胰腺癌及其并发症的影像学表现及解剖特点

Frank Acosta, HMS IV Gillian Lieberman, MD Radiologic and Anatomic Characterization of Radiologic and Anatomic Characterization of Pancreatic Cancer and Implications for Pancreatic Cancer and Implications for TreatmentTreatment Frank L. Acosta, Jr., Harvard Medical School Year IV Gillian Lieberman, MD July 2001 2 Frank Acosta, HMS IV Gillian Lieberman, MD Agenda • Epidemiology • Classification • Relevant anatomy • Clinical presentation • Imaging studies • Management strategies • Salient points 3 Frank Acosta, HMS IV Gillian Lieberman, MD Epidemiology of Pancreatic CA • Fifth leading cause of cancer-related death in U.S. • 29,000 new cases per year • Significant morbidity and mortality: – 5 year survival rate: 2-5% – Median survival 15-20 months – Most patients have advanced disease at initial presentation – Only 15-20% are surgical candidates 4 Frank Acosta, HMS IV Gillian Lieberman, MD Classification of Pancreatic Neoplasms I. Epithelial nonendocrine tumors A. Duct cell origin 1. Cystic a. Microcystic (serous) adenoma b. Mucinous cystic neoplasm (cystadenocarcinoma) c. Ductectatic neoplasms 2. Solid a. Duct cell adenocarcinoma b. Variant carcinomas (1) Pleomorphic giant cell carcinoma (2) Adenosquamous carcinoma (3) Mucinous (colloid) carcinoma (4) Anaplastic carcinoma (5) Small cell carcinoma (6) Ciliated cell adenocarcinoma (7) Oncocytic carcinoma (8) Clear cell carcinoma B. Acinar cell origin 1. Acinar cell carcinoma 2. Acinar cell cystadenocarcinoma 3. Pancreaticoblastoma C. Indeterminate origin 1. Osteoclast-type giant cell carcinoma 2. Solid and papillary epithelial neoplasm 3. Mixed endocrine-exocrine tumors 4. Microadenocarcinoma II. Endocrine (islet cell) tumors A. Insulinoma B. Gastrinoma C. Glucagonoma D. VIPoma E. Somatostatinoma F. Pancreatic polypeptidoma G. Carcinoid H. Miscellaneous III. Other pancreatic neoplasms A. Nonepithelial (mesenchymal) tumors B. Metastases C. Lymphoma Friedman AC: Pancreatic Neoplasms. In Friedman AC, Dachman AH, eds: Radiology of the liver, biliary tract, pancreas, and spleen, St. Louis, 1994, Mosby-Year Book, pp 807-934 5 Frank Acosta, HMS IV Gillian Lieberman, MD Classification of Pancreatic Neoplasms I.I.I. Epithelial Epithelial Epithelial nonendocrinenonendocrinenonendocrine tumorstumorstumors A.A.A. Duct cell originDuct cell originDuct cell origin 1.1.1. CysticCysticCystic a.a.a. MicrocysticMicrocysticMicrocystic (serous) adenoma(serous) adenoma(serous) adenoma b.b.b. MucinousMucinousMucinous cystic neoplasm cystic neoplasm cystic neoplasm (((cystadenocarcinomacystadenocarcinomacystadenocarcinoma))) c.c.c. DuctectaticDuctectaticDuctectatic neoplasmsneoplasmsneoplasms 2.2.2. SolidSolidSolid a. DUCT CELL ADENOCARCINOMA (90%) b.b.b. Variant carcinomasVariant carcinomasVariant carcinomas (1)(1)(1) PleomorphicPleomorphicPleomorphic giant cell carcinomagiant cell carcinomagiant cell carcinoma (2)(2)(2) AdenosquamousAdenosquamousAdenosquamous carcinomacarcinomacarcinoma (3)(3)(3) MucinousMucinousMucinous (colloid) carcinoma(colloid) carcinoma(colloid) carcinoma (4)(4)(4) AnaplasticAnaplasticAnaplastic carcinomacarcinomacarcinoma (5)(5)(5) Small cell carcinomaSmall cell carcinomaSmall cell carcinoma (6)(6)(6) Ciliated cell Ciliated cell Ciliated cell adenocarcinomaadenocarcinomaadenocarcinoma (7)(7)(7) OncocyticOncocyticOncocytic carcinomacarcinomacarcinoma (8)(8)(8) Clear cell carcinomaClear cell carcinomaClear cell carcinoma B.B.B. AcinarAcinarAcinar cell origincell origincell origin 1.1.1. AcinarAcinarAcinar cell carcinomacell carcinomacell carcinoma 2.2.2. AcinarAcinarAcinar cell cell cell cystadenocarcinomacystadenocarcinomacystadenocarcinoma 3.3.3. PancreaticoblastomaPancreaticoblastomaPancreaticoblastoma C.C.C. Indeterminate originIndeterminate originIndeterminate origin 1.1.1. OsteoclastOsteoclastOsteoclast---type giant cell carcinomatype giant cell carcinomatype giant cell carcinoma 2.2.2. Solid and papillary epithelial neoplasmSolid and papillary epithelial neoplasmSolid and papillary epithelial neoplasm 3.3.3. Mixed endocrineMixed endocrineMixed endocrine---exocrine tumorsexocrine tumorsexocrine tumors 4.4.4. MicroadenocarcinomaMicroadenocarcinomaMicroadenocarcinoma II.II.II. Endocrine (islet cell) tumorsEndocrine (islet cell) tumorsEndocrine (islet cell) tumors A.A.A. InsulinomaInsulinomaInsulinoma B.B.B. GastrinomaGastrinomaGastrinoma C.C.C. GlucagonomaGlucagonomaGlucagonoma D.D.D. VIPomaVIPomaVIPoma E.E.E. SomatostatinomaSomatostatinomaSomatostatinoma F.F.F. Pancreatic Pancreatic Pancreatic polypeptidomapolypeptidomapolypeptidoma G.G.G. CarcinoidCarcinoidCarcinoid H.H.H. MiscellaneousMiscellaneousMiscellaneous III.III.III. Other pancreatic Other pancreatic Other pancreatic neoplasmsneoplasmsneoplasms A.A.A. NonepithelialNonepithelialNonepithelial (((mesenchymalmesenchymalmesenchymal) tumors) tumors) tumors B.B.B. MetastasesMetastasesMetastases C.C.C. LymphomaLymphomaLymphoma Friedman AC: Pancreatic Neoplasms. In Friedman AC, Dachman AH, eds: Radiology of the liver, biliary tract, pancreas, and spleen, St. Louis, 1994, Mosby-Year Book, pp 807-934 6 Frank Acosta, HMS IV Gillian Lieberman, MD Vascular Supply & Innervation Netter FH. Atlas of Human Anatomy, New Jersey, 1989, Novartis. 7 Frank Acosta, HMS IV Gillian Lieberman, MD Pancreatic Duct Gray H: Anatomy, Descriptive and Surgical. Pick TP, Howden R, eds. Philadelphia, 1974, Running Press. 8 Frank Acosta, HMS IV Gillian Lieberman, MD Establishing the Diagnosis • Initial presentation varies with the location of tumor: – Head of pancreas Æ Symptoms of obstruction of the intrapancreatic portion of common bile duct (steatorrhea, weight loss, jaundice) – Body, tail Æ Symptoms from invasion of celiac ganglia (pain, weight loss). Obstruction less common – Courvoisier’s law • Imaging studies play two primary roles: – Diagnosis – Selecting optimal treatment strategies (i.e. surgical vs. nonsurgical) 9 Frank Acosta, HMS IV Gillian Lieberman, MD Menu of tests for Imaging Pancreatic CA Test Sensitivity Specificity Useful in Staging US 80% 90% No EUS 90% 90% Yes CT 90% 95% Yes ERCP 90% 90% No MRI 90% 90% No FNA 90% 98% No Steer ML: Clinical manifestations and diagnosis of exocrine pancreatic cancer. From UpToDate literature search, http://www.uptodate.com 10 Frank Acosta, HMS IV Gillian Lieberman, MD Radiologic Studies in the Evaluation and Treatment of Suspected Pancreatic CA Zeman RK, Silverman PM: Computed Tomography. In Evans SRT, Ascher SM, eds: Hepatobiliary and Pancreatic Surgery: Imaging Strategies and Surgical Decision Making, New York, 1998, Wiley-Liss, pp 445-463. Contrast-enhanced helical CT scan (or MRI) Dilated biliary tree Suspected pancreatic CA Nondilated biliary tree Unresectable on CT criteria Unresectable FNA ERCP (MRCP) +/- stent placement Resectable based on CT criteria Surgical exploration Resectable Questionable resectability based on CT criteria Visceral angiography or EUS 11 Frank Acosta, HMS IV Gillian Lieberman, MD J.C. E.G. • 74 yo female • 2 weeks intermittent upper abdominal pain – “Achy” in nature – Radiating to back – Worse with eating – 5-10 lb weight loss • PE no focal findings • Lab findings: wnl • 70 yo male • Steatorrhea, weight loss • PE: Jaundice, nontender palpable gallbladder • Lab findings: Bili, Alk Phos Let’s Discuss 2 Patients 12 Frank Acosta, HMS IV Gillian Lieberman, MD Radiologic Diagnosis - CT • Patient J.C. • Diffuse enlargement • Focal low density mass, noncalcified, at neck-body junction • Dilated pancreatic duct Image courtesy of BIDMC Department of Radiology 13 Frank Acosta, HMS IV Gillian Lieberman, MD DDX: Mass in the Region of the Pancreas on CT or MRI • COMMON: – Pancreatic CA – Abscess (pancreas, lesser sac) – Aortic aneurysm – CA of duodenum, ampulla, bile duct, gallbladder, liver – Gastric neoplasm – Lymphadenopathy – Metastasis – Pancreatic pseudocyst, cyst, or benign neoplasm – Pancreatitits – Renal cyst or neoplasm – Splenic mass • UNCOMMON: – Hydatid cyst – Portal vein thromboembolism – Retroperitoneal cyst or neoplasm Reeder & Felson’s Gamuts in Radiology: Comprehensive List of Roentgen Differential Diagnoses. Pathologic analysis is ‘gold standard’ for dx. 14 Frank Acosta, HMS IV Gillian Lieberman, MD Patient J.C.: Intact Mesenteric Artery- ResectableResectable • CT revealed preservation of fat plane around SMA • No evidence of metastatic disease Image courtesy of BIDMC Department of Radiology Hypodense fat plane surrounding SMA, indicating tumor has not invaded this vessel 15 Frank Acosta, HMS IV Gillian Lieberman, MD Surgical Treatment: Pancreaticoduodenectomy (Whipple) http://pathology2.jhu.edu/pancreas/surgery.cfm 16 Frank Acosta, HMS IV Gillian Lieberman, MD Radiologic Diagnosis - CT • Patient E.G. • Heterogeneous mass in pancreatic head • Dilated pancreatic and common bile ducts – “double duct” sign Image courtesy of BIDMC Department of Radiology 17 Frank Acosta, HMS IV Gillian Lieberman, MD Patient E.G.: Involvement of Porto-Mesenteric Vasculature-Non Resectable • CT-Angiogram (CTA) reconstruction demonstrated encased and compressed main portal vein at the origin of the superior mesenteric vein • Not amenable to surgical resection Image courtesy of BIDMC Department of Radiology 18 Frank Acosta, HMS IV Gillian Lieberman, MD Management Strategies • Neoadjuvant chemotherapy • Surgical resection • Palliation • Depends on extent, location of tumor at diagnosis •• Radiologic studies have a key role in Radiologic studies have a key role in determining optimal treatment (i.e. determining optimal treatment (i.e. surgical vs. nonsurgical)surgical vs. nonsurgical) 19 Frank Acosta, HMS IV Gillian Lieberman, MD A different patient A showing Obliteration of Splenic Vein with Liver Metastases - Non Resectable Image courtesy of BIDMC Department of Radiology Obliterated splenic vein Hepatic metastases Siegelman ES: Pancreatic MR defines ducts, pinpoints disease. http://www.dimag.com/bodymri/pancreatic • CT demonstrating: • MR max. intensity projection image (portal venous phase of contrast enhancement) showing: Obliterated splenic vein (no contrast-asterix) Prominent collateral vessel (gastroepiploic vein) 20 Frank Acosta, HMS IV Gillian Lieberman, MD This patient may benefit from Palliation: Celiac Plexus Neurolysis (CPN) • Chemical splanchnicectomy of celiac plexus (absolute ethanol) • Ablates afferent nerve fibers that transmit visceral pain • Approx. 70% will have relief of pain for up to 24 weeks From Wiersema MJ, Wiersema LM. Endosonography-guided celiac plexus neurolysis. Gastrointest Endosc 1996; 44:656. 21 Frank Acosta, HMS IV Gillian Lieberman, MD Image-Guided Palliative Therapy From Wiersema MJ, Wiersema LM. Endosonography-guided celiac plexus neurolysis. Gastrointest Endosc 1996; 44:656. EUS Fluoroscopic monitoring Ethanol distribution following injection into L periaortic space 22 Frank Acosta, HMS IV Gillian Lieberman, MD Lets review the appearance of Pancreatic Cancer on other imaging modalities 23 Frank Acosta, HMS IV Gillian Lieberman, MD Patient B:Magnetic Resonance • MR imaging useful when clinical suspicion for disease is high, but CT results are negative or equivocal • T1-weighted fat-suppressed images usually provide better resolution – Desmoplastic reaction of most pancreatic CA lowers signal intensity of tumor on T2-weighted images – Better contrast between tumor and normal pancreas Friedman AC: Pancreatic Neoplasms and Cysts. In Friedman AC, Dachman AH, eds: Radiology of the liver, biliary tract, pancreas, and spleen, St. Louis, 1994, Mosby-Year Book, pp 807-934. T1-weighted image without fat-suppression shows poor contrast between tumor and normal pancreas T1-weighted fat-suppressed image allows better contrast; normal pancreas (white arrow) increases in signal much more than tumor (black arrow) A B A B 24 Frank Acosta, HMS IV Gillian Lieberman, MD ERCP & MRCP Dilated, irregular pancreatic duct with filling defects Images courtesy of BIDMC Department of Radiology ERCP: Patient C Dilated side branches of pancreatic duct MRCP: Patient D Dilated pancreatic duct and side branches Gallbladder 25 Frank Acosta, HMS IV Gillian Lieberman, MD Patient E: Endoscopic Ultrasound (EUS) • Improved diagnosis and localization of small (<2- 3cm) lesions – Early identification is crucial – 30% 5-year survival rate • Useful in detecting lymph node and vascular involvement • Can determine invasion of duodenal wall and pancreas by ampullary tumors • More accurately detailed staging information • Does not reliably detect lesions distant from the pancreas http://www.mc.Vanderbilt.Edu/surgery/pncnprog.html http://www.mgh.harvard.edu/endoscopy/Endo%20site/EUS.html EUS of pancreatic mass Involving SMV-portal vein confluence Diagram of echoendoscope imaging pancreatic mass through pyloric wall 26 Frank Acosta, HMS IV Gillian Lieberman, MD Patient F: The Preoperative Response to Treatment may be evaluated by Nuclear Medicine • 18FDG-PET scan performed before (A) and after (B) taxol-based neoadjuvant chemoradiation. URL: http://www.mc.Vanderbilt.Edu/surgery/pncnprog.html Near total reduction in tumor-specific signal following completion of taxol-based neoadjuvant chemoradiation 27 Frank Acosta, HMS IV Gillian Lieberman, MD Take Home Points • Carcinoma of the pancreas is an almost uniformly fatal cancer • Disturbances in pancreatic structure/function determine initial presentation • Duct cell adenocarcinoma and its variants account for ~90% of all pancreatic tumors – most occur in the head of the pancreas • CT is the best pancreatic imaging modality Æ useful in detection and staging of pancreatic CA • Helical CT and CTA are useful in determining vascular involvement, resectability of pancreatic tumors (10-15%): • Radiologic techniques are essential in the performance of nonoperative palliation – CPN 28 Frank Acosta, HMS IV Gillian Lieberman, MD References • Friedman AC: Pancreatic Neoplasms and Cysts. In Friedman AC, Dachman AH, eds: Radiology of the liver, biliary tract, pancreas, and spleen, St. Louis, 1994, Mosby-Year Book, pp 807-934. • Gray H: Anatomy, Descriptive and Surgical. Pick TP, Howden R, eds. Philadelphia, 1974, Running Press. • Kuroda A, Nagai H: Surgical Anatomy of the Pancreas. In Howard J, et al., eds: Surgical Diseases of the Pancreas, Baltimore, 1998, Williams & Wilkins, pp 11-21. • Massachusetts General Hospital Endoscopy, http://mgh.harvard.edu/endoscopy. • Netter FH. Atlas of Human Anatomy, New Jersey, 1989, Novartis. • Novelline RA. Squire’s Fundamentals of Radiology, Cambridge, 1997, Harvard University Press. • Raptopoulos V, Steer ML, Sheiman RG, Vrachliotis TG, Gougoutas CA, Movson JS. The use of helical CT and CT angiography to predict vascular involvement from pancreatic cancer: correlation with findings at surgery. AJR 1997; 168:971-977. • Reeder & Felson’s Gamuts in Radiology: Comprehensive List of Roentgen Differential Diagnoses. • Siegelman ES: Pancreatic MR defines ducts, pinpoints disease. http://www.dimag.com/bodymri/pancreatic. • Steer ML: Clinical manifestations and diagnosis of exocrine pancreatic cancer. From UpToDate literature search, http://www.uptodate.com. • Thoeni RF, Blankenberg F: Pancreatic Imaging, Radiol Clin North Am 1993; 31:1085-1113. • Vanderbilt Department of Surgery, http://www.mc.Vanderbilt.Edu/surgery/pncnprog. • Wiersema MJ, Wiersema LM: Endosonography-guided celiac plexus neurolysis, Gastrointest Endosc 1996; 44:656 • Zeman RK, Silverman PM: Computed Tomography. In Evans SRT, Ascher SM, eds: Hepatobiliary and Pancreatic Surgery: Imaging Strategies and Surgical Decision Making, New York, 1998, Wiley-Liss, pp 445- 463. 29 Frank Acosta, HMS IV Gillian Lieberman, MD Acknowledgments • Vassilios Raptopoulos, MD • Chad Brecher, MD • Gillian Lieberman, MD • Beverlee Turner & Pamela Lepkowski • Larry Barbaras and Cara Lyn D’amour, our webmasters Radiologic and Anatomic Characterization of Pancreatic Cancer and Implications for Treatment Agenda Epidemiology of Pancreatic CA Classification of Pancreatic Neoplasms Classification of Pancreatic Neoplasms Vascular Supply & Innervation Pancreatic Duct Establishing the Diagnosis Menu of tests for �Imaging Pancreatic CA Radiologic Studies in the Evaluation and Treatment of Suspected Pancreatic CA J.C. E.G. Radiologic Diagnosis - CT DDX: Mass in the Region of the Pancreas on CT or MRI Patient J.C.: Intact Mesenteric Artery- Resectable Surgical Treatment: Pancreaticoduodenectomy (Whipple) Radiologic Diagnosis - CT Patient E.G.: Involvement of Porto-Mesenteric Vasculature-Non Resectable Management Strategies A different patient A showing Obliteration of Splenic Vein with Liver Metastases - Non Resectable This patient may benefit from �Palliation: Celiac Plexus Neurolysis (CPN) Image-Guided Palliative Therapy Lets review the appearance of Pancreatic Cancer on other imaging modalities Patient B:Magnetic Resonance ERCP & MRCP Patient E: Endoscopic Ultrasound (EUS) Patient F: The Preoperative �Response to Treatment may be �evaluated by Nuclear Medicine Take Home Points References Acknowledgments