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