Comprehensive Preoperative Assessment of Pancreatic Carcinoma

Dr. Muhammad Bin ZulfiqarPGR III FCPS New Radiology Department

Services Institute of Medical Sciences / Services Hospital

Imaging Scheme (Modalities)

• Ultrasound– Gray Scale and Doppler Ultrasound– Contrast Enhanced Ultrasound– Endoscopic Ultrasound

• CT– CECT– Unenhanced CT

• PET CT• MRI• Interventional Radiology– Ultrasound Guided– Transcatheter

Aims of Imaging

• Whichever imaging modality is used, the aim of preoperative assessment should be to – localize the pancreatic adenocarcinoma,– stage the tumor and determine if it is

unresectable– Preoperatively suggest vascular anatomy for

surgeon

Brennan et al. Comprehensive Preoperative Assessment of Pancreatic Adenocarcinoma with 64-Section Volumetric CT. RadioGraphics 2007; 27:1653–1666

• CECT Axial image shows a heterogeneously contrast enhancing mass lesion with few necrotic elements in the tail and part of the body of pancreas approximately measuring 4-5 cm. This mass is encircling the vessels (small arrow), infiltrating the peripancreatic fat planes, abutting and infiltrating the crura (Large arrow).

• CECT Axial image in addition to above mentioned findings show engulfement of left adrenal and encasement Celiac Trunk and its branches. There are no definitive enlarged lymph nodes. No evidence of liver deposits.

• CECT Axial image shows a heterogeneously contrast enhancing mass lesion with few necrotic elements in the tail and part of the body of pancreas approximately measuring 4-5 cm. This mass is encircling the vessels (small arrow), infiltrating the peripancreatic fat planes and abutting and infiltrating the crura (Large

arrow).

Staging of Pancreatic Tumor• T

– TX—Primary tumor not assessed– Tis—Carcinoma in situ– T1—Tumor less than or equal to 2 cm in diameter and confined to the pancreas– T2—Tumor greater than 2 cm in diameter and confined to the pancreas– T3—Tumor extends beyond the pancreas but does not involve the celiac axis or

SMA– T4—Primary tumor involves either the celiac axis or the SMA

• N– NX—Regional lymph nodes not assessed– N0—No involvement of the regional lymph nodes– N1—Involvement of the regional lymph nodes

• M– MX—Distant metastases cannot be assessed– M0—No distant metastasis– M1—Distant metastasis Brennan et al. Comprehensive Preoperative Assessment of Pancreatic

Adenocarcinoma with 64-Section Volumetric CT. RadioGraphics 2007; 27:1653–1666

Resectability CriteriaStage Description TNM Levels

Additional Features

IResectable T1 or T2, N0,

M0No extrapancreatic disease, no encasement of the celiac axis or SMA

II

Typicallyresectable

T1 or T2, N1, M0; T3, N0 or N1, M0

Regional lymph nodes may be involved, no encasement of the celiac axis or SMA, possible extrapancreatic involvement

III

Unresectable T4, N0 or N1, M0

Regional lymph nodes may be involved, encasement of the celiac axis or SMA

IV

Unresectable T (any), N (any), M1

Liver, peritoneal, lung metastases

Brennan et al. Comprehensive Preoperative Assessment of Pancreatic Adenocarcinoma with 64-Section Volumetric CT. RadioGraphics 2007; 27:1653–1666

Resectability and Vessel Ingrowth

Preserved Fat Planes between tumor and Vessel

Resectable

Vessel Surrounded < 180 Doubtful resectable

Vessel surrounded >180 or occlusion

Not resectable

Otto van Delden and Robin Smithuis. http://www.radiologyassistant.nl/en/p43848b63def9d/pancreas-carcinoma.html

Conclusion of imaging data

• On the Basis Of CT imaging findings, our patient is T4, N1, M0 (Stage III) and his tumor is unresectable.

Role of PET CT

• Provides functional information– Depicting localized extension– Differentiating benign from malignant– Unknown metastases and – Differentiates fibrosis from tumor.– monitoring tumor recurrence (1)

• may become the imaging test of choice in the management of pancreatic cancer (2)

• In our opinion in our circumstances we should go for PET CT if our diagnosis hang between Stage II / III

1. V. Sahani et al. State-of-the-Art PET/CT of the Pancreas: Current Role and Emerging Indications. RadioGraphics 2012; 32:1133–1158

2. Dibble et al. PET/CT of Cancer Patients: Part 1, Pancreatic Neoplasms. AJR:199, November 2012

Role of Intervention Radiology

• Carcinoma of the exocrine pancreas is the fourth leading cause of cancer-related death in the United States and the Western world. 1. Because of the frequent delay in diagnosis,

approximately 80% of patients have unresectable disease at presentation

2. Therefore, patients with locally advanced pancreatic cancer predominate in clinical practice.

Modes of interventions• Arterial infusion chemotherapy (TACE) for

unresectable pancreatic cancer—Unification of pancreatic blood supply (1).

– superior mesenteric artery is embolized – 5-fluorouracil, leucovorin, epirubicin and carboplatin (FLEC

regimen) [2]

• high-intensity focused ultrasound ablation is safe and feasible in the treatment of advanced pancreatic cancer (3). Continued

1. Tanaka et al. A Novel Interventional Radiology Technique for Arterial Infusion Chemotherapy Against Advanced Pancreatic Cancer. AJR:192, April 2009

2. Sanguinetti F et al. Intraarterial infusion of 5-fluorouracil, leucovorin, epirubicin and carboplatin (FLEC regimen) in unresectable pancreatic cancer: results of a tenyear experience. In Vivo 2006; 20:751–75

3. Wu et al. Feasibility of US-guided High-Intensity Focused Ultrasound Treatment in Patients with Advanced Pancreatic Cancer: Initial Experience Radiology 2005; 236:1034–1040 TACE (Transcatheter Arterial Chemoembolization)

Modes of interventions

Palliative Management:• Drainage Procedures:– Endoscopic placement of catheters for biliary

drainage.– Percutaneous biliary drainage

• Pain Management:– Percutaneous celiac plexus blockage

• Endoscopic placement of expandable metallic stents to relieve intestinal obstruction

Frank J. Brescia, MD, MA, FACP. Palliative Care in Pancreatic Cancer. January/February 2004, Vol. 11, No. 1

• http://www.annalskemu.org/journal/index.php/annals/article/view/709

Take Home message

• By imaging using MDCT 16 Slices we are able to preoperatively.– Localize the tumor– Stage it – Suggest resectability & – Comment on vascular anatomy.

THANK YOU