Pancreatic Cancer: Pancreatic Cancer: Diagnostic & Maintenance ToolsDiagnostic & Maintenance Tools

Felice Schnoll-Sussman, MDFelice Schnoll-Sussman, MD

Jay Monahan Center for Gastrointestinal HealthJay Monahan Center for Gastrointestinal Health

New York Hospital/ Weill Cornell Medical CollegeNew York Hospital/ Weill Cornell Medical College

Normal Hepatobiliary AnatomyNormal Hepatobiliary Anatomy

An abnormality of the An abnormality of the hepatobiliary system is hepatobiliary system is

suspected...suspected...

WHAT IS THE NEXT STEP???WHAT IS THE NEXT STEP???

ULTRASOUNDULTRASOUND

CT SCANCT SCAN MRCP MRCP

?????? MRI MRI EUS EUS

CA19-9CA19-9

UltrasoundUltrasound Least invasive radiologic techniqueLeast invasive radiologic technique Portable, quick and can guide interventional Portable, quick and can guide interventional

proceduresprocedures No ionizing radiationNo ionizing radiation High sensitivity for detected dilated bile ducts and High sensitivity for detected dilated bile ducts and

biliary tract obstruction (obstructive jaundice)biliary tract obstruction (obstructive jaundice) Very sensitive for differentiating cystic from solid Very sensitive for differentiating cystic from solid

lesionslesions Overlying gas may obscure visualizationOverlying gas may obscure visualization

Ultrasound (Sonogram)Ultrasound (Sonogram)Patient PreparationPatient Preparation

Clear liquid diet for 24 hours prior to examClear liquid diet for 24 hours prior to exam Liquids include clear juices such as apple, Liquids include clear juices such as apple,

cranberry & grape, clear soups, jello, coffee cranberry & grape, clear soups, jello, coffee or tea. No milk products or carbonated or tea. No milk products or carbonated bevaragesbevarages

CT SCANCT SCAN(Computed Tomography)(Computed Tomography)

Primary imaging study for patients Primary imaging study for patients suspected of having pancreatic lesionsuspected of having pancreatic lesion

Thin section dual-phase spiral CT scanThin section dual-phase spiral CT scan Obtained during optimal pancreatic arterial Obtained during optimal pancreatic arterial

and portal venous enhancement and hepatic and portal venous enhancement and hepatic phasephase

CT (CAT SCAN)CT (CAT SCAN)Patient PreparationPatient Preparation

Clear liquid diet for 24 hours prior to examClear liquid diet for 24 hours prior to exam Patients with prior reactions to iodinated Patients with prior reactions to iodinated

contrast or allergic history require contrast or allergic history require pretreatment medicationpretreatment medication

Diabetics: Alert doctor if your are taking Diabetics: Alert doctor if your are taking glucophage glucophage

ERCPERCP(Endoscopic Retrograde (Endoscopic Retrograde

Cholangiopancreatography)Cholangiopancreatography)Patient PreparationPatient Preparation

Nothing by mouth after midnight the Nothing by mouth after midnight the evening before procedureevening before procedure

No aspirin or nonsteroidal medications one No aspirin or nonsteroidal medications one week before procedureweek before procedure

Pancreatic CancerPancreatic Cancer

                                                            

ERCP ToolsERCP Tools

Sphincterotome

ERCP ToolsERCP Tools

Balloon

ERCP ToolsERCP Tools

Stents

ERCP ToolsERCP Tools

Wallstent

Normal ERCP

GB

Bile Duct

Pancreatic Duct

Cystic Duct

Pancreatic CancerPancreatic Cancer

stricture

Balloon Dilatation of StrictureBalloon Dilatation of Stricture

Diagnostic ERCP

CBD Stricture

Main PD stricture

Double duct sign

StentStent

Combined ProcedureCombined Procedure

PTC

ERCP

Wall Street JournalWall Street JournalOctober 28, 1981October 28, 1981

MRI has arrived ...MRI has arrived ...

What is MRCP?What is MRCP?Magnetic Resonance Magnetic Resonance

CholangiopancreatographyCholangiopancreatography Well established tool for evaluating the Well established tool for evaluating the

biliary tree, pancreatic ducts and biliary tree, pancreatic ducts and gallbladdergallbladder

Well toleratedWell tolerated Role:Role:

– To DIAGNOSE (not treat) diseases of the To DIAGNOSE (not treat) diseases of the biliary and pancreatic ductsbiliary and pancreatic ducts

– To avoid invasive procedure risksTo avoid invasive procedure risks– Reduce morbidityReduce morbidity

MRCP: BackgroundMRCP: Background

MRI of the bile ducts and pancreatic ductsMRI of the bile ducts and pancreatic ducts Relies on radiofrequency, pulse-induced excitation Relies on radiofrequency, pulse-induced excitation

of protons within a magnetic field to generate an of protons within a magnetic field to generate an imageimage

Fluid in the biliary and pancreatic ducts serves as Fluid in the biliary and pancreatic ducts serves as an intrinsic contrast mediuman intrinsic contrast medium

The ductal systems appear white against the black The ductal systems appear white against the black background, providing images similar to those of background, providing images similar to those of ERCPERCP

MRI Patient preparationMRI Patient preparationInform doctor if you have any of the following:Inform doctor if you have any of the following: Surgical vascular clipsSurgical vascular clips NeurostimulatorsNeurostimulators Cochlear ImplantsCochlear Implants Breast Tissue ExpanderBreast Tissue Expander History of claustrophobiaHistory of claustrophobia IVC FilterIVC Filter Penile ImplantsPenile Implants PacemakerPacemaker Silver backed dermal patchesSilver backed dermal patches

MRI Patient PreparationMRI Patient Preparation

Do not wear make-upDo not wear make-up Music is available during the examination. Music is available during the examination.

Most centers will allow you to bring your Most centers will allow you to bring your own tape or CDown tape or CD

Pancreatic cancer - ERCP vs. MRCP

EUSEUS

ENDOSCOPIC ULTRASOUNDENDOSCOPIC ULTRASOUND

EUS TOOLSEUS TOOLS

EUS TOOLSEUS TOOLS

EUS TOOLSEUS TOOLS

Doppler Vessel Identification

EUSEUS(Endoscopic Ultrasound)(Endoscopic Ultrasound)

Patient PreparationPatient Preparation

Nothing by mouth after midnight the Nothing by mouth after midnight the evening before procedureevening before procedure

No aspirin or nonsteroidal medications one No aspirin or nonsteroidal medications one week before procedureweek before procedure

Pancreatic Cancer StagingPancreatic Cancer Staging

Primary Tumor (T)Primary Tumor (T)TXTX Primary Tumor cannot be assessedPrimary Tumor cannot be assessedT0T0 No evidence of primary tumorNo evidence of primary tumorTisTis Carcinoma in situCarcinoma in situT1T1 Tumor limited to pancreas, 2 cm or lessTumor limited to pancreas, 2 cm or lessT2T2 Tumor limited to pancreas, greater than 2 cmTumor limited to pancreas, greater than 2 cmT3T3 Tumor extends beyond pancreas, no celiac or SMA involvementTumor extends beyond pancreas, no celiac or SMA involvementT4T4 Tumor involves celiac axis or SMA (unresectable primary)Tumor involves celiac axis or SMA (unresectable primary)

Regional Lymph Nodes (N)Regional Lymph Nodes (N)NX Regional lymph nodes cannot be assessedNX Regional lymph nodes cannot be assessedN0 No regional lymph nodesN0 No regional lymph nodesN1 Regional lymph node metastasisN1 Regional lymph node metastasis

Distant Metastasis (M)Distant Metastasis (M)MX Presence of distant metastasis cannot be assessedMX Presence of distant metastasis cannot be assessedM0 No distant metastasisM0 No distant metastasisM1 Distant metastasisM1 Distant metastasis

CA 19-9CA 19-9

Tumor markerTumor marker Amongst markers found to have the greatest Amongst markers found to have the greatest

sensitivity (70%) and tumor specificity (87%)sensitivity (70%) and tumor specificity (87%) Cutoff value of 70 U/mlCutoff value of 70 U/ml Can be elevated with biliary tract obstruction Can be elevated with biliary tract obstruction

by a noncancerous lesionby a noncancerous lesion

The diagnosis is made...The diagnosis is made...

Can you do anything for the pain?Can you do anything for the pain?

Therapeutic EUSTherapeutic EUS

Celiac Plexus BlockCeliac Plexus Block

ConclusionsConclusions

Myriad of well established tools to help Myriad of well established tools to help guide diagnosis and managementguide diagnosis and management

Studies are complementary and should be Studies are complementary and should be used together used together

Future holds great promise for additional Future holds great promise for additional innovationsinnovations