Post on 14-Feb-2020
C.Y. Nio,
AMC, Amsterdam
Introduction
Pancreatic adenocarcinoma
“Key facts” pancreatic carcinoma
What makes a good CT?
How effective is each modality?
What is the role of each modality?
Content
1750 new cases per year
0.5-3.6 per 100.000 (< 50 yrs)
55.9-89.2 per 100.000 (> 75 yrs)
caput (75%), corpus (15%), cauda (10%)
Without therapy: median survival 4-6 m
curative resection: 10-20% 5-yr survival
Epidemiology
Richtlijn pancreascarcinoom.2011
Tumor + locoregional lymphnodes
Tumor + resection margins
Differentiation grade tumor
Diameter tumor
Kuhlmann et al, Eur.J.Cancer 2004
Prognostic factors for low survival
after resection
Curative: pylorus preserving pancreaticoduodenectomy
(Whipple or PPPD)
Palliative:
Biliary stenting Pain relief double by-pass (chemotherapy/radiation) ,
Therapy
100 pts with pancreatic carcinoma
40 pts (40%)
locally irresectable
40 pts (40%)
distant metastases
20 pts (20%) laparotomy with curative intent
20 pts laparotomy with curative intent
13 á 14 (± 65%) pts:
resection
6 á 7 (± 35%) pts
irresectable in OR:
-local invasion
-metastases
PPPD Double by-pass
± 50% “radical R0”
resectie
Kuhlmann et al, Surgery 2006;139:188-96
Survival
(%)
1-yr 3-yr 5-yr
R0 69 28 11
R1 60 9 6
P=0.02
R1 versus R0
Kuhlmann et al, Surgery 2006;139:188-96
Survival Median 1-yr 3-yr 5-jyr
R1 N=80
15.8 59.9 8.9 5.7
Loc. adv
disease N=90
9.4 34.4 2.2 0
R1 versus locally advanced disease
Kuhlmann et al, Surgery 2006;139:188-96
Survival Median 1-yr 3-yr 5-yr
R1 N=80
15.8 59.9 8.9 5.7
Loc. adv
disease N=90
9.4 34.4 2.2 0
P < 0.01
R1 versus locally advanced disease
van Geenen et al, Surgery 2001;129:158-63
215 resections (‘92-’98)
34 PV/SMV resection
20 (59%) pos. margin
Median survival:
Pos. margin: 14 m
Neg. margin: 11 m
Partial resection PV/SMV
Siriwardana et al, Br J Surg 2006;93:662-73
52 studies with 1646 pts
Median survival 13 m
5-yr survival 7%
Peri-operative mortality 5.9%
Positive nodes 67.4%
Positive margins 39.8%
Conclusion:
involvement of PV/SMV precludes curative resection
Partial resection PV/SMV
What CT-technique ?
Optimal timing ?
arterial phase (AP)
±25 sec. scan delay
pancreatic phase (PPP)
±50 sec. scan delay
portal-venous phase (PVP) ±70 sec. scan delay
Desired:
maximal arterial enhancement
maximal portal enhancement
maximal tumor-pancreas contrast
Enhancement portal veins and
visceral arteries
AP PPP PVP
SMV 52 140 171
Portal vein
50 147 180
AP PPP PVP
Coel
trunk
228 293 157
SMA 245 299 158
McNulty et al. Radiology 2001; 220: 97
McNulty et al. Radiology 2001; 220: 97
AP PPP PVP
Pancreas 70 122 109
Difference
with tumor 16 49 44
maximal contrast
Pancreas parenchyma-tumor
No: early arterial phase
Yes: dual-phase, i.e. pancreatic phase
+ portal phase
Alterative: one phase, late pancreatic /
early-portal phase
Slice thickness: < 5 mm (2 à 3 mm).
Contrast: always, ≥130ml, 3-5 ml/sec.
CT Protocol?
What imaging modality?
Ultrasound ?
CT ?
MRI ?
CT 23/959 91 (86-94) 85 (76-91)
MRI 11/583 84 (78-89)* 82 (67-92)
datasets /
N ptt
sensitivity specificity
US 14/2909 76 (69-82)* 75 (51-89)
How good are US, CT and MRI for tumor
detection?
*significantly lower as compared to CT
Bipat et al, J Comput Assist Tomogr 2005;29:438-45
CT 32/1823 81 (76-85) 82 (77-87)
MRI 7/516 82 (69-91) 78 (63-87)
datasets /
N patt
sensitivity specificity
US 6/1233 83 (68-91) 63 (45-79)*
How good are US, CT and MRI for
assessment of resectability?
Bipat et al, J Comput Assist Tomogr 2005;29:438-45
*significantly lower as compared to CT
Algorithm imaging pancreatic lesion
US
Tumor / suspection of solid
tumor
CT No tumor
EUS
resectable
exploration
irresectable borderline
PA / neo-adjuvant
chemoradiation
PA / palliation
MRI Pancreas
No primary role in solid tumors
Useful in cystic pancreatic tumors
MRI protocol (30 min)
T2 TSE FS ax (6mm) RT
T2 3D cor (1 mm) met ax. reconstr.
T2 HASTE (40 mm) cor
EP 2D Diff (4 mm): b50/400/800
T1 FS ax (3 mm) before and dyn after gado (0/30/60 sec)
Presence/absence of tumor
size tumor
obstruction CBD/PD
relation tumor with surrounding organs and portovenous and
arterial vessels
Presence/absence of liver metastases
Presence/absence locoregional or distant nodes (trunc/para-
aortal/mesenterial)
Presence/absence peritoneal metastases
anatomical variants vessels and stenosis coel trunc/SMA
ascites
Reporting
without therapy: median survival 4-6 m
curative resection: 10-20% 5-yr survival
6-7% R0 resection
R1 resection ↑ median survival 9 → 16 m
involvement PV/SMV: no curative resection
Conclusions 1
Staging CT with dual phase series PPP en PVP
1 phase CT with late-pancreatic/early-portal phase
2 -3 mm slices with ≥130ml, 3-5 ml/sec
Tumor detection: CT > MRI
Tumor resectability: CT = MRI
Cystic lesions: MR > CT
Conclusions 2