cross sectional imaging in pancreatic cancer · 2015-05-15 · background • 3% cancers in uk •...
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Cross Sectional Imaging in Pancreatic Cancer
Raneem Albazaz MBChB (Hons) BSc (Hons) MRCS FRCR
Consultant GI Radiologist
Leeds Teaching Hospitals NHS Trust
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Background
• 3% cancers in UK
• Ductal adenocarcinoma commonest
• Predilection for head and neck
• Obstructive jaundice
• Surgery primary treatment
• 5 year survival following resection only 10%
• NETs and cystic tumours less common but better prognosis
Vincent et al, Lancet 2011;378:607-620
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How is Suspected Pancreatic Cancer Investigated?
• Tumour markers
• Ultrasound
• Computed tomography (CT)
• Magnetic resonance imaging (MRI incl. MRCP)
• Endoscopic ultrasound (EUS)
• Endoscopic retrograde cholangiopancreatography (ERCP)
• Positron emission tomography (PET-CT)
• Other nuclear medicine eg. octreotide scan, nanocolloid
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How is Suspected Pancreatic Cancer Investigated?
• Tumour markers
• Ultrasound
• Computed tomography (CT)
• Magnetic resonance imaging (MRI incl. MRCP)
• Endoscopic ultrasound (EUS)
• Endoscopic retrograde cholangiopancreatography (ERCP)
• Positron emission tomography (PET-CT)
• Other nuclear medicine eg. octreotide scan, nanocolloid
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What is the Role of Imaging?
• Preoperative • Is it cancer?
• Localise tumour
• Is it resectable? • Local extent • Distant disease
• Anatomic variants • Vascular/biliary tree
• Post-operative • Identify complications • Recurrence
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What is the Role of Imaging?
• Palliative
• Size of tumour if chemorad considered (<5cm)
• Response to palliative treatment
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CT vs MRI
• If we know it’s cancer then it doesn’t matter which!
• Similar capability to assess local tumour extent
• NB. both can underestimate disease
Takakura et al. Abdom Imaging 2011;36:457-62
Motosugi et al, Radiology 2011;260:446-453
Verbeke et al, Pancreatology 2010;10:300
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Spatial Resolution (Clarity)
• CT better than MRI • Wide anatomical coverage • Comprehensive local and distant disease assessment • Rapid
• Eliminates artefact • Multi-planar reconstruction
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Contrast Resolution (Intensity)
• MRI better than CT • MRI parameters can be altered to improve resolution
• Better for lesion characterisation/detection
• Long examination time
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Liver lesion characterisation in pancreatic cancer ? Metastasis
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MRI
• Indications • Equivocal CT findings • Characterising lesions (primary tumour, liver lesion) • Defining anatomy of biliary tree and PD • Patient factors
• Renal impairment precluding CECT • Iodine contrast allergy
• Contraindications • Pacemaker • Aneurysm clips • Metal FB eye • Claustrophobia • Inability to breath hold
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56 year old male Abdominal pain, drinks half litre vodka per day
art
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56 year old male Drinks half litre vodka per day
T2 T1 T1 art
T1 delayed DWI ADC
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Staging CT
• Contrast
• Timing crucial
• Pancreas protocol
• Triple phase CAP
• Non contrast (calcification)
• Late arterial phase 35 sec (pancreatic phase = primary tumour & vessels)
• Portal venous phase 70 sec (metastases)
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86 year old female #NOF, acutely deranged LFTS
art pv non con
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Pancreatic Cancer Diagnosis
• Pancreatic adenocarcinoma • Hypovascular
• Compared to adjacent enhancing pancreas
• 10% isoattenuating • Secondary signs helpful • Double duct sign • Atrophic distal pancreas • Interrupted duct • Vascular occlusion
• Biliary stents / pancreatitis can be problematic
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62year old male Early satiety and epigastric pain, normal OGD, borderline abnormal LFTs
pv
pv
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54 year old female 6 week history central abdo pain radiating to back, dilated PD on US
non con
pv
art
MIP
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EUS
• Indeterminate findings on CT/MRI
• FNA possible
• Cytological assessment
• Operator dependent
• Limited availability
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Pancreatic Cancer Staging
• T staging (90% focal mass) • TX
• Primary tumor cannot be assessed • T0
• No evidence of primary tumor • Tis
• Carcinoma in situ • T1
• ≤ 2 cm in diameter and confined to the pancreas • T2
• > 2 cm in diameter and confined to the pancreas • T3
• Extension beyond pancreas but not involving coeliac axis or SMA • T4
• Involvement of coeliac axis, SMA, stomach, bowel (unresectable) • Lymphatic channels along coeliac axis or SMV
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Pancreatic Cancer Staging
• N staging • NX
• Regional lymph nodes not assessed
• N0 • No involvement of regional lymph nodes
• N1 • Involvement of regional lymph nodes
• Prognosis directly related to nodal involvement
• CT not accurate for nodal involvement
Roche et al, AJR 2003; 180:475–480
Geer et al, Am J Surg 1993; 165:68–73
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Pancreatic Cancer Staging
• CT limited in detection of small liver and peritoneal metastases
• Lung metastases not usually found if no other contraindication to surgery
Nordback et al, Scand J Gastroenterol 2004;39:81–86
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Vascular Resectability
• Venous invasion • PV • Splenic vein • SMV
• Gastrocolic trunk • First jejunal branch
• Arterial invasion • Coeliac trunk • Hepatic artery • SMA
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Vascular Invasion
• Loss of fat plane between tumour and vessel
• Flattening / slight irregularity of one side (ie. <180°) • Questionable involvement
• Tumour extending around at least two sides (ie. 180°) • Definite involvement, en bloc venous resection may still be
possible
• Circumferential narrowing or occlusion • Mostly unresectable • Short-segment focal venous occlusion may allow local resection
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72 year old male Abdo pain, hypotension, PR bleeding
pv
pv
pv
pv
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72 year old male Abdo pain, hypotension, PR bleeding
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72 year old male Abdo pain, hypotension, PR bleeding
T2 T1 + gad DWI ADC
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65 year old female Abdominal pain and distension, ascites on US
pv
pv
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58 year old female Upper abdo pain, dilated CBD on US
art
pv
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72 year old male Abdo and back pain with weight loss, normal OGD
art
art
pv
pv
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Follow-up
• No role for routine imaging post surgery
• Only if symptomatic
• Only if recurrence suspected clinically
• Assess response to chemotherapy in palliative cases
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Take Home Points
• CT usually provides required information (pancreatic CT for staging)
• Other tests available for problem solving
• Consider suitability of test in clinical context