Download Radiologic Staging of Pancreatic Cancer

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