Download Atlas of Radiologic Findings in Pancreatic Adenocarcinoma

Narie Yoo Storer, HMS III
Gillian Lieberman, MD
January 2012
Atlas of Radiologic Findings in
Pancreatic Adenocarcinoma
Narie Yoo Storer, Harvard Medical School Year III
Gillian Lieberman, MD
1
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
Pancreatic Adenocarcinoma: Facts
• Fourth most common cause of cancer-related death in the
United States.
• Fewer than 20% of patients present with localized, resectable
disease. Surgical resection is the only potentially curative
treatment.
• 5-year survival is less than 5%.
• Patients typically present with upper abdominal pain, weight
loss and/or jaundice.
2
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
Anatomy of the Pancreas
Over 60% of ductal
adenocarcinomas
occur in the
pancreatic head.
Image from: Hansen JT. Netter’s Clinical Anatomy. 2nd edition. Philadelphia, PA:
Saunders Elsevier; 2009.
3
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
Our patient: history of present illness
• 69 year-old man with a remote history of testicular cancer
and melanoma, treated with radiation.
• Presented to his PCP with ongoing, intermittent “stomach
pain” of a few months duration.
• Had a 20 pound weight loss in the preceding 8 months that
he attributed to a change in his diet.
• Initially had an abdominal ultrasound.
ACR Appropriateness Criteria: Abdominal US is the most appropriate
first imaging modality for the work-up of RUQ pain without fever
(Rating=9).
4
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
Our patient: abdominal US
Transverse view
PACS, BIDMC
Limited views of the pancreas were normal.
The tail was obscured by overlying bowel
gas.
Sagittal view
PACS, BIDMC
A simple cystic lesion was seen in the
upper pole of the L kidney.
5
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
US of the abdomen revealed no significant
abnormalities.
After one month of persistent abdominal
pain, a CT abdomen with contrast was
performed.
6
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
Our patient: pancreatic adenocarcinoma on
abdominal CT
There is an ill-defined
mass in the body of
the pancreas, with
atrophy of the distal
pancreas. A renal cyst
can also be visualized.
PACS, BIDMC
Axial C+ CT, arterial phase
7
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
Our patient: relationship of mass to blood
vessels on CT
The ill-defined,
hypodense mass is
seen adjacent to a
patent, proximal portal
vein. Atrophy of the
pancreatic tail is again
visualized.
PACS, BIDMC
Axial C+ CT, venous phase
8
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
Our patient: pancreatic adenocarcinoma on
CT, coronal reconstruction
The mass is seen
closely associated with
the proximal SMV.
*
PACS, BIDMC
Coronal C+ CT, venous phase
9
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
Differential diagnosis of pancreatic
masses
Chronic pancreatitis
Autoimmune pancreatitis
Pancreatic adenocarcinoma
Islet cell tumors
Cystic pancreatic neoplasms
Ampullary carcinoma
Lymphoma
Metastases
10
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
The use of imaging in the diagnosis and
management of pancreatic adenocarcinoma
1. Tumor detection
2. Surgical staging
3. Tissue diagnosis
11
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
The role of imaging in tumor detection-1
CT: the modality of choice for initial detection and
staging.
ƒBiphasic technique using IV contrast is optimal for visualization of
primary tumor and liver metastases.
ƒArterial phase: visualization of involvement of the celiac axis, SMA and
peripancreatic arteries.
ƒVenous phase: visualization of involvement of the SMV, splenic vein,
and portal vein. Liver metastases are optimally detected in this phase.
Callery MP, Chang KJ, Fishman EK, Talamonti MS, Traverso W, Linehan DC. Pretreatment assessment of resectable and
borderline resectable pancreatic cancer: expert consensus statement. Annals of Surgical Oncology.
Oncology. 2009; 16(7):172716(7):1727-1733.
Faria SC, Tamm EP, Loyer EM, Szklaruk J, Choi H, Charnsangavej C. Diagnosis and staging of pancreatic tumors. Seminars in
Roentgenology.
Roentgenology. 2004; 39(3): 397397-411.
12
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
The role of imaging in tumor detection-2
MRI: No significant benefit over CT; can be performed in
patients with contraindication to iodinated contrast or where
CT findings are indeterminate.
Endoscopic US (EUS): Useful for evaluating small lesions
that cannot be well-characterized on CT or MRI.
Faria SC, Tamm EP, Loyer EM, Szklaruk J, Choi H, Charnsangavej C. Diagnosis and staging of pancreatic tumors. Seminars in
Roentgenology.
Roentgenology. 2004; 39(3): 397397-411.
Talamonti MS, Denham WD. Staging and surgical management of pancreatic and
and biliary cancer and inflammation. Radiologic
Clinics of North America.
America. 2002; 40(6): 13971397-1410.
13
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
Companion patient 1: classic appearance of
pancreatic adenocarcinoma on CT
Ill-defined, hypoattenuating
mass
Pancreatic duct dilatation
Atrophy of pancreas distal to
the mass
Axial C+ CT
Image from: Peddu P, Quaglia A, Kane PA, Karani JB. Role of imaging in the management of pancreatic
mass. Critical Reviews in Oncology/Hematology. 2009; 70(1):12-23.
14
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
Companion patient 2: double duct sign on
abdominal CT
Tumors involving the
pancreatic head can
demonstrate the “double
duct sign,” dilatation of the
common bile duct and
pancreatic duct.
Axial C- CT
Image from: Dasari A, McCarter M, McManus MC, Russ P, Messersmith WA. Recurrent pancreatic
adenocarcinoma after pancreatic resection. Oncology (Williston Park). 2010; 24(14):1329-1334.
15
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
Companion patient 3: pancreatic
adenocarcinoma on MRI
Axial T1-weighted MRI
Low-signal intensity mass
Axial T2-weighted MRI
Low- or high-signal intensity mass
Images from: Faria SC, Tamm EP, Loyer EM, Szklaruk J, Choi H, Charnsangavej C. Diagnosis and staging of
pancreatic tumors. Seminars in Roentgenology. 2004; 39(3): 397-411.
16
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
Our patient: findings consistent with
pancreatic adenocarcinoma on CT
The hypodense mass
is closely associated
with the proximal
SMV. Pancreatic
ductal dilatation can
be appreciated on this
view.
PACS, BIDMC
Coronal C+ CT, venous phase
17
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
The role of imaging in surgical staging
CT is the modality of choice for preoperative
staging.
Resectable
Unresectable
-No distant metastases
-Distant metastases
-No evidence of SMV or portal vein
abutment, distortion, tumor
thrombus or encasement
-Significant thrombosis of SMV or
portal vein
-Clear fat planes around celiac axis,
hepatic artery and SMA
-Circumferential encasement of
SMA, celiac axis or proximal hepatic
artery
Callery MP, Chang KJ, Fishman EK, Talamonti MS, Traverso W, Linehan DC. Pretreatment assessment of resectable and
borderline resectable pancreatic cancer: expert consensus statement. Annals of Surgical Oncology.
Oncology. 2009; 16(7):172716(7):1727-1733.
18
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
Surgical resection of the pancreatic head:
Whipple procedure
Image from: Mayo Clinic,
http://www.mayoclinic.com/health/medical/IM04381
19
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
Companion patient 4: unresectable
pancreatic adenocarcinoma on CT
There is an ill-defined
hypodense mass encasing
the SMA.
Liver metastases can also
be seen.
Axial C+ CT
Images from: Faria SC, Tamm EP, Loyer EM, Szklaruk J, Choi H, Charnsangavej C. Diagnosis and staging of
20
pancreatic tumors. Seminars in Roentgenology. 2004; 39(3): 397-411.
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
Our patient: proximity of mass to hepatic
and splenic arteries on abdominal CT
The superior portion
of the mass can be
seen abutting the
common hepatic and
splenic arteries. Both
arteries are patent.
PACS, BIDMC
Axial C+ CT, arterial phase
21
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
Our patient: pancreatic mass encasing the
SMV on abdominal CT
The SMV is encased
by the hypodense
mass and is decreased
in caliber at the level
of the portosplenic
confluence. The
proximal splenic vein
is not visualized.
PACS, BIDMC
Axial C+ CT, venous phase
22
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
CT imaging revealed total encasement of
the SMV, and the patient’s disease was
deemed unresectable.
23
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
The use of imaging in tissue diagnosis in
pancreatic adenocarcinoma
If the patient is a good surgical candidate, tissue diagnosis may
not be required before surgical resection. However, tissue
diagnosis is required before any non-surgical treatment.
EUS-guided FNA is the most effective modality for obtaining
a tissue diagnosis.
ERCP and image-guided percutaneous biopsy are less
commonly used for tissue sampling.
Callery MP, Chang KJ, Fishman EK, Talamonti MS, Traverso W, Linehan DC. Pretreatment assessment of resectable and
borderline resectable pancreatic cancer: expert consensus statement. Annals of Surgical Oncology.
Oncology. 2009; 16(7):172716(7):1727-1733.
24
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
The patient underwent EUS-guided FNA
for further evaluation and tissue diagnosis.
25
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
Our patient: pancreatic adenocarcinoma on
endoscopic ultrasound
PACS, BIDMC
An ill-defined, hypoechoic mass with heterogeneous echotexture in the
neck/body of the pancreas is visualized from the duodenal bulb.
26
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
Our patient: patent CBD and pancreatic
duct on endoscopic ultrasound
PACS, BIDMC
The common bile duct and pancreatic duct are normal in diameter at the
level of the head of the pancreas.
27
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
Our patient: pancreatic adenocarcinoma on
endoscopic ultrasound with Doppler imaging
PACS, BIDMC
The porto-splenic confluence is invaded by the mass.
28
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
Our patient: EUS-guided fine needle
aspiration of mass
PACS, BIDMC
A 25-gauge needle within the pancreatic mass.
29
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
Our patient: FNA findings consistent with
pancreatic adenocarcinoma
Nuclear pleomorphism, with a
number of cells containing
large nuclei.
Coarse granular chromatin
with irregular distribution
Prominent nucleoli
Irregularly shaped cells
Image courtesy of David Azar, MD
30
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
With the aid of imaging, the patient was
found to have locally advanced pancreatic
adenocarcinoma that was surgically
unresectable.
After these studies were performed, he was
scheduled to undergo chemotherapy with
adjuvant radiotherapy.
31
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
Summary
Imaging plays key roles in the diagnosis and management of
pancreatic adenocarcinoma.
CT with contrast is the modality of choice for the initial
characterization and staging of tumors.
• Characteristic appearance on CT: ill-defined, hypoattenuating mass, often
accompanied by dilatation of the biliary and/or pancreatic ducts and distal
atrophy.
• Detection of distant metastases as well as local involvement of blood
vessels.
EUS is useful for further characterization of small masses
found on CT and is the best modality for obtaining
diagnostic tissue samples.
32
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
References
Callery MP, Chang KJ, Fishman EK, Talamonti MS, Traverso W, Linehan DC. Pretreatment
assessment of resectable and borderline resectable pancreatic cancer: expert consensus statement.
Annals of Surgical Oncology. 2009; 16(7):1727-1733.
Dasari A, McCarter M, McManus MC, Russ P, Messersmith WA. Recurrent pancreatic
adenocarcinoma after pancreatic resection. Oncology (Williston Park). 2010; 24(14):1329-34.
Faria SC, Tamm EP, Loyer EM, Szklaruk J, Choi H, Charnsangavej C. Diagnosis and staging of
pancreatic tumors. Seminars in Roentgenology. 2004; 39(3):397-411.
Hansen JT. Netter’s Clinical Anatomy. 2nd edition. Philadelphia, PA: Saunders Elsevier; 2009.
Hidalgo, MH. Pancreatic cancer. New England Journal of Medicine. 2010; 362(17):1605-1617.
Mayo Clinic. Pancreatic cancer. http://www.mayoclinic.com/health/medical/IM04381. Accessed
on: January 22, 2012.
Peddu P, Quaglia A, Kane PA, Karani JB. Role of imaging in the management of pancreatic mass.
Critical Reviews in Oncology/Hematology. 2009; 70(1):12-23.
Talamonti MS, Denham W. Staging and surgical management of pancreatic and biliary cancer and
inflammation. Radiologic Clinics of North America. 2002; 40(6):1397-1410.
33
Narie Yoo Storer, HMS III
Gillian Lieberman, MD
Acknowledgments
Gillian Lieberman, MD, Course Director
Claire Odom, Education Coordinator
Tamuna Chadashvili, MD, Radiology
Mai-Lan Ho, MD, Radiology
Ahmad Alharbi, MD, Gastroenterology
David Azar, MD, Cytopathology
34