Pancreatic Adenocarcinoma: Everything You Need to Know From Cross-Sectional Imaging to Treatment

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1 Pancreatic Adenocarcinoma: Everything You Need to Know From Cross-Sectional Imaging to Treatment Andrew W. Bowman, MD PhD Assistant Professor of Radiology Mayo Clinic Florida SCBT-MR Annual Meeting Nashville, TN Sep 11, MFMER slide-1

2 Disclosures No financial relationships to disclose No off-label uses will be discussed 2012 MFMER slide-2

3 Learning Objectives Review MR features of pancreas adenocarcinoma Illustrate how MR can diagnose and stage pancreas adenocarcinoma Describe the MR findings of pancreas adenocarcinoma after neoadjuvant therapy and surgical resection 2012 MFMER slide-3

4 Imaging Pancreas Adenocarcinoma Diagnosis Stage disease Monitor treatment Restage disease after neoadjuvant therapy Postoperative surveillance 2012 MFMER slide-4

5 Imaging Pancreas Adenocarcinoma MR is a feasible and acceptable method for imaging pancreas adenocarcinoma MR and CT have demonstrated similar performance in the evaluation of pancreas adenocarcinoma MR may be superior to CT in diagnosing hepatic metastatic disease Chen FM et al. Am J Roentgenol 2016;206: Holzapfel K et al. Abdom Imaging 2011;36(2): Motosugi U et al. Radiology 2011;260(2): MFMER slide-5

6 MCF Pancreas Mass Imaging Protocol 3T exam, with IV glucagon Coronal, axial (FS), sagittal T2 Axial in-out phase Axial diffusion Axial, coronal, sagittal precontrast T1FS Axial MRA thru pancreas, liver (2 sequences) Axial, coronal, sagittal PV phase postcontrast T1FS MRCP sequences centered on pancreas Axial delayed postcontrast T1FS Motion-corrected subtractions 2012 MFMER slide-6

7 Diagnosis 2012 MFMER slide-7

8 MR Features of Pancreas Adenocarcinoma Hypointense, hypoenhancing mass Variable T2 intensity (typically slightly hyperintense to pancreas) Restricts diffusion Locoregional disease may enhance more than primary tumor Metastases typically restrict diffusion, poorly or peripherally enhance 2012 MFMER slide-8

9 Hypointense, hypoenhancing mass in pancreatic head 2012 MFMER slide-9

10 Pancreatic duct dilatation 2012 MFMER slide-10

11 Restricted diffusion 2012 MFMER slide-11

12 Malignant transformation of sidebranch IPMN 2012 MFMER slide-12

13 Mucinous cystadenoma with mural carcinoma 2012 MFMER slide-13

14 Main duct IPMN 2012 MFMER slide-14

15 Diagnosis Mimics 2012 MFMER slide-15

16 2012 MFMER slide-16

17 2 months later 2012 MFMER slide-17

18 2 months later Initial exam Resolved focal uncinate pancreatitis 2012 MFMER slide-18

19 Groove pancreatitis 2012 MFMER slide-19

20 Neuroendocrine tumor with liver metastases 2012 MFMER slide-20

21 Pseudopapillary tumor 2012 MFMER slide-21

22 Duodenal periampullary carcinoma 2012 MFMER slide-22

23 Stage Disease 2012 MFMER slide-23

24 MFMER slide-24

25 2012 MFMER slide-25

26 Tumor localized to pancreatic head 2012 MFMER slide-26

27 2012 MFMER slide-27

28 SMV, possible SMA abutment 2012 MFMER slide-28

29 2012 MFMER slide-29

30 Extensive celiac, SMA encasement 2012 MFMER slide-30

31 Celiac encasement on CT 2012 MFMER slide-31

32 No celiac encasement on MR 2012 MFMER slide-32

33 2012 MFMER slide-33

34 Enlarged peripancreatic node 2012 MFMER slide-34

35 Omental deposit 2012 MFMER slide-35

36 2012 MFMER slide-36

37 Liver metastases 2012 MFMER slide-37

38 MCF Pancreas Mass Imaging Protocol 3T exam, with IV glucagon Coronal, axial (FS), sagittal T2 Axial in-out phase Axial diffusion Axial, coronal, sagittal precontrast T1FS Axial MRA thru pancreas, liver (2 sequences) Axial, coronal, sagittal PV phase postcontrast T1FS MRCP sequences centered on pancreas Axial delayed postcontrast T1FS Motion-corrected subtractions 2012 MFMER slide-38

39 2012 MFMER slide-39

40 Hemangioma or metastasis? 2012 MFMER slide-40

41 Metastasis 2012 MFMER slide-41

42 ?? 2012 MFMER slide-42

43 6 months later Initial staging Progression of liver metastases 2012 MFMER slide-43

44 2012 MFMER slide-44

45 ? Liver metastasis 2012 MFMER slide-45

46 Restage Disease After Neoadjuvant Therapy 2012 MFMER slide-46

47 Initial Staging 2012 MFMER slide-47

48 2 months later 2012 MFMER slide-48

49 2 months later Initial staging Tumor regression from SMV, SMA 2012 MFMER slide-49

50 Initial staging 2012 MFMER slide-50

51 Initial staging 2012 MFMER slide-51

52 4 months later 2012 MFMER slide-52

53 4 months later 2012 MFMER slide-53

54 4 months later Initial staging Decreased soft tissue about hepatic artery 2012 MFMER slide-54

55 4 months later Initial staging Decreased soft tissue about hepatic artery and portal vein 2012 MFMER slide-55

56 Initial staging 2012 MFMER slide-56

57 5 months later 2012 MFMER slide-57

58 5 months later Initial staging Decreased soft tissue around celiac, SMA 2012 MFMER slide-58

59 Postoperative Surveillance 2012 MFMER slide-59

60 2012 MFMER slide-60

61 Expected appearance post resection 2012 MFMER slide-61

62 18 months later 2012 MFMER slide-62

63 18 months later Initial postop exam Local tumor recurrence 2012 MFMER slide-63

64 2012 MFMER slide-64

65 Initial postop exam 2012 MFMER slide-65

66 6 months later 2012 MFMER slide-66

67 6 months later Initial postop exam Tumor recurrence causing PD dilatation 2012 MFMER slide-67

68 Post distal pancreatectomy 2012 MFMER slide-68

69 6 months later 2012 MFMER slide-69

70 6 months later Prior postop exam Tumor recurrence narrowing portal vein 2012 MFMER slide-70

71 Initial postop exam 2012 MFMER slide-71

72 2 months later 2012 MFMER slide-72

73 3 more months later 2012 MFMER slide-73

74 3 more months later Initial postop exam 2 months later Hepatic microabscesses 2012 MFMER slide-74

75 Prior central pancreatectomy for NET 2012 MFMER slide-75

76 8 months later 2012 MFMER slide-76

77 8 months later Postop exam Tail pancreatitis 2012 MFMER slide-77

78 Post neoadjuvant treatment 2012 MFMER slide-78

79 Post Appleby procedure with total pancreatectomy 2012 MFMER slide-79

80 Post Appleby with stents in the portal vein, hepatic artery 2012 MFMER slide-80

81 Post neoadjuvant treatment 2012 MFMER slide-81

82 Post Appleby with subtotal pancreatectomy 2012 MFMER slide-82

83 Post Appleby with hepatic arterial collaterals and portal vein thrombosis 2012 MFMER slide-83

84 Summary MRI can be an excellent modality in the diagnoses, staging, and surveillance of pancreas adenocarcinoma MRI may be superior to CT in detecting metastatic disease from pancreas adenocarcinoma Newer imaging techniques may further refine the ability of MRI to evaluate pancreatic cancer 2012 MFMER slide-84

85 Thank You!! 2012 MFMER slide-85

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