Fig. 4

CT images from a 57-year-old male with pancreatic ductal adenocarcinoma in the pancreas head. A Portal venous phase axial contrast-enhanced CT image (window width, 400 HU; window level, 40 HU) obtained using the standard protocol displaying a 3.5 cm hypo-attenuating lesion in the pancreas head (arrows) abutting both the SMV and SMA. B Portal venous phase coronal CT image obtained through the standard protocol also revealed abutment of the pancreatic ductal adenocarcinoma to the SMV. Based on these imaging findings, all three reviewers initially categorized this patient as having borderline resectable pancreatic ductal adenocarcinoma. C Using the high-resolution protocol, a portal venous phase axial contrast-enhanced CT image (window width, 400 HU; window level, 40 HU) also identifies the 3.5 cm hypo-attenuating lesion (highlighted by an arrow) abutting the SMV and SMA. D Notably, the high-resolution coronal CT image reveals luminal narrowing of the SMV due to tumor encasement (indicated by arrows) with an involved length of 2.7 cm. Based on this, two out of the three reviewers reclassified the patient's condition as locally advanced pancreatic ductal adenocarcinoma. While a surgical resection was undertaken, the post-operative histopathologic examination confirmed an R1 resection