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Michelle Lee Gillian Lieberman, MD July 2002 Radiologic Staging of Pancreatic Cancer Michelle A. Lee, Harvard Medical School Year IV Gillian Lieberman, MD Michelle Lee Gillian Lieberman, MD Pancreatic Cancer • 4th leading cause of cancer deaths in men and women • peak incidence at 60-80 years of age • in the US, incidence and mortality are decreasing for men and increasing for women • in the US, higher incidence and mortality in black persons than white persons • associated with Northern European or Jewish ancestry and genetic syndromes: NHPCC, BRCA2, hereditary pancreatitis, ataxia-telangectasia, Peutz-Jeghers, FAMMM • risk factors: smoking, occupational, pernicious anemia, lower SES, industrialized society, ? chronic pancreatitis 2 Michelle Lee Gillian Lieberman, MD The Pancreas in the Retroperitoneum common hepatic duct cystic duct splenic artery and vein common bile duct portal vein celiac artery superior mesenteric artery superior mesenderic vein Netter, F.H. with Colacino, S., consulting editor. Atlas of Human Anatomy. Summit, NJ: CIBA-GEIGY Corp., 1993. 3 Michelle Lee Gillian Lieberman, MD Anatomy of the Pancreas common bile duct (ductus choledochus) tail body neck uncinate head principal pancreatic duct of Wirsung accessory pancreatic duct of Santorini Netter, F.H. with Colacino, S., consulting editor. Atlas of Human Anatomy. Summit, NJ: CIBA-GEIGY Corp., 1993. 4 Michelle Lee Gillian Lieberman, MD Embryology of the Pancreas stomach liver dorsal pancreatic bud gall bladder ventral pancreatic bud week 6 week 7 week 8 main pancreatic duct ventral bud dorsal bud duodenum ampulla of Vater ventral bud dorsal bud Moore, K. and Persaud, T.V.N. The Developing Human: Clinically Oriented Embryology. 5 5th edition. Philadelphia: WB Saunders Co., 2001. Michelle Lee Gillian Lieberman, MD Physiology of the Pancreas • Endocrine function: metabolism – Islets of Langerhans cells make glucagon, insulin, gastrin – also somatostatin, pancreatic polypeptide, VIP • Exocrine function: digestion – acinar cells make amylase, lipase, trypsinogen, procarboxypeptidase – ductal cells make Na+ HCO36 Michelle Lee Gillian Lieberman, MD Differential Diagnosis of the Pancreatic Mass • pancreatitis • pancreatic pseudocyst, cyst, or benign neoplasm • pancreatic carcinoma • metastasis 7 Michelle Lee Gillian Lieberman, MD Imaging Pancreatic Cancer • CT with iv contrast to identify tumor or assess resectability – with contrast there is increased signal intensity of normal pancreatic parenchyma – pancreatic carcinoma, which is hypovascular, is seen as a focal hypodense mass – pancreatic cancer is associated with dilation of bile duct (58%) or pancreatic duct (67%) or both (“double duct” sign) 8 Michelle Lee Gillian Lieberman, MD Imaging pancreatic cancer - 2 • CT angiogram for equivocal CT or to examine pre-op vascular anatomy – patency and location of celiac access and superior mesenteric artery, as well as portal and systemic veins can be visualized 9 Michelle Lee Gillian Lieberman, MD Imaging pancreatic cancer - 3 • MR when CT cannot be performed or would be limited by streak artifact – T1 spin echo sequence with fat suppression shows pancreatic cancer with decreased signal intensity relative to normal pancreatic parenchyma 10 Michelle Lee Gillian Lieberman, MD Imaging pancreatic cancer - 4 • ERCP for equivocal CT – pancreatic cancer encases or obstructs pancreatic and/or bile ducts, and causes acinar defects and duct necrosis with tumor cavitation • Ultrasound for initial evaluation for obstructive jaundice – pancreatic cancer appears as an anechoic focal or diffuse mass at head of the pancreas associated with dilated pancreatic and/or bile ducts 11 Michelle Lee Gillian Lieberman, MD PATIENT 1 • Hx: 1 month of fatigue and abdominal distention, now with bright red blood per rectum • Labs: Hct 24% • Dx: ischemic colitis in the splenic flexure of the colon identified by colonoscopy • STUDY: CT with iv contrast to look for pathology at the splenic flexure of the colon 12 Michelle Lee Gillian Lieberman, MD Patient 1: Scout Film paucity of air in the descending colon BIDMC PACS 13 Michelle Lee Gillian Lieberman, MD Patient 1: Mass in the tail of the pancreas stomach transverse colon pancreatic tail mass duodenum sma aorta ivc spleen BIDMC PACS 14 Michelle Lee Gillian Lieberman, MD Patient 1: Mass invading the stomach and liver metastasis metastasis stomach pancreatic mass liver BIDMC PACS 15 Michelle Lee Gillian Lieberman, MD Patient 1: Mass invading the spleen and encasing the colon descending colon pancreatic mass spleen BIDMC PACS 16 Michelle Lee Gillian Lieberman, MD Patient 1: Mass completely encasing the right splenic artery pancreatic mass splenic artery BIDMC PACS 17 Michelle Lee Gillian Lieberman, MD Patient 1: Thrombus in the superior mesenteric vein smv, patent smv, thrombosed BIDMC PACS BIDMC PACS 18 Michelle Lee Gillian Lieberman, MD PATIENT 1: UNRESECTABLE PANCREATIC ADENOCARCINOMA • • • • • • • 88% mass continuous with the surface of adjacent structures extracapsular extension contiguous organ invasion distant metastasis to liver or nodes vascular involvement ascites (indicating carcinomatosis) • Tx: supportive care and pain control 19 Michelle Lee Gillian Lieberman, MD Pancreatic Ductal Adenocarcinoma • 95% of exocrine pancreatic carcinomas • histology: infiltrating glands surrounded by dense reactive fibrosis • gross pathology: 60% arise in the head of the pancreas, others from the body/tail or diffuse • metastasis: to liver, peritoneum, lungs, pleura, adrenals • Prognosis – 5% survival at 5 years s/p resection – death in months to 2 years without resection 20 Michelle Lee Gillian Lieberman, MD PATIENT 2 • Hx: jaudice, weight loss, abdominal pain (also anorexia, pruritis, steatorrhea, thrombophlebitis, depression, glucose intolerance could be associated) • STUDY: CT with iv contrast to identify the cause of biliary obstruction 21 Michelle Lee Gillian Lieberman, MD Patient 2: Mass at the head of the pancreas gall bladder stomach pancreatic mass duodenum small bowel sma aorta BIDMC PACS 22 Michelle Lee Gillian Lieberman, MD Patient 2: Dilated common bile duct and pancreatic duct pancreatic duct common bile duct splenic artery BIDMC PACS 23 Michelle Lee Gillian Lieberman, MD Patient 2: Dilated Intrahepatic Bile Ducts portal veins intrahepatic ducts BIDMC PACS 24 Michelle Lee Gillian Lieberman, MD PATIENT 2: RESECTABLE PANCREATIC ADENOCARCINOMA • • • • 12% <2cm mass normal surrounding parenchyma no local or extracapsular extension, vascular invasion, or nodal or hepatic metastases • Tx: pylorus-sparing pancreatoduodectomy-Whipple or total pancreatectomy 25 Michelle Lee Gillian Lieberman, MD Resection of pancreatic cancer gallbladder end to side hepatojejunostomy proximal jejunum end to end pancreatojejunostomy duodenum tumor end to side duodenojejunostomy pancreas Redlick, P.N., Ahrendt, S.A., and Pitt, H.A. Tumors of the pancreas, gallbladder, and bile ducts. In Clinical Oncology. Lenhard, R.E., Osteen, R.T., and Gansler, T., pp. 373-394, Atlanta: American Cancer Society, 2001. 26 Michelle Lee Gillian Lieberman, MD PATIENT 3 • Hx: long history of alcohol abuse, known pancreatic cystic mass, now with abdominal pain • STUDY: US (transverse shown) indicated increased size of cystic mass with nodules • STUDY: CT angiogram obtained to assess resectability 27 Michelle Lee Gillian Lieberman, MD Patient 3: Cystic mass with nodules in the head of the pancreas dilated pancreatic duct normal pancreas pancreatic cystic mass with nodules air in bowel sma BIDMC PACS 28 Michelle Lee Gillian Lieberman, MD Patient 3: Normal body and tail of the pancreas BIDMC PACS tail of pancreas BIDMC PACS body of pancreas 29 Michelle Lee Gillian Lieberman, MD Patient 3: Two cystic masses in the head of the pancreas with dilation of the common bile duct and pancreatic duct common bile duct mass 1 pancreatic duct duodenum mass 2 BIDMC PACS normal pancreas BIDMC PACS normal pancreas 30 Michelle Lee Gillian Lieberman, MD Patient 3: CTA Reconstructions celiac artery sma mass 1 calcifications mass 2 BIDMC PACS portal vein normal pancreas mass 1 smv mass 2 BIDMC PACS 31 Michelle Lee Gillian Lieberman, MD Biliary Obstruction Secondary to Pancreatic Cancer gall bladder and biliary ducts duodenum BIDMC PACS mass 2: cancer or dilated accessory duct? 32 Michelle Lee Gillian Lieberman, MD PATIENT 3: Resectable Pancreatic Cancer? • mass >2cm, not surrounded by normal parenchyma, abutting adjacent tissues • no local or extracapsular extension, vascular invasion, or nodal or hepatic metastases • but the mass is cystic 33 Michelle Lee Gillian Lieberman, MD Differential Diagnosis of Pancreatic Cystic Lesions • fluid collection • pseudocyst • less likely – serous cystic neoplasm (rarely malignant) – mucinous cystic neoplasm (malignant potential or malignant, but with 40-50% 5 year survival) * Patient 3’s diagnosis: resectable mucinous cystic neoplasm 34 Michelle Lee Gillian Lieberman, MD Early Detection of Pancreatic Cancer • screening of patients with familial syndromes radiologically (using EUS, then ERCP if the patient is symptomatic or the EUS is abnormal) has been shown to be effective – all patients with findings who underwent pancreatectomy had pancreatic dysplasia on pathology • laboratory screening may ultimately be combined with radiologic screening – mutant K-ras oncogene can be detected in pancreaic juice or stool samples – tumor marker CA-19-9 can be measured in plasma 35 Michelle Lee Gillian Lieberman, MD Summary • pancreatic carcinoma appears as a focal or diffuse mass, or possibly a cyst, associated with dilated pancreatic and/or biliary ducts – on CT: a hypodense lesion – on MR: a hypointense lesion – on US: a hypoechoic lesion 36 Michelle Lee Gillian Lieberman, MD Summary - 2 • Identification of candidates for surgical resection is imperative • CT is the primary imaging modality for assessing resectability of pancreatic carcinoma • Equivocal CT studies can be followed by CT angiography, MR, or ERCP • Both CT and MR overpredict resectability (CT: PPV 72%, NPV 100%) 37 Michelle Lee Gillian Lieberman, MD References *All radiographic images were copied from BIDMC PACS. Fishman, E.K. and Horton, K.M. Imaging pancreatic cancer: the role of multidetector CT with three-dimensional CT angiography. Pancreatology Vol. 1, pp. 610-624, 2001. Freeny, P.C. Radiologic diagnosis and staging of pancreatic ductal adenocarcinoma. In Radiologic Clinics of North America: Radiology of the Pancreas. Freeny, P.C. ed. Vol. 27, pp. 121-128, Philadelphia: W.B. Saunders Co., 1989. Reader, M.M. and Bradley, Jr., W.G. Gamuts in Radiology: Comprehensive Lists of Roentgen Differential Diagnosis. 3rd edition. New York: Springer-Verlag, 1993. Moore, K. and Persaud, T.V.N. The Developing Human: Clinically Oriented Embryology. 5th edition. Philadelphia: WB Saunders Co., 2001. 38 Michelle Lee Gillian Lieberman, MD References - 2 Netter, F.H. with Colacino, S., consulting editor. Atlas of Human Anatomy. Summit, NJ: CIBA-GEIGY Corp., 1993. Nghiem, H.V., and Freeny, P.C. Radiologic staging of pancreatic adenocarcinoma. In Radiologic Clinics of North America: Staging neoplasms. Thompson, W.M. ed., Vol. 32, pp. 71-79, Philadelphia:W.B. Saunders, 1994. Redlick, P.N., Ahrendt, S.A., and Pitt, H.A. Tumors of the pancreas, gallbladder, and bile ducts. In Clinical Oncology. Lenhard, R.E., Osteen, R.T., and Gansler, T., pp. 373-394, Atlanta: American Cancer Society, 2001. Rulyak, S.J. and Brentnall, T.A. Inherited pancreatic cancer: surveillance and treatment strategies for affected families. Pancreatology Vol. 1, pp. 477-485, 2001. Weyman, P.J., Stanley, R.J., and Levilt, R.G. Computed tomography in evaluation of the pancreas. Seminars in Roentgenology Vol. 16, pp. 301-311, 1981. 39 Michelle Lee Gillian Lieberman, MD Acknowledgements • • • • • • Damon Soeiro, MD Chad Brecher, MD Jonathon Kruskal, MD Gillian Lieberman, MD Pamela Lepkowski Webmasters: Larry Barbara and Cara Lyn D’amour 40