IMAGING SOLID AND CYSTIC Disclosures LESIONS IN...
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IMAGING SOLID AND CYSTIC LESIONS IN PANCREAS
IMAGING SOLID AND CYSTIC LESIONS IN PANCREAS
Dushyant Sahani, M.DDushyant Sahani, M.DDirector of CT
Associate Professor Department of Radiology
Massachusetts General HospitalHarvard Medical School
Director of CTAssociate Professor
Department of Radiology Massachusetts General Hospital
Harvard Medical School
Disclosures Disclosures
• Received Grant Support from GE Healthcare • Received Grant Support from GE Healthcare
Solid Pancreas LesionsSolid Pancreas Lesions
ExocrineDuctal adeno Ca (80%)
– Rare• Solid pseudopapillary
• Acinar cell
• Giant-cell
• Pancreaticoblastoma
ExocrineDuctal adeno Ca (80%)
– Rare• Solid pseudopapillary
• Acinar cell
• Giant-cell
• Pancreaticoblastoma
Endocrine– Islet Cell (1-5%)
Endocrine– Islet Cell (1-5%)
Other– Metastases
– Lymphoma
– Mimics
– Pancreatitis
– IP Spleen
– Lymph nodes
– Focal Fat
•Fourth most common in cancer mortality (33,370 deaths in 2007 & 34,200 diagnosis*)
• Aggressive biology & late
presentation
– <20% are resectable
• Complex regional anatomy
• Lack of reliable tumor markers
•Fourth most common in cancer mortality (33,370 deaths in 2007 & 34,200 diagnosis*)
• Aggressive biology & late
presentation
– <20% are resectable
• Complex regional anatomy
• Lack of reliable tumor markers
Pancreas Adenocarcinoma Facts
Warshaw AL et al. NEJM 1992
*American Cancer Society 2007 data
Pancreas LesionPancreas Lesion
Jan 2004 June 2004
June 2002
Lesion Detection Lesion Detection
8-2006 10-2006 2-2007 9-2007
MGH Management AlgorithmMGH Management Algorithm
SUSPECTED PANCREATIC CANCER
IMAGING
Group 3
•NO METASTASES
•No/partial encasement
Surgery
Group 1
+METASTASES
Chemotherapy
Group 2
•NO METASTASES
•+Vascular encasement
Chemoradiation +/- IORT
Fernandez-del Castillo et al. Arch Surg 1995
Technique: Pancreas MDCT/CTA
Technique: Pancreas MDCT/CTA
• Optimal scan timing for dual-phase technique
• Thin collimation– 1-3 mm
• Oral contrast • IV contrast
– Rapid injection 4-5 cc/sec
• Post processing
• Optimal scan timing for dual-phase technique
• Thin collimation– 1-3 mm
• Oral contrast • IV contrast
– Rapid injection 4-5 cc/sec
• Post processing
Lu D et al. Radiology 1996/97. Boland G et al AJR 1999. Ichikawa T et al. AJR 2006
Lesion Detection CT: Sub-optimal Technique
Lesion Detection CT: Sub-optimal Technique
Portal phase
Optimal TechniqueOptimal Technique
Islet cell
Adeno CA
Arterial Venous
Arterial Pancreatic
30 sec
45 sec
Portal Venous Phase for Liver Metastases
Portal Venous Phase for Liver Metastases
2D/3D Display: Staging2D/3D Display: Staging
Pancreatic Duct Changes
Vargas R et al. AJR 2004
Sahani D et al. Radiology 2005
Fukushima H et al. Eur Radiol 2006
CTA Visualization tools:Vascular Involvement
CTA Visualization tools:Vascular Involvement
Divisum IPMN in Ventral duct
Combined IPMN
CT PancreatogramCT Pancreatogram
MRCP: Recent AdvancementsMRCP: Recent Advancements
Pre-secretin Post-secretin
3D-MRCP
PD Stricture
PD obstruction- “Ominous” sign
Aggressive approach to evaluate the site of transition
Gangi et al AJR 2002
Duct “Cut off”: Early Detection Duct “Cut off”: Early Detection
06-2005 07-2006
PVP
AP
• Unresectable tumor
– Tumor occlusing SMV/PV
– Reduced vessel caliber
• Tear drop SMV (borderline)
– Involvement of (> 25% lumen) CA/HA/SMA
– Distant metastasis (liver peritoneum)
GDA/SA/SV
Small veins
Lymph nodes
Resectable
Criteria: Unresectable TumorCriteria: Unresectable Tumor
Saldinger J. Gastrointest Surg 2000Warshaw AL et al Archives of Surgery 1990
SMV
SMV
SMV
Resectable
Borderline
Tumor (T)Staging of
Pancreatic CA
Tumor (T)Staging of
Pancreatic CA
Saldinger J. Gastrointest Surg 2000
UnresectableUnresectable
SMV Celiac
Nakao A et alWorld J of Surgery 2006
Stitzenberg KB et al. Ann of Surg Onc 2008
Surgical mortlity 34% when arterial reconstruction undertaken and 2.7 % for venous resection
Multiphase Helical CT In Evaluating Resectability Of
Pancreatic Carcinoma
Multiphase Helical CT In Evaluating Resectability Of
Pancreatic Carcinoma• NPV 97.5% (unresectable)
• PPV 75.86% (Resectable)
• Sensitivity 90.67%
• Accuracy 90.72%
• NPV 97.5% (unresectable)
• PPV 75.86% (Resectable)
• Sensitivity 90.67%
• Accuracy 90.72%
Lu D et al Radiology 1999. Keogan MT et al. Radiology 1997
Huang QJ et al Hepatobiliary Pancreat Dis Int.2002 Nov;1(4):614-9
Multiphase MDCT In Evaluating Resectability Of Pancreatic
Carcinoma
Multiphase MDCT In Evaluating Resectability Of Pancreatic
Carcinoma• NPV 100%
• PPV 89%• Sensitivity 100%
• Specificity 72%
• NPV 100%
• PPV 89%• Sensitivity 100%
• Specificity 72%
Fletcher JG et al. Radiology 2003.
Vargas R et al AJR 2004.
Zamboni G et al Radiology. 2007
• 1-5% of Pancreas neoplasm
– 10-30% in MEN-1/ 1%VHL
• NF-PNET >F-PNET
– Insulinomas > Gastrinomas> Glucaganomas
• NF-PNET and Insulinomas often single
• Tail-48%, Body-16%, Head-31%
• Curative resection 15 year survival 96 %
– 26% with liver metastases
• 1-5% of Pancreas neoplasm
– 10-30% in MEN-1/ 1%VHL
• NF-PNET >F-PNET
– Insulinomas > Gastrinomas> Glucaganomas
• NF-PNET and Insulinomas often single
• Tail-48%, Body-16%, Head-31%
• Curative resection 15 year survival 96 %
– 26% with liver metastases
Pancreas Neuroendocrine Tumors
Plockinger U et al. Neuroendocrinology 2004
Archives of Surgery 2007; 142:347-354
MGH 2007 58.3% 4.5cm 30% 78%
Johns Hopkins 1998 47.5% 5.1cm 60% 52%
Mayo Clinic 1981 15% 92% 44%
Study non-functional size malignancy 5yr survival
Comparison of Non-functional PNENs
n=168
n=125
Notavailable
n=168
Archives of Surgery 2007; 142:347-354
Functioning PNETFunctioning PNET
Small (< 2 cm) and arterially enhancing
>2 cm lesions can be heterogeous
Liver metastases often arterially enhancing Pfannenberg AC et al. Abd Imaging 2005.
Bordianau L et al. Surgery 2008
Large (> 3cm), exophytic, heterogenous lesions +/- cytic changes (degeneration). Vascular enacesment and metastases +/-
Non-Functioning PNETNon-Functioning PNET
CT Accuracy in F-PNET Detection(Tumor size & CT Technique)
CT Accuracy in F-PNET Detection(Tumor size & CT Technique)
• < 1cm - 20%• 1-3 cm- 30-40%• > 3 cm -> 75%
Extra pancreatic Sn 35%
MDCT 63-94% Sn
• Octreoscan (50% SR+)
• EUS 94% Sn for < 1cm lesions
• < 1cm - 20%• 1-3 cm- 30-40%• > 3 cm -> 75%
Extra pancreatic Sn 35%
MDCT 63-94% Sn
• Octreoscan (50% SR+)
• EUS 94% Sn for < 1cm lesions
Wank SA. Gastroenterology 1987
Fidler J et al. AJR 2003. Gouya H et al. AJR 2003. Yong, E and Canto, M. GIE 2007;65(5)
MDCT Pitfall: “Small Liver Lesion Detection and Characterization”
MDCT Pitfall: “Small Liver Lesion Detection and Characterization”
CECT Vs. MRI
Holalkere et al. JCAT 2005
M-Stage: CT and MRM-Stage: CT and MR
MRMRCECTCECTCT understages (>25% complete response @ CT macroscopic disease @ surgery)
M-Stage: Role DWI imaging
DWI-MRDWI-MRT2 WIT2 WI Post -Gd T1 FSPost -Gd T1 FS
Rummney E et al. AJR. 2002Koh DM et al. Eur Radiol. 2008
Bruegel M et al. Eur Radiol. 2008Laurent V et al. Eur J Radiol. 2009
B
M-stage: MR vs. FDG-PETM-stage: MR vs. FDG-PET
FDG-PET
Metastases: 65
Lesions <1cm: 12
MRI
Metastases: 88
Lesions <1cm 33Kinkel. Radiology 2002. Sahani. AJR 2005. Akhurst T. JCO 2005.
Coenegrachts K. Radiology 2009.
PET Sensitivity
Lesions > 2 cm=100%, 30-60% lesions < 10 mm
Post-CXT 63% overall sensitivity
M Stage: MRI-PET-CT M Stage: MRI-PET-CT
AuthorPrimary Cancer
nGold
Standard
Accuracy
CE-MRI PET CT
Rappeport et al. (18)
CRC 35 Surgery IOUS 82% 77% 77%
Delbeke et al. (25)
CRC 52Surgery
Follow-up -- 92% 78%
Sahani et al. (28)
CRC and Pancreatic
Cancer34
Surgery Follow-up 97 % 85.3% --
Ward et al. (34)CRC (56), Others (2)
58 Surgery IOUS 92% -- 82%
Regge et al. (76)
CRC 125 Surgery IOUS 82.4 -- 72.8%
MDCT: Small Lesion Detection MDCT: Small Lesion Detection
CT T2 MRI T1 FS
Schima W et al. AJR 2002
MRI/MRCP: Non-contour Deforming Mass
MRI/MRCP: Non-contour Deforming Mass
Schima W et al. AJR 2002
• Diffuse “sausage-shaped” enalargement of the pancreas
• Absence of the normal pancreatic clefts (featureless)
• Peripheral “halo” – rim of hypoattenuation
• Lack of vascular encasement
• ↑↑ IgG4
• Steroid responsive
• Diffuse “sausage-shaped” enalargement of the pancreas
• Absence of the normal pancreatic clefts (featureless)
• Peripheral “halo” – rim of hypoattenuation
• Lack of vascular encasement
• ↑↑ IgG4
• Steroid responsiveSahani et al. Radiology 2005
Takahashi et al. AJR 2008
PDAC
• ADC mass 1.93±0.93 x10-3
mm2/s• ADC “normal” pancreas
2.37±0.98x 10-3 mm2/s• ADC ratio 0.8±0.07
MF-AIP
• ADC mass 1.11±0.14 x10-3
mm2/s• ADC “normal” pancreas
1.03±0.22x 10-3 mm2/s• ADC ratio 1.1±0.01
(p 0.01)
(p < 0.001)
(p < 0.001)
DWI MRI: Tissue CharacterizationDWI MRI: Tissue Characterization
Catalano et al. RSNA 2009
Benefits of State of art MDCT and PET
Morphology + Function = PET-CT
PET-CT: PANCREATIC CANCERPET-CT: PANCREATIC CANCER
Heinrich S et al. Ann Surg 2005
Author Sensitivity Specificity Accuracy
Zimmy (1997) 85 85 84
Debelke (1999) 92 85 91
Martin (2000) 77 74
Heinrich (2005) 93
PET/PET-CT: PANCREATIC CANCER
PET/PET-CT: PANCREATIC CANCER
ROLE OF PET/CT-CHARACTERIZATION
ROLE OF PET/CT-CHARACTERIZATION
CT FDG-PET Tumor
LYMPH NODE (N) STAGINGLYMPH NODE (N) STAGING
PET-CT
PET/CT: PANCREATIC CANCER STAGING
PET/CT: PANCREATIC CANCER STAGING
• Management changed in 16%, initially considered resectable
• Additional distant metastasis in 5 patients• Synchronous rectal cancer in 2 patients.
• Management changed in 16%, initially considered resectable
• Additional distant metastasis in 5 patients• Synchronous rectal cancer in 2 patients.
Heinrich S et al. Ann Surg 2005;242:234-243
FDG-PET-CT: PNET
PET-CT attractive but its role is unclear
Differentiation between benign and malignant lesions is difficult
• PD dilatation with a “cut-off” ominous sign
• MDCT first line modality – For pancreas mass evaluation
– Pre-operative staging
• Optimal scanning technique and 2D/3D display– For lesion detection and staging
• MRI for liver evaluation and problem solving indications (small lesion detection)
• PET-CT attractive but its role is still evolving
• PD dilatation with a “cut-off” ominous sign
• MDCT first line modality – For pancreas mass evaluation
– Pre-operative staging
• Optimal scanning technique and 2D/3D display– For lesion detection and staging
• MRI for liver evaluation and problem solving indications (small lesion detection)
• PET-CT attractive but its role is still evolving
Summary Summary Summary Functional imaging is complimentary to cross
sectional imaging for F-NET location•Assessment of prognosis and response to therapy
PET-CT attractive but its role is unclear
• Differentiation between benign and malignant lesions is difficult
•EUS has the best performance for small lesion detection
Pancreas Surgery At MGH 1990-2000Pancreas Surgery At MGH 1990-2000
1988-1998 increase in cystic tumors from 16-30%
Fernandez-del Castillo C. Adv Surg 2000
Serous cystadenoma: 32-39%
Mucinous neoplasm: 10-45%
Cystic Tumor DistributionCystic Tumor Distribution
IPMN: 21-33%
Cystic Degeneration in Solid Tumors
Cystic Degeneration in Solid Tumors
Neuroendocrine
Solid and Pseudopaillary Neoplasm (SPEN)
Adenocarcinoma
< 10%
Cystic Lesion: Imaging ObjectivesCystic Lesion: Imaging ObjectivesMorphologic details
Unilocular or Multilocular
Microcystic
Cyst communication with PD
Extent of PD involvement
Morphologic details
Unilocular or Multilocular
Microcystic
Cyst communication with PD
Extent of PD involvement
Megibow A Radiology 1992, Procacci C JCAT 1999/2000.
Sahani DV ECNA 2005/Radiograhics 2005/JACR 2009
Cystic Lesion: Imaging ObjectivesCystic Lesion: Imaging Objectives
Benign or Malignant
• Mural nodules
• Thick Septae
• Cyst/MPD size
• Metastases
Benign or Malignant
• Mural nodules
• Thick Septae
• Cyst/MPD size
• Metastases
SEROUS CYSTADENOMA: MICROCYSTIC
SEROUS CYSTADENOMA: MICROCYSTIC
• Middle age Women >Men
• Numerous (> 6) tiny cysts
• “Sponge”/ “Honeycomb”
• Lobulated outline
• Sharp interface with vessels
• Rarely obstruction– Bile duct
– Pancreatic duct
• Middle age Women >Men
• Numerous (> 6) tiny cysts
• “Sponge”/ “Honeycomb”
• Lobulated outline
• Sharp interface with vessels
• Rarely obstruction– Bile duct
– Pancreatic duct
Buck et al. Radiograhics 1990
SEROUSCYSTADENOMASEROUSCYSTADENOMA
“Sponge”
“Honeycomb”
MUCINOUS CYSTIC NEOPLASM (MCN)
MUCINOUS CYSTIC NEOPLASM (MCN)
• Middle age women
• Tail location (85%) most common
• Single/few cysts ( < 6 cyst) > 2cm
• Peripheral/septal Ca+/mural nodules
• No communication with PD
• Benign or malignant
• 10-20% are carcinoma
MUCINOUS CYSTIC NEOPLASM
MUCINOUS CYSTIC NEOPLASM
CT
INTRADUCTAL PAPILLARY MUCINOUS NEOPLASMS (IPMN)
INTRADUCTAL PAPILLARY MUCINOUS NEOPLASMS (IPMN)• Increasingly recognized• Similar to MCNs
– cystic tumor that secrete mucin• Arise from a duct papillary
epithelium • Affect a mostly elderly men. • Dilatation of the ducts as a result of
tumor growth and mucin • Upto 49% of IPMNs may be
malignant
• Increasingly recognized• Similar to MCNs
– cystic tumor that secrete mucin• Arise from a duct papillary
epithelium • Affect a mostly elderly men. • Dilatation of the ducts as a result of
tumor growth and mucin • Upto 49% of IPMNs may be
malignant
Ohhashi K et al Prog Dig Endosc 1982;20:348-351
IPMNClassification
IPMNClassification
IMAGING FEATURES:SB-IPMNIMAGING FEATURES:SB-IPMN
•Uncinate >other
•Septated cyst -lobulated
•Channel of communication -MPD
•96% specific for diagnosis
•+/- MPD dilatation > 5mm
15-20 % risk of malignancyInvasive Ca less common
SB-IPMN Vs MCNSB-IPMN Vs MCNMCN
Macrocystic
<6 cysts, > 2 cm in size
Surface-Smooth
85%Tail
SB IPMN
SB-IPMNMacrocystic or mixed
>6 cysts of < 2cm
Communication
Lobulatated
+/-MPD dilatation
Irie et al Radiology 2002 Fukukura ,Y Acta Radiol 2003, Sahani et al Radiology 2005
MAIN DUCT IPMN
•Segmental or diffuse dilated MPD > 6 mm without cut-off
Irie H et al. AJR 2000; 174: 1403-1408
ERCP
MRCP
Tumor foci
MD-IPMN:FEATURESMD-IPMN:FEATURESMPD++/ SB-changesAtrophy =MPD dilatation Bulging papilla
Mural nodules
Irie et al Radiology 2002, Fukukura Y Acta Radiol 2003, Sahani et al Radiology 2005
PD Dilatation: DifferentialPD Dilatation: Differential
Pancreatic Duct Changes
Vargas R et al. AJR 2004
Sahani D et al. Radiology 2005
Fukushima H et al. Eur Radiol 2006
C-Pancreatitis
PDAC
IPMN
CYST CLASSIFICATION-NON MUCINOUS
CYST CLASSIFICATION-NON MUCINOUS
SOLID MASS WITH CYSTIC DEGENRATION
Associated changes in duct, parenchyma, vascular or ductal
invasion or LN
Complex solid + cystic
No characteristic features
NET/Adenoca/Met
SOLID PSEUDOPAPILLARY TUMOR
Solid + cystic Irregular enhancing peripheral component
Capsule, Ca+ rim
Young women (20-30 yrs)
Pancreas Cyst ReviewPancreas Cyst Review
CYST PSEUDOCYST IPMN MUC CYSTADENOMA
SER CYSTADENOMA MUC CYSTADENOMA
MUC CYSTADENOCARCINOMA MALIG IPMN
unilocular
multilocular
complex
Challenges in Cyst Characterization: Morphologic
Overlap
Challenges in Cyst Characterization: Morphologic
Overlap
Mucinous Pseudocyst IPMNCohen-Scali F et al. Radiolgy 2003
Khurana B et al. AJR 2003
Kim S et al. AJR 2006
SCA Morphology ChallengesSCA Morphology Challenges
Central scar: < 20%
Macrocystic
? Solid MRI Diffuse
Cysts Features: Predictors of Malignancy Cysts Features: Predictors of Malignancy
Mural nodularity / solid mass
Peripheral Calcification
Macrocyst > 5cm
MPD>8 mmWHAT IS THE ROLE OF EUS?WHAT IS THE ROLE OF EUS?
Hollerbach: Endoscopy 2001 Oct;33(10):824-31
• Cyst fluid aspiration– Amylase– Tumor markers
• CEA, CA 72-4, CA 125, CA 19-9, CA 15-3
• Biopsy suspicious areas• Less risk of spillage of cyst contents
• Cyst fluid aspiration– Amylase– Tumor markers
• CEA, CA 72-4, CA 125, CA 19-9, CA 15-3
• Biopsy suspicious areas• Less risk of spillage of cyst contents
Cyst Fluid Analysis (CEA,amylase,cytology)
CEA<5 CEA 5-200 CEA 200-500 >500
•Serous cyst•Duplication
•Mucinous•Pseudocyst
•Mucinous •Malignant
Non-mucinouscytology
Mucinous orinflammatory
cytology
Mucinouscytology
Benign ormalignant
Brugge W et al. AGA 2002
Cyst with associated mass
Septated/Macrocystic
Microcystic
Unilocular
Morphology
Sahani et al. Radiograhics 2005
MDCT CATEGORIZATION: CYST MORPHOLOGY
MDCT CATEGORIZATION: CYST MORPHOLOGY
ALGORITHM FOR MANAGEMENT OF PATIENTS WITH A PANCREATIC
CYSTIC LESION
ALGORITHM FOR MANAGEMENT OF PATIENTS WITH A PANCREATIC
CYSTIC LESION
Abdominal CT scan
InflammatoryCyst/pancreatitis
Microcystic Macrocystic Malignant
Premalignant or malignant
•Management depends on* –Age & presentation, –location of the lesion and size–presence or absence of malignancy
Gigiot JF et al Arch Surg 2001;136:1256-62*
MANAGEMENT ALGORITHMMANAGEMENT ALGORITHM
Macrocystic Malignant
Surgery ObservationMonitoring
CT scanning
EUS-FNA Surgery
lowhighRisk / BenefitAssessment
Cytology and CEACEA>500Atypia
CEA<10Non-mucinous
CEA 10-500Benign mucinous
CHALLENGES WITH SMALL CYSTS (< 3 CM).
CHALLENGES WITH SMALL CYSTS (< 3 CM).
• Accurate diagnosis difficult with imaging.
• Most benign side branch IPMN
• MRCP better for small cyst morphology
• Criteria for F/U– No solid component
– No MPD involvement
– Clinical
• Accurate diagnosis difficult with imaging.
• Most benign side branch IPMN
• MRCP better for small cyst morphology
• Criteria for F/U– No solid component
– No MPD involvement
– ClinicalSpinelli 2004Fernandez del-castillo 2004Sohn 2004Sahani 2006
CT MR
Cyst Follow-upCyst Follow-upMay 2006 August 2007
Nov 2001 June 2003
August 2004 Sept 2005
Worrisome
1cm growth/year
Solid mass
PD
APPROACH ON IMAGINGAPPROACH ON IMAGING
Sahani, D. V. et al. Radiographics 2005;25:1471-1484
MORPHOLOGIAL DETAILS
PseudocystEpithelial cyst
Serous Cystic deg. insolid tumors
MucinousMCN
PeripheralIPMNDuctal
SummarySummary• MDCT/MR has good predictive value for malignancy, better for
benignity
• Differentiation of borderline and CIS changes (prevalent in mucinous lesions) is difficult on imaging
• MDCT/MR has good predictive value for malignancy, better for benignity
• Differentiation of borderline and CIS changes (prevalent in mucinous lesions) is difficult on imaging
Called Malignant Called BenignSmall, C IPMN
Triaging Patients–MDCT features–Clinical presentation–Age–Surgical risk–Lesion size / location
Summary Summary
• Incidental < 3 cm cysts (-solid component) have
low incidence of malignancy
– MR>CT for cyst morphology
– FU with CT or MR starting @ 6 months
• EUS and cyst aspiration useful but should
considered in select patients.
• Incidental < 3 cm cysts (-solid component) have
low incidence of malignancy
– MR>CT for cyst morphology
– FU with CT or MR starting @ 6 months
• EUS and cyst aspiration useful but should
considered in select patients.
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