IMAGING SOLID AND CYSTIC LESIONS IN PANCREAS

IMAGING SOLID AND CYSTIC LESIONS IN PANCREAS

Dushyant Sahani, M.DDushyant Sahani, M.DDirector of CT

Associate Professor Department of Radiology

Massachusetts General HospitalHarvard Medical School

Director of CTAssociate Professor

Department of Radiology Massachusetts General Hospital

Harvard Medical School

Disclosures Disclosures

• Received Grant Support from GE Healthcare • Received Grant Support from GE Healthcare

Solid Pancreas LesionsSolid Pancreas Lesions

ExocrineDuctal adeno Ca (80%)

– Rare• Solid pseudopapillary

• Acinar cell

• Giant-cell

• Pancreaticoblastoma

ExocrineDuctal adeno Ca (80%)

– Rare• Solid pseudopapillary

• Acinar cell

• Giant-cell

• Pancreaticoblastoma

Endocrine– Islet Cell (1-5%)

Endocrine– Islet Cell (1-5%)

Other– Metastases

– Lymphoma

– Mimics

– Pancreatitis

– IP Spleen

– Lymph nodes

– Focal Fat

•Fourth most common in cancer mortality (33,370 deaths in 2007 & 34,200 diagnosis*)

• Aggressive biology & late

presentation

– <20% are resectable

• Complex regional anatomy

• Lack of reliable tumor markers

•Fourth most common in cancer mortality (33,370 deaths in 2007 & 34,200 diagnosis*)

• Aggressive biology & late

presentation

– <20% are resectable

• Complex regional anatomy

• Lack of reliable tumor markers

Pancreas Adenocarcinoma Facts

Warshaw AL et al. NEJM 1992

*American Cancer Society 2007 data

Pancreas LesionPancreas Lesion

Jan 2004 June 2004

June 2002

Lesion Detection Lesion Detection

8-2006 10-2006 2-2007 9-2007

MGH Management AlgorithmMGH Management Algorithm

SUSPECTED PANCREATIC CANCER

IMAGING

Group 3

•NO METASTASES

•No/partial encasement

Surgery

Group 1

+METASTASES

Chemotherapy

Group 2

•NO METASTASES

•+Vascular encasement

Chemoradiation +/- IORT

Fernandez-del Castillo et al. Arch Surg 1995

Technique: Pancreas MDCT/CTA

Technique: Pancreas MDCT/CTA

• Optimal scan timing for dual-phase technique

• Thin collimation– 1-3 mm

• Oral contrast • IV contrast

– Rapid injection 4-5 cc/sec

• Post processing

• Optimal scan timing for dual-phase technique

• Thin collimation– 1-3 mm

• Oral contrast • IV contrast

– Rapid injection 4-5 cc/sec

• Post processing

Lu D et al. Radiology 1996/97. Boland G et al AJR 1999. Ichikawa T et al. AJR 2006

Lesion Detection CT: Sub-optimal Technique

Lesion Detection CT: Sub-optimal Technique

Portal phase

Optimal TechniqueOptimal Technique

Islet cell

Adeno CA

Arterial Venous

Arterial Pancreatic

30 sec

45 sec

Portal Venous Phase for Liver Metastases

Portal Venous Phase for Liver Metastases

2D/3D Display: Staging2D/3D Display: Staging

Pancreatic Duct Changes

Vargas R et al. AJR 2004

Sahani D et al. Radiology 2005

Fukushima H et al. Eur Radiol 2006

CTA Visualization tools:Vascular Involvement

CTA Visualization tools:Vascular Involvement

Divisum IPMN in Ventral duct

Combined IPMN

CT PancreatogramCT Pancreatogram

MRCP: Recent AdvancementsMRCP: Recent Advancements

Pre-secretin Post-secretin

3D-MRCP

PD Stricture

PD obstruction- “Ominous” sign

Aggressive approach to evaluate the site of transition

Gangi et al AJR 2002

Duct “Cut off”: Early Detection Duct “Cut off”: Early Detection

06-2005 07-2006

PVP

AP

• Unresectable tumor

– Tumor occlusing SMV/PV

– Reduced vessel caliber

• Tear drop SMV (borderline)

– Involvement of (> 25% lumen) CA/HA/SMA

– Distant metastasis (liver peritoneum)

GDA/SA/SV

Small veins

Lymph nodes

Resectable

Criteria: Unresectable TumorCriteria: Unresectable Tumor

Saldinger J. Gastrointest Surg 2000Warshaw AL et al Archives of Surgery 1990

SMV

SMV

SMV

Resectable

Borderline

Tumor (T)Staging of

Pancreatic CA

Tumor (T)Staging of

Pancreatic CA

Saldinger J. Gastrointest Surg 2000

UnresectableUnresectable

SMV Celiac

Nakao A et alWorld J of Surgery 2006

Stitzenberg KB et al. Ann of Surg Onc 2008

Surgical mortlity 34% when arterial reconstruction undertaken and 2.7 % for venous resection

Multiphase Helical CT In Evaluating Resectability Of

Pancreatic Carcinoma

Multiphase Helical CT In Evaluating Resectability Of

Pancreatic Carcinoma• NPV 97.5% (unresectable)

• PPV 75.86% (Resectable)

• Sensitivity 90.67%

• Accuracy 90.72%

• NPV 97.5% (unresectable)

• PPV 75.86% (Resectable)

• Sensitivity 90.67%

• Accuracy 90.72%

Lu D et al Radiology 1999. Keogan MT et al. Radiology 1997

Huang QJ et al Hepatobiliary Pancreat Dis Int.2002 Nov;1(4):614-9

Multiphase MDCT In Evaluating Resectability Of Pancreatic

Carcinoma

Multiphase MDCT In Evaluating Resectability Of Pancreatic

Carcinoma• NPV 100%

• PPV 89%• Sensitivity 100%

• Specificity 72%

• NPV 100%

• PPV 89%• Sensitivity 100%

• Specificity 72%

Fletcher JG et al. Radiology 2003.

Vargas R et al AJR 2004.

Zamboni G et al Radiology. 2007

• 1-5% of Pancreas neoplasm

– 10-30% in MEN-1/ 1%VHL

• NF-PNET >F-PNET

– Insulinomas > Gastrinomas> Glucaganomas

• NF-PNET and Insulinomas often single

• Tail-48%, Body-16%, Head-31%

• Curative resection 15 year survival 96 %

– 26% with liver metastases

• 1-5% of Pancreas neoplasm

– 10-30% in MEN-1/ 1%VHL

• NF-PNET >F-PNET

– Insulinomas > Gastrinomas> Glucaganomas

• NF-PNET and Insulinomas often single

• Tail-48%, Body-16%, Head-31%

• Curative resection 15 year survival 96 %

– 26% with liver metastases

Pancreas Neuroendocrine Tumors

Plockinger U et al. Neuroendocrinology 2004

Archives of Surgery 2007; 142:347-354

MGH 2007 58.3% 4.5cm 30% 78%

Johns Hopkins 1998 47.5% 5.1cm 60% 52%

Mayo Clinic 1981 15% 92% 44%

Study non-functional size malignancy 5yr survival

Comparison of Non-functional PNENs

n=168

n=125

Notavailable

n=168

Archives of Surgery 2007; 142:347-354

Functioning PNETFunctioning PNET

Small (< 2 cm) and arterially enhancing

>2 cm lesions can be heterogeous

Liver metastases often arterially enhancing Pfannenberg AC et al. Abd Imaging 2005.

Bordianau L et al. Surgery 2008

Large (> 3cm), exophytic, heterogenous lesions +/- cytic changes (degeneration). Vascular enacesment and metastases +/-

Non-Functioning PNETNon-Functioning PNET

CT Accuracy in F-PNET Detection(Tumor size & CT Technique)

CT Accuracy in F-PNET Detection(Tumor size & CT Technique)

• < 1cm - 20%• 1-3 cm- 30-40%• > 3 cm -> 75%

Extra pancreatic Sn 35%

MDCT 63-94% Sn

• Octreoscan (50% SR+)

• EUS 94% Sn for < 1cm lesions

• < 1cm - 20%• 1-3 cm- 30-40%• > 3 cm -> 75%

Extra pancreatic Sn 35%

MDCT 63-94% Sn

• Octreoscan (50% SR+)

• EUS 94% Sn for < 1cm lesions

Wank SA. Gastroenterology 1987

Fidler J et al. AJR 2003. Gouya H et al. AJR 2003. Yong, E and Canto, M. GIE 2007;65(5)

MDCT Pitfall: “Small Liver Lesion Detection and Characterization”

MDCT Pitfall: “Small Liver Lesion Detection and Characterization”

CECT Vs. MRI

Holalkere et al. JCAT 2005

M-Stage: CT and MRM-Stage: CT and MR

MRMRCECTCECTCT understages (>25% complete response @ CT macroscopic disease @ surgery)

M-Stage: Role DWI imaging

DWI-MRDWI-MRT2 WIT2 WI Post -Gd T1 FSPost -Gd T1 FS

Rummney E et al. AJR. 2002Koh DM et al. Eur Radiol. 2008

Bruegel M et al. Eur Radiol. 2008Laurent V et al. Eur J Radiol. 2009

B

M-stage: MR vs. FDG-PETM-stage: MR vs. FDG-PET

FDG-PET

Metastases: 65

Lesions <1cm: 12

MRI

Metastases: 88

Lesions <1cm 33Kinkel. Radiology 2002. Sahani. AJR 2005. Akhurst T. JCO 2005.

Coenegrachts K. Radiology 2009.

PET Sensitivity

Lesions > 2 cm=100%, 30-60% lesions < 10 mm

Post-CXT 63% overall sensitivity

M Stage: MRI-PET-CT M Stage: MRI-PET-CT

AuthorPrimary Cancer

nGold

Standard

Accuracy

CE-MRI PET CT

Rappeport et al. (18)

CRC 35 Surgery IOUS 82% 77% 77%

Delbeke et al. (25)

CRC 52Surgery

Follow-up -- 92% 78%

Sahani et al. (28)

CRC and Pancreatic

Cancer34

Surgery Follow-up 97 % 85.3% --

Ward et al. (34)CRC (56), Others (2)

58 Surgery IOUS 92% -- 82%

Regge et al. (76)

CRC 125 Surgery IOUS 82.4 -- 72.8%

MDCT: Small Lesion Detection MDCT: Small Lesion Detection

CT T2 MRI T1 FS

Schima W et al. AJR 2002

MRI/MRCP: Non-contour Deforming Mass

MRI/MRCP: Non-contour Deforming Mass

Schima W et al. AJR 2002

• Diffuse “sausage-shaped” enalargement of the pancreas

• Absence of the normal pancreatic clefts (featureless)

• Peripheral “halo” – rim of hypoattenuation

• Lack of vascular encasement

• ↑↑ IgG4

• Steroid responsive

• Diffuse “sausage-shaped” enalargement of the pancreas

• Absence of the normal pancreatic clefts (featureless)

• Peripheral “halo” – rim of hypoattenuation

• Lack of vascular encasement

• ↑↑ IgG4

• Steroid responsiveSahani et al. Radiology 2005

Takahashi et al. AJR 2008

PDAC

• ADC mass 1.93±0.93 x10-3

mm2/s• ADC “normal” pancreas

2.37±0.98x 10-3 mm2/s• ADC ratio 0.8±0.07

MF-AIP

• ADC mass 1.11±0.14 x10-3

mm2/s• ADC “normal” pancreas

1.03±0.22x 10-3 mm2/s• ADC ratio 1.1±0.01

(p 0.01)

(p < 0.001)

(p < 0.001)

DWI MRI: Tissue CharacterizationDWI MRI: Tissue Characterization

Catalano et al. RSNA 2009

Benefits of State of art MDCT and PET

Morphology + Function = PET-CT

PET-CT: PANCREATIC CANCERPET-CT: PANCREATIC CANCER

Heinrich S et al. Ann Surg 2005

Author Sensitivity Specificity Accuracy

Zimmy (1997) 85 85 84

Debelke (1999) 92 85 91

Martin (2000) 77 74

Heinrich (2005) 93

PET/PET-CT: PANCREATIC CANCER

PET/PET-CT: PANCREATIC CANCER

ROLE OF PET/CT-CHARACTERIZATION

ROLE OF PET/CT-CHARACTERIZATION

CT FDG-PET Tumor

LYMPH NODE (N) STAGINGLYMPH NODE (N) STAGING

PET-CT

PET/CT: PANCREATIC CANCER STAGING

PET/CT: PANCREATIC CANCER STAGING

• Management changed in 16%, initially considered resectable

• Additional distant metastasis in 5 patients• Synchronous rectal cancer in 2 patients.

• Management changed in 16%, initially considered resectable

• Additional distant metastasis in 5 patients• Synchronous rectal cancer in 2 patients.

Heinrich S et al. Ann Surg 2005;242:234-243

FDG-PET-CT: PNET

PET-CT attractive but its role is unclear

Differentiation between benign and malignant lesions is difficult

• PD dilatation with a “cut-off” ominous sign

• MDCT first line modality – For pancreas mass evaluation

– Pre-operative staging

• Optimal scanning technique and 2D/3D display– For lesion detection and staging

• MRI for liver evaluation and problem solving indications (small lesion detection)

• PET-CT attractive but its role is still evolving

• PD dilatation with a “cut-off” ominous sign

• MDCT first line modality – For pancreas mass evaluation

– Pre-operative staging

• Optimal scanning technique and 2D/3D display– For lesion detection and staging

• MRI for liver evaluation and problem solving indications (small lesion detection)

• PET-CT attractive but its role is still evolving

Summary Summary Summary Functional imaging is complimentary to cross

sectional imaging for F-NET location•Assessment of prognosis and response to therapy

PET-CT attractive but its role is unclear

• Differentiation between benign and malignant lesions is difficult

•EUS has the best performance for small lesion detection

Pancreas Surgery At MGH 1990-2000Pancreas Surgery At MGH 1990-2000

1988-1998 increase in cystic tumors from 16-30%

Fernandez-del Castillo C. Adv Surg 2000

Serous cystadenoma: 32-39%

Mucinous neoplasm: 10-45%

Cystic Tumor DistributionCystic Tumor Distribution

IPMN: 21-33%

Cystic Degeneration in Solid Tumors

Cystic Degeneration in Solid Tumors

Neuroendocrine

Solid and Pseudopaillary Neoplasm (SPEN)

Adenocarcinoma

< 10%

Cystic Lesion: Imaging ObjectivesCystic Lesion: Imaging ObjectivesMorphologic details

Unilocular or Multilocular

Microcystic

Cyst communication with PD

Extent of PD involvement

Morphologic details

Unilocular or Multilocular

Microcystic

Cyst communication with PD

Extent of PD involvement

Megibow A Radiology 1992, Procacci C JCAT 1999/2000.

Sahani DV ECNA 2005/Radiograhics 2005/JACR 2009

Cystic Lesion: Imaging ObjectivesCystic Lesion: Imaging Objectives

Benign or Malignant

• Mural nodules

• Thick Septae

• Cyst/MPD size

• Metastases

Benign or Malignant

• Mural nodules

• Thick Septae

• Cyst/MPD size

• Metastases

SEROUS CYSTADENOMA: MICROCYSTIC

SEROUS CYSTADENOMA: MICROCYSTIC

• Middle age Women >Men

• Numerous (> 6) tiny cysts

• “Sponge”/ “Honeycomb”

• Lobulated outline

• Sharp interface with vessels

• Rarely obstruction– Bile duct

– Pancreatic duct

• Middle age Women >Men

• Numerous (> 6) tiny cysts

• “Sponge”/ “Honeycomb”

• Lobulated outline

• Sharp interface with vessels

• Rarely obstruction– Bile duct

– Pancreatic duct

Buck et al. Radiograhics 1990

SEROUSCYSTADENOMASEROUSCYSTADENOMA

“Sponge”

“Honeycomb”

MUCINOUS CYSTIC NEOPLASM (MCN)

MUCINOUS CYSTIC NEOPLASM (MCN)

• Middle age women

• Tail location (85%) most common

• Single/few cysts ( < 6 cyst) > 2cm

• Peripheral/septal Ca+/mural nodules

• No communication with PD

• Benign or malignant

• 10-20% are carcinoma

MUCINOUS CYSTIC NEOPLASM

MUCINOUS CYSTIC NEOPLASM

CT

INTRADUCTAL PAPILLARY MUCINOUS NEOPLASMS (IPMN)

INTRADUCTAL PAPILLARY MUCINOUS NEOPLASMS (IPMN)• Increasingly recognized• Similar to MCNs

– cystic tumor that secrete mucin• Arise from a duct papillary

epithelium • Affect a mostly elderly men. • Dilatation of the ducts as a result of

tumor growth and mucin • Upto 49% of IPMNs may be

malignant

• Increasingly recognized• Similar to MCNs

– cystic tumor that secrete mucin• Arise from a duct papillary

epithelium • Affect a mostly elderly men. • Dilatation of the ducts as a result of

tumor growth and mucin • Upto 49% of IPMNs may be

malignant

Ohhashi K et al Prog Dig Endosc 1982;20:348-351

IPMNClassification

IPMNClassification

IMAGING FEATURES:SB-IPMNIMAGING FEATURES:SB-IPMN

•Uncinate >other

•Septated cyst -lobulated

•Channel of communication -MPD

•96% specific for diagnosis

•+/- MPD dilatation > 5mm

15-20 % risk of malignancyInvasive Ca less common

SB-IPMN Vs MCNSB-IPMN Vs MCNMCN

Macrocystic

<6 cysts, > 2 cm in size

Surface-Smooth

85%Tail

SB IPMN

SB-IPMNMacrocystic or mixed

>6 cysts of < 2cm

Communication

Lobulatated

+/-MPD dilatation

Irie et al Radiology 2002 Fukukura ,Y Acta Radiol 2003, Sahani et al Radiology 2005

MAIN DUCT IPMN

•Segmental or diffuse dilated MPD > 6 mm without cut-off

Irie H et al. AJR 2000; 174: 1403-1408

ERCP

MRCP

Tumor foci

MD-IPMN:FEATURESMD-IPMN:FEATURESMPD++/ SB-changesAtrophy =MPD dilatation Bulging papilla

Mural nodules

Irie et al Radiology 2002, Fukukura Y Acta Radiol 2003, Sahani et al Radiology 2005

PD Dilatation: DifferentialPD Dilatation: Differential

Pancreatic Duct Changes

Vargas R et al. AJR 2004

Sahani D et al. Radiology 2005

Fukushima H et al. Eur Radiol 2006

C-Pancreatitis

PDAC

IPMN

CYST CLASSIFICATION-NON MUCINOUS

CYST CLASSIFICATION-NON MUCINOUS

SOLID MASS WITH CYSTIC DEGENRATION

Associated changes in duct, parenchyma, vascular or ductal

invasion or LN

Complex solid + cystic

No characteristic features

NET/Adenoca/Met

SOLID PSEUDOPAPILLARY TUMOR

Solid + cystic Irregular enhancing peripheral component

Capsule, Ca+ rim

Young women (20-30 yrs)

Pancreas Cyst ReviewPancreas Cyst Review

CYST PSEUDOCYST IPMN MUC CYSTADENOMA

SER CYSTADENOMA MUC CYSTADENOMA

MUC CYSTADENOCARCINOMA MALIG IPMN

unilocular

multilocular

complex

Challenges in Cyst Characterization: Morphologic

Overlap

Challenges in Cyst Characterization: Morphologic

Overlap

Mucinous Pseudocyst IPMNCohen-Scali F et al. Radiolgy 2003

Khurana B et al. AJR 2003

Kim S et al. AJR 2006

SCA Morphology ChallengesSCA Morphology Challenges

Central scar: < 20%

Macrocystic

? Solid MRI Diffuse

Cysts Features: Predictors of Malignancy Cysts Features: Predictors of Malignancy

Mural nodularity / solid mass

Peripheral Calcification

Macrocyst > 5cm

MPD>8 mmWHAT IS THE ROLE OF EUS?WHAT IS THE ROLE OF EUS?

Hollerbach: Endoscopy 2001 Oct;33(10):824-31

• Cyst fluid aspiration– Amylase– Tumor markers

• CEA, CA 72-4, CA 125, CA 19-9, CA 15-3

• Biopsy suspicious areas• Less risk of spillage of cyst contents

• Cyst fluid aspiration– Amylase– Tumor markers

• CEA, CA 72-4, CA 125, CA 19-9, CA 15-3

• Biopsy suspicious areas• Less risk of spillage of cyst contents

Cyst Fluid Analysis (CEA,amylase,cytology)

CEA<5 CEA 5-200 CEA 200-500 >500

•Serous cyst•Duplication

•Mucinous•Pseudocyst

•Mucinous •Malignant

Non-mucinouscytology

Mucinous orinflammatory

cytology

Mucinouscytology

Benign ormalignant

Brugge W et al. AGA 2002

Cyst with associated mass

Septated/Macrocystic

Microcystic

Unilocular

Morphology

Sahani et al. Radiograhics 2005

MDCT CATEGORIZATION: CYST MORPHOLOGY

MDCT CATEGORIZATION: CYST MORPHOLOGY

ALGORITHM FOR MANAGEMENT OF PATIENTS WITH A PANCREATIC

CYSTIC LESION

ALGORITHM FOR MANAGEMENT OF PATIENTS WITH A PANCREATIC

CYSTIC LESION

Abdominal CT scan

InflammatoryCyst/pancreatitis

Microcystic Macrocystic Malignant

Premalignant or malignant

•Management depends on* –Age & presentation, –location of the lesion and size–presence or absence of malignancy

Gigiot JF et al Arch Surg 2001;136:1256-62*

MANAGEMENT ALGORITHMMANAGEMENT ALGORITHM

Macrocystic Malignant

Surgery ObservationMonitoring

CT scanning

EUS-FNA Surgery

lowhighRisk / BenefitAssessment

Cytology and CEACEA>500Atypia

CEA<10Non-mucinous

CEA 10-500Benign mucinous

CHALLENGES WITH SMALL CYSTS (< 3 CM).

CHALLENGES WITH SMALL CYSTS (< 3 CM).

• Accurate diagnosis difficult with imaging.

• Most benign side branch IPMN

• MRCP better for small cyst morphology

• Criteria for F/U– No solid component

– No MPD involvement

– Clinical

• Accurate diagnosis difficult with imaging.

• Most benign side branch IPMN

• MRCP better for small cyst morphology

• Criteria for F/U– No solid component

– No MPD involvement

– ClinicalSpinelli 2004Fernandez del-castillo 2004Sohn 2004Sahani 2006

CT MR

Cyst Follow-upCyst Follow-upMay 2006 August 2007

Nov 2001 June 2003

August 2004 Sept 2005

Worrisome

1cm growth/year

Solid mass

PD

APPROACH ON IMAGINGAPPROACH ON IMAGING

Sahani, D. V. et al. Radiographics 2005;25:1471-1484

MORPHOLOGIAL DETAILS

PseudocystEpithelial cyst

Serous Cystic deg. insolid tumors

MucinousMCN

PeripheralIPMNDuctal

SummarySummary• MDCT/MR has good predictive value for malignancy, better for

benignity

• Differentiation of borderline and CIS changes (prevalent in mucinous lesions) is difficult on imaging

• MDCT/MR has good predictive value for malignancy, better for benignity

• Differentiation of borderline and CIS changes (prevalent in mucinous lesions) is difficult on imaging

Called Malignant Called BenignSmall, C IPMN

Triaging Patients–MDCT features–Clinical presentation–Age–Surgical risk–Lesion size / location

Summary Summary

• Incidental < 3 cm cysts (-solid component) have

low incidence of malignancy

– MR>CT for cyst morphology

– FU with CT or MR starting @ 6 months

• EUS and cyst aspiration useful but should

considered in select patients.

• Incidental < 3 cm cysts (-solid component) have

low incidence of malignancy

– MR>CT for cyst morphology

– FU with CT or MR starting @ 6 months

• EUS and cyst aspiration useful but should

considered in select patients.

Bulfinch Building, Massachusetts General Hospital

THANK YOUTHANK YOU