Michelle LeeGillian Lieberman, MD

Radiologic Staging of Pancreatic Cancer

Michelle A. Lee, Harvard Medical School Year IVGillian Lieberman, MD

Michelle LeeGillian Lieberman, MD

July 2002

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Michelle LeeGillian Lieberman, MD

Pancreatic Cancer• 4th leading cause of cancer deaths in men and women• peak incidence at 60-80 years of age• in the US, incidence and mortality are decreasing for men

and increasing for women• in the US, higher incidence and mortality in black persons

than white persons• associated with Northern European or Jewish ancestry and

genetic syndromes: NHPCC, BRCA2, hereditary pancreatitis, ataxia-telangectasia, Peutz-Jeghers, FAMMM

• risk factors: smoking, occupational, pernicious anemia,lower SES, industrialized society, ? chronic pancreatitis

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Michelle LeeGillian Lieberman, MD

The Pancreas in the Retroperitoneum

superior mesenteric arterysuperior mesenderic vein

celiacartery

splenic arteryand vein

portalvein

commonbile duct

cystic duct

commonhepatic duct

Netter, F.H. with Colacino, S., consulting editor. Atlas of Human Anatomy.Summit, NJ: CIBA-GEIGY Corp., 1993.

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Michelle LeeGillian Lieberman, MD

Anatomy of the Pancreascommon bile duct (ductus choledochus)

accessory pancreatic duct of Santorini

principal pancreatic ductof Wirsung

head

uncinate

body

tail

neck

Netter, F.H. with Colacino, S., consulting editor. Atlas of Human Anatomy.Summit, NJ: CIBA-GEIGY Corp., 1993.

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Michelle LeeGillian Lieberman, MD

Embryology of the Pancreas

ventral pancreatic bud

dorsal pancreatic budliver

gallbladder

stomach

week 6 week 8

ampullaof Vater

ventral bud dorsal bud

dorsalbud

ventralbud

duodenum

main pancreatic ductweek 7

Moore, K. and Persaud, T.V.N. The Developing Human: Clinically Oriented Embryology.5th edition. Philadelphia: WB Saunders Co., 2001.

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Michelle LeeGillian Lieberman, MD

Physiology of the Pancreas

• Endocrine function: metabolism– Islets of Langerhans cells make glucagon,

insulin, gastrin– also somatostatin, pancreatic polypeptide, VIP

• Exocrine function: digestion– acinar cells make amylase, lipase, trypsinogen,

procarboxypeptidase– ductal cells make Na+ HCO3

-

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Michelle LeeGillian Lieberman, MD

Differential Diagnosis of the Pancreatic Mass

• pancreatitis• pancreatic pseudocyst, cyst, or benign

neoplasm• pancreatic carcinoma• metastasis

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Michelle LeeGillian Lieberman, MD

Imaging Pancreatic Cancer

• CT with iv contrast to identify tumor or assess resectability– with contrast there is increased signal intensity of

normal pancreatic parenchyma – pancreatic carcinoma, which is hypovascular, is seen

as a focal hypodense mass– pancreatic cancer is associated with dilation of bile duct

(58%) or pancreatic duct (67%) or both (“double duct” sign)

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Michelle LeeGillian Lieberman, MD

Imaging pancreatic cancer - 2

• CT angiogram for equivocal CT or to examine pre-op vascular anatomy– patency and location of celiac access and superior

mesenteric artery, as well as portal and systemic veins can be visualized

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Michelle LeeGillian Lieberman, MD

Imaging pancreatic cancer - 3• MR when CT cannot be performed or would be

limited by streak artifact– T1 spin echo sequence with fat suppression shows

pancreatic cancer with decreased signal intensity relative to normal pancreatic parenchyma

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Michelle LeeGillian Lieberman, MD

Imaging pancreatic cancer - 4

• ERCP for equivocal CT – pancreatic cancer encases or obstructs pancreatic and/or

bile ducts, and causes acinar defects and duct necrosis with tumor cavitation

• Ultrasound for initial evaluation for obstructive jaundice – pancreatic cancer appears as an anechoic focal or

diffuse mass at head of the pancreas associated with dilated pancreatic and/or bile ducts

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Michelle LeeGillian Lieberman, MD

PATIENT 1

• Hx: 1 month of fatigue and abdominal distention, now with bright red blood per rectum

• Labs: Hct 24%• Dx: ischemic colitis in the splenic flexure of the

colon identified by colonoscopy

• STUDY: CT with iv contrast to look for pathology at the splenic flexure of the colon

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Michelle LeeGillian Lieberman, MD

Patient 1: Scout Film

paucity of airin thedescending colon

BIDMC PACS

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Michelle LeeGillian Lieberman, MD

Patient 1: Mass in the tail of the pancreas

pancreatictail mass

stomach

sma

aorta

spleenivc

duodenum

transversecolon

BIDMC PACS

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Michelle LeeGillian Lieberman, MD

Patient 1: Mass invading the stomach and liver metastasis

pancreaticmass

metastasisstomach

liver

BIDMC PACS

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Michelle LeeGillian Lieberman, MD

Patient 1: Mass invading the spleen and encasing the colon

pancreaticmass

descendingcolon

spleen

BIDMC PACS

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Michelle LeeGillian Lieberman, MD

Patient 1: Mass completely encasing the right splenic artery

splenic artery

pancreaticmass

BIDMC PACS

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Michelle LeeGillian Lieberman, MD

Patient 1: Thrombus in the superior mesenteric vein

smv, patent smv, thrombosed

BIDMC PACS BIDMC PACS

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Michelle LeeGillian Lieberman, MD

PATIENT 1: UNRESECTABLE PANCREATIC ADENOCARCINOMA

• 88%• mass continuous with the surface of adjacent structures• extracapsular extension• contiguous organ invasion• distant metastasis to liver or nodes• vascular involvement • ascites (indicating carcinomatosis)

• Tx: supportive care and pain control

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Michelle LeeGillian Lieberman, MD

Pancreatic Ductal Adenocarcinoma• 95% of exocrine pancreatic carcinomas• histology: infiltrating glands surrounded by dense reactive

fibrosis• gross pathology: 60% arise in the head of the pancreas,

others from the body/tail or diffuse• metastasis: to liver, peritoneum, lungs, pleura, adrenals

• Prognosis– 5% survival at 5 years s/p resection– death in months to 2 years without resection

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Michelle LeeGillian Lieberman, MD

PATIENT 2

• Hx: jaudice, weight loss, abdominal pain (also anorexia, pruritis, steatorrhea, thrombophlebitis, depression, glucose intolerance could be associated)

• STUDY: CT with iv contrast to identify the cause of biliary obstruction

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Michelle LeeGillian Lieberman, MD

Patient 2: Mass at the head of the pancreas

stomach

small bowelsmaaorta

duodenum

pancreaticmass

gall bladder

BIDMC PACS

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Michelle LeeGillian Lieberman, MD

Patient 2: Dilated common bile duct and pancreatic duct

pancreaticductcommon

bile duct

splenicartery

BIDMC PACS

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Michelle LeeGillian Lieberman, MD

Patient 2: Dilated Intrahepatic Bile Ducts

intrahepaticducts

portal veins

BIDMC PACS

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Michelle LeeGillian Lieberman, MD

PATIENT 2: RESECTABLE PANCREATIC ADENOCARCINOMA

• 12%• <2cm mass• normal surrounding parenchyma• no local or extracapsular extension, vascular invasion, or

nodal or hepatic metastases

• Tx: pylorus-sparing pancreatoduodectomy-Whipple or total pancreatectomy

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Michelle LeeGillian Lieberman, MD

Resection of pancreatic cancer

gallbladder

duodenumtumor

pancreas

proximaljejunum

end to side duodenojejunostomy

end to end pancreatojejunostomy

end to side hepatojejunostomy

Redlick, P.N., Ahrendt, S.A., and Pitt, H.A. Tumors of the pancreas, gallbladder,and bile ducts. In Clinical Oncology. Lenhard, R.E., Osteen, R.T., and Gansler, T.,

pp. 373-394, Atlanta: American Cancer Society, 2001.

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Michelle LeeGillian Lieberman, MD

PATIENT 3

• Hx: long history of alcohol abuse, known pancreatic cystic mass, now with abdominal pain

• STUDY: US (transverse shown) indicated increased size of cystic mass with nodules

• STUDY: CT angiogram obtained to assess resectability

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Michelle LeeGillian Lieberman, MD

Patient 3: Cystic mass with nodules in the head of the pancreas

sma

normalpancreas

dilatedpancreaticduct

air inbowel

pancreatic cystic mass with nodules

BIDMC PACS

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Michelle LeeGillian Lieberman, MD

Patient 3: Normal body and tail of the pancreas

tail of pancreas body of pancreas

BIDMC PACS BIDMC PACS

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Michelle LeeGillian Lieberman, MD

Patient 3: Two cystic masses in the head of the pancreas with dilation of the common bile duct and pancreatic duct

normal pancreas

mass 1commonbile duct duodenum mass 2

normal pancreas

pancreatic duct

BIDMC PACS BIDMC PACS

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Michelle LeeGillian Lieberman, MD

Patient 3: CTA Reconstructions

smv

portal vein

normalpancreas

mass 1

mass 2

celiac arterysma

mass 1

mass 2calcifications

BIDMC PACS

BIDMC PACS

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Michelle LeeGillian Lieberman, MD

Biliary Obstruction Secondary to Pancreatic Cancer

duodenum

gall bladderandbiliary ducts

mass 2: cancer or dilated accessory duct?

BIDMC PACS

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Michelle LeeGillian Lieberman, MD

PATIENT 3: Resectable Pancreatic Cancer?

• mass >2cm, not surrounded by normal parenchyma, abutting adjacent tissues

• no local or extracapsular extension, vascular invasion, or nodal or hepatic metastases

• but the mass is cystic

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Michelle LeeGillian Lieberman, MD

Differential Diagnosis of Pancreatic Cystic Lesions

• fluid collection• pseudocyst• less likely

– serous cystic neoplasm (rarely malignant)– mucinous cystic neoplasm (malignant potential

or malignant, but with 40-50% 5 year survival)

* Patient 3’s diagnosis: resectable mucinous cystic neoplasm

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Michelle LeeGillian Lieberman, MD

Early Detection of Pancreatic Cancer

• screening of patients with familial syndromes radiologically (using EUS, then ERCP if the patient is symptomatic or the EUS is abnormal) has been shown to be effective– all patients with findings who underwent

pancreatectomy had pancreatic dysplasia on pathology• laboratory screening may ultimately be combined with

radiologic screening– mutant K-ras oncogene can be detected in pancreaic

juice or stool samples– tumor marker CA-19-9 can be measured in plasma

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Michelle LeeGillian Lieberman, MD

Summary• pancreatic carcinoma appears as a focal or diffuse

mass, or possibly a cyst, associated with dilated pancreatic and/or biliary ducts

– on CT: a hypodense lesion – on MR: a hypointense lesion – on US: a hypoechoic lesion

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Michelle LeeGillian Lieberman, MD

Summary - 2

• Identification of candidates for surgical resection is imperative

• CT is the primary imaging modality for assessing resectability of pancreatic carcinoma

• Equivocal CT studies can be followed by CT angiography, MR, or ERCP

• Both CT and MR overpredict resectability (CT: PPV 72%, NPV 100%)

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Michelle LeeGillian Lieberman, MD

References*All radiographic images were copied from BIDMC PACS.

Fishman, E.K. and Horton, K.M. Imaging pancreatic cancer: the role of multidetector CT with three-dimensional CT angiography. Pancreatology Vol. 1, pp. 610-624, 2001.

Freeny, P.C. Radiologic diagnosis and staging of pancreatic ductal adenocarcinoma. In Radiologic Clinics of North America: Radiology of the Pancreas. Freeny, P.C. ed. Vol. 27, pp. 121-128, Philadelphia: W.B. Saunders Co., 1989.

Reader, M.M. and Bradley, Jr., W.G. Gamuts in Radiology: Comprehensive Lists of Roentgen Differential Diagnosis. 3rd edition. New York: Springer-Verlag, 1993.

Moore, K. and Persaud, T.V.N. The Developing Human: Clinically Oriented Embryology. 5th edition. Philadelphia: WB Saunders Co., 2001.

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Michelle LeeGillian Lieberman, MD

References - 2Netter, F.H. with Colacino, S., consulting editor. Atlas of Human

Anatomy. Summit, NJ: CIBA-GEIGY Corp., 1993.Nghiem, H.V., and Freeny, P.C. Radiologic staging of pancreatic

adenocarcinoma. In Radiologic Clinics of North America: Staging neoplasms. Thompson, W.M. ed., Vol. 32, pp. 71-79, Philadelphia:W.B. Saunders, 1994.

Redlick, P.N., Ahrendt, S.A., and Pitt, H.A. Tumors of the pancreas, gallbladder, and bile ducts. In Clinical Oncology. Lenhard, R.E., Osteen, R.T., and Gansler, T., pp. 373-394, Atlanta: American Cancer Society, 2001.

Rulyak, S.J. and Brentnall, T.A. Inherited pancreatic cancer: surveillance and treatment strategies for affected families. Pancreatology Vol. 1, pp. 477-485, 2001.

Weyman, P.J., Stanley, R.J., and Levilt, R.G. Computed tomography in evaluation of the pancreas. Seminars in Roentgenology Vol. 16, pp. 301-311, 1981.

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Michelle LeeGillian Lieberman, MD

Acknowledgements

• Damon Soeiro, MD • Chad Brecher, MD• Jonathon Kruskal, MD• Gillian Lieberman, MD• Pamela Lepkowski• Webmasters: Larry Barbara

and Cara Lyn D’amour