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Staging Pancreatic Carcinoma and Liver Carcinoma using CT SCAN HHHoldorf CT Scan Computed tomography (CT or CAT scan) is a noninvasive diagnostic imaging procedure that uses a combination of Xrays and computer technology to produce horizontal, or axial, images (often called slices) of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than standard X-rays. CT Scan CT scans may be done with or without "contrast." Contrast refers to a substance taken by mouth and/or injected into an intravenous (IV) line that causes the particular organ or tissue under study to be seen more clearly. Contrast examinations may require you to fast for a certain period of time before the procedure.Your doctor will notify you of this prior to the procedure. Coronal Image Axial Image Patient Preparation Preparation for a CT scan can vary from patient to patient. The X- ray department, your doctor or nurse will tell you what you need to do before you go along for your scan. If your procedure involves the use of contrast dye, you will be asked to sign a consent form that gives permission to do the procedure. Read the form carefully and ask questions if something is not clear. Notify the radiologic technologist if you have ever had a reaction to any contrast dye, or if you are allergic to iodine. Patient Preparation Notify your doctor of all medications (prescribed and over-the- counter) and herbal supplements that you are taking. Notify the technologist if you have any body piercing on your chest and/or abdomen. Based on your medical condition, your doctor may request other specific preparation. Patient Preparation YOU MAY RECEIVE AN INJECTION OF IV CONTRAST (X-RAY DYE) DURING YOUR EXAM If your CT scan is scheduled for the morning: You may have a normal diet until midnight of the day before your test. On the day of the test, you should have clear liquids; no solid foods. We encourage you to drink clear liquids prior to the test. If your CT scan is scheduled for the afternoon or evening: You may have a normal diet until 4 hours prior to your appointment, then you should only have clear liquids until the test is performed. We encourage you to drink clear liquids prior to the test. Diabetic Patients For patients on Metformin * therapy and undergoing procedures involving intravenous administration of contrast, the information, released by the drug manufacturers state that they "should be stopped at the time of, or prior to the procedure." Then, they should be withheld for 48 hours after the procedure. Once renal function is found to be normal, medication therapy can be started again. Your referring physician will be informed of these conditions prior to your study.You should then refer to your physician's instructions for restarting this medication therapy. * Diabetic Patients on METFORMIN therapy which includes brand names such as: ACTOplus, AVANDIMET, AVANDAMET, FORTAMET, GLUCOPHAGE, GLUCOPHAGE XR, GLUCOVANCE, GLUMETZA, METAGLIP, RIOMET Pre-Diagnosis Imaging: US Sound waves and echoes are used to produce a picture of internal organs or masses. This test can show masses (tumors) which can then be tested for cancer, if needed. Very simple exam and uses no radiation For most ultrasound exams, you simply lie on a table while the transducer (which is shaped like a wand) is moved around on the area being looked at. This test is used in people with certain cancer risk factors to help find cancers earlier. Many experts recommend that the test be done every 6 to 12 months. Limitations of CT Scanning A person who is very large may not fit into the opening of a conventional CT scanner or may be over the weight limit— usually 450 pounds—for the moving table. For very large patients, some facilities have extra-large bariatric-capable CT scanners. If this is necessary, contact your doctor for more information. For some conditions, including but not limited to some liver, adrenal, kidney, pancreatic, uterine or ovarian abnormalities, the evaluation and diagnosis with MRI may be preferable over CT scanning. Average Radiation dose RADIATION CT scan, full body CT scan, chest Cardiac Catheterization Nuclear Stress Test - Technician Nuclear Stress Test - Thallium CT scan, brain CT scan, abdomen CT scan, abdomen (liver) CT Scan, pelvis CT Scan, abdomen pelvis CT scan, Chest abdomen Pelvis AMOUNT* 10–12 mSv 7 mSv Up to 22.7 mSv 9.4 mSv 40.7 mSv 2.0 mSv 8 mSv 15 mSv 6mSv 14 mSv 18 mSv We absorb radiation from a variety of sources. How much is too much? Experts say 3 mSv per year is probably OK for most of us; 20 mSv for those who must have medical tests. Pancreatic Carcinoma Anatomy of the Pancreas The pancreas is an elongated, tapered organ located across the back of the abdomen, and behind the stomach. • The right side of the organ (called the head) is the widest part of the organ and lies in the curve of the duodenum (the first section of the small intestine). • The tapered left side extends slightly upward (called the body of the pancreas) and ends near the spleen (called the tail). Anatomy of the Pancreas The pancreas is made up of two types of glands: Exocrine. The exocrine gland secretes digestive enzymes. These enzymes are secreted into a network of ducts that join the main pancreatic duct, which runs the length of the pancreas. Endocrine. The endocrine gland, which consists of the islets of Langerhans, secretes hormones into the bloodstream. Normal pancreas Normal Body of Pancreas, Tail of Pancreas, Splenic Flexure, Splenic Vein What is Pancreatic Carcinoma? Cancer that arises in the pancreas Tumors that affect the exocrine functions are the most common type of pancreatic cancer. Sometimes these tumors or cysts are benign, called cystadenomas. It is more likely to find malignant tumors called adenocarcinomas, which account for 95% of exocrine pancreatic cancers. Other types of pancreatic cancers that are associated with exocrine functions include adenosquamous carcinoma squamous cell carcinomas giant cell carcinomas Tumors that affect the endocrine functions of the pancreas are called neuroendocrine or islet cell tumors, but these are fairly uncommon. These tumors are named for the type of hormone-producing cell that is initially affected. Causes of Pancreatic Carcinoma The exact cause of pancreatic cancer is unknown. It is more common in: People with diabetes People with long-term inflammation of the pancreas (chronic pancreatitis) Smokers A small number of cases are related to genetic syndromes that are passed down through families. Stages of Pancreatic Cancer Using information from staging tests, your doctor assigns your pancreatic cancer a stage. The stages of pancreatic cancer are: Stage I. Cancer is confined to the pancreas. Stage II. Cancer has spread beyond the pancreas to nearby tissues and organs and may have spread to the lymph nodes. Stage III. Cancer has spread beyond the pancreas to the major blood vessels around the pancreas and may have spread to the lymph nodes. Stage IV. Cancer has spread to distant sites beyond the pancreas, such as the liver, lungs and the lining that surrounds your abdominal organs (peritoneum). Pancreatic Carcinoma Statistics Pancreatic cancer is the fourth leading cause of cancer-related death in the United States. In 2010, there were over 43,000 estimated new cases of pancreatic cancer and over 36,000 deaths attributed to it in the United States. It comprises about 2.5 % of all newly diagnosed tumors and 5% of all cancer. The estimated lifetime risk of developing Pancreatic Carcinoma is about 1 in 71 (1.41%). Pancreatic Carcinoma Statistics The disease is rare before age 45 but incidence rises rapidly after that and peaks in the seventh decade of life. It is more common in men (1.5:1) between the age of 60 and 70 years. Pancreatic cancer has a poor prognosis: for all stages combined, the 1- and 5-year relative survival rates are 25% and 6%, respectively for local disease the 5-year survival is approximately 20% the median survival for locally advanced and for metastatic disease, which collectively represent over 80% of individuals, is about 10 and 6 months respectively Clinical Symptoms A tumor or cancer in the pancreas may grow without any symptoms at first. This means pancreatic cancer is often advanced when it is first found. Early symptoms of pancreatic cancer include: Dark urine and clay-colored stools Fatigue and weakness Jaundice (a yellow color in the skin, mucus membranes, or eyes) Loss of appetite and weight loss Nausea and vomiting Pain or discomfort in the upper part of the belly or abdomen Other possible symptoms are: Back pain Blood clots Diarrhea Indigestion Blood test Blood test.Your doctor may test your blood for specific proteins (tumor markers) shed by pancreatic cancer cells. One tumor marker test used in pancreatic cancer is called CA19-9. Some research indicates that the more elevated your level of CA19-9 is, the more advanced the cancer. But the test isn't always reliable, and it isn't clear how best to use the CA199 test results. Some doctors measure your levels before, during and after treatment. Others use it to gauge your prognosis. Why is CT important to Pancreatic CA? CT is the test of choice to help diagnose pancreatic cancer. A CT scan can locate small tumors in the pancreas that might be missed by ultrasound. A CT scan can accurately show whether the mass has extended beyond the pancreas and what the relation is to nearby blood vessels and organs - information vital to a surgeon planning an operation to remove the cancer. If a pancreatic tumor is suspected, then a specialized CT scan, called a pancreatic protocol scan, is preferred prior to surgery. CT Protocol Depending on the type of multidetector CT, 120 - 150 ml contrast is given at an injection rate of 3-5 ml/s. Slice thickness depends on the type of scanner that is used, but should be preferentially 2-3 mm or less. An early arterial phase-scan (delay 30 sec) does not add significant information on the staging of the pancreas tumor, since there is not enough contrast in the pancreas. Only if the surgeons want to get optimal pre-operative 3Dinformation on the anatomy of the mesenteric arteries this phase is included. Early Portal Phase The early-portal phase is also called the pancreatic phase. It has a scan-delay of 40-50 sec. This is the most important phase for detecting and staging a pancreatic tumor. At that moment the normal pancreatic parenchyma will enhance optimally, because it gets all of its blood supply through the arterial and capillary system. In this phase there is optimal attenuation difference between the hypodense tumor and the normal enhancing pancreatic parenchyma. This phase helps in the differentiation of liver lesions and usually the mesenteric arteries and veins are well opacified. Late Portal Phase The 'late portal' or hepatic phase has a scan-delay of 70-80 sec. At that moment the normal liver parenchyma will enhance optimally, because normal liver cells get 80% of their blood supply through the portal venous system. Liver metastases do not get their blood supply from the portal venous system and will be seen in this phase as hypovascular or hypodense lesions. This phase is performed for the overall assessment of the abdomen to look for liver metastases, lymphnodes and peritoneal implants. This phase is also helpful for local staging of the tumor and detection of venous ingrowth. CT of Pancreatic Carcinoma As pancreatic carcinoma is a hypovascular tumor, it presents as a hypodense mass on a CECT (contrast enhanced CT) The mass is usually ill-defined. In 10 - 15% the tumor is isodense and therefore may be difficult to detect. Tumors smaller than 2 cm may also be difficult to detect on CECT. In these cases indirect signs may be helpful such as the presence of the double duct sign, atrophy of the pancreatic tail, or fullness of the pancreatic head (loss of the lobular appearance of the pancreatic parenchyma). CT of Abnormal Pancreas Dynamic contrast enhanced axial CT image of a 55-year-old man with known pancreatic adenocarcinoma. A hypodense, mildly enhancing mass is seen in the pancreatic head and neck involving the common bile duct and proximal portal vein. CT of Abnormal Pancreas CT of Abnormal Pancreas Results of CT with contrast, including evidence of a mass in the pancreas just anterior to the portal vein (2.8cm maximum diameter) and a second mass in the pancreas head (3.5cm maximum diameter) CT of Abnormal Pancreas CT scan of the abdomen, axial section, showing pancreatic cancer CT of Pancreas Treatment Options for treatment include Surgical removal (called resection) Chemotherapy (treatment with drugs that kill the cancer cells) Radiotherapy (using radiation to kill cancer cells) As well as treatment for pain and other symptoms and complications of the disease. Liver Carcinoma Liver Anatomy The liver is located in the upper right-hand portion of the abdominal cavity, beneath the diaphragm, and on top of the stomach, right kidney, and intestines. Shaped like a cone dark reddish-brown organ, weighs 3 pounds There are two distinct sources that supply blood to the liver, including the following: oxygenated blood flows in from the hepatic artery nutrient-rich blood flows in from the hepatic portal vein The liver consists of two main lobes, both of which are made up of thousands of lobules. The hepatic duct transports the bile produced by the liver cells to the gallbladder and duodenum CT LIVER Anatomy CT Liver Anatomy What is Liver Carcinoma? Cancer that arises from the liver AKA primary liver cancer or hepatoma The liver is made up of different cells types including bile duct, blood vessels, and fat storing cells. Hepatocytes make up 80% of liver tissue Therefore the majority of primary liver cancers arise from these cells (Hepatocellular carcinoma) Liver Carcinoma Statistics Frequency in Southeast Asia and Sub-Saharan Africa is greater than 100 cases per 100,000 population. Frequency in North American and Europe is less than five cases per 100,000 population This reflects the prevalence of hepatitis B which is the most common cause of liver cancer worldwide. Liver Carcinoma Statistics The frequency of liver carcinoma in the U.S. is rising due to an increase in obesity, diabetes, hepatitis C, and other liver infections Frequently spreads to lung through bloodstream Rarely can spread to brain or bone Clinical Symptoms Unexplained weight loss and fevers are warning signs for patients with cirrhosis Sudden complications including ascites, jaundice, or muscle wasting Esophageal Varices (When CA invades and blocks portal vein there is an increased pressure in the vein which causes them to become dilated which may result in esophageal varices) Clinical Symptoms On physical examination: an enlarged and tender liver Since cancers are very vascular, increased amounts of blood to the hepatic artery which will cause turbulent flow Nausea and vomiting Enlarged spleen Abdominal pain or pain near the right shoulder blade Clinical Symptoms High blood calcium levels (nausea) Low blood sugar levels High red blood cell count High cholesterol levels LAB Work: Why do we use it? To help diagnose liver cancer To help determine what might have caused your liver cancer To learn how well the liver is working, which may affect what types of treatments you can have To get an idea of your general health and how well your other organs are working, which also may affect what types of treatments you can have To see how well treatment is working To look for signs that the cancer has come back after treatment Blood Work AFP: It can be helpful in determining if a liver mass might be cancer. - A low or normal value on this test means it is less likely you have liver cancer - high value makes it more likely The test can be used after treatment as well, to look for possible signs that the cancer has come back (recurred). Kidney function tests: Tests of blood urea nitrogen (BUN) and creatinine levels are often done to assess how well your kidneys are working. Complete blood count (CBC): This test measures levels of red blood cells, white blood cells (which fight infections), and platelets (which help the blood clot). It gives an idea of how well the bone marrow, where new blood cells are made, is functioning. Blood Work Liver function tests (LFTs): A series of blood tests that can help assess the condition of the part of your liver not affected by the cancer. It measures levels of certain substances in your blood that show how well your liver is working. If your liver is not healthy, you might not be able to have surgery to try to cure the cancer, as the surgery might require removal of a large part of your liver. This is a common problem in people with liver cancer. Blood Work Blood clotting tests: The liver also makes proteins that help blood clot when you are bleeding. A damaged liver may not make enough of these clotting factors, which could increase your risk of bleeding.Your doctor may order blood tests such as a prothrombin time (PT) to help assess this risk. Tests for viral hepatitis: If liver cancer has not yet been diagnosed, your doctor may order blood tests to check for hepatitis B and C. Results showing you have been infected with either of these viruses may make it more likely that you have liver cancer. Why is CT important to Liver Carcinoma? CT has a high sensibility and specificity for detecting liver carcinoma Most accurate modality for detecting liver carcinoma when contrast is used CT is preferred because it out performs US and MRI Easily accessible Quickly performed If contrasts cannot be administered due to an allergy or renal insufficiency the accuracy of the CT will be poor and an MRI should be performed. Imaging to Enhance Liver CT Contrast is routinely used for imaging the liver Improves contrast to noise ratio between lesions and normal liver tissue Limitations: need for radiation dose and low sensitivity for the detections and characterization of lesions small than 1cm Four phases: - pre contrast - arterial phase - portal venous phase - delayed phase Imaging to Enhance Liver CT Pre contrast of Liver CT : Used to detect: Calcifications Hemorrhage from trauma Arterial Phase: Performed approximately 30 seconds after the injection (bolus) Hypervascular lesions will enhance during this phase and appear hyperdense Used as preoperative evaluation Imaging to Enhance Liver CT Portal Venous phase 60-65 seconds post contrast Hypovascular lesions appear as hypodense Hypervascular lesions appear as isodense (same as surrounding liver) Delayed Phase -5 -10 minutes post contrast -used to further characterize lesions Post Diagnosis Imaging MRI has emerged as the best imaging test for liver lesion detection and characterization This modality provides high lesion-to-liver contrast No ionizing radiation Recent advances: breath-hold 3D imaging and rapid half-Fourier acquisition help image the liver in a single breath-hold with a high spatial resolution CT Imaging CT scan in the hepatic arterial phase of contrast enhancement showing neo-vascularity in a low-density hepatic mass. CT of Abnormal Liver CT Imaging Normal CT Scan Normal liver on CT scan, with smooth liver contours; normal size spleen Abnormal CT Scan Cirrhotic liver with small nodular appearance, enlarged spleen, ascites around the liver Incidental Findings When scanning through the abdomen, incidental findings in surrounding anatomy can occur. Some locations include: Liver Gallbladder Pancreas Adrenals Kidneys Stomach IVC/AO Incidental Findings The abdominal CT scan may show problems in the: Gallblader, Liver, or Pancreas, including: Acute cholecystitis Alcoholic liver disease Cholelithiasis Pancreatic abscess Pancreatic pseudocyst Pancreatitis Sclerosing cholangitis •Kidney including: •Acute bilateral obstructive uropathy •Acute unilateral obstructive uropathy •Chronic bilateral obstructive uropathy •Chronic unilateral obstructive uropathy •Complicated UTI (pyelonephritis) •Kidney stones •Kidney Cysts •Kidney swelling (hydronephrosis) •Kidney or ureter damage •Polycystic kidney disease •Uterocele Incidental findings Contrast-enhanced CT: Incidental finding of multiple small focal hypodense cysts in both lobes of the liver with variable density and size, indistinguishable from small hypovascular metastases that may have a similar appearance Incidental Findings CT of liver with contrast shows low attenuation lesions in the liver and a mass within the left kidney, with some low attenuation within it. Incidental Findings The CT scan showed an incidental finding of a herniation of the stomach, small bowel, and colon into the thoracic cavity (type IV hiatal hernia). Incidental Findings The following image is a computerized tomogram study with contrast demonstrating a simple renal cyst and its characteristic lack of enhancement Incidental Findings Acute pancreatitis (AP) is an inflammatory condition of the pancreas that can extend to extrapancreatic tissues. AP is broadly classified as mild or severe. Mild AP is often referred to as interstitial pancreatitis, based on its radiographic appearance. The pancreatic blood supply is preserved in interstital pancreatitis. Severe AP implies organ failure, local complications, or pancreatic necrosis. There is disruption of the pancreatic blood supply in necrotizing pancreatitis, with resulting ischemia. Abdominal computed tomography scan of acute pancreatitis. Pseudocyst formation can be noted (arrowheads) References Abdominal Ct Scan. (2012, November 21). Retrieved November 2012, from PubMed Health: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004248/ Pavan Tummala, O. J. (2011, September). Retrieved from Imaging of pancreatic cancer: An overview: http://www.thejgo.org/article/view/213/427 Smithuis, O. v. (n.d.). Pancreatic Carcinoma. Retrieved from The Radiology Assistant: http://www.radiologyassistant.nl/en/p43848b63def9d/pancreas-carcinoma.html Stevens, T. (n.d.). Pancreatic Disorders. 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