fundamentals of radiographic staging of pancreatic cancer · fundamentals of radiographic staging...
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Fundamentals of Radiographic Staging of Pancreatic Cancer
Parag P. Tolat, MD
Medical College of Wisconsin
Department of Radiology
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Disclosures
• None
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Tumor detection
& characterization Staging
Predict if R0 resection can be achieved safely
Detect and describe vascular variants for pre-surgical planning
Role of Imaging
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Keys to Success
Great imaging
Ease of access and reproducibility
Standardized Interpretation &
Reporting
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Keys to Success
Great imaging
*MDCT pancreas protocol
*Image before any intervention
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Why MDCT?
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Why MDCT?
• Good spatial resolution
• Wide field of coverage in one exam
• Good contrast differentiation between
tumor and normal parenchyma
• 3-D data sets for multi-planar vascular
and pancreatic reconstructions
• Reproducibility
• Ease of access
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Keys To Success
Imaging that is easily
available and reproducible
*Enterprise access with standardization
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Access & Standardization
11 Locations for CT
Imaging
17 CT scanners
11 Different CT models
3 CT vendors
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Access & Standardization
Standardized Acquisition
*Lead CT Technologist(s) are
critical working in conjunction with
MD champion
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MDCT Technique
MDCT » Scanner with 64-slice or greater preferred
Oral Contrast» Neutral contrast agent (water)
» No positive contrast
Intravenous contrast » 100-120cc of IV contrast injected at 3-5cc/sec
Phases» Pancreatic phase (Late arterial phase)
» Hepatic phase (Portal venous phase)
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CT Protocol
• Dual-phase Technique
» Late-arterial (Pancreatic) Phase
–Peak aortic arrival + 15 sec.
–Best phase for detecting tumors
–Best phase to evaluate for arterial anatomy and
tumor involvement
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CT Protocol
• Dual-phase Technique
» Portal Venous Phase
–Peak aortic arrival + 45 sec.
–Best phase to evaluate for venous anatomy
and tumor involvement
–Best phase to evaluate liver for mets
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Late Arterial Phase
Portal-Venous Phase
Courtesy WD Foley, MD
Tumor detection
(adenocarcinoma &
neuroendocrine tumor)
Arterial anatomy
Tumor-artery relationship
Identify metastases
Venous Anatomy
Tumor-vein relationship
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Late Arterial Phase Portal-Venous Phase
Tumor Detection
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Reformations
Curved Plane Reconstruction
Courtesy WD Foley, MD
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Reformations
Resectable adenocarcinoma of the pancreatic head/uncinate process (arrow)
confined to the pancreas. Note the low attenuation tumor is distinct from the
SMA and SMV with persistent fat plane (arrowhead).
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Keys to success
Standardized Radiographic
Staging
*Standardized interpretation and reporting
using an accepted staging system
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Operable
Resectable
Borderline Resectable
Inoperable
Locally Advanced
(Type A vs. B)
Metastatic
Clinical Staging
Arterial involvement
Venous involvement
Extrapancreatic disease
Courtesy Naveen Kulkarni, MD
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Tissue
Plane
Abutment
(≤ 180º)
Encasement
(> 180º)
SMA
CA
CHA
SMV/PV
Resectable Borderline Locally Adv
MD Anderson Clinical/Imaging Staging
Courtesy WD Foley, MD
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NCCN Guidelines
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MCW Clinical/Imaging Staging
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Tissue
Plane
Abutment
(≤ 180º)
Encasement
(> 180º)
SMA
CA
CHA
SMV/PV
Resectable Borderline Locally Adv
MCWClinical/Imaging Staging
If reconstruction possible If reconstruction possible
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MCW Locally Advanced
Type A vs. B
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Keys to success
Standardized Radiographic
Staging
*Standardized interpretation and reporting
using an accepted staging system
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Standardized Interpretation
Radiologists interpreting the study
working in conjunction with the care team
(Surgical Oncology, GI, Rad Onc, Med
Onc)
* Sub-specialized radiologists
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Resectable
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Patient 1
Late Arterial Phase Portal-Venous Phase
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Resectable adenocarcinoma of the pancreatic head/uncinate process (arrow) confined to
the pancreas. Note the low attenuation tumor is distinct from the SMA and SMV with
persistent fat plane (arrowhead).
Patient 2
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Reformations
Resectable adenocarcinoma of the pancreatic head/uncinate process (arrow)
confined to the pancreas. Note the low attenuation tumor is distinct from the
SMA and SMV with persistent fat plane (arrowhead).
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Resectable adenocarcinoma of the pancreatic head/uncinate process (arrow)
confined to the pancreas. Note the low attenuation tumor is distinct from the
SMA and SMV with persistent fat plane (arrowhead).
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Borderline Resectable
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Gastroenterology 2014 146, 291-304.e1DOI: (10.1053/j.gastro.2013.11.004)
Copyright © 2014 AGA Institute and RSNA Terms and Conditions
Abutment vs. Encasement
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Patient 1
Late Arterial Phase Portal-Venous Phase
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Patient 2Initial Staging Exam
Late Arterial Phase Portal-Venous Phase
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Completion Neoadjuvant Rx
Late Arterial Phase Portal-Venous Phase
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Initial Exam Completion Neo-Adjuvant
Portal-Venous Phase
Patient 2
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Patient 2Post-Op Scan
Segmental PV-SMV
resection with re-
anastomosis
Spleno-renal shunt
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Locally Advanced
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Locally advanced pancreatic adenocarcinoma of the uncinate process with
tumor encasement of the SMA (arrow). Note the low-attenuation soft-tissue
with encases the SMA for 360 degrees of the vessels. Note plastic biliary stent
(curved arrow).
Patient 1
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Locally advanced pancreatic adenocarcinoma of the uncinate process with
tumor encasement of the SMA (arrow). Note the low-attenuation soft-tissue
with encases the SMA for 360 degrees of the vessels.
Patient 1
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Locally advanced pancreatic
adenocarcinoma at the junction of
the pancreatic neck/body with tumor
encasement of the CHA (arrow) and
PV-SV-SMV confluence (arrowhead).
Note the low-attenuation soft-tissue
with encases the CHA and PV-SV-
SMV confluence for 360 degrees of
the vessels.
Patient 2
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Locally advanced pancreatic adenocarcinoma at the junction of the pancreatic neck/body
with tumor encasement of the CHA (arrow) and PV-SV-SMV confluence with severe focal
narrowing (arrowhead). Note the low-attenuation soft-tissue with encases the CHA and PV-
SV-SMV confluence for 360 degrees of the vessels.
Patient 2
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Metastatic
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Patient 1
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Patient 2
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Patient 2
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Patient 2
Metastatic Peritoneal Implants
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Imaging after GI Intervention
Difficult to Stage
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*
December 18, 2017 February 8, 2018 March 12, 2018
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Arterial Anatomy
• Normal (Type 1)
• Right HA replaced to SMA
• Completely replaced CHA to
SMA
• Accessory or direct origin of
Left HA to Left Gastric A.
• Branches of SMA which may
be involved with tumor
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• Portal Vein
• Splenic Vein
• SMV and draining
branches
• 1st jejunal branch
• IMV
Venous Anatomy
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Standardized Reporting
Pancreatic Cancer SR creates a
CHECKLIST to comprehensively STAGE
and report all findings that may affect
SURGICAL PLANNING
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Reporting
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The Case for Structured Reports
Published in: Olga R. Brook; Alexander Brook; Charles M. Vollmer; Tara S. Kent; Norberto Sanchez; Ivan Pedrosa; Radiology 2015, 274, 464-472.
DOI: 10.1148/radiol.14140206 2014 by the Radiological Society of North America, Inc.
Structured Reporting of Multiphasic CT for Pancreatic Cancer:
Potential Effect on Staging and Surgical Planning4
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Example SR
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Emerging Technologies
Dual Energy CT
PET/MR
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CT – Dual Energy
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A B (MD Iodine)
Courtesy of Dr. Naveen Kulkarni
CT – Dual Energy
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PET/MR
• First PET/MR in
Wisconsin
• Purchase cost $5.5M
• Any PET agent can be
utilized (i.e., FDG or Ga-
Dotatate)
• Reimbursed for same
indications as PET-CT
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PET/MR
Late Arterial Phase Portal-Venous Phase
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PET/MR
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PET/MR
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PET/MR
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PET/MR
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Thank You!
Any Questions?
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Courtesy of Dr. Naveen Kulkarni