Aaron Wieland HMS III Gillian Lieberman MD
March 2003
Imaging Pancreatic Cancer Focus on Intraductal Papillary Mucinous Tumor
Aaron Wieland, HMS III Gillian Lieberman, MD
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Aaron Wieland HMS III Gillian Lieberman MD
Mr. P’s presentation Mr. P is a 65 year-old gentleman with a 10 year history of chronic pancreatitis and a more recent diagnosis of diabetes mellitus who presented with left-sided flank pain that radiated to the lower abdomen. He complained of several days of nausea and vomiting. 2
Aaron Wieland HMS III Gillian Lieberman MD
Presentation continued Mr. P’s symptoms were thought to be due to a renal or ureteral calculus and he received a CT scan for further work-up. His initial studies were done at an outside hospital and were unavailable. His scan may have have looked similar to the following. 3
Aaron Wieland HMS III
CT scan with contrast
Gillian Lieberman MD
Mass in pancreatic head Causing a dilated pancreatic duct Stomach w/ oral contrast
Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 7th ed
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Anatomy, Antatomie, Anatomia
Clayton, Martin. Leonardo Da Vinci: The Anatomy of Man. Bullfinch Press, 1992.
Aaron Wieland HMS III Gillian Lieberman MD
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Aaron Wieland HMS III
Anatomy
Gillian Lieberman MD
Body Tail Neck Head
www.yahooligans.com/reference/gray/fig/1098.html 6
Uncinate Process (behind sma and smv)
Aaron Wieland HMS III
Uncinate process
Gillian Lieberman MD
The uncinate is that part of the head that wraps behind the SMA and SMV
Portal v. CBD
SMA
SMV Uncinate Process Soboth, McMurrich and Watt. Atlas of Human Anatomy. GE Stechert and Co. New York, 1939.
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Aaron Wieland HMS III
Vasculature
Gillian Lieberman MD
Aorta IVC Portal vein
Celiac Trunk
Splenic Artery
Splenic vein Inferior mesenteric vein
mywebpages.comcast.net/wnor/pancreas.htm
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Aaron Wieland HMS III
Splenic Vein
Gillian Lieberman MD
Splenic vein
Portal vein
Pancreas body BIDMC PACS 9
Aaron Wieland HMS III
Vascular Relationships
Gillian Lieberman MD
Pancreas Superior Mesenteric Vein
Superior Mesenteric Artery
IV C
BIDMC PACS
A
LR V
1010
Aaron Wieland HMS III
Pancreatic Ducts Major pancreatic duct
Gillian Lieberman MD
Common bile duct Accessory duct
Minor papilla
Duodenum
mywebpages.comcast.net/wnor/pancreas.htm
Major papilla11
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Aaron Wieland HMS III Gillian Lieberman MD
Cross-sectional anatomy at T12 Stomach body
Splenic artery and vein Body
IVC
A
Tail
Ellis, Logen and Dixon. Human Cross-sectional Anatomy: Atlas of body sections and CT images. Butterworth-Heinemann, Oxford, 1991.
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Cross sectional anatomy at T12
Aaron Wieland HMS III Gillian Lieberman MD
sp l
ee n
GB
Adrenal gland
Ellis, Logen and Dixon. Human Cross-sectional Anatomy: Atlas of body sections and CT images. Butterworth-Heinemann, Oxford, 1991.
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Aaron Wieland HMS III
Cross sectional anatomy at T12-L1
Gillian Lieberman MD
neck
Ellis, Logen and Dixon. Human Cross-sectional Anatomy: Atlas of body sections and CT images. Butterworth-Heinemann, Oxford, 1991.
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Aaron Wieland HMS III Gillian Lieberman MD
Cross sectional anatomy L1-L2
H
Ellis, Logen and Dixon. Human Cross-sectional Anatomy: Atlas of body sections and CT images. Butterworth-Heinemann, Oxford, 1991.
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Aaron Wieland HMS III Gillian Lieberman MD
Cross sectional anatomy at L2 Pancreas (head and uncinate) Head
Uncinate
H
D
U
Duodenum w/ contrast
Duodenum
Ellis, Logen and Dixon. Human Cross-sectional Anatomy: Atlas of body sections and CT images. Butterworth-Heinemann, Oxford, 1991.
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Aaron Wieland HMS III Gillian Lieberman MD
ERCP
BIDMC PACS
ERCP – diagnostic procedure (biopsy obtained)
MRCP
BIDMC PACS
MRCP showing dilated and irregular distal pancreatic duct (Patent common bile duct) 17
Aaron Wieland HMS III Gillian Lieberman MD
Histology of ERCP biopsy specimen Intraductal papillary mucinous tumor
Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 7th ed
Rivera JA, et al. Annals of Surgery. 1997 225(6):637-44
Papillary villous projections extending into the lumen of a pancreatic duct
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Aaron Wieland HMS III Gillian Lieberman MD
Note the motion artifact
T1 weighted image with fat suppression BIDMC PACS
Dilated main duct and multiple small cystic structures in head of pancreas
Courtesy BIDMC PACS 19 19
Aaron Wieland HMS III Gillian Lieberman MD
MRCP with hyperintense pancreatobiliary system
BIDMC PACS
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Aaron Wieland HMS III Gillian Lieberman MD
Large mass in head of pancreas
BIDMC PACS
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Aaron Wieland HMS III
MRCP coronal section
Gillian Lieberman MD
Pancreatic duct and cysts Duodenum
BIDMC PACS
2222
Aaron Wieland HMS III
Uncinate
BIDMC PACS
Gillian Lieberman MD
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Aaron Wieland HMS III Gillian Lieberman MD
Differential Diagnosis (Cystic lesions of the pancreas) • Pseudocysts – 10% incidence with acute pancreatitis – Chronic pancreatitis • Acute exacerbation • Progressive obstruction due to stricture and/or protein plugging
– Trauma
• Retention cysts • Neoplasms – – – – –
Serous cystadenoma Mucinous cystadenocarcinoma Ductal adenocarcinoma Papillary cystic tumors Rare entities – sarcoma, teratoma, cystic islet cell tumor, lymphangioma 24
Aaron Wieland HMS III Gillian Lieberman MD
Intraductal papillary mucinous tumor of the pancreas – IPMT – first described by Ohhashi in 1982 who made a distinction between this tumor and the more common mucinous cystic neoplasm – World Health Organization classification in 1996 – Cystic neoplasms of the pancreas are not common • 10% of pancreatic cysts • 5% of pancreatic neoplasms – Slow growing tumor of head and uncinate process of pancreas • Prognosis better due to location and growth rate Moesinger RC, Talamini MA, Hruban RH, et al.: Ann Surg Oncol 1999, 6: 682-690. Adsay NV, Conlon KC, Zee SY, et al.: Cancer 2002, 94: 62-77. 25
Aaron Wieland HMS III Gillian Lieberman MD
IPMT features • Where? Head and uncinate process of pancreas • Who? Older men (60-70) – Mucinous cystadenocarcinoma more common in young women
• How? Obstructive pancreatitis, pancreatic insufficiency, pain and weight loss (biliary obstruction less common) – Recurrent pancreatitis 25% (patients lack EtOH history)
• Associations - Diabetes mellitus in 50-75 % pts. • Prognosis – 3 year survival 55-76% if malignancy present Lichtenstein, DR, Carr-Locke, DL. Gastrointest Endosc Clin N Am 1995; 5:237. Navarro F, Michel J, Bauret P, et al. Eur J Surg 1999; 165:43-48
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Aaron Wieland HMS III Gillian Lieberman MD
Imaging the Pancreas – – – – – –
Plain Film Computed Tomagraphy Magnetic Resonance Imaging Magnetic Resonance Cholangiopancreatography Endoscopic Retrograde Cholangiopancreatography Ultrasound • Endoscopic • Intraductal (experimental)
– Positron Emission Tomography (experimental) 27
Aaron Wieland HMS III
CT +/- contrast
Gillian Lieberman MD
• Standard abdominal CT vs. pancreas protocol scan • Multiple phase study necessary – Arterial, venous and parenchymal phases – Multirow detector scanner have highest sensitivity
• Tumors enhance less than normal parenchyma • Role of 3-dimensional reconstruction – Visualization of ducts – Vasculature
• Weaknesses – Micrometastatic spread to liver – Lymph node involvement Howard TJ, Chin AC, Streib EW et al. Am J Surg 1997; 174(3):237-241.Taoka H, Hauptmann E, Traverso WL et al. Am J Surg 1999; 177(5):428-432. 28
Aaron Wieland HMS III Gillian Lieberman MD
Encasement of celiac trunk Celiac Trunk
Spleen
Ascites
BIDMC PACS
Vascular involvement is almost an absolute contraindication to resection29 29
Aaron Wieland HMS III Gillian Lieberman MD
MRI • Pre-operative staging performed with MRI or CT scanning • T1 weighted images with fat suppression ideal for pancreatic parenchyma • MRCP obtained at the same time
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Aaron Wieland HMS III Gillian Lieberman MD
MRCP • MRCP – demonstrate the cystic lesions of IPMT – Not uncomfortable for the patients – Preoperative staging and postoperative follow-up – Findings in malignancy • Main Duct Tumor – dilation of Main Duct > 15 mm suggests malignancy • Branch Duct Tumor – Cystic dilation >30 mm suggests malignancy, multiple small cystic lesions (“cluster of grapes”)
– Mural nodules vs. mucin globs Izuishi, K, Nakagohri, T, Konishi, M, et al. Am J Surg 2001; 182:188. Koito, K, Namieno, T, Ichimura, T, et al. Radiology 1998; 208(1):231-7. 31
Aaron Wieland HMS III Gillian Lieberman MD
ERCP – ERCP findings • • • • • •
Invasive vs. noninvasive lesions Branch and main duct tumors Mucinous secretion through Ampulla of Vater Biopsy Therapeutic procedures (protein plug removal) Disadvantages compared to MRCP – Safety – Operator dependency – Inferior sensitivity and specificity? 32
Aaron Wieland HMS III Gillian Lieberman MD
Endoscopic ultrasound • EUS findings in IPMT – Main and branch duct tumor findings – Staging
• Invasive vs. noninvasive disease • IPMT vs. chronic pancreatitis Aithal, GP, Chen, RY, Cunningham, JT, et al. Gastrointest Endosc 2002; 56:701. Cellier, C, Cuillerier, E, Palazzo, L, et al. Gastrointest Endosc 1998; 47:42. Sugiyama, M, Atomi, Y, Saito, M. Gastrointest Endosc 1998; 48:164. 33
Aaron Wieland HMS III Gillian Lieberman MD
Conclusion • Role of imaging in pancreatic cancer – Determine which pts. are not eligible for surgical intervention. Surgeries are wrought with morbidity and mortality and deciding when to pursue palliative care is crucial. • Vascular involvement • Metastatic disease to liver and other adjacent organs
• IPMT – Main duct vs. Branch Duct – Good prognosis
• Differences among imaging modalities – Institution and surgeon dependent – Given seriousness of surgical resection a combination of studies is not unreasonable 34
Aaron Wieland HMS III Gillian Lieberman MD
References Adsay NV, Conlon KC, Zee SY, et al. Cancer 2002; 94:62-77. Aithal, GP, Chen, RY, Cunningham, JT, et al. Gastrointest Endosc 2002; 56:701. Cellier, C, Cuillerier, E, Palazzo, L, et al. Gastrointest Endosc 1998; 47:42. Clayton, M. Leonardo Da Vinci: The Anatomy of Man. Bullfinch Press, 1992. Ellis, Logen and Dixon. Human Cross-sectional Anatomy: Atlas of body sections and CT images. Butterworth-Heinemann, Oxford, 1991. Feldman: Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, 7th ed. 2002. Howard TJ, Chin AC, Streib EW et al. Am J Surg 1997; 174(3):237-241. Izuishi, K, Nakagohri, T, Konishi, M, et al. Am J Surg 2001; 182:188. Koito K, Namieno, T Ichimura, T, et al. Radiology 1998; 208(1):231-7.
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Aaron Wieland HMS III Gillian Lieberman MD
References cont. Moesinger RC, Talamini MA, Hruban RH, et al. Ann Surg Oncol 1999; 6:682690. Navarro F, Michel J, Bauret P, et al. Eur J Surg 1999; 165:43-48. Ohashi, K, Murakami, Y, Maruyama, M. Prog Dig Endosc 1982; 20:348. Rivera JA, et al. Annals of Surgery 1997; 225(6):637-44. Sheth SG, Howell DA. Intraductal papillary mucinous tumor of the pancreas. In: UpToDate, 11.1(Nov. 2002). Soboth, McMurrich and Watt. Atlas of Human Anatomy. GE Stechert and Co. New York, 1939. Sugiyama, M, Atomi, Y, Saito, M. Gastrointest Endosc 1998; 48:164. Taoka H, Hauptmann E, Traverso WL et al. Am J Surg 1999; 177(5):428-432. 36
Aaron Wieland HMS III Gillian Lieberman MD
Acknowledgements Dr. Gillian Lieberman Dr. Daniel Saurborn Pamela Lepkowski Larry Barbaras Cara Lyn D’amour
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