Fundamentals of Radiographic Staging of Pancreatic Cancer · Fundamentals of Radiographic Staging...

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Fundamentals of Radiographic Staging of Pancreatic Cancer Parag P. Tolat, MD Medical College of Wisconsin Department of Radiology

Transcript of Fundamentals of Radiographic Staging of Pancreatic Cancer · Fundamentals of Radiographic Staging...

Page 1: Fundamentals of Radiographic Staging of Pancreatic Cancer · Fundamentals of Radiographic Staging of Pancreatic Cancer Parag P. Tolat, MD Medical College of Wisconsin Department of

Fundamentals of Radiographic Staging of Pancreatic Cancer

Parag P. Tolat, MD

Medical College of Wisconsin

Department of Radiology

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Disclosures

• None

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Tumor detection

& characterization Staging

Predict if R0 resection can be achieved safely

Detect and describe vascular variants for pre-surgical planning

Role of Imaging

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Keys to Success

Great imaging

Ease of access and reproducibility

Standardized Interpretation &

Reporting

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Keys to Success

Great imaging

*MDCT pancreas protocol

*Image before any intervention

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Why MDCT?

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Why MDCT?

• Good spatial resolution

• Wide field of coverage in one exam

• Good contrast differentiation between

tumor and normal parenchyma

• 3-D data sets for multi-planar vascular

and pancreatic reconstructions

• Reproducibility

• Ease of access

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Keys To Success

Imaging that is easily

available and reproducible

*Enterprise access with standardization

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Access & Standardization

11 Locations for CT

Imaging

17 CT scanners

11 Different CT models

3 CT vendors

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Access & Standardization

Standardized Acquisition

*Lead CT Technologist(s) are

critical working in conjunction with

MD champion

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MDCT Technique

MDCT » Scanner with 64-slice or greater preferred

Oral Contrast» Neutral contrast agent (water)

» No positive contrast

Intravenous contrast » 100-120cc of IV contrast injected at 3-5cc/sec

Phases» Pancreatic phase (Late arterial phase)

» Hepatic phase (Portal venous phase)

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CT Protocol

• Dual-phase Technique

» Late-arterial (Pancreatic) Phase

–Peak aortic arrival + 15 sec.

–Best phase for detecting tumors

–Best phase to evaluate for arterial anatomy and

tumor involvement

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CT Protocol

• Dual-phase Technique

» Portal Venous Phase

–Peak aortic arrival + 45 sec.

–Best phase to evaluate for venous anatomy

and tumor involvement

–Best phase to evaluate liver for mets

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Late Arterial Phase

Portal-Venous Phase

Courtesy WD Foley, MD

Tumor detection

(adenocarcinoma &

neuroendocrine tumor)

Arterial anatomy

Tumor-artery relationship

Identify metastases

Venous Anatomy

Tumor-vein relationship

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Late Arterial Phase Portal-Venous Phase

Tumor Detection

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Reformations

Curved Plane Reconstruction

Courtesy WD Foley, MD

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Reformations

Resectable adenocarcinoma of the pancreatic head/uncinate process (arrow)

confined to the pancreas. Note the low attenuation tumor is distinct from the

SMA and SMV with persistent fat plane (arrowhead).

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Keys to success

Standardized Radiographic

Staging

*Standardized interpretation and reporting

using an accepted staging system

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Operable

Resectable

Borderline Resectable

Inoperable

Locally Advanced

(Type A vs. B)

Metastatic

Clinical Staging

Arterial involvement

Venous involvement

Extrapancreatic disease

Courtesy Naveen Kulkarni, MD

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Tissue

Plane

Abutment

(≤ 180º)

Encasement

(> 180º)

SMA

CA

CHA

SMV/PV

Resectable Borderline Locally Adv

MD Anderson Clinical/Imaging Staging

Courtesy WD Foley, MD

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NCCN Guidelines

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MCW Clinical/Imaging Staging

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Tissue

Plane

Abutment

(≤ 180º)

Encasement

(> 180º)

SMA

CA

CHA

SMV/PV

Resectable Borderline Locally Adv

MCWClinical/Imaging Staging

If reconstruction possible If reconstruction possible

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MCW Locally Advanced

Type A vs. B

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Keys to success

Standardized Radiographic

Staging

*Standardized interpretation and reporting

using an accepted staging system

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Standardized Interpretation

Radiologists interpreting the study

working in conjunction with the care team

(Surgical Oncology, GI, Rad Onc, Med

Onc)

* Sub-specialized radiologists

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Resectable

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Patient 1

Late Arterial Phase Portal-Venous Phase

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Resectable adenocarcinoma of the pancreatic head/uncinate process (arrow) confined to

the pancreas. Note the low attenuation tumor is distinct from the SMA and SMV with

persistent fat plane (arrowhead).

Patient 2

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Reformations

Resectable adenocarcinoma of the pancreatic head/uncinate process (arrow)

confined to the pancreas. Note the low attenuation tumor is distinct from the

SMA and SMV with persistent fat plane (arrowhead).

Page 40: Fundamentals of Radiographic Staging of Pancreatic Cancer · Fundamentals of Radiographic Staging of Pancreatic Cancer Parag P. Tolat, MD Medical College of Wisconsin Department of

Resectable adenocarcinoma of the pancreatic head/uncinate process (arrow)

confined to the pancreas. Note the low attenuation tumor is distinct from the

SMA and SMV with persistent fat plane (arrowhead).

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Borderline Resectable

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Gastroenterology 2014 146, 291-304.e1DOI: (10.1053/j.gastro.2013.11.004)

Copyright © 2014 AGA Institute and RSNA Terms and Conditions

Abutment vs. Encasement

http://www.elsevier.com/termsandconditions
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Patient 1

Late Arterial Phase Portal-Venous Phase

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Patient 2Initial Staging Exam

Late Arterial Phase Portal-Venous Phase

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Completion Neoadjuvant Rx

Late Arterial Phase Portal-Venous Phase

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Initial Exam Completion Neo-Adjuvant

Portal-Venous Phase

Patient 2

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Patient 2Post-Op Scan

Segmental PV-SMV

resection with re-

anastomosis

Spleno-renal shunt

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Locally Advanced

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Locally advanced pancreatic adenocarcinoma of the uncinate process with

tumor encasement of the SMA (arrow). Note the low-attenuation soft-tissue

with encases the SMA for 360 degrees of the vessels. Note plastic biliary stent

(curved arrow).

Patient 1

Page 52: Fundamentals of Radiographic Staging of Pancreatic Cancer · Fundamentals of Radiographic Staging of Pancreatic Cancer Parag P. Tolat, MD Medical College of Wisconsin Department of

Locally advanced pancreatic adenocarcinoma of the uncinate process with

tumor encasement of the SMA (arrow). Note the low-attenuation soft-tissue

with encases the SMA for 360 degrees of the vessels.

Patient 1

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Locally advanced pancreatic

adenocarcinoma at the junction of

the pancreatic neck/body with tumor

encasement of the CHA (arrow) and

PV-SV-SMV confluence (arrowhead).

Note the low-attenuation soft-tissue

with encases the CHA and PV-SV-

SMV confluence for 360 degrees of

the vessels.

Patient 2

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Locally advanced pancreatic adenocarcinoma at the junction of the pancreatic neck/body

with tumor encasement of the CHA (arrow) and PV-SV-SMV confluence with severe focal

narrowing (arrowhead). Note the low-attenuation soft-tissue with encases the CHA and PV-

SV-SMV confluence for 360 degrees of the vessels.

Patient 2

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Metastatic

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Patient 1

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Patient 2

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Patient 2

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Patient 2

Metastatic Peritoneal Implants

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Imaging after GI Intervention

Difficult to Stage

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*

December 18, 2017 February 8, 2018 March 12, 2018

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Arterial Anatomy

• Normal (Type 1)

• Right HA replaced to SMA

• Completely replaced CHA to

SMA

• Accessory or direct origin of

Left HA to Left Gastric A.

• Branches of SMA which may

be involved with tumor

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• Portal Vein

• Splenic Vein

• SMV and draining

branches

• 1st jejunal branch

• IMV

Venous Anatomy

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Standardized Reporting

Pancreatic Cancer SR creates a

CHECKLIST to comprehensively STAGE

and report all findings that may affect

SURGICAL PLANNING

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Reporting

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The Case for Structured Reports

Published in: Olga R. Brook; Alexander Brook; Charles M. Vollmer; Tara S. Kent; Norberto Sanchez; Ivan Pedrosa; Radiology 2015, 274, 464-472.

DOI: 10.1148/radiol.14140206 2014 by the Radiological Society of North America, Inc.

Structured Reporting of Multiphasic CT for Pancreatic Cancer:

Potential Effect on Staging and Surgical Planning4

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Example SR

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Emerging Technologies

Dual Energy CT

PET/MR

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CT – Dual Energy

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A B (MD Iodine)

Courtesy of Dr. Naveen Kulkarni

CT – Dual Energy

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PET/MR

• First PET/MR in

Wisconsin

• Purchase cost $5.5M

• Any PET agent can be

utilized (i.e., FDG or Ga-

Dotatate)

• Reimbursed for same

indications as PET-CT

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PET/MR

Late Arterial Phase Portal-Venous Phase

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PET/MR

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PET/MR

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PET/MR

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PET/MR

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Thank You!

Any Questions?

Page 80: Fundamentals of Radiographic Staging of Pancreatic Cancer · Fundamentals of Radiographic Staging of Pancreatic Cancer Parag P. Tolat, MD Medical College of Wisconsin Department of

Courtesy of Dr. Naveen Kulkarni


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