CT Assessment of Resectability
Otto van Delden and Robin Smithuis
From the Radiology Department of the Academical Medical Centre, Amsterdam and the Rijnland Hospital, Leiderdorp, the Netherlands
Introduction
Treatment
Imaging Work-up
Ultrasound
CT
MRI
ERCP
Endoscopic ultrasound
Diagnostic laparoscopy
CT protocol
Local Tumorspread
Resectable
Not resectable
Vessel ingrowth
Differential diagnosis
Publicationdate April 18, 2006
Pancreatic adenocarcinoma has a poor prognosis.
Complete resection of the tumor is the only curative treatment.
About 10-15% of all patients with a pancreatic carcinoma will finally undergo resection and
only in half of these cases the resection will prove to be radical.
In this article we will focus on the CT-findings that are used to select patients with probable
resectable tumors.
As the clinical presentation, staging and treatment of other types of pancreatic neoplasms is
distinctly different from adenocarcinomas, these are not discussed in this article.
by Otto van Delden and Robin Smithuis
Introduction
Non-resectable
junction
with thepancreatic
splenic vein.
headParaaortic
tumor obstructing
and celiacthe
lymphnodes
common bile
andduct
a small
and pancreatic
liver metastasis.
duct. Tumor surrounds the superior mesenteric vein at the
Pancreatic carcinoma is a relatively common tumor with an incidence of 7,6 per 100.000 per
year in Western-Europe.
It comprises about 2,5 % of all newly diagnosed tumors and 5% of all cancer.
The majority of pancreatic cancers (85%) are adenocarcinoma of ductal origin.
It is more common in men (men:woman 1,5:1) between the age of 60 and 70 years [1-4].
In spite of the limited tumor size the majority of pancreatic head cancers (80%) are not
eligible for resection at the time of diagnosis.
This is due to advanced local tumor extension (40%) or the presence of distant metastatic
disease (40%) mostly due to liver metastases of para-aortic lymphadenopathy.
Treatment
Operation
The only curative treatment option is surgical resection.
Out of every hundred patients with pancreatic carcinoma only 20 patients will be sceduled for
explorative laparotomy.
Out of these 20 only about 13-14 patients will undergo resection of the tumor, but only half of
these resections will finally prove to be radical at pathologic examination of the resected
specimen..
The resection consists of a partial pancreaticoduodenectomy according to Whipple or the
modern variant, the so-called 'pylorus-preserving' pancreaticoduodenectomy.
Palliation
When the tumor proves to be unresectable during exploratory laparotomy, a so-called 'double
bypass' (gastro-enterostomy en hepaticojejunostomy) is usually performed for palliative
reasons.
When curative resection is not considered an option, based on preoperative imaging and
cytology or histology, palliation consists of endoscopic or percutaneous biliary stenting and
celiac plexus block for relief of pain.
Patients with a relatively short life expectancy (e.g. patients with extensive hepatic
metastases), are probably best served by palliation by means of endoscopic bile duct
stenting.
In patients with a longer life expectancy (e.g. patients with a small, but locally unresectable
tumor without distant metastatic disease), a double bypass is generally also considered
acceptable palliation.
Ultrasound
The most striking clinical symptom leading to diagnostic imaging is painless obstructive
jaundice, which is caused by compression or ingrowth of the distal common bile duct.
US is the first line imaging test for the evaluation of these patients.
US can determine the level of obstruction in most cases (sensitivity >90%).
In patients with a pancreatic head tumor, typically dilatation of the common bile duct and
pancreatic duct (double duct sign) is seen, which is very suggestive for a mass in the
pancreatic head, even in the absence of a visible mass.
The tumor itself usually presents as a hypoechoic mass (figure).
In the detection of pancreatic cancers US has an overall sensitivity of 75% and a specificity
of 75%.
However in many cases US will suffice as the only imaging test for diagnosis and staging.
This is particularely true in patients with tumors > 3 cm and liver metastases > 2 cm.
The overall sensitivity and specificity for determining resectability of all pancreatic
carcinomas however is only 63% and 83% respectively.
CT
If the cause of a distal bile duct obstruction is not revealed by US and there is a high
suspicion for a pancreatic or periampullary tumor, the next diagnostic test is CT.
ERCP (or MRCP) is only the next step when there is a high suspicion of bile duct stones.
Whenever a pancreatic tumor is detected with US and no definite signs of unresectability are
found, the next step is CT.
CT should be done before ERCP and insertion of an endoprosthesis, because artifacts and
post-ERCP pancreatitis may hamper the diagnostic accuracy of CT.
As pancreatic carcinoma is a hypovascular tumor, it presents as a hypodens mass on a CECT.
The mass is usually ill-defined. In 10 - 15% the tumor is isodens and therefore may be
difficult to detect.
Tumors smaller than 2 cm. may also be difficult to detect on CECT.
In these cases
indirect signs may be helpful such as the presence of the double duct sign, atrophy of the
pancreatic tail, or fullness of the pancreatic head (loss of the lobular appearance of the
pancreatic parenchyma).
Double duct sign indicating pancreatic head carcinoma
MRI
CT and MRI both have a higher sensitivity than ultrasound for the detection of small ( MRIsequences should involve at least T2W-images en dynamic T1W-images after intravenous
administration of gadolinium.
MRCP is also very sensitive for detecting a periampullary mass, but offers no significant
additional staging information [9].
ERCP
Many patients in whom a pancreatic head tumor is detected by ultrasound still undergo
ERCP.
Although ERCP has a high sensitivity for detecting pancreatic head tumors, it is nowadays no
longer indicated because the diagnosis can usually be made with non-invasive tests.
ERCP offers no usefull tumor staging information.
It is doubtfull whether pre-operative bile duct drainage by ERCP is beneficial for the patient
[12].
Pre-operative biliary drainage may potentially even increase the risk for post-operative
infectious complications.
Endoscopic US of small pancreatic head tumor obstructing the common bile duct
Endoscopic ultrasound
Endoscopic ultrasound is generally accepted as the most sensitive imaging test for the
detection of small pancreatic head tumors, particularly when smaller than 2 cm [10].
These pancreatic head tumors can be missed even on a technically excellent CT and therefore
a 'negative' CT-scan in a patient with a strong suspicion for pancreatic head cancer requires
additional imaging with endoscopic ultrasound.
Unfortunately, there are only a few centers in The Netherlands with sufficient experience in
this operator-dependent-technique.
Endoscopic ultrasound has also been used for local tumor staging, but is currently not
frequently used as such in the Netherlands.
Diagnostic laparoscopy
It may be usefull in selected cases where there is doubt about resectability or when suspected
metastatic disease cannot be proven otherwise.
CT protocol
Local Tumorspread
Since the pancreas has no capsule, pancreatic tumor will easily spread into adjacent structures
(figure).
Because the confluens of the portal and superior mesenteric vein is in direct continuity with
the pancreatic head, ingrowth into this vessel will often be the first sign of tumor extension
outside the pancreas.
Ingrowth into the celiac axis or superior mesenteric artery is always considered a criterium
for unresectability.
Although partial resection of the portal vein or superior mesenteric vein are technically
possible and are being performed, ingrowth into these vessels is considered a criterium for
unresectability by most oncologic surgeons in the Netherlands.
Some centers in the US and Japan will resect part of the portal vein in case of tumor
ingrowth.
Resectable
On the left two cases of pancreatic tumors with tumor-vessel contiguity These patients
generally will be given the benefit of the doubt and will be sceduled for operation.
Peritoneal metastases (arrowheads) in a patient with a pancreatic tumor
Not resectable
Tumor ingrowth into stomach, colon, mesocolon, inferior vena cava or aorta constitute
definite criteria for unresectability.
Also the presence of hepatic metastases, peritoneal metastases or para-aortic lymfnode
metastases is an absolute sign of unresectability.
Mesenteric lymph node metastases, not immediately adjacent to the pancreas usually also
indicate unresectability.
Liver metastases and distant lymph node metastases should allways be proven by means of
cytologic or histologic biopsy before refraining from exploratory laparotomy.
Ingrowth into the celiac axis, hepatic artery or superior mesenteric artery also preclude
resection.
Vessel ingrowth
When a fatplane or normal pancreatic parenchyma is visible between the tumor and the
vessel, the tumor is usually locally resectable.
When there is tumor-vessel contiguity, but the vessel is surrounded by tumor for less than
half the circumference ( This group of patients will usually get the benefit of the doubt and
undergo exploratory laparotomy.
Tumor in direct contiguity with the confluens >180?
On the left a pancreatic tumor in direct contiguity with the confluens of the portal and
superior mesenteric vein.
The tumor surrounds the confluens for more than half the cirumference (>180?).
This tumor was regarded as unresectable.
LEFT: Irresectable tumor surrounding the AMS >180?.RIGHT: Irresectable tumor totaly surrounding the AMS.
When the tumor surrounds the vessel for more than half the cirumference (>180?), the tumor
will nearly allways be unresectable. Most surgeons will consider this a solid criterium for
unresectability [13-16]. Flattening of the vessel or irregular vascular contours are also
indicative of ingrowth. When the tumor surrounds the portal vein or superior mesenteric vein
completely (360?) or occludes the vessel, the tumor is allways unresectable [13-16].
Other criteria for vascular ingrowth have been described, such as dilatation of the gastrocolic
trunk (a sidebranch of the superior mesenteric vein) and the 'mesenteric teardrop sign'.
These signs are not more sensitive or specific than the abovementioned criteria and therefore
probably do not have much additional value as other criteria for unresectability are usually
also present in these cases[17,18].
Tumor thrombus is present in the lumen of the superior mesenteric vein
On the left a tumor thrombus is present in the lumen of the superior mesenteric vein.
This is also a sign of unresectability.
On the left a pancreatic carcinoma with encasement of the hepatic artery.
The pancreatic duct is obstructed with subsequent atrophy of pancreatic tail.
This tumor is not resectable.
Differential diagnosis
The differential diagnosis of a pancreatic head tumor includes carcinoma, focal pancreatitis,
lymphoma and metastasic disease.
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