Radiologic and Anatomic Characterization of Pancreatic Cancer and ...
Transcript of Radiologic and Anatomic Characterization of Pancreatic Cancer and ...
Frank Acosta, HMS IV
Gillian Lieberman, MD
Radiologic and Anatomic Characterization of Radiologic and Anatomic Characterization of Pancreatic Cancer and Implications for Pancreatic Cancer and Implications for
TreatmentTreatment
Frank L. Acosta, Jr., Harvard Medical School Year IVGillian Lieberman, MD
July 2001
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Frank Acosta, HMS IV
Gillian Lieberman, MD
Agenda• Epidemiology• Classification• Relevant anatomy• Clinical presentation• Imaging studies• Management strategies • Salient points
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Frank Acosta, HMS IV
Gillian Lieberman, MD
Epidemiology of Pancreatic CA
• Fifth leading cause of cancer-related death in U.S.• 29,000 new cases per year• Significant morbidity and mortality:
– 5 year survival rate: 2-5%– Median survival 15-20 months– Most patients have advanced disease at initial
presentation– Only 15-20% are surgical candidates
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Frank Acosta, HMS IV
Gillian Lieberman, MD
Classification of Pancreatic NeoplasmsI. Epithelial nonendocrine tumors
A. Duct cell origin1. Cystic
a. Microcystic (serous) adenomab. Mucinous cystic neoplasm
(cystadenocarcinoma)c. Ductectatic neoplasms
2. Solida. Duct cell adenocarcinomab. Variant carcinomas
(1) Pleomorphic giant cell carcinoma(2) Adenosquamous carcinoma(3) Mucinous (colloid) carcinoma(4) Anaplastic carcinoma(5) Small cell carcinoma(6) Ciliated cell adenocarcinoma(7) Oncocytic carcinoma(8) Clear cell carcinoma
B. Acinar cell origin1. Acinar cell carcinoma2. Acinar cell cystadenocarcinoma3. Pancreaticoblastoma
C. Indeterminate origin1. Osteoclast-type giant cell carcinoma2. Solid and papillary epithelial neoplasm3. Mixed endocrine-exocrine tumors4. Microadenocarcinoma
II. Endocrine (islet cell) tumorsA. InsulinomaB. GastrinomaC. GlucagonomaD. VIPomaE. SomatostatinomaF. Pancreatic polypeptidomaG. CarcinoidH. Miscellaneous
III. Other pancreatic neoplasmsA. Nonepithelial (mesenchymal) tumorsB. MetastasesC. Lymphoma
Friedman AC: Pancreatic Neoplasms. In Friedman AC, Dachman AH, eds: Radiology of the liver, biliary tract, pancreas, and spleen, St. Louis, 1994, Mosby-Year Book, pp 807-934
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Frank Acosta, HMS IV
Gillian Lieberman, MD
Classification of Pancreatic NeoplasmsI.I.I. Epithelial Epithelial Epithelial nonendocrinenonendocrinenonendocrine tumorstumorstumors
A.A.A. Duct cell originDuct cell originDuct cell origin1.1.1. CysticCysticCystic
a.a.a. MicrocysticMicrocysticMicrocystic (serous) adenoma(serous) adenoma(serous) adenomab.b.b. MucinousMucinousMucinous cystic neoplasm cystic neoplasm cystic neoplasm
(((cystadenocarcinomacystadenocarcinomacystadenocarcinoma)))c.c.c. DuctectaticDuctectaticDuctectatic neoplasmsneoplasmsneoplasms
2.2.2. SolidSolidSolida. DUCT CELL
ADENOCARCINOMA (90%)b.b.b. Variant carcinomasVariant carcinomasVariant carcinomas
(1)(1)(1) PleomorphicPleomorphicPleomorphic giant cell carcinomagiant cell carcinomagiant cell carcinoma(2)(2)(2) AdenosquamousAdenosquamousAdenosquamous carcinomacarcinomacarcinoma(3)(3)(3) MucinousMucinousMucinous (colloid) carcinoma(colloid) carcinoma(colloid) carcinoma(4)(4)(4) AnaplasticAnaplasticAnaplastic carcinomacarcinomacarcinoma(5)(5)(5) Small cell carcinomaSmall cell carcinomaSmall cell carcinoma(6)(6)(6) Ciliated cell Ciliated cell Ciliated cell adenocarcinomaadenocarcinomaadenocarcinoma(7)(7)(7) OncocyticOncocyticOncocytic carcinomacarcinomacarcinoma(8)(8)(8) Clear cell carcinomaClear cell carcinomaClear cell carcinoma
B.B.B. AcinarAcinarAcinar cell origincell origincell origin1.1.1. AcinarAcinarAcinar cell carcinomacell carcinomacell carcinoma2.2.2. AcinarAcinarAcinar cell cell cell cystadenocarcinomacystadenocarcinomacystadenocarcinoma3.3.3. PancreaticoblastomaPancreaticoblastomaPancreaticoblastoma
C.C.C. Indeterminate originIndeterminate originIndeterminate origin1.1.1. OsteoclastOsteoclastOsteoclast---type giant cell carcinomatype giant cell carcinomatype giant cell carcinoma2.2.2. Solid and papillary epithelial neoplasmSolid and papillary epithelial neoplasmSolid and papillary epithelial neoplasm3.3.3. Mixed endocrineMixed endocrineMixed endocrine---exocrine tumorsexocrine tumorsexocrine tumors4.4.4. MicroadenocarcinomaMicroadenocarcinomaMicroadenocarcinoma
II.II.II. Endocrine (islet cell) tumorsEndocrine (islet cell) tumorsEndocrine (islet cell) tumorsA.A.A. InsulinomaInsulinomaInsulinomaB.B.B. GastrinomaGastrinomaGastrinomaC.C.C. GlucagonomaGlucagonomaGlucagonomaD.D.D. VIPomaVIPomaVIPomaE.E.E. SomatostatinomaSomatostatinomaSomatostatinomaF.F.F. Pancreatic Pancreatic Pancreatic polypeptidomapolypeptidomapolypeptidomaG.G.G. CarcinoidCarcinoidCarcinoidH.H.H. MiscellaneousMiscellaneousMiscellaneous
III.III.III. Other pancreatic Other pancreatic Other pancreatic neoplasmsneoplasmsneoplasmsA.A.A. NonepithelialNonepithelialNonepithelial (((mesenchymalmesenchymalmesenchymal) tumors) tumors) tumorsB.B.B. MetastasesMetastasesMetastasesC.C.C. LymphomaLymphomaLymphoma
Friedman AC: Pancreatic Neoplasms. In Friedman AC, Dachman AH, eds: Radiology of the liver, biliary tract, pancreas, and spleen, St. Louis, 1994, Mosby-Year Book, pp 807-934
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Frank Acosta, HMS IV
Gillian Lieberman, MD
Vascular Supply & Innervation
Netter FH. Atlas of Human Anatomy, New Jersey, 1989, Novartis.
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Frank Acosta, HMS IV
Gillian Lieberman, MD
Pancreatic Duct
Gray H: Anatomy, Descriptive and Surgical. Pick TP, Howden R, eds. Philadelphia, 1974, Running Press.
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Frank Acosta, HMS IV
Gillian Lieberman, MD
Establishing the Diagnosis• Initial presentation varies with the location of
tumor:– Head of pancreas Symptoms of obstruction of
the intrapancreatic portion of common bile duct (steatorrhea, weight loss, jaundice)
– Body, tail Symptoms from invasion of celiac ganglia (pain, weight loss). Obstruction less common
– Courvoisier’s law• Imaging studies play two primary roles:
– Diagnosis– Selecting optimal treatment strategies (i.e. surgical
vs. nonsurgical)
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Frank Acosta, HMS IV
Gillian Lieberman, MD
Menu of tests for Imaging Pancreatic CA
Test Sensitivity Specificity Useful in StagingUS 80% 90% No
EUS 90% 90% YesCT 90% 95% Yes
ERCP 90% 90% NoMRI 90% 90% NoFNA 90% 98% No
Steer ML: Clinical manifestations and diagnosis of exocrine pancreatic cancer. From UpToDate literature search, http://www.uptodate.com
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Frank Acosta, HMS IV
Gillian Lieberman, MD
Radiologic Studies in the Evaluation and Treatment of Suspected Pancreatic CA
Zeman RK, Silverman PM: Computed Tomography. In Evans SRT, Ascher SM, eds: Hepatobiliaryand Pancreatic Surgery: Imaging Strategies and Surgical Decision Making, New York, 1998, Wiley-Liss, pp 445-463.
Contrast-enhanced helical CT scan (or MRI)
Dilated biliary tree
Suspected pancreatic CA
Nondilated biliary tree
Unresectable on CT criteria
Unresectable FNA
ERCP (MRCP) +/- stent placement
Resectable based on CT criteria
Surgical exploration
Resectable
Questionable resectabilitybased on CT criteria
Visceral angiography or EUS
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Frank Acosta, HMS IV
Gillian Lieberman, MD
J.C. E.G.• 74 yo female• 2 weeks intermittent
upper abdominal pain– “Achy” in nature– Radiating to back– Worse with eating– 5-10 lb weight loss
• PE no focal findings• Lab findings: wnl
• 70 yo male• Steatorrhea, weight loss• PE: Jaundice,
nontender palpable gallbladder
• Lab findings: Bili, Alk Phos
Let’s Discuss 2 Patients
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Frank Acosta, HMS IV
Gillian Lieberman, MD
Radiologic Diagnosis - CT
• Patient J.C.• Diffuse enlargement• Focal low density
mass, noncalcified, at neck-body junction
• Dilated pancreatic duct
Image courtesy of BIDMC Department of Radiology
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Frank Acosta, HMS IV
Gillian Lieberman, MD
DDX: Mass in the Region of the Pancreas on CT or MRI
• COMMON:– Pancreatic CA– Abscess (pancreas,
lesser sac)– Aortic aneurysm– CA of duodenum,
ampulla, bile duct, gallbladder, liver
– Gastric neoplasm– Lymphadenopathy– Metastasis– Pancreatic pseudocyst,
cyst, or benign neoplasm– Pancreatitits– Renal cyst or neoplasm– Splenic mass
• UNCOMMON:– Hydatid cyst– Portal vein
thromboembolism– Retroperitoneal cyst
or neoplasmReeder & Felson’s Gamuts in Radiology: Comprehensive List of Roentgen Differential Diagnoses.
Pathologic analysis is ‘gold standard’ for dx.
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Frank Acosta, HMS IV
Gillian Lieberman, MD
Patient J.C.: Intact Mesenteric Artery- ResectableResectable
• CT revealed preservation of fat plane around SMA
• No evidence of metastatic disease
Image courtesy of BIDMC Department of Radiology
Hypodense fat plane surrounding SMA, indicating tumor has not invaded this vessel
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Frank Acosta, HMS IV
Gillian Lieberman, MD
Surgical Treatment: Pancreaticoduodenectomy (Whipple)
http://pathology2.jhu.edu/pancreas/surgery.cfm
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Frank Acosta, HMS IV
Gillian Lieberman, MD
Radiologic Diagnosis - CT
• Patient E.G.• Heterogeneous
mass in pancreatic head
• Dilated pancreatic and common bile ducts – “double duct” sign
Image courtesy of BIDMC Department of Radiology
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Frank Acosta, HMS IV
Gillian Lieberman, MD
Patient E.G.: Involvement of Porto-Mesenteric Vasculature-Non Resectable
• CT-Angiogram (CTA) reconstruction demonstrated encased and compressed main portal vein at the origin of the superior mesenteric vein
• Not amenable to surgical resection
Image courtesy of BIDMC Department of Radiology
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Frank Acosta, HMS IV
Gillian Lieberman, MD
Management Strategies
• Neoadjuvant chemotherapy • Surgical resection• Palliation• Depends on extent, location of tumor at
diagnosis•• Radiologic studies have a key role in Radiologic studies have a key role in
determining optimal treatment (i.e. determining optimal treatment (i.e. surgical vs. nonsurgical)surgical vs. nonsurgical)
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Frank Acosta, HMS IV
Gillian Lieberman, MD
A different patient A showing Obliteration of Splenic Vein with Liver Metastases - Non Resectable
Image courtesy of BIDMC Department of Radiology
Obliterated splenic vein
Hepatic metastases
Siegelman ES: Pancreatic MR defines ducts, pinpoints disease. http://www.dimag.com/bodymri/pancreatic
• CT demonstrating: • MR max. intensity projection image (portal venousphase of contrast enhancement) showing:
Obliterated splenic vein (no contrast-asterix)Prominent collateral vessel (gastroepiploic vein)
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Frank Acosta, HMS IV
Gillian Lieberman, MD
This patient may benefit from Palliation: Celiac Plexus Neurolysis (CPN)
• Chemical splanchnicectomy of celiac plexus (absolute ethanol)
• Ablates afferent nerve fibers that transmit visceral pain
• Approx. 70% will have relief of pain for up to 24 weeks
From Wiersema MJ, Wiersema LM. Endosonography-guided celiac plexus neurolysis. Gastrointest Endosc 1996; 44:656.
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Frank Acosta, HMS IV
Gillian Lieberman, MD
Image-Guided Palliative Therapy
From Wiersema MJ, Wiersema LM. Endosonography-guided celiac plexus neurolysis. Gastrointest Endosc 1996; 44:656.
EUS Fluoroscopic monitoringEthanol distribution followinginjection into L periaortic space
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Frank Acosta, HMS IV
Gillian Lieberman, MD
Lets review the appearance of Pancreatic Cancer on other
imaging modalities
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Frank Acosta, HMS IV
Gillian Lieberman, MD
Patient B:Magnetic Resonance• MR imaging useful when clinical
suspicion for disease is high, but CT results are negative or equivocal
• T1-weighted fat-suppressed images usually provide better resolution– Desmoplastic reaction of
most pancreatic CA lowers signal intensity of tumor on T2-weighted images
– Better contrast between tumor and normal pancreas
Friedman AC: Pancreatic Neoplasms and Cysts. In Friedman AC, Dachman AH, eds: Radiology of the liver, biliary tract, pancreas, and spleen, St. Louis, 1994, Mosby-Year Book, pp 807-934.
T1-weighted image without fat-suppression shows poor contrast between tumor and normal pancreas
T1-weighted fat-suppressed image allows bettercontrast; normal pancreas (white arrow)increases in signal much more than tumor (blackarrow)
A
B
A
B
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Frank Acosta, HMS IV
Gillian Lieberman, MD
ERCP & MRCP
Dilated, irregular pancreatic ductwith filling defects
Images courtesy of BIDMC Department of Radiology
ERCP: Patient C
Dilated side branches of pancreatic duct
MRCP: Patient D
Dilated pancreatic duct and side branches
Gallbladder
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Frank Acosta, HMS IV
Gillian Lieberman, MD
Patient E: Endoscopic Ultrasound (EUS)• Improved diagnosis and
localization of small (<2- 3cm) lesions– Early identification is
crucial– 30% 5-year survival rate
• Useful in detecting lymph node and vascular involvement
• Can determine invasion of duodenal wall and pancreas by ampullary tumors
• More accurately detailed staging information
• Does not reliably detect lesions distant from the pancreas
http://www.mc.Vanderbilt.Edu/surgery/pncnprog.html
http://www.mgh.harvard.edu/endoscopy/Endo%20site/EUS.html
EUS of pancreatic massInvolving SMV-portal vein confluence
Diagram of echoendoscopeimaging pancreatic massthrough pyloric wall
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Frank Acosta, HMS IV
Gillian Lieberman, MD
Patient F: The Preoperative Response to Treatment may be evaluated by Nuclear Medicine
• 18FDG-PET scan performed before (A) and after (B) taxol-based neoadjuvant chemoradiation.
URL: http://www.mc.Vanderbilt.Edu/surgery/pncnprog.html
Near total reduction in tumor-specific signal following completion of taxol-based neoadjuvant chemoradiation
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Frank Acosta, HMS IV
Gillian Lieberman, MD
Take Home Points• Carcinoma of the pancreas is an almost uniformly
fatal cancer• Disturbances in pancreatic structure/function
determine initial presentation• Duct cell adenocarcinoma and its variants account for
~90% of all pancreatic tumors – most occur in the head of the pancreas
• CT is the best pancreatic imaging modality useful in detection and staging of pancreatic CA
• Helical CT and CTA are useful in determining vascular involvement, resectability of pancreatic tumors (10-15%):
• Radiologic techniques are essential in the performance of nonoperative palliation – CPN
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Frank Acosta, HMS IV
Gillian Lieberman, MD
References• Friedman AC: Pancreatic Neoplasms and Cysts. In Friedman AC, Dachman AH, eds: Radiology of the
liver, biliary tract, pancreas, and spleen, St. Louis, 1994, Mosby-Year Book, pp 807-934.• Gray H: Anatomy, Descriptive and Surgical. Pick TP, Howden R, eds. Philadelphia, 1974, Running Press.• Kuroda A, Nagai H: Surgical Anatomy of the Pancreas. In Howard J, et al., eds: Surgical Diseases of the
Pancreas, Baltimore, 1998, Williams & Wilkins, pp 11-21.• Massachusetts General Hospital Endoscopy, http://mgh.harvard.edu/endoscopy.• Netter FH. Atlas of Human Anatomy, New Jersey, 1989, Novartis.• Novelline RA. Squire’s Fundamentals of Radiology, Cambridge, 1997, Harvard University Press.• Raptopoulos V, Steer ML, Sheiman RG, Vrachliotis TG, Gougoutas CA, Movson JS. The use of helical CT
and CT angiography to predict vascular involvement from pancreatic cancer: correlation with findings at surgery. AJR 1997; 168:971-977.
• Reeder & Felson’s Gamuts in Radiology: Comprehensive List of Roentgen Differential Diagnoses.• Siegelman ES: Pancreatic MR defines ducts, pinpoints disease.
http://www.dimag.com/bodymri/pancreatic.• Steer ML: Clinical manifestations and diagnosis of exocrine pancreatic cancer. From UpToDate literature
search, http://www.uptodate.com.• Thoeni RF, Blankenberg F: Pancreatic Imaging, Radiol Clin North Am 1993; 31:1085-1113.• Vanderbilt Department of Surgery, http://www.mc.Vanderbilt.Edu/surgery/pncnprog.• Wiersema MJ, Wiersema LM: Endosonography-guided celiac plexus neurolysis, Gastrointest Endosc
1996; 44:656• Zeman RK, Silverman PM: Computed Tomography. In Evans SRT, Ascher SM, eds: Hepatobiliary and
Pancreatic Surgery: Imaging Strategies and Surgical Decision Making, New York, 1998, Wiley-Liss, pp 445- 463.
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Frank Acosta, HMS IV
Gillian Lieberman, MD
Acknowledgments
• Vassilios Raptopoulos, MD• Chad Brecher, MD• Gillian Lieberman, MD• Beverlee Turner & Pamela Lepkowski• Larry Barbaras and Cara Lyn D’amour,
our webmasters