Frank Acosta, HMS IV

Gillian Lieberman, MD

July 2001

Radiologic and Anatomic Characterization of

Pancreatic Cancer and Implications for
Treatment

Frank L. Acosta, Jr., Harvard Medical School Year IV

Gillian Lieberman, MD

Frank Acosta, HMS IV

Gillian Lieberman, MD

Agenda

Epidemiology
Classification
Relevant anatomy
Clinical presentation
Imaging studies
Management strategies
Salient points
2

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
3

Frank Acosta, HMS IV

Gillian Lieberman, MD

Classification of Pancreatic Neoplasms

I.

Epithelial nonendocrine tumors

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
A.

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

4
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

Frank Acosta, HMS IV

Gillian Lieberman, MD

Classification of Pancreatic Neoplasms

I.I.

Epithelial
Epithelial nonendocrine
nonendocrine tumors
tumors
A.
Duct
cell
origin
A.
Duct cell origin
1.
Cystic
1.
Cystic
a.
Microcystic
a.
Microcystic (serous)
(serous) adenoma
adenoma
b.
Mucinous
b.
Mucinous cystic
cystic neoplasm
neoplasm
((cystadenocarcinoma
cystadenocarcinoma))
c.
Ductectatic
c.
Ductectatic neoplasms
neoplasms
2.
Solid
2.
Solid

a.
b.
b.

B.
B.

C.
C.

II.
II.

Endocrine
Endocrine (islet
(islet cell)
cell) tumors
tumors
A.
Insulinoma
A.
Insulinoma
B.
Gastrinoma
B.
Gastrinoma
Glucagonoma
C.
C.
Glucagonoma
D.
VIPoma
D.
VIPoma
E.
Somatostatinoma
E.
Somatostatinoma
F.
Pancreatic
F.
Pancreatic polypeptidoma
polypeptidoma
G.
Carcinoid
G.
Carcinoid
H.
Miscellaneous
H.
Miscellaneous

III.
III.

Other
Other pancreatic
pancreatic neoplasms
neoplasms
A.
Nonepithelial
A.
Nonepithelial ((mesenchymal
mesenchymal)) tumors
tumors
B.
Metastases
B.
Metastases
C.
Lymphoma
C.
Lymphoma

DUCT CELL
ADENOCARCINOMA (90%)

Variant
Variant carcinomas
carcinomas
(1)
Pleomorphic
(1)
Pleomorphic giant
giant cell
cell carcinoma
carcinoma
(2)
Adenosquamous
(2)
Adenosquamous carcinoma
carcinoma
(3)
Mucinous
(3)
Mucinous (colloid)
(colloid) carcinoma
carcinoma
(4)
Anaplastic
carcinoma
(4)
Anaplastic carcinoma
(5)
Small
(5)
Small cell
cell carcinoma
carcinoma
(6)
Ciliated
cell
(6)
Ciliated cell adenocarcinoma
adenocarcinoma
(7)
Oncocytic
(7)
Oncocytic carcinoma
carcinoma
(8)
Clear
(8)
Clear cell
cell carcinoma
carcinoma
Acinar
cell
origin
Acinar cell origin
1.
Acinar
1.
Acinar cell
cell carcinoma
carcinoma
2.
Acinar
cell
cystadenocarcinoma
2.
Acinar cell cystadenocarcinoma
3.
Pancreaticoblastoma
3.
Pancreaticoblastoma
Indeterminate
Indeterminate origin
origin
1.
Osteoclast
1.
Osteoclast--type
type giant
giant cell
cell carcinoma
carcinoma
2.
Solid
2.
Solid and
and papillary
papillary epithelial
epithelial neoplasm
neoplasm
3.
Mixed
endocrine
exocrine
tumors
3.
Mixed endocrine-exocrine tumors
4.
Microadenocarcinoma
4.
Microadenocarcinoma

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

Frank Acosta, HMS IV

Gillian Lieberman, MD

Vascular Supply & Innervation

6
Netter FH. Atlas of Human Anatomy, New Jersey, 1989, Novartis.

Frank Acosta, HMS IV

Gillian Lieberman, MD

Pancreatic Duct

Gray H: Anatomy, Descriptive and Surgical. Pick TP, Howden R, eds. Philadelphia, 1974, Running Press.

Frank Acosta, HMS IV

Gillian Lieberman, MD

Establishing the Diagnosis

Initial presentation varies with the location of
tumor:
Head of pancreas Symptoms of obstruction of
the intrapancreatic portion of common bile duct
(steatorrhea, weight loss, jaundice)
Body, tail Symptoms from invasion of celiac
ganglia (pain, weight loss). Obstruction less
common
Courvoisiers law

Imaging studies play two primary roles:

Diagnosis
Selecting optimal treatment strategies (i.e. surgical
vs. nonsurgical)
8

Frank Acosta, HMS IV

Gillian Lieberman, MD

Menu of tests for

Imaging Pancreatic CA
Test

Sensitivity

Specificity

Useful in Staging

US
EUS
CT
ERCP
MRI
FNA

80%
90%
90%
90%
90%
90%

90%
90%
95%
90%
90%
98%

No
Yes
Yes
No
No
No

Steer ML: Clinical manifestations and diagnosis of exocrine pancreatic cancer. From UpToDate literature search, http://www.uptodate.com

Frank Acosta, HMS IV

Gillian Lieberman, MD

Radiologic Studies in the Evaluation and Treatment of Suspected

Pancreatic CA
Suspected pancreatic CA

Contrast-enhanced helical CT scan (or MRI)

Dilated biliary tree

Nondilated biliary tree

ERCP (MRCP)
+/- stent placement
Questionable resectability
based on CT criteria

Unresectable on CT criteria

Resectable based on CT criteria

Visceral angiography or EUS
Surgical exploration
Resectable

Unresectable

FNA
10

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.

Frank Acosta, HMS IV

Gillian Lieberman, MD

Lets Discuss 2 Patients

J.C.
74 yo female
2 weeks intermittent
upper abdominal pain

Achy in nature
Radiating to back
Worse with eating
5-10 lb weight loss

E.G.
70 yo male
Steatorrhea, weight loss
PE: Jaundice,
nontender palpable
gallbladder
Lab findings: Bili, Alk
Phos

PE no focal findings
Lab findings: wnl
11

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

12

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 & Felsons Gamuts in Radiology: Comprehensive List of
Roentgen Differential Diagnoses.

Pathologic analysis is gold

standard for dx.

13

Frank Acosta, HMS IV

Gillian Lieberman, MD

Patient J.C.: Intact Mesenteric ArteryResectable

CT revealed
preservation of fat
plane around SMA
No evidence of
metastatic disease
Hypodense fat plane surrounding
SMA, indicating tumor has not
invaded this vessel

Image courtesy of BIDMC Department of Radiology

14

Frank Acosta, HMS IV

Gillian Lieberman, MD

Surgical Treatment:
Pancreaticoduodenectomy (Whipple)

http://pathology2.jhu.edu/pancreas/surgery.cfm

15

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

16

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

17

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
determining optimal treatment (i.e.
surgical vs. nonsurgical)
18

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

CT demonstrating:
Obliterated splenic vein
Hepatic metastases

Siegelman ES: Pancreatic MR defines ducts, pinpoints disease.

http://www.dimag.com/bodymri/pancreatic

MR max. intensity projection image (portal venous

phase of contrast enhancement) showing:
Obliterated splenic vein (no contrast-asterix)
Prominent collateral vessel (gastroepiploic vein)
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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.

20

Frank Acosta, HMS IV

Gillian Lieberman, MD

Image-Guided Palliative Therapy

EUS

Fluoroscopic monitoring
Ethanol distribution following
injection into L periaortic space

From Wiersema MJ, Wiersema LM. Endosonography-guided celiac plexus neurolysis. Gastrointest Endosc 1996; 44:656.

21

Frank Acosta, HMS IV

Gillian Lieberman, MD

Lets review the appearance of

Pancreatic Cancer on other
imaging modalities

22

Frank Acosta, HMS IV

Gillian Lieberman, MD

Patient B:Magnetic Resonance

A

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

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)

23

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.

Frank Acosta, HMS IV

Gillian Lieberman, MD

ERCP & MRCP

ERCP: Patient C

Dilated, irregular pancreatic duct

with filling defects
Dilated side branches of pancreatic duct
Images courtesy of BIDMC Department of Radiology

MRCP: Patient D

Dilated pancreatic duct and side branches

Gallbladder

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Frank Acosta, HMS IV

Gillian Lieberman, MD

Patient E: Endoscopic Ultrasound (EUS)

Diagram of echoendoscope
imaging pancreatic mass
through pyloric wall

http://www.mgh.harvard.edu/endoscopy/Endo%20site/EUS.html

EUS of pancreatic mass

Involving SMV-portal vein
confluence

Improved diagnosis and

localization of small (<23cm) 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
25

http://www.mc.Vanderbilt.Edu/surgery/pncnprog.html

Frank Acosta, HMS IV

Gillian Lieberman, MD

Patient F: The Preoperative

Response to Treatment may be
evaluated by Nuclear Medicine

URL: http://www.mc.Vanderbilt.Edu/surgery/pncnprog.html

18FDG-PET

scan performed before (A) and

after (B) taxol-based neoadjuvant
chemoradiation.
Near total reduction in tumor-specific signal following completion of
taxol-based neoadjuvant chemoradiation

26

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 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
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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. Squires 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 & Felsons 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 445463.

28

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 Damour,
our webmasters
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