Comprehensive preoperative assessment of pancreatic carcinoma Dr. Muhammad Bin Zulfiqar
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Comprehensive preoperative assessment of pancreatic carcinoma Dr. Muhammad Bin Zulfiqar here we will discuss the the resectability of the pancreatic tumors preoperatively using 16 slice MDCT
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Comprehensive preoperative assessment of pancreatic carcinoma Dr. Muhammad Bin Zulfiqar
- 1. Comprehensive Preoperative Assessment of Pancreatic Carcinoma Dr. Muhammad Bin Zulfiqar PGR III FCPS New Radiology Department Services Institute of Medical Sciences / Services Hospital
- 2. 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
- 3. 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
- 4. • 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).
- 5. • 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.
- 6. • 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).
- 7. 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
- 8. Resectability Criteria Stage Description TNM Levels Additional Features I Resectable T1 or T2, N0, M0 No extrapancreatic disease, no encasement of the celiac axis or SMA II Typically resectable 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
- 9. 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
- 10. Conclusion of imaging data • On the Basis Of CT imaging findings, our patient is T4, N1, M0 (Stage III) and his tumor is unresectable.
- 11. 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
- 12. 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.
- 13. 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)
- 14. 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
- 16. 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.
- 17. THANK YOU
Hinweis der Redaktion
- Unenhanced and contrast-enhanced MR imaging with MRCP and MR angiography offers potential as a noninvasive tool for assessment of patients suspected of having pancreatic tumors.
- The current study, therefore, was initiated to prospectively determine the accuracy of a single noninvasive modality in the clinical work-up of patients suspected of having pancreatic tumors who were referred for evaluation with regard to lesion detectability, assessment of lesion status (malignant vs benign), and resectability of the lesion. In our study, overall accuracy was calculated at 90% and, thus, was superior or similar to accuracy in previous studies in which MR imaging was used for pancreatic cancer evaluation (22,23). Nevertheless, among the 37 confirmed pancreatic adenocarcinomas described in this series, surgical and histopathologic assessment demonstrated no tumor that was locally confined to the pancreas. Compared with findings in previous studies that have been published so far in which CT, US, and PET were used for pancreatic tumor detection, the sensitivity of MR imaging appeared to be superior to that of CT and similar to the best values for sensitivity with US and PET. Fused positron emission tomography (PET)/computed tomography (CT) is a recently developed technology that couples the functional information of PET with the anatomic details of CT. Integrated PET/ CT scanners produce both PET and contrast material–enhanced CT images of the entire body in one setting. Typically, the amount of fluorine 18 (18F) fluorodeoxyglucose (FDG) uptake in normal pancreatic parenchyma is insignificant compared with that of the liver. However, both malignant (eg, adenocarcinoma) and benign (eg, acute pancreatitis) pancreatic conditions may demonstrate intense FDG uptake. PET/CT provides an opportunity to depict pancreatic tumors and distant metastases, perform preoperative staging, and monitor response to treatment, and it has proved useful in distinguishing postoperative fibrosis from recurrence. In selected cases, PET/CT findings may be used to help diagnose autoimmune pancreatitis mimicking a mass by depicting systemic involvement. PET/CT may also be used to direct biopsy to sites more likely to yield representative tumor tissue. Novel radiolabeled molecules, such as sigma-receptor ligands and 18F-3′-fluoro-3′-deoxy-l-thymidine (FLT), may play an even greater role in distinguishing tumor recurrence from postoperative fibrosis or inflammation. Published studies have shown that FDG-positive cystic neoplasms are frankly malignant or invasive (Fig 16). Conversely, FDG-negative lesions may be benign, borderline malignant, or noninvasive malignant (5). By using a cut-off SUV of 2.5, differentiating between benign and malignant IPMNs was feasible, with malignant lesions (range, 6.7–2.7) demonstrating significantly higher SUVmax than benign lesions (range, 2.1–1.8) (4,6,7). The sensitivity (94%) and specificity (100%) of PET/CT for depicting malignant cystic pancreatic lesions have been shown to be superior to those of FDG PET (56% sensitivity and 83% specificity) and CT (81% sensitivity and 100% specificity) (84).
- The management of neuroendocrine tumors (NETs) is complex. Although NETs can affect a variety of organ systems, hepatic metastatic disease in particular lends itself to a wide range of interventional treatment options. Prior detailed radiologic assessment and careful patient selection are required. Curative surgery should always be considered but is rarely possible. Embolization, radionuclide therapy, or ablative techniques may then be undertaken. Transcatheter arterial embolization (TAE) may be used alone or in combination with transcatheter arterial chemoembolization (TACE). NET type and extent of hepatic involvement are factors that can help predict the success of either TAE or TACE. Embolization techniques can also be useful in patients with nonhepatic NETs. Radionuclide therapy is emerging as a valuable adjunct and is dependent on positive somatostatin receptor status. Therapeutic radiopeptides may be delivered arterially. Ablative techniques have been shown to play a role in the palliation of symptoms and principally involve radiofrequency ablation. Hepatic cryotherapy and percutaneous ethanol injection have also been used. A multidisciplinary approach to treatment and follow-up is important. Imaging should involve dual-phase multidetector computed tomography and contrast material–enhanced magnetic resonance imaging. The role of the interventional radiologist will continue to expand as imaging techniques become more refined.
- Page 1134 Malignant lesions generally demonstrate avid FDG uptake, whereas most benign lesions are characterized by normal or minimally increased FDG accumulation. Focal areas of abnormally increased FDG uptake are considered suspicious for malignant disease, and in many cases, metabolic alterations precede the morphologic changes associated with malignant tumors. Page 1134 However, false-positive and false-negative results also may occur with FDG PET, and its inherent low spatial resolution may interfere with precise anatomic localization of findings (25,26). The reported sensitivity and specificity of FDG PET for depiction of pancreatic adenocarcinoma are 46%–71% and 63%–100%, respectively (18). Serum glucose levels also affect FDG PET findings. It has been reported that, among patients with pancreatic malignancy, FDG PET has relatively better sensitivity (83%–86%) for tumor depiction in patients who are euglycemic than in those with elevated glucose levels (42%–69%). Page 1141 Fused PET/CT may improve the specificity of nodal staging compared with CT alone, helping identify metastatic deposits in lymph nodes that demonstrate nonspecific or borderline enlargement at CT. Page 1144 Postoperative inflammatory changes in the pancreas, radiation therapy, or stent placement may also cause some FDG uptake. To minimize these false-positive results, it is recommended that follow-up PET or PET/CT be performed at least 6 weeks after surgery. Page 1152 PET/CT may help in the diagnosis of AIP and assessment of response to corticosteroid therapy by depicting resolution of or decrease in diffuse FDG uptake in the pancreas.