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To Whipple or Not to Whipple, that is the Question:

Evaluating the Resectability of Pancreatic Adenocarcinoma

Christina Ramirez, Harvard Medical School Year III

Gillian Lieberman, MD

August 2009

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Agenda

• Our Patient• Background information about Pancreatic

Cancer• Anatomy of the Pancreas• Menu of Tests• Criteria for Unresectability• Film Interpretation• Conclusions

Our Patient C.B.: Clinical Presentation

• CC : 75F w/ epigastric pain

• Historyo Evaluated by PCP following an episode of post-prandial

epigastric pain to backo Also, jaundice, clay-colored stools, dark urineo PCP performed US and found an enlarged gallbladdero The patient was referred to a gastroenterologist ERCP w/ brushings was performed and showed CBD

dilatation and narrowing at pancreas Additionally, the patient’s labs revealed elevated LFTs,

Alkaline Phoshatase, and T billirubin There was high clinical suspicion of a pancreatic head mass

and patient underwent a CTA CTA revealed hypoattenuating mass at the head of the pancreas

Our Patient C.B.: Diagnosis and Treatment

Diagnosis: Pancreatic Adenocarcinoma

Management: Whipple Procedure

Agenda

• Our Patient• Background information about

Pancreatic Cancer• Anatomy of the Pancreas• Menu of Tests• Criteria for Unresectability• Film Interpretation• Conclusions

Pancreatic Cancer• Epidemiology

o ~30,000 cases/yr are diagnosed in the U.S.o 4th most frequent cause cancer deatho 5% survival at 5 yrso 80% diagnosed after age 60

• Etiologyo Majority ductal adenocarcinoma

o Usually in head of pancreaso >10% islet cell and cystadenocarcinoma

• Risk Factorso Family historyo Smokingo Diabeteso AlcoholShaib et al, 2006

Lawrence, 2006Brand, 2001

Pancreatic Cancer Cont.

• Clinical Presentationo Weight losso Abdominal pain radiating to backo Jaundice (Obstructive) Clay-colored stools Dark urine Pruritus

o Palpable gallbladder (Courvoisier's sign)• Treatment

o Resectable Whipple Procedure

May increase 5 year survival to 24%o Unresectable Endoscopic biliary stenting Surgical palliation: double bypass procedureBrand, 2001

Lawrence, 2006

Agenda



Diagram of the Anatomy of Pancreas

http://anatomy.med.umich.edu/gastrointestinal_system/duodenum_ans.html

•The pancreas and duodenum are intimately associated, and even share the same blood supply (gastroduodenal artery)

•It is obvious from this diagram why a pancreatic head mass would cause obstructive jaundice by occluding the common bile duct

•Furthermore, the pancreas is located near several important vessels: superior mesenteric artery and superior mesenteric vein, splenic vein, and portal vein

Agenda



Menu of Tests

• Common Testso CT scano MRIo Ultrasound

• Special Testso MRCPo ERCP

Let’s review some of the advantages and disadvantages of using CT and also study the appearance of a normal pancreas on CT.

Companion Patient 1: Normal Pancreas on CT

• Computed tomography is the best study for detecting and staging pancreatic adenocarcinoma

• Advantage: Faster than MRI, ability to generate reconstructions

• Disadvantage: Exposure to ionizing radiationApproach:•Morphology (size, shape position)•Lucencies/Opacities•Mass•Duct dilatation•Abnormal fat•Vessels and nodes•Peritoneal fluid•Surrounding structures

Abdominal C+ CT, Axial View www.joplink.net/prev/200407/01_fig2.jpg

Companion Patient 1

Hanbidge, 2002Lieberman, Gillian. http://eradiology.bidmc.harvard.edu/interactivetutorials/

CT is the current gold standard for diagnosing and staging pancreatic cancers. Therefore, radiologists use a very specific template for evaluating and dictating pancreatic masses.

In the next slide, you will see this template.

Approach to Evaluating Pancreatic TumorsEvalute for:

I: Is the pancreatic tumor present:a) Location, Size, Enhancement

relative to pancreasb)Confined to pancreas with clear fat

planes c) Remaining pancreas

II. Is lymphadenopathy present:a) Size and location of largest lymph node:b) Necrosis in lymph nodesC) Size of gastroduodenal artery node, “node of importance”

III. Is metastatic disease, definitely present

IV: Is there ascites/peripancreatic fluid

V: Is there vascular tumor involvement

a) Celiac involvementb) SMA involvementc) SMV involvement and percent encasement:d) Less than 1 cm SMV between tumor and first major SMV branche) Portal vein involvement:g) Splenic vein involvementh) Splenic artery involvement and distance from tumor to celiac artery bifurcationi) Vascular Involvement,

VI: Is there thrombosis of any vessel

As you saw in the last slide, the template for evaluating pancreatic masses is quite detailed. It is not important that you memorize all of those details. However, it is important to understand that the template is a systematic way of evaluating the resectability of pancreatic masses.

In the next slide you will see the specific criteria for unresectable pancreatic cancer.

Summary: Criteria for Unresectability

• >50% encasement of peripancreatic vessels

• Lymph node metastasis

• Distant metastasis

• Extrapancreatic invasion of adjacent tissues

• Peritoneal carcinomatosis

Diehl, 1998

Zamboni, 2007

Now that we have seen learned about the advantages of CT, viewed a normal pancreas on CT, and reviewed a systematic approach to evaluating pancreatic masses, let’s now take a look at the CT scan from our patient C.B.

Our Patient C.B.: Pancreatic Mass on CT

Abdominal C+ CT, Axial ViewPACS, BIDMC


Our Patient C.B. Our Patient C.B.

Our patient C.B. has a mass located at the head of the pancreas causing pancreatic ductal dilatation. Can you identify these findings?

Our Patient C.B.: Pancreatic Mass on CT

Film Findings:Pancreas head with hypodense massPancreas body with ductal dilatation



Our Patient C.B. Our Patient C.B.

Now let’s learn about the advantages and disadvantages of MRI, and evaluate a normal pancreas on MRI.

Companion Patient 2: Normal Pancreas on MRI

• MRI is useful for imaging equivocal masses on CT • Advantage: Better duct visualization, no exposure to

ionizing radiation• Disadvantage: Lower resolution than CT

Approach:•Morphology (size, shape position)•Mass•Duct dilatation•Abnormal fat•Vessels and nodes•Peritoneal fluid•Surrounding structures

Abdominal T1 Weighted C- MRI, Axial ViewPACS, BIDMC

Companion Patient 2


Now that we have examined a normal pancreas on MRI, let’s see what pancreatic adenocarcinoma looks like on MRI.

Companion Patient 3: Pancreatic Mass on MRI



This patient also has a pancreatic head mass and pancreatic ductal dilatation. Can you identify these findings?

Companion Patient 3 Companion Patient 3

Companion Patient 3: Pancreatic Mass on MRI

Film Findings:Pancreas with hypointense mass and ductal dilatation



Film Findings:Pancreas with hyperintense dilated duct


As you saw on the images from Patient 3, pancreatic adenocarcinoma typically appears hypointense on T1 weighted MRI. Also, T2 weighted MRI is ideal for identifying pancreatic ductal dilatation, as static pancreatic fluid appears bright on this imaging modality.

Now, let’s learn about the utility of ultrasound in evaluating the pancreas.

Companion Patient 4: Normal Pancreas on Ultrasound

• May be used if CT/MRI contraindicated• Advantage: Fast and inexpensive, ability to assess blood flow, no

ionizing radiation• Disadvantage: highly user dependent, patient dependent, bowel

gasApproach:•Morphology (size, shape position)•Echotexture

•Focal changes in echotexture•Masses•Duct dilatation•Vessel patency•Peritoneal fluid

Transabdominal US, Transverse ViewPACS, BIDMC

Companion Patient 4


Pancreas

Liver

Vertebral body

Aorta

SMA

L Renal Vein

Now that we have examined a normal pancreas on ultrasound, let’s take a look at the appearance of pancreatic adenocarcinoma on ultrasound.

Companion Patient 5: Pancreatic Mass on US and MRI

Patient 5 also has a mass in the head of the pancreas. Finding anatomical structures can be difficult on US. The MRI is shown to help orient you. Can you find the mass?


Transabdominal US, Transverse viewPACS, BIDMC


Companion Patient 5: Pancreatic Mass on US and MRI

Film Findings:Hypoechoic mass in head of pancreasConfluence SMV and splenic veinSuperior Mesenteric Artery


Transabdominal US, Transverse viewPACS, BIDMC


As you saw on the images from Patient 5, pancreatic adenocarcinoma typically appears hypoechoic on ultrasound.

Now, let’s learn about the utility of magnetic resonance cholangiopancreatography (MRCP) in evaluating the pancreatic ducts.

Companion Patient 6: Normal Bile and Pancreatic Ducts on MRCP

• May be used to visualize biliary tree and pancreatic duct

• Advantage: Noninvasive, 3D reconstruction, no ionizing radiation

• Disadvantage: Not specific for masses

Approach:•Stenosis•Dilatation•Filling defect•Outpouching


MRCPhttp://www.mghradrounds.org/index.php?src=gendocs&link=june_2004

Companion Patient 6

Pancreatic duct

As you saw on the previous slide, a normal pancreatic duct is thin, smooth, and gradually tapers.

Let’s take a look at a patient with a pancreatic adenocarcinoma obstructing the pancreatic duct.

Companion Patient 7: Pancreatic Duct Dilatation on MRCP

Can you identify the dilated pancreatic duct?

And can you see the obstructing cancer?

Companion Patient 7

MRCPPACS, BIDMC

Companion Patient 7: Pancreatic Duct Dilatation on MRCP

Film Findings:Pancreatic ductObstructing massCommon bile ductGallbladder

Companion Patient 7

MRCPPACS, BIDMC

**

As you saw on the images from Patient 7, the pancreatic duct was dilated and failed to taper distally. Also, an obstructing pancreatic head mass appears as a filling defect on MRCP.

Now, let’s learn about the utility of endoscopic retrograde cholangiopancreatography (ERCP) in evaluating the pancreatic ducts.

Companion Patient 8: Normal Pancreatic and Biliary Ducts on ERCP

• ERCP be used to visualize biliary tree and pancreatic duct if MRCP contraindicated

• Advantage: Obtain biopsy/brushings during procedure• Disadvantage: Not specific for masses, invasive, may

cause pancreatitisApproach:•Stenosis•Dilatation•Filling defect•Outpouching

Companion Patient 8

ERCP C+http://www.geocities.com/gastroyu/dec2001/Slika2.jpg


Pancreatic duct

Similar to the findings on MRCP, a normal pancreatic duct is thin, smooth, and gradually tapers on ERCP.

Let’s take a look at our patient C.B.’s ERCP. As you recall, she presented with the symptoms of obstructive jaundice due to obstruction of her common bile duct.

Our Patient C.B.: Common Bile Duct Stenosis on ERCP

ERCP C+PACS, BIDMC

Our patient C.B.’s pancreatic mass extrinsically compressed her common bile duct. Can you identify the area of stenosis?

Our Patient C.B.

Our Patient C.B.: Common Bile Duct Stenosis on ERCP

ERCP C+PACS, BIDMC

Film Findings:Dilated common bile duct

Narrowing of common bile duct due to pancreatic mass

Our Patient C.B.

*

We have now reviewed the appearance of the normal pancreas and pancreatic adenocarcinoma on various imaging modalities. We will now take a look at some patients with unresectable pancreatic cancer.

Let’s first review the criteria for unresectability.

Review: Criteria for Unresectability

• Encasement of peripancreatic vessels





Diehl, 1998Zamboni, 2007

Companion Patient 9: Peripancreatic Vascular Encasement on CT


Coronal C+ CT, Axial ViewPACS, BIDMC


This patient has a superior mesenteric vein that is completely occluded by the pancreatic cancer. Can you identify this finding?

Companion Patient 9: Peripancreatic Vascular Encasement on CT


Coronal C+ CT, Axial ViewPACS, BIDMC

Film Findings:Hypodense mass encasing confluence of SMV and splenic vein


Film Findings:Pancreatic mass occluding SMV

Companion Patient 10: Distant Lymph Node Metastasis on CT

Abdominal C+ CT, Coronal View

Zamboni et al, 2007

Companion Patient 10

Imaging Findings:Lymphadenopathy

Lymphadenopathy is difficult to identify on CT scanning, and is not specific for lymph node metastasis.

This patient underwent surgical exploration and the diagnosis of metastasis was made based on tissue pathology

Companion Patient 11: Distant Metastasis on CT




This patient was actually worked up for a small liver mass, and was found to have metastatic pancreatic cancer.Can you identify the liver metastasis and the pancreatic mass?

Companion Patient 11: Distant Metastasis on CT




Imaging Findings:Hypodense mass at pancreas headVenous involvement at confluence SMV and splenic vein

Imaging Findings:Hypodense liver mass

*

Companion Patient 12: Peritoneal Carcinomatosis on MRI



Unfortunately, this patient presented with late stage pancreatic cancer that seeded to the omentum. Can you identify the ascites, pancreatic mass, and omental seeding?



Companion Patient 12: Peritoneal Carcinomatosis on MRI



Imaging Findings:Pancreas MetastasisAscites

**

*


Abdominal T1 Weighted C- MRI, Axial ViewPACS, BIDMCImaging Findings:Hypointense pancreatic mass MetastasisAscites

**

*

Conclusions

• Clinical features of pancreatic cancer•Appropriate imaging studies

•Identify the pancreas in different modalities•Identify pancreatic masses

•Understand the critical role of radiologists in diagnosing and staging pancreatic cancer

Acknowledgements

• Gillian Lieberman, MD• Aaron Hochberg, MD• James Kang, MD• Maria Levantakis

References1. Shaib, YH, Davila, JA, El-Serag, HB. The Epidemiology of Pancreatic Cancer in

the United States: Changes Below the Surface. Aliment Pharmacol Ther 2006; 24:87.

2. Lawrence, Peter. Essentials of General Surgery. Lippincott 2006.3. Brand, Randall. The Diagnosis of Pancreatic Cancer. The Cancer Journal 2001;

7(4):287-297.4. Hanbidge, Anthony. Cancer of the Pancreas: the Best Image for Early

Detection-CT, MRI, PET, or US? The Canadian Journal of Gastroenterology; 16(2):101-105.

5. Lieberman, Gillian. Lieberman’s Interactive Tutorials, Pancreas. http://eradiology.bidmc.harvard.edu/interactivetutorials/. Accessed on August 15, 2009.

6. http://anatomy.med.umich.edu/gastrointestinal_system/duodenum_ans.html7. Diehl, Steffen, et al. Pancreatic Cancer: Value of Dual-Phase Helical CT in

Assessing Resectability. Radiology 1998; 206(2):373-378.8. Zamboni, et al. Pancreatic Adenocarcinoma: Value of Multidetector CT

Angiography in Preoperative Evaluation; Radiology 2007; 245(3):770-778.

http://eradiology.bidmc.harvard.edu/interactivetutorials/

http://anatomy.med.umich.edu/gastrointestinal_system/duodenum_ans.html

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