Download Pancreatobiliary Imaging in a Patient with Pancreatic Adenocarcinoma

Carl Lokko, HMS III
Gillian Lieberman, MD
November 2010
Pancreatobiliary Imaging in a
Patient with Pancreatic
Adenocarcinoma
Carl Lokko
Harvard Medical School Year III
Gillian Lieberman, MD
Carl Lokko, HMS III
Gillian Lieberman, MD
Presentation
52-year old female with jaundice, epigastric
pain, and weakness
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Carl Lokko, HMS III
Gillian Lieberman, MD
Jaundice
• Production
• Metabolism
• Obstruction
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Carl Lokko, HMS III
Gillian Lieberman, MD
Physical and Labs
• Afebrile and hemodynamically stable with
BP 150/81, HR 68
• Abdomen soft and non-tender
• WBC 8.6
• LFTs
– ALT 265, AST 225, Alk phos 897
– Tbili 15.0, direct bili 11.8
• normal amylase and lipase.
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Clinical Reasoning
• The picture created by the labs and the
presentation were quite suggestive of an
obstructive process.
• Distal obstruction can account for the RUQ
pain as well as the jaundice and elevated
LFTs.
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Carl Lokko, HMS III
Gillian Lieberman, MD
Anatomy of RUQ
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http://www.arizonatransplant.com/images/pancreas_large_1.JPG (www.medivisuals.com)
Carl Lokko, HMS III
Gillian Lieberman, MD
RUQ Pain
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Cholecystitis
Cholangitis
Choledocholithiasis
Cholelithiasis (80% asymptomatic)
Viral/drug hepatitides
Tumor
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Carl Lokko, HMS III
Gillian Lieberman, MD
Cholangitis
• Charcot Triad
– Fever (often with leukocytosis)
– Jaundice
– Right upper quadrant pain
• Reynold Pentad
– Altered mental status
– Shock
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Carl Lokko, HMS III
Gillian Lieberman, MD
Imaging Options
http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonGastrointestinalImaging/JaundiceDoc7.aspx
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Carl Lokko, HMS III
Gillian Lieberman, MD
RUQ US
Evidence of cholecystitis
Major criteria
• sonographic Murphy’s sign
• cholelithiasis
Minor criteria
• thickened gall bladder wall greater than 3mm
• pericholecystic fluid
• gall bladder dilatation
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Carl Lokko, HMS III
Gillian Lieberman, MD
Our Patient’s Dilated Gallbladder on US
• Distended
GB
• Dilated
cystic duct
PACS, BIDMC
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Carl Lokko, HMS III
Gillian Lieberman, MD
US
• RUQ US
– No definitive intraluminal stones/sludge
– No sonographic Murphy’s sign
– No gallbladder wall thickening
– No pericholecystic fluid
– dilated CBD to 1.1cm
– intrahepatic biliary dilatation in the right lobe of the
liver, concerning for obstructive lesion or stone
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Carl Lokko, HMS III
Gillian Lieberman, MD
Gallbladder US
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PACS, BIDMC
Carl Lokko, HMS III
Gillian Lieberman, MD
Distal Obstruction Ddx
Pancreatic carcinoma
Pancreatitis
Ampullary Carcinoma
Lymphadenopathy
Pseudocyst
Stricture (post surgical)
Ampulla of Vater/Sphincter of Oddi dysfunction
Lymphoma
Benign bile duct tumor
Parasites
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Carl Lokko, HMS III
Gillian Lieberman, MD
EUS and CT
• Endoscopic Ultrasound
– Stones, Masses, Cysts
– Staging local tumors and nodes
– US guided FNA
• CT
– Diagnosis and staging
– Distant metastasis
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Carl Lokko, HMS III
Gillian Lieberman, MD
CT abdomen
• CT abd/pelvis
– irregular 1.4 x 1.5 x 1.2cm mass in pancreatic
head uncinate region
– mild pancreatic duct dilation to 5mm and CBD
dilation to 1.3cm with abrupt taper at the
region of the mass
– no definitive findings of metastases in the
abdomen/pelvis
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Carl Lokko, HMS III
Gillian Lieberman, MD
Our Patient’s CT
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Axial, C+, Portal venous phase CT
Axial, C+, arterial phase CT
Malignant somatostatinoma in companion patient 1
presenting as a hypo attenuating mass (arrow)
Sheila Sheth. http://www.ajronline.org/cgi/content/full/179/3/725/FIG2
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PACS, BIDMC
Tail of pancreas
Celiac artery
Inferior Vena Cava
Portal Vein
Hypoattenuating mass in head of pancreas (measured)
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Carl Lokko, HMS III
Gillian Lieberman, MD
CT Appearance of Various
Pancreatic tumors
• Pancreatic adenocarcinoma
– Hypoattenuating mass
• Islet cell tumor (hypoechoic on US)
– Hypervascular
• Mucinous cystic tumor –potentially malignant
– Most commonly multilocular dilated ducts, thick internal septa
– Hypovascular
• Serous cystadenoma (microcystic adenoma)
– Hyperattenuating
– Honeycomb appearance/Swiss cheese
– sunburst central calcification spongy mass (10%)
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Carl Lokko, HMS III
Gillian Lieberman, MD
CT protocols for imaging pancreatic
masses
• Parenchymal phase and portal venous
phase superior to arterial phase
– tumor-to-pancreas attenuation difference
– tumor conspicuity.
• Phase timing
– Arterial 25-40s
– Parenchymal 40s
– Venous 50s
– Portal venous 60-85s
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Carl Lokko, HMS III
Gillian Lieberman, MD
Pancreatic Cancer: Some Facts
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Adenocarcinoma is 90% of all pancreatic tumors.
More common in men than women.
More common in African Americans.
Mean age of 60-80 years.
Several known risk factors include cigarette smoking,
hereditary nonpolyposis colon cancer, Peutz-Jeghers,
and BRCA-2.
• Pain and weight loss are the most common presenting
symptoms. Jaundice occurs in patients with tumors
located in the pancreatic head that cause biliary
obstruction.
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Carl Lokko, HMS III
Gillian Lieberman, MD
ERCP
• Endoscopic Retrograde
Cholangiopancreatography
– Lower complication rate than Percutaneous
Transhepatic Cholangiography
Allows for:
– Endoscopic directed brushing
– Stent placement and drainage
– Stone extraction
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Carl Lokko, HMS III
Gillian Lieberman, MD
Diagram of ERCP Stent Placement
From Brugge WR, Van Dam J. Pancreatic and Biliary Endoscopy. N Engl J Med 1999; 341: 1808-16.
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Carl Lokko, HMS III
Gillian Lieberman, MD
Our Patient’s Obstruction on ERCP
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Abnormal narrowing of distal CBD and pancreatic duct.
Dilatation of proximal CBP and pancreatic ducts- double duct sign.
Common bile
duct
Pancreatic
duct
PACS, BIDMC 23
Abnormal narrowing
from mass
PACS, BIDMC
Carl Lokko, HMS III
Gillian Lieberman, MD
ERCP of Companion Patient 2
Biliary Tree
Guide wire
Surgical clips
Common bile
duct
PACS, BIDMC
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Carl Lokko, HMS III
Gillian Lieberman, MD
Possible ERCP Findings in
Pancreatic Adenocarcinoma
• Double-duct sign– dilation of both the pancreatic and common
bile ducts
• Biductal lesions less than 1 cm apart
• Abrupt stricture with irregular margins
• Complete or high-grade obstruction of the
CBD
• Rat-tail or nipplelike occlusion of CBD
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Carl Lokko, HMS III
Gillian Lieberman, MD
Cytology
ERCP brushing reveals malignant cells
consistent with pancreatic adenocarcinoma
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Carl Lokko, HMS III
Gillian Lieberman, MD
Pancreatic Adenocarcinoma
• 4th leading cause of death by cancer
• 5 year survival 5%
• Treatment options
– Surgery is only curative
– Chemotherapy + radiation
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Carl Lokko, HMS III
Gillian Lieberman, MD
Pancreatic Cancer Surgical Approach
• Determine radiographically if the lesion is
resectable
– CT
– MRI (MRCP) if CT is contraindicated
• Resectable lesions
– Staging laparoscopy
– Open exploration
• Whipple procedure
• Palliative operations
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Carl Lokko, HMS III
Gillian Lieberman, MD
Vascular Neighborhood
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http://academic.kellogg.edu/herbrandsonc/bio201_mckinley/f20-13at_pancreas_c.jpg
Carl Lokko, HMS III
Gillian Lieberman, MD
Resectability Criteria
• Encasement or obstruction of vasculature
– arterial encasement,
– > 50% venous encasement
• Evidence of metastasis
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Liver
Nodes
Mesentery (peritoneal carcinomatosis)
Adjacent organs
• Diameter > 5 cm
Only 10-15% of cancers are resectable at presentation.
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Carl Lokko, HMS III
Gillian Lieberman, MD
Resectability
• CT determination of nonresectability
– Positive predictive value ranges from 89% to
100%
– Negative predictive value ranges from 74% to
79%
• EUS is more accurate for local T and N
staging and predicting vascular invasion
• CT also detects distant metastasis.
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Carl Lokko, HMS III
Gillian Lieberman, MD
Resectability cont.
• Radiographically resectable cancer with
normal tissue plane between mass and
the SMA and SMV.
Joseph Fischer. Mastery of Surgery 2007
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Carl Lokko, HMS III
Gillian Lieberman, MD
Operation
• Negative staging laparoscopy
• Open staging
– Hard nodule roughly 5 mm in size in the upper
surface of segment 5.
• Pathology
– frozen section analysis yielded metastatic
adenocarcinoma of pancreatic origin.
• Palliative mode.
– Cholecystectomy
– gastroenterostomy
– biliary bypass with Roux-en-Y choledochojejunostomy
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Carl Lokko, HMS III
Gillian Lieberman, MD
Non-surgical Treatment of
Pancreatic Adenocarcinoma
• 5-FU and gemcitabine are main chemotherapeutic
agents
• Metal or plastic stents may be placed for resolution of
jaundice and biliary obstruction
• Celiac plexus blocks may be used for pain treatment.
• Chemoradiotherapy
– concurrent chemotherapy to EBRT modestly improves outcomes
compared to either alone in patients with locally advanced
pancreatic cancer.
– cancer-related pain is diminished and cachexia and obstructive
symptoms may also improve.
– Radiotherapy for patients with locally confined disease may
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result in downstaging and resectability
Carl Lokko, HMS III
Gillian Lieberman, MD
Prognosis of Pancreatic
Adenocarcinoma
• Median survival from diagnosis is less
than 10 months.
• In cases where resection can be
performed, the average survival rate is 18
to 20 months.
• Complete resection has 5-year survival
rates of 18-24%.
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Carl Lokko, HMS III
Gillian Lieberman, MD
An Algorithm
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Carlos Fernandez-del Castillo. Clincal Manifestations, Diagnosis, and Surgical Staging of Exocrine Pancreatic Cancer.UpToDate 18.2
Carl Lokko, HMS III
Gillian Lieberman, MD
Summary
• Use of ultrasound, endoscopic US, endoscopic
retrograde cholangiopancreatography, CT, and
MRI in pancreaticobiliary imaging.
• Appearance of pancreatic malignancies on CT.
• Treatment of pancreatic cancer.
• Algorithm for using imaging in cases of
suspected obstructing lesions.
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Carl Lokko, HMS III
Gillian Lieberman, MD
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Carl Lokko, HMS III
Gillian Lieberman, MD
Acknowledgments
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Behroze Vaccha, MD
Jay Pahade, MD
Adam Jeffers, MD
Laura Myers, HMS III
Gillian Lieberman, MD
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