evidence based imaging of the pancreas - wild …...radiology (1994) 193: 297-306 0 20 40 60 80 100...
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D.Vanbeckevoort , D.Bielen,
K.Op de beeck, R.Vanslembrouck
Department of RadiologyChairman Prof. Dr. R.Oyen
Evidence based imaging of the pancreas
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Non-invasive imaging tests available for the diagnosis of pancreatic disease
1. Ultrasound
– Transabdominal• Color Doppler US, Power Doppler US, CE-US
– Endoscopic ultrasound• Conventional EUS, Color Doppler EUS, CE-EUS, Intraductal US,
EUS-guided fine needle aspiration (FNAC)
2. Computed tomography• MSCT
• PET-CT
3. Magnetic Resonance Imaging• Ultrafast breath-hold dynamic contrast-enhanced imaging
• High field strength magnet systems (3T)
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Learning objectives
• 1. Current status of basic imaging techniques– Application
– Value
• 2. How to determine a logical approach– Imaging strategies
• pancreatic inflammatory disease
• pancreatic malignancy
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Acute pancreatitis
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Question 1
• Is US a useful diagnostic imaging technique to confirm the clinical suspicion of acute pancreatitis ?
ECR Vienna, 2006
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Transabdominal ultrasound (US)
• Can identify:– Pancreatic enlargement
– Reduction in parenchymal reflectivity
– Fluid accumulation
ECR Vienna, 2006
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Severe pancreatitis
ECR Vienna, 2006
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Transabdominal ultrasound (US)
A. Limited in the initial phase– less successful
• in early diagnosis/staging
– effective • in diagnosing gallbladder stones and biliary obstruction
ERCP• in extremely ill patients too unstable to undergo CT
B. Valuable in the follow-up– pseudocysts– vascular complications
Maher M. et al. Cardiovasc. Intervent. Radiol. (2004) 27:208-225
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Endoscopic ultrasound (EUS)
• Pro:– More sensitive than transabdominal US in the
identification of cholelithiasis
– Can distinguish mild from severe pancreatitis
• Contra:– Little information regarding the viability of
pancreatic tissue
Bhutani et al. Gastro-enterol Clin North Am (1999) 28:747-77O
Hayakawa et al. JOP (2000) 1: 46-48
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Question 2:
• What is the imaging technique of choice for the diagnosis and staging of acute pancreatitis ?
ECR Vienna, 2006
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• Modality of choice– accuracy, reproducibility, availability
• Imaging features:– pancreatic swelling, stranding
– acute fluid collections
– pancreatic necrosis
Piironen A et al. Eur Radiol 2001; 26: 225-233
Computer tomography (CT)
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A
DC
B
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E E
Severe pancreatitis
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Prognostic indicators Characteristics P
pancreatic inflammation normal pancreas 0/A
focal or diffuse enlargement of the pancreas 1/B
intrinsic pancreatic abnormalities with inflammatory changes in peripancreatic fat
2/C
single, ill-defined fluid collection or phlegmon 3/D
two or more poorly defined collections or presence of gas in or adjacent to the pancreas
4/E
pancreatic necrosis no necrosis 0
30 % or less 2
30 %- 50 % 4
greater than 50 % 6
The Balthazar classification and CT severity index
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> 50 %
< 30 %
< 50 %
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Balthazar EJ, et al. Imaging and intervention in acute pancreatitis. Radiology (1994) 193: 297-306
0
20
40
60
80
100
1-3 points 4-6 points 7-10 points
mortality morbidity
3388
66
3535
1717
9292
The Balthazar classification and CT severity index
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vanSonnenberg et al. Radiology (1989) 170: 757-761
CT: complications
• Pseudocyst– Collection of pancreatic juice enclosed by a
wall of granulation tissue
• Infected necrosis– Infection of a focal or diffuse area of
nonviable pancreatic parenchyma
• Pancreatic abscess– Circumscribed collection of pus containing
little or no necrosis
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Pancreatic abscess
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Role of interventional radiology in the management of acute pancreatitis
ECR Vienna, 2006
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CT: complications
• Vascular complications
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Question 3:
• At what timepoint is CT best performed ?
ECR Vienna, 2006
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Recommendations for the use of CT
• CT should be guided by the natural history of the disease
• Should be timed to yield maximum diagnostic information, which will alter clininal management
ECR Vienna, 2006Maher M. et al. Cardiovasc. Intervent. Radiol. (2004) 27:208-225
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Recommendations for the use of CT
ECR Vienna, 2006Balthazar et al. Radiology (1994);193:297-306
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Question 4:
• Is MRI – MRCP useful in patients with acute pancreatitis ?
ECR Vienna, 2006
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Magnetic resonance imaging (MRI)
• Imaging features– pancreatic edema (low T1 / high T2)
– acute fluid collections (T2 WI)
– hemorrhage (T1 high)
– pancreatic necrosis
ECR Vienna, 2006
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Gad-T1
T2 T2
FS-T1
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Role of MRI
• Limited BUT superior to CT– for detection of mild acute pancreatitis– for staging
• in the depiction of necrosis• drainability of the collections
– for choledocholithiasis MRCP
• Replace CT in patients with renal failure
Amano et al. Abdom Imaging (2001) 26:59-63Kalra et al. JCAT (2002) 26:661-675
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Acute pancreatitis: imaging strategies
(E)US in the early management – to select those who would benefit from endoscopic
stone extraction and drainage
CT in severe pancreatitis– to detect complications
(MRI) ?– patients with severe pancreatitis are generally too
ill to cooperate for an MRI examination
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Chronic pancreatitis
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Question 1:
• Is US a useful diagnostic imaging technique to confirm the clinical suspicion of chronic pancreatitis ?
ECR Vienna, 2006
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Transabdominal US
• Features– Calcifications
– Parenchymal atrophy
– Pancreatic duct dilatation
ECR Vienna, 2006
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Transabdominal US
• Accurate for the diagnosis of:– advanced/complicated pancreatitis
• Rather limited:– For the diagnosis of early chronic pancreatitis
– For differentiating adenocarc >< chron pancreatitis
Frulloni et al. Digestive and Liver Disease 42 (2010) S381-S406
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Endoscopic US
• High sensitivity in diagnosing CP– ALSO of early chronic pancreatitis *
• Problem solving– For differentiating adenocarc >< chron
pancreatitis• EUS + FNAC
* Raimondo et al. JOP (2004) 5:1-7
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Question 2:
• What is the most appropriate imaging technique for the identification of the site and the topography of pancreatic stones?
ECR Vienna, 2006
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Computed Tomography (CT)
• Superior for detecting calcifications • ONLY in advanced stages
– Insensitive in the diagnosis of early CP
Glasbrenner et al. Eur J gastroenterol Hepatol (2002) 14: 935-941
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• Features– calcifications– duct dilation– parenchymal atrophy– intra- and peripancreatic pseudocysts– tapering of common bile duct– enhancement (heterogeneous)
CT features
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CT: complicated chronic pancreatitis
• inflammatory masses, pseudocysts, calculi in the pancreatic duct or pseudo-aneurysms
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Endoscopic US
• EUS is comparable to CT
– in depicting site and topography of pancreatic stones
– also very small stones (< 3mm)
Frulloni et al. Digestive and Liver Disease 42 (2010) S381-S406
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Question 3:
• What is the imaging technique of choice to diagnose early chronic pancreatitis ?
ECR Vienna, 2006
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MRI after secretin stimulation
• enhance the diagnosis of early chronic pancreatitis in the absence of marked ductal alteration
Manfredi et al. Radiology (2000) 214: 849-55Cappeliez et al. Radiology (2000) 215: 358-364
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MRI
• Imaging features– T1: decreased signal intensity
– T2: variable (may be normal)
– enhancement (less and delayed)
– MRCP: extent of morphologic ductal changes classifies severity of disease
– << calcifications
ECR Vienna, 2006
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MRI
• MRI is less sensitive than CT – for detection of calcifications *
• MRI is more sensitive than CT– for parenchymal changes **
• abnormal low signal intensity on fat-suppressed T1-weighted sequence
– for glandular enhancement **• decreased enhancement on the immediate and delayed postgadolinium images
* Remer et al. Radiol Clin N Am (2002) 1229-1242 ** Ly et al. Radiol Clin N Am (2002) 1289-1306
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Endoscopic US
• Has recently shown its ability to diagnose early chronic pancreatitis by assessing morphological and structural changes of the pancreatic parenchyma
• Risk of overdiagnosis?
Frulloni et al. Digestive and Liver Disease 42 (2010) S381-S406
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Question 4:
• What is the imaging technique of choice to identify pancreatic malignancy in patients with chronic pancreatitis ?
ECR Vienna, 2006
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Mass lesion in chronic pancreatic: benign or malignant?
“ Duct penetrating sign ”
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Mass lesion in chronic pancreatic: benign or malignant?
Negative duct-penetrating sign
“corona sign”
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Mass lesion in chronic pancreatic: MRI & MRCP
“ The duct penetrating sign on MRCP images was more helpful to distinguish inflammatory mass from pancreatic adenocarcinoma than were the enhancement patterns on CT or MR images. “
* Ichikawa et al. Radiology (2001) 221: 107-116
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Endoscopic US
• Used as problem solving
• Indeterminate mass on CT and MRI
• EUS-guided FNAB can increase the diagnostic accuracy.
Frulloni et al. Digestive and Liver Disease 42 (2010) S381-S406
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Chronic pancreatitis: imaging strategies
• US as initial step for screening
• CT/EUS more accurate– for the detection of calcifications
– in the diagnosis of complications
– in the differential diagnosis of focal pancreatitis and pancreatic cancer
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Chronic pancreatitis: imaging strategies
• MRI + MRCP: best modality
– EARLY detection of chronic pancreatitis• prior to the development of calcifications
– PROBLEM SOLVING• atypical presentation of CP
• differentiation CP from neoplasms
– FOLLOW-UP of parenchymal and duct abnormalities associated with CP
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Pancreatic tumors
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Key issues
• Early diagnosis of cancer
• Differentiation between cancer and inflammation
• Correct staging– appropriate management options
• Identification of patients who would profit from radical surgery and of those who would not
– ultimate prognosis of the disease
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Question 1:
• Is US a useful diagnostic imaging technique to confirm the clinical suspicion of a pancreatic tumor ?
ECR Vienna, 2006
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Transabdominal US
• Features– Echo-poor/heterogeneous mass
– Duct dilatation
– Atrophy
– Abnormal contour
ECR Vienna, 2006
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Transabdominal US
• Primary screening method
• Detection of pancreatic carcinoma• Sensitivity : 44-95%
• 80 - 95% (head)
• < 50 % for lesions < 1 cm
Lynch H.T. et al. Journal of Hepatobiliary Pancreatic Surgery 9 (2002), 12-31
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BUT,… sensitivity of US depends on :
• Size and location of the tumor
• small tumors
• tumors in the body and tail
• Patient-dependent factors
• Overlying bowel gas
• Obesity
• Operator’s degree of training
• Technical quality of US equipment
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Transabdominal US
• Less frequently employed for staging• US is inferior to CT staging
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Endoscopic US: complementary to CT and MRI
• Important imaging modality – in assessing small pancreatic tumors (< 2 cm),
undetectable by CT or MRI
– in the management of cystic lesions
Hunt G. et al.Gastrointestine Endoscopy 55 (2002),232-237
Insulinoma
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Limitations of EUS
• Need for patient sedation
• Operator dependency
• Inability to examine the entire liver
• To detect peritoneal metastases
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Question 2:
• What is the imaging technique of choice for the diagnosis and staging of suspected pancreatic cancer?
ECR Vienna, 2006
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Helical CT: primary imaging modality
• Detection – Overall accuracy of CT: 80% to 97%
• Sensitivity lower for small tumors
• Staging
Conv Helical– PPV unresectability 88-100% 92-100%– PPV resectability 45-72% 76-90%
Legmann et al. AJR (1998) 170:1315-1322Kalra et al. JCAT (2002) 26: 661-675Freeny et al. Pancreatology (2001) 1: 604-609
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• Primary tumor– focal mass (95%)
• low density area (75%)– ill-defined borders
• Secondary findings– duct dilation
• pancreatic duct (50%)• CBD (40%)
– atrophy of the tail (20%)– dilated collateral veins (12%)– duodenal invasion
Ductal adenocarcinoma: CT findings
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Staging: tumor is resectable or not ?
• Need to access– Vascular involvement
• Tumor contact > ½ circumference of vessel• Dilated peripancreatic veins• Focal decrease in vessel calibre
– Local invasion into retroperitoneal structures
– Metastases to liver, peritoneum, lymph nodes
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Staging: tumor is resectable or not ?
• Need to access– Vascular involvement
• Tumor contact > ½ circumference of vessel• Dilated peripancreatic veins• Focal decrease in vessel calibre
– Local invasion into retroperitoneal structures
– Metastases to liver, peritoneum, lymph nodes
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CT-limitations in the staging of pancreatric carcinoma
• Poor sensitivity for detecting small metastatic peritoneal implants
• Multi-slice CT – earlier detection of enlarged lymph nodes
– BUT does not allow differentiation between benign and malignant causes
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PET- CT: “add-on” procedure?
• Additional staging information– detection of unsuspected metastases
• Helps in the evaluation of – masses with equivocal CT and MRI diagnosis
– locoregional recurrence
• Documentation of tumor cell vitality– susceptibility to adjuvant treatment
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Question 3:
• Is MRI with MRCP useful in patients with suspected pancreatic cancer?
ECR Vienna, 2006
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MRI
• Diagnosis of tumor– Sensitivity: 95% (42/44)
• Cancer non-resectability– PPV: 90%
– NPV: 83%
* Hänninen et al. Radiology (2002) 224: 34-41
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MRI superior to CT
• For detection of – small pancreatic lesions
– small liver metastasis
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ECR Vienna, 2006
Malignant cystic neuroendocrine tumor with small liver metastasis
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MRI is superior to CT: in the differential diagnosis of cystic neoplasms
ECR Vienna, 2006
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IPMN
ECR Vienna, 2006
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IPMN
ECR Vienna, 2006
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Malignant IPMN
ECR Vienna, 2006
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Limitations of MRI
• Availability
• Detection of – small peripancreatic lymph nodes
– peritoneal implants
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Pancreatic tumors: imaging strategies
• Detection – US (large/head)
– CT EUS, MRI: smaller/cystic pancreatic tumors
• Staging– CT and MRI
– (EUS) ECR Vienna, 2006
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CONCLUSION
• Single “correct” approach does not exist
• Imaging tests have a much higher PPV than NPV
• All of the available diagnostic methods have their strenghtsand weakness
• Ultimate choosen strategy dependson local expertise and availibility of equipment
ECR Vienna, 2006
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Acknowlegments
• O.Van Rillaer• F.Claus• D.Bielen • A.L.Baert• S.Dymarkowski• K.Op de beeck• M.Thijs• E. Nijs• R. Van Slembrouck• L.Van Hoe• G.Marchal
ECR Vienna, 2006