevens T, Toskes PP, Gardner TB, Gelrud A, Wu BU, Forsmark CE, Vege SS (2014) American Pancreatic Association Practice Guidelines in Chronic Pancreatitis: evidence-based report on diagnostic guidelines. Pancreas 43 (8):1143-1162. CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Khandelwal A, Shanbhogue AK, Takahashi N, Sandrasegaran K, Prasad SR (2014) Recent advances in the diagnosis and management of autoimmune pancreatitis. AJR Am J Roentgenol 202 (5):1007-1021. CrossRefPubMedGoogle Scholar
  25. 25.
    Fattahi R, Balci NC, Perman WH, Hsueh EC, Alkaade S, Havlioglu N, Burton FR (2009) Pancreatic diffusion-weighted imaging (DWI): comparison between mass-forming focal pancreatitis (FP), pancreatic cancer (PC), and normal pancreas. J Magn Reson Imaging 29 (2):350-356. CrossRefPubMedGoogle Scholar
  26. 26.
    Duggan SN, HM NC, Lawal O, O’Connor DB, Conlon KC (2016) Chronic pancreatitis: A diagnostic dilemma. World J Gastroenterol 22 (7):2304-2313. CrossRefGoogle Scholar
  27. 27.
    Zhang XM, Shi H, Parker L, Dohke M, Holland GA, Mitchell DG (2003) Suspected early or mild chronic pancreatitis: enhancement patterns on gadolinium chelate dynamic MRI. Magnetic resonance imaging. J Magn Reson Imaging 17 (1):86-94. CrossRefGoogle Scholar
  28. 28.
    Miller FH, Keppke AL, Wadhwa A, Ly JN, Dalal K, Kamler VA (2004) MRI of pancreatitis and its complications: part 2, chronic pancreatitis. AJR Am J Roentgenol 183 (6):1645-1652. CrossRefPubMedGoogle Scholar
  29. 29.
    Ilic M, Ilic I (2016) Epidemiology of pancreatic cancer. World J Gastroenterol 22 (44):9694-9705. CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Tong GX, Geng QQ, Chai J, Cheng J, Chen PL, Liang H, Shen XR, Wang DB (2014) Association between pancreatitis and subsequent risk of pancreatic cancer: a systematic review of epidemiological studies. Asian Pac J Cancer Prev 15 (12):5029-5034CrossRefGoogle Scholar
  31. 31.
    Zhang L, Sanagapalli S, Stoita A (2018) Challenges in diagnosis of pancreatic cancer. World J Gastroenterol 24 (19):2047-2060. CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Ma X, Zhao X, Ouyang H, Sun F, Zhang H, Zhou C (2014) Quantified ADC histogram analysis: a new method for differentiating mass-forming focal pancreatitis from pancreatic cancer. Acta Radiol 55 (7):785-792. CrossRefPubMedGoogle Scholar
  33. 33.
    Balachandran A, Bhosale PR, Charnsangavej C, Tamm EP (2014) Imaging of pancreatic neoplasms. Surg Oncol Clin N Am 23 (4):751-788. CrossRefPubMedGoogle Scholar
  34. 34.
    Lu N, Feng XY, Hao SJ, Liang ZH, Jin C, Qiang JW, Guo QY (2011) 64-slice CT perfusion imaging of pancreatic adenocarcinoma and mass-forming chronic pancreatitis. Acad Radiol 18 (1):81-88. CrossRefPubMedGoogle Scholar
  35. 35.
    Kirkegard J, Mortensen FV, Cronin-Fenton D (2017) Chronic Pancreatitis and Pancreatic Cancer Risk: A Systematic Review and Meta-analysis. Am J Gastroenterol 112 (9):1366-1372. CrossRefPubMedGoogle Scholar
  36. 36.
    Shadhu K, Xi C (2019) Inflammation and pancreatic cancer: An updated review. Saudi J Gastroenterol 25 (1):3-13. CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Pinho AV, Chantrill L, Rooman I (2014) Chronic pancreatitis: a path to pancreatic cancer. Cancer Lett 345 (2):203-209. CrossRefPubMedGoogle Scholar
  38. 38.
    Jha P, Yeh BM, Zagoria R, Collisson E, Wang ZJ (2018) The Role of MR Imaging in Pancreatic Cancer. Magn Reson Imaging Clin N Am 26 (3):363-373. CrossRefPubMedGoogle Scholar
  39. 39.
    Ahualli J (2007) The double duct sign. Radiology 244 (1):314-315. CrossRefPubMedGoogle Scholar
  40. 40.
    Toft J, Hadden WJ, Laurence JM, Lam V, Yuen L, Janssen A, Pleass H (2017) Imaging modalities in the diagnosis of pancreatic adenocarcinoma: A systematic review and meta-analysis of sensitivity, specificity and diagnostic accuracy. Eur J Radiol 92:17-23. CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Vachiranubhap B, Kim YH, Balci NC, Semelka RC (2009) Magnetic resonance imaging of adenocarcinoma of the pancreas. Top Magn Reson Imaging 20 (1):3-9. CrossRefPubMedGoogle Scholar
  42. 42.
    Ichikawa T, Erturk SM, Motosugi U, Sou H, Iino H, Araki T, Fujii H (2007) High-b value diffusion-weighted MRI for detecting pancreatic adenocarcinoma: preliminary results. AJR Am J Roentgenol 188 (2):409-414. CrossRefPubMedGoogle Scholar
  43. 43.
    Kim JK, Altun E, Elias J, Jr., Pamuklar E, Rivero H, Semelka RC (2007) Focal pancreatic mass: distinction of pancreatic cancer from chronic pancreatitis using gadolinium-enhanced 3D-gradient-echo MRI. J Magn Reson Imaging 26 (2):313-322. CrossRefPubMedGoogle Scholar
  44. 44.
    Tamm EP, Balachandran A, Bhosale PR, Katz MH, Fleming JB, Lee JH, Varadhachary GR (2012) Imaging of pancreatic adenocarcinoma: update on staging/resectability. Radiol Clin North Am 50 (3):407-428. CrossRefPubMedGoogle Scholar
  45. 45.
    Chung YS, Ho JJ, Kim YS, Tanaka H, Nakata B, Hiura A, Motoyoshi H, Satake K, Umeyama K (1987) The detection of human pancreatic cancer-associated antigen in the serum of cancer patients. Cancer 60 (7):1636-1643CrossRefGoogle Scholar
  46. 46.
    DelMaschio A, Vanzulli A, Sironi S, Castrucci M, Mellone R, Staudacher C, Carlucci M, Zerbi A, Parolini D, Faravelli A, et al. (1991) Pancreatic cancer versus chronic pancreatitis: diagnosis with CA 19-9 assessment, US, CT, and CT-guided fine-needle biopsy. Radiology 178 (1):95-99. CrossRefPubMedGoogle Scholar
  47. 47.
    Lammer J, Herlinger H, Zalaudek G, Hofler H (1985) Pseudotumorous pancreatitis. Gastrointest Radiol 10 (1):59-67. CrossRefPubMedGoogle Scholar
  48. 48.
    Hamano H, Arakura N, Muraki T, Ozaki Y, Kiyosawa K, Kawa S (2006) Prevalence and distribution of extrapancreatic lesions complicating autoimmune pancreatitis. J Gastroenterol 41 (12):1197-1205. CrossRefPubMedGoogle Scholar
  49. 49.
    Hocke M, Ignee A, Dietrich CF (2012) Advanced endosonographic diagnostic tools for discrimination of focal chronic pancreatitis and pancreatic carcinoma–elastography, contrast enhanced high mechanical index (CEHMI) and low mechanical index (CELMI) endosonography in direct comparison. Z Gastroenterol 50 (2):199-203. CrossRefPubMedGoogle Scholar
  50. 50.
    Elmas N, Oran I, Oyar O, Ozer H (1996) A new criterion in differentiation of pancreatitis and pancreatic carcinoma: artery-to-vein ratio using the superior mesenteric vessels. Abdom Imaging 21 (4):331-333CrossRefGoogle Scholar
  51. 51.
    Karasawa E, Goldberg HI, Moss AA, Federle MP, London SS (1983) CT pancreatogram in carcinoma of the pancreas and chronic pancreatitis. Radiology 148 (2):489-493. CrossRefPubMedGoogle Scholar
  52. 52.
    Gu X, Liu R (2016) Application of 18F-FDG PET/CT combined with carbohydrate antigen 19-9 for differentiating pancreatic carcinoma from chronic mass-forming pancreatitis in Chinese elderly. Clin Interv Aging 11:1365-1370. CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Lee SS, Byun JH, Park BJ, Park SH, Kim N, Park B, Kim JK, Lee MG (2008) Quantitative analysis of diffusion-weighted magnetic resonance imaging of the pancreas: usefulness in characterizing solid pancreatic masses. J Magn Reson Imaging 28 (4):928-936. CrossRefPubMedGoogle Scholar
  54. 54.
    Momtahen AJ, Balci NC, Alkaade S, Akduman EI, Burton FR (2008) Focal pancreatitis mimicking pancreatic mass: magnetic resonance imaging (MRI)/magnetic resonance cholangiopancreatography (MRCP) findings including diffusion-weighted MRI. Acta Radiol 49 (5):490-497. CrossRefPubMedGoogle Scholar
  55. 55.
    Johnson PT, Outwater EK (1999) Pancreatic carcinoma versus chronic pancreatitis: dynamic MR imaging. Radiology 212 (1):213-218. CrossRefPubMedGoogle Scholar
  56. 56.
    Zhang TT, Wang L, Liu HH, Zhang CY, Li XM, Lu JP, Wang DB (2017) Differentiation of pancreatic carcinoma and mass-forming focal pancreatitis: qualitative and quantitative assessment by dynamic contrast-enhanced MRI combined with diffusion-weighted imaging. Oncotarget 8 (1):1744-1759. CrossRefPubMedGoogle Scholar
  57. 57.
    Huang WC, Sheng J, Chen SY, Lu JP (2011) Differentiation between pancreatic carcinoma and mass-forming chronic pancreatitis: usefulness of high b value diffusion-weighted imaging. J Dig Dis 12 (5):401-408. CrossRefPubMedGoogle Scholar
  58. 58.
    Matsuki M, Inada Y, Nakai G, Tatsugami F, Tanikake M, Narabayashi I, Masuda D, Arisaka Y, Takaori K, Tanigawa N (2007) Diffusion-weighed MR imaging of pancreatic carcinoma. Abdom Imaging 32 (4):481-483. CrossRefPubMedGoogle Scholar
  59. 59.
    Wang Y, Chen ZE, Nikolaidis P, McCarthy RJ, Merrick L, Sternick LA, Horowitz JM, Yaghmai V, Miller FH (2011) Diffusion-weighted magnetic resonance imaging of pancreatic adenocarcinomas: association with histopathology and tumor grade. J Magn Reson Imaging 33 (1):136-142. CrossRefPubMedGoogle Scholar
  60. 60.
    Wiggermann P, Grutzmann R, Weissenbock A, Kamusella P, Dittert DD, Stroszczynski C (2012) Apparent diffusion coefficient measurements of the pancreas, pancreas carcinoma, and mass-forming focal pancreatitis. Acta Radiol 53 (2):135-139. CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.The Department of Diagnostic RadiologyThe University of Texas M. D. Anderson Cancer CenterHoustonUSA
  2. 2.The Department of Internal MedicineWeiss Memorial Hospital, Affiliate of the University of Illinois at ChicagoChicagoUSA

Personalised recommendations