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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. Biphasic technique using IV contrast is optimal for visualization of primary tumor and liver metastases. Arterial phase: visualization of involvement of the celiac axis, SMA and peripancreatic arteries. Venous 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