Diagnostics of Pancreatic Carcinoma

Transcription

1 Diagnostics of Pancreatic Carcinoma Jens Ricke Charité - Universitätsmedizin Berlin Klinik für Strahlenheilkunde (Director: Prof. Dr. Dr. Roland Felix)

2 Imaging in Pancreatic Carcinoma CT MRT ERCP? FDG-PET US EUS

3 Diagnostic challenge: Pancreas - overlooked

4 Diagnostic challenge: Pancreas - overlooked - misinterpreted

5 Diagnostic challenge: Pancreas - overlooked - misinterpreted - delayed diagnosis

6 Diagnostic challenge: Pancreas - overlooked - misinterpreted - delayed diagnosis - resectable or not resectable?

7 MRI Pancreas

8 Detection

9 Detection Lopez Hänninen et al. 2005

10 Adenocarcinoma Pancreas: CT and PET SMV SMA Adenocarcinoma PET-CT

11 Detection

12 Characterisation

13 Characterisation Chronic Pancreatitis

14 Chronic Pancreatitis Characterisation

15 Characterisation Chronic Pancreatitis Chronic Pancreatitis AND Adenocarcinoma (histol. proof)

16 MRI/CT Detection and Characterisation Sensitivity Specificity (n) (%) (%) Grenacher et al. 89/95 75/77 (50) 2005 Lopez Hänninen et al (66) 2002 Adamek et al (124) 2000 Diehl et al (56) 1999

17 Detection and Characterisation PET Criterion Sensitivity Specificity Accuracy (%) (%) (%) Bares et al. V/SUV Zinny et al. V/SUV Ho et al. SUV Mertz et al. V/SUV all literature ( )

18 Diagnostic Window

19 Diagnostic Window 3,5 months later not resectable

20 Prospective Comparison of Imaging Modalities Ultrasound (US) Endoscopic US (EUS) ERCP CT MRI, MRCP FDG-PET

21 Michael Böhmig (1), Inga Koch (1), Enrique Lopez- Hänninen (2), Rainer E. Hintze (1), Holger Amthauer (2), Nicolas Hoepffner (1), Hans Peter Müller (1), Jens Ricke (2), Tania Schink (4), Norbert Hosten (2), Jan Langrehr (3), Klaus-Dieter Wernecke (4), Peter Neuhaus (3), R. Felix (2), Bertram Wiedenmann (1), Thomas Rösch (1), and Stefan Rosewicz (1)

22 Prospective Comparison of Imaging Modalities Methods Sonography (US) and endoscopic US (EUS) Olympus UM 20; 2 investigators ERCP 2 investigators w/ more than 10-years experience

23 Prospective Comparison Methods Computed tomography (Single slice-ct, Siemens) MRI (incl. MRCP) (1,5 Tesla, Philips ACS-NT) 2 reviewers each; Consensus diagnoses FDG-PET: Quantitative assessment (SUV > 3.5)

24 Prospective Comparison n= 193 patients Diagnostic proof Laparotomy: n=141 Percutaneous biopsy: n=21 Follow up >12 months: n=31 Lesion Character Malignant: n=119 Benign: n=74 Patients with distant metastasis excluded

25 Detection of Pancreatic Carcinoma Sens. Spez. Acc U S 66% (*) 64% 72% (*) E U S 72% 82% (n.s.) 78% E R C P 95% (*) 71% (*) 79% C T 81% 78% (*) 82% M R T 91% (*) 76% 87% (*) FDG-PET 83% 69% 75%

26 Detection of Pancreatic Carcinoma Positive Likelihood Ratio (LR+) Negative Likelihood Ratio (LR+) CT 6,17 MRI 5,45 EUS 4,45 US 3,71 ERCP 3,61 PET 2,63 ERCP 0,08 MRI 0,10 CT 0,20 PET 0,24 EUS 0,31 US 0,33

27 Prospective Comparison Take home points To proof a pancreatic carcinoma if clinically suspected use CT or MRI (high positive Likelihood Ratio)

28 Prospective Comparison Take home points To exclude a malignancy use MRI or ERCP (low negative Likelihood Ratio) or rely on visual PET if you don t see it in PET, it is not a tumor

29 Criteria Assessment of Resectability Local: Infiltration of the mesenterial root Invasion of arterial vessels (not portal vein, not SMV) Invasion of adjacent organs (not CBD, not duodenum, not tumor size) Systemic: Distant metastasis (e.g. liver); peritoneal carcinosis

30 MRI/CT Sensitivity Specificity (n) (%) (%) Ellsmere et al (44) MDCT 2005 Vargas et al (34) MDCT 2004 Lopez Hänninen et al (66) MRT 2002 Resectable vs. non-resectable

31 Vessel assessment: arteries CT T1 GRE FS

32 Vessel assessment: arteries CTA; MIP (axial, sagittal)

33 Vessel assessment: arteries Pancreatic head/corpus-carcinoma HA RHA LHA SMA GDA Infiltration Common hepatic artery

34 Vessel assessment CT - Criteria Sensitivity Specificity PPV NPV Infiltration if tumor encircling > 50% 84 % 98 % 95 % 93 % Lu et al. AJR 1997 Typ Criteria n Resectability Resection w/o reconstruction A Fatty plane % 100 % B Pancreas parenchyma % 86 % C Convexity of contact 9 89 % 55 % D Concavity of contact % 7 % E Encircling tumor 7 0 % 0 % F Occlusion 3 0 % 0 % Loyer et al. Abd Imaging 1996

35 Prediction of Resectability Methods Prospective evaluation of 119 patients Ultrasound (US) Endoscopic Ultrasound (EUS) Computed tomography(ct) MRI incl. MRCP, MRA Patients with distant metastasis excluded

36 Prediction of Resectability pancreatic malignancy n = 119 exploration n = 90 no exploration n = 29 resected n = 63# irresectable n = 25 inoperable n = 2 irresectable n = 16 other n =13 local n = 11# local + mets n = 3# mets n = 11 local n=1 local+mets n = 3 mets n = 12

37 Prediction of Resectability (n=77) Sensitivity Specificity US EUS CT MRI 94% 50/53 84% 29% 8/28 29% 0,80 98% 49/50 96% 21% 4/19 87% 48/55 46% 13/28 95% 55/58 33% 8/24 LR + 1,32 1,24 1,63 1,42 5,90 20% 0,80 10,0 83% 98% 57% 50% 0,50 0,50 4,70 30,0 LR - 0,20 0,10 0,27 0,16 Sensitivity: correct diagnosis of resectability Specificity: correct diagnosis of irresectability LR+: Pt.is resectable LR-: Pt.is irresectable

38 Prediction of Resectability Take home points The diagnosis resectable lesion is useless regardless of the modality The diagnosis unresectable lesion after EUS or MRI has a valuable clinical impact

39 Imaging in Pancreatic Carcinoma Challenges: Diagnostic window Chronic pancreatitis vs. adenocarcinoma Resectability vs. Irresectability desmoplastic reaction adjacent ot the tumor Livermetastasis (specifically lesions < 1cm) Peritoneal carcinosis

40 What your Radiologist can also do for you... SMV SMA SMV SMA Adenocarcinoma CT-guided biopsy

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