1. PANCREATIC CANCER AND ROLE OF IMAGING IN DETERMINING THE SURGICAL RESECTABILITIY
Dr.M.MATAR
CONSULTANT RADIOLOGY AND INTERVENTINAL RADIOLOGY
ALShifa Hospital
&
Dr.M. Alzaanin
Radiologist at ALShifa Hospital
21-April-2017

5. PANCREATIC CANCER 1* Exocrine pancreatic cancer
2* Neuroendocrine pancreatic tumors

6. Introduction
Pancreatic ductal adenocarcinoma (PDA) is the second most common gastrointestinal malignancy after colorectal cancer. It is a highly aggressive tumor that carries a high mortality rate and is the fourth most common cause of cancer-related death in the United States in both men and women
- will become the second most common cause of cancer-related deaths in the United States by 2020 with new cases every year .

8. In the UK it is the 9th commonest cancer with the 5th commonest cause of cancer death
In 2014, new case with death in same year
Less than 1% Survive pancreatic cancer for 10 or more years,

9. In GAZA as that mention in the reference of cancer in Gaza strip ,the pancreatic cancer is not in the list of most ten frequent cancers and there is no list of cancer related death list

10. سرطان الغدد الليمفاوية
نوع السرطان
% of all cancers
Nu.
Type of cancer
سرطان الثدي
18.1
1283
Breast Cancer
سرطان القولون
10.0
709
Colo-rectal Cancer
سرطان الرئة
7.3
522
Lung Cancer
سرطان نخاع العظم
6.9
490
Leukemia Cancer
سرطان الغدد الليمفاوية
5.8
409
Lymphoma Cancer
سرطان الدماغ
5.1
364
Brain Cancer
سرطان الغدو الدرقية
4.6
325
Thyroid Cancer
سرطان البروستاتا
3.8
270
Prostate Cancer
سرطان المثانة
3.3
234
Urinary Bladder Cancer
سرطان المعدة
3.2
226
Stomach Cancer

11. Pancreatic Cancer Stats

13. Most of the increase in overall cancer death rates for men prior to 1990 was attributable to the rapid increase in lung cancer deaths due to the tobacco epidemic. However, since 1990, the lung cancer death rate in men has been decreasing; this decline has accounted for over 40% of the overall decrease in cancer death rates in men since The death rate for stomach cancer, which was the leading cause of cancer death among men early in the 20th century, has decreased by 90% since Death rates for prostate and colorectal cancers have been declining since the early 1990s and 1980s, respectively. In contrast to declining death rates for most cancer types, liver cancer death rates increased by more than 2% per year during the past decade of data (2001 to 2010). Death rates for pancreatic cancer have also been increasing slightly.

14. The lung cancer death rate in women began declining in the early 2000s after increasing for the previous 70 years. The lag in the decline in lung cancer in women compared to men reflects differences in smoking patterns; smoking rates peaked about two decades later in women than in men and women lagged behind men in quitting smoking in large numbers. In comparison, breast cancer death rates changed little between 1930 and 1990, but decreased 34% between the peak year (1989) and Since 1930, the death rate for stomach cancer has decreased by more than 90%. The death rate for uterine cancer (uterine cervix and uterine corpus combined), which was the leading cause of cancer death in the early 20th century, declined 80% from 1930 to 1997, but has since been fairly stable. Colorectal cancer death rates have been decreasing for more than 60 years. Similar to men, pancreatic cancer death rates have been increasing slightly, from 8.8 (per 100,000 women) in 1980 to 9.6 in 2010.

15. The high mortality rate is due to the aggressive disease biology and the delayed diagnosis of most cases at an un-resectable stage.

16. Risk Factors Baseline ~ 10/100,000 population/year

17. Risk
Proportion of cancers
Smoking
x 2 30
Genetic factors
x 5-10 10
Chronic Pancreatitis
x 10-20 1
Hereditary Pancreatitis
x 35-70
<1
Age >70
x 5 -
Type II DM
x 1.5-2
Obesity
x 1.7
High fat diet
Previous gastric surgery
x 1.8
Sclerosing Cholangitis
x 14
Helicobacter Pylori

18. ‘Classic’ symptoms

19. Jaundice is yellowing of the eyes and skin
Jaundice is yellowing of the eyes and skin. Most people with pancreatic cancer (and nearly all people with ampullary cancer) will have jaundice as one of their first symptoms,

20. Investigations Blood tests
Full blood count
anaemia rare except for ampullary tumours
Liver function tests
Obstructive jaundice
Elevated gamma GT / Alk Phos may precede bilirubin
Serum glucose
Diabetes or impaired glucose tolerance
CA19-9
Sensitivity of ~80% and a specificity of 83%
Normal levels do not exclude diagnosis
Better for treatment monitoring

21. Diagnostic imaging U/S Contrast-enhanced CT
Often first line for jaundice
May demonstrate pancreatic mass
Contrast-enhanced CT
Gold standard
Essential for staging

22. PDA Staging  American Joint Committee on Cancer (AJCC) and the National Comprehensive Cancer Network (NCCN).
Tumor size
Location within the pancreas, and
Local extent which may involve surrounding vessels,
The presence of metastatic lesions.
The reported imaging data must allow clinicians to translate the information in the  imaging report into established clinical staging systems

23. American Joint Committee on Cancer (AJCC):
Based on the TNM staging system, is used to assess the immediate and long-term clinical prognosis and to generate survival data for patients on the basis of the stage of disease.

24. National Comprehensive Cancer Network :
NCCN consensus report guidelines define a staging system based on tumor extent and offer treatment recommendations  
Cases are classified into three main categories:
1*Resectable: If the cancer is only in the pancreas (or has spread just beyond it) and the surgeon believes the entire tumor can be removed, it is called resectable
2*Borderline resectable: just reached nearby blood vessels, but which the doctors feel might still be removed completely with surgery
3*Locally advanced/unresectable disease: These cancers can’t be removed entirely by surgery

25. The disease category selection depends on tumor location within the pancreas and the arterial or venous involvement.
In the guidelines, less than or equal to 180° tumor contact of the vessel circumference is described as “abutment” and more than 180° tumor contact of the vessel circumference is referred to as “encasement.”  

26. b a c d
Figure 1a: Tumor location. Tumor located to the right of the superior mesenteric vein (SMV) in the (a) pancreatic head or (b) Uncinate process is potentially suitable for a Whipple procedure or Pancreaticoduodenectomy procedure. Tumor located to the left of the SMV in the (c) pancreatic body or (d) tail is potentially suitable for distal Pancreatectomy. T = tumor.

27. T T b a b a T T c d

28. b a c
Figure 2a: Arterial tumor contact. (a) Less than or equal to 180° tumor contact without deformity. (b) More than 180° tumor contact without deformity. (c) Tumor contact with deformity (arrow). A = artery, T = tumor. Dashed line = 180° of lumen circumference.

29. a b c d
Figure 3a: Venous tumor contact. (a) Less than or equal to 180° tumor contact without deformity. (b) More than 180° tumor contact without deformity. (c) Less than or equal to 180° tumor contact with deformity (arrows). (d) Tear drop deformity (arrows). T = tumor, V = vein. Dashed line = 180° of lumen circumference.

30. Figure 4a: Images in a 60-year-old man with less than 180° of circumferential tumor contact with the SMA. (a) Axial contrast-enhanced biphasic multidetector CT angiogram demonstrates a pancreatic body mass (T) directly contacting less than 180° of the SMA circumference without contour deformity (short arrow). (b) On the sagittal reformatted image, the length of tumor contact and vessel caliber are better delineated (short arrow). Finding less than 180° of tumor contact with the SMA places the patient in the borderline resectable category.

31. celic T
Images in a 66-year-old man with less than 180° of circumferential tumor contact with the Celic artery.
(a) Axial contrast-enhanced biphasic Multidetector CT angiogram demonstrates a mass (T) directly contacting less than 180° of the SMA

32. Figure 5a: Images in a 73-year-old woman with more than 180° of circumferential tumor contact with the SMA. (a) Axial contrast-enhanced biphasic Multidetector CT angiogram demonstrates a pancreatic head mass (T) contacting more than 180° of the SMA circumference (short arrows). (b) Extension and involvement of the first SMA branch (short arrow) is better delineated on the coronal reformatted image. The presence of greater than 180° of tumor in contact with the SMA and tumor in contact with the SMA branch places the patient in the unresectable category.

33. SMA
SMA bb aa
68 Y old man with more than 180° of circumferential tumor contact with the SMA.
(a) Axial contrast-enhanced.
(b) Coronal reformatted image.
(c) Sagittal reformatted image.
SMA ac

34. SMA T
68 Y old man with more than 180° of circumferential tumor contact with the SMA.
Axial contrast-enhanced

35. SMA T
Zoomed image of mass (T) show more 180 contact with SMA coronal reconstructed image

36. A
Figure 6a: Images in a 71-year-old woman with tumor involvement of the celiac axis (CA). (a) Axial contrast-enhanced biphasic multidetector CT angiogram demonstrates a mass in the pancreatic body (T) that is in contact with less than 180° of the celiac axis circumference (short arrow). (b) On the sagittal reformatted image, the contact with the celiac axis is better delineated (short arrow). The presence of less than 180° of tumor contact with the celiac axis places the patient in the borderline resectable category.

37. T
celiac axis
Axial contrast-enhanced biphasic multidetector CT angiogram demonstrates a mass in the pancreatic body (T) that is in contact with less than 180° of the celiac axis circumference (arrow).

38. celiac axis T
On the sagittal reformatted image, the contact with the celiac axis is better delineated (short arrow). The presence of less than 180° of tumor contact with the celiac axis places the patient in the borderline resectable category.

39. Figure 7a: Images in a 58-year-old man show tumor contact with several SMA branches. (a) Axial contrast-enhanced biphasic Multidetector CT angiogram demonstrates a pancreatic head mass (T) in contact with the adjacent SMA branches. (b) The SMA branches involvement on the coronal reformatted image. The tumor involvement of the SMA branches places the patient in the unresectable category.

40. Figure 8a: Images in a 70-year-old man with tumor in contact with the CHA. (a) Axial contrast-enhanced biphasic multidetector CT angiogram demonstrates a mass in the pancreatic head mass (T) in contact with the CHA (short arrow). (b) The length of contact is better delineated on the curved planar reformatted image through the length of the vessel, which shows that the tumor contact extends to the hepatic artery bifurcation (short white arrow) and the celiac axis (short black arrow). The extension to the celiac axis places the patient in the unresectable category. HA = hepatic artery.

41. CHA T
Axial contrast-enhanced biphasic Multidetector CT angiogram demonstrates a mass in the pancreatic head mass (T) in contact with the CHA (arrow)

42. Venous evaluation:
The most important veins that can affect tumor resectability include the portal vein and SMV

43. Figure 9a: Images in a 55-year-old women with tumor with less than 180° of contact with the SMV. (a) Axial contrast-enhanced biphasic multidetector CT angiogram demonstrates a pancreatic head mass (T) contacting less than 180° of the SMV circumference without contour deformity or focal narrowing (short arrow). (b) The length of contact and vessel caliber is better delineated on the coronal reformatted image (short arrow). The limited tumor contact with the SMV and the identification of suitable vessel proximal and distal to the lesion, which allows safe resection and venous replacement, places the patient in the borderline resectable category.

44. SMV T
37 y male patient axial contrast-enhanced biphasic Multidetector CT angiogram demonstrates a pancreatic head mass (T) with tumor contact extending less than 180° around the SMV

45. SMV T
SMV T a b
(a) Axial contrast-enhanced biphasic Multidetector CT angiogram demonstrates a pancreatic head mass (T) with tumor contact extending more than 180° around the SMV (arrows). (b) coronal reformatted image show that the tumor more than 180 contact with the SMV

46. Figure 10a: Images in a 76-year-old man with tumor with more than 180° contact with the main portal vein (MPV). (a) Axial contrast-enhanced biphasic Multidetector CT angiogram demonstrates a pancreatic head mass (T) with tumor contact extending more than 180° around the MPV (short arrows). (b) The focal vessel narrowing and length of contact is better delineated on the coronal view (short arrow). Despite the degree of tumor contact with the MPV, the presence of suitable vessel proximal and distal to the narrowing potentially allows for safe resection and venous replacement, which places the patient in the borderline resectable category.

47. T
portal vein
Axial contrast-enhanced biphasic Multidetector CT angiogram demonstrates a pancreatic head mass (T) with tumor contact extending more than 180° around the MPV (arrows).

48. portal vein T
The focal vessel narrowing and length of contact is better delineated on the coronal view (short arrow). Despite the degree of tumor contact with the MPV

49. Figure 13a: Images in a 55-year-old man with venous thrombosis
Figure 13a: Images in a 55-year-old man with venous thrombosis. (a) Axial contrast-enhanced biphasic Multidetector CT angiogram demonstrates a pancreatic body mass (T). Note the upstream dilatation of the pancreatic duct (short arrow). (b) Image at a lower level shows bland intraluminal thrombus in the SMV (short arrow). (c) Coronal reformatted CT image displays the extent of the thrombosis (short arrows).

50. SMV T a
Images in a 78-year-old man with venous thrombosis. (a) Axial contrast-enhanced biphasic Multidetector CT angiogram demonstrates a pancreatic body mass (T)

51. SMV b
(b) Image at a lower level shows bland intraluminal thrombus in the SMV

52. The presence of extra pancreatic tumor extension, either local or distant, should also be described (focal hepatic lesions )
Direct local extension into surrounding adjacent structures such as stomach, small bowel or colon/ mesocolon, kidneys, adrenal glands, inferior vena cava, aorta, or spleen should be noted as it can affect the surgical decision making.

53. Figure 14a: Liver metastases in a 59-year-old man with a mass in the pancreatic tail. (a, b) Axial contrast-enhanced multidetector CT images obtained in the portal venous phase show a mass in the pancreatic tail (T) as well as multiple solid liver lesions with poor margins and complete rim enhancement (arrows).

54. Liver metastases in a 77-year-old man with a mass in the
Pancreatic head

55. Peritoneal nodules a
Peritoneal nodules (a) or the presence of ascites (b,c) , suggest disseminated disease that would render the patient unsuitable for a curative resection.

56. ascites
ascites b c b
axial image of 55y old female with pancreatic head mass and diffuse ascites

57. - The presence of enlarged lymph nodes can also affect surgical resectability and indicate need for additional therapy.
- The presence and location of suspicious lymph nodes should be noted.
A 55 y old male patient with pancreatic mass , this left inguinal large metastatic looking Lymph node
L.N

58. Summary
The PDA aggressive disease with high mortality rate mostly due to delayed diagnosis of most cases at an unresectable stage.
The central role of high-quality imaging for the diagnosis and proper description of the extent of tumor at the time of tumor staging is of great importance for optimal therapeutic decision making
The awareness play un role vary important in early detection of cancer disease and improve the diagnosis , and prognosis