C.Y. Nio,

AMC, Amsterdam

Introduction

Pancreatic adenocarcinoma

“Key facts” pancreatic carcinoma

What makes a good CT?

How effective is each modality?

What is the role of each modality?

Content

1750 new cases per year

0.5-3.6 per 100.000 (< 50 yrs)

55.9-89.2 per 100.000 (> 75 yrs)

caput (75%), corpus (15%), cauda (10%)

Without therapy: median survival 4-6 m

curative resection: 10-20% 5-yr survival

Epidemiology

Richtlijn pancreascarcinoom.2011

Tumor + locoregional lymphnodes

Tumor + resection margins

Differentiation grade tumor

Diameter tumor

Kuhlmann et al, Eur.J.Cancer 2004

Prognostic factors for low survival

after resection

Curative: pylorus preserving pancreaticoduodenectomy

(Whipple or PPPD)

Palliative:

Biliary stenting Pain relief double by-pass (chemotherapy/radiation) ,

Therapy

100 pts with pancreatic carcinoma

40 pts (40%)

locally irresectable

40 pts (40%)

distant metastases

20 pts (20%) laparotomy with curative intent

20 pts laparotomy with curative intent

13 á 14 (± 65%) pts:

resection

6 á 7 (± 35%) pts

irresectable in OR:

-local invasion

-metastases

PPPD Double by-pass

± 50% “radical R0”

resectie

Kuhlmann et al, Surgery 2006;139:188-96

Survival

(%)

1-yr 3-yr 5-yr

R0 69 28 11

R1 60 9 6

P=0.02

R1 versus R0

Kuhlmann et al, Surgery 2006;139:188-96

Survival Median 1-yr 3-yr 5-jyr

R1 N=80

15.8 59.9 8.9 5.7

Loc. adv

disease N=90

9.4 34.4 2.2 0

R1 versus locally advanced disease

Kuhlmann et al, Surgery 2006;139:188-96

Survival Median 1-yr 3-yr 5-yr

R1 N=80

15.8 59.9 8.9 5.7

Loc. adv

disease N=90

9.4 34.4 2.2 0

P < 0.01

R1 versus locally advanced disease

van Geenen et al, Surgery 2001;129:158-63

215 resections (‘92-’98)

34 PV/SMV resection

20 (59%) pos. margin

Median survival:

Pos. margin: 14 m

Neg. margin: 11 m

Partial resection PV/SMV

Siriwardana et al, Br J Surg 2006;93:662-73

52 studies with 1646 pts

Median survival 13 m

5-yr survival 7%

Peri-operative mortality 5.9%

Positive nodes 67.4%

Positive margins 39.8%

Conclusion:

involvement of PV/SMV precludes curative resection

Partial resection PV/SMV

What CT-technique ?

Optimal timing ?

arterial phase (AP)

±25 sec. scan delay

pancreatic phase (PPP)

±50 sec. scan delay

portal-venous phase (PVP) ±70 sec. scan delay

Desired:

maximal arterial enhancement

maximal portal enhancement

maximal tumor-pancreas contrast

Enhancement portal veins and

visceral arteries

AP PPP PVP

SMV 52 140 171

Portal vein

50 147 180

AP PPP PVP

Coel

trunk

228 293 157

SMA 245 299 158

McNulty et al. Radiology 2001; 220: 97

McNulty et al. Radiology 2001; 220: 97

AP PPP PVP

Pancreas 70 122 109

Difference

with tumor 16 49 44

maximal contrast

Pancreas parenchyma-tumor

No: early arterial phase

Yes: dual-phase, i.e. pancreatic phase

+ portal phase

Alterative: one phase, late pancreatic /

early-portal phase

Slice thickness: < 5 mm (2 à 3 mm).

Contrast: always, ≥130ml, 3-5 ml/sec.

CT Protocol?

What imaging modality?

Ultrasound ?

CT ?

MRI ?

CT 23/959 91 (86-94) 85 (76-91)

MRI 11/583 84 (78-89)* 82 (67-92)

datasets /

N ptt

sensitivity specificity

US 14/2909 76 (69-82)* 75 (51-89)

How good are US, CT and MRI for tumor

detection?

*significantly lower as compared to CT

Bipat et al, J Comput Assist Tomogr 2005;29:438-45

CT 32/1823 81 (76-85) 82 (77-87)

MRI 7/516 82 (69-91) 78 (63-87)

datasets /

N patt

sensitivity specificity

US 6/1233 83 (68-91) 63 (45-79)*

How good are US, CT and MRI for

assessment of resectability?

Bipat et al, J Comput Assist Tomogr 2005;29:438-45

*significantly lower as compared to CT

Algorithm imaging pancreatic lesion

US

Tumor / suspection of solid

tumor

CT No tumor

EUS

resectable

exploration

irresectable borderline

PA / neo-adjuvant

chemoradiation

PA / palliation

MRI Pancreas

No primary role in solid tumors

Useful in cystic pancreatic tumors

MRI protocol (30 min)

T2 TSE FS ax (6mm) RT

T2 3D cor (1 mm) met ax. reconstr.

T2 HASTE (40 mm) cor

EP 2D Diff (4 mm): b50/400/800

T1 FS ax (3 mm) before and dyn after gado (0/30/60 sec)

Presence/absence of tumor

size tumor

obstruction CBD/PD

relation tumor with surrounding organs and portovenous and

arterial vessels

Presence/absence of liver metastases

Presence/absence locoregional or distant nodes (trunc/para-

aortal/mesenterial)

Presence/absence peritoneal metastases

anatomical variants vessels and stenosis coel trunc/SMA

ascites

Reporting

without therapy: median survival 4-6 m

curative resection: 10-20% 5-yr survival

6-7% R0 resection

R1 resection ↑ median survival 9 → 16 m

involvement PV/SMV: no curative resection

Conclusions 1

Staging CT with dual phase series PPP en PVP

1 phase CT with late-pancreatic/early-portal phase

2 -3 mm slices with ≥130ml, 3-5 ml/sec

Tumor detection: CT > MRI

Tumor resectability: CT = MRI

Cystic lesions: MR > CT

Conclusions 2