MRI bij de ziekte van Crohn

Introduction
Pancreatic adenocarcinoma
C.Y. Nio,
AMC, Amsterdam
Content
“Key facts” pancreatic carcinoma
What makes a good CT?
How effective is each modality?
What is the role of each modality?
Epidemiology
1750 new cases per year
0.5-3.6 per 100.000 (< 50 yrs)
55.9-89.2 per 100.000 (> 75 yrs)
caput (75%), corpus (15%), cauda
(10%)
Without therapy: median survival 4-6 m
curative resection: 10-20% 5-yr survival
Richtlijn pancreascarcinoom.2011
Prognostic factors for low survival
after resection
Tumor + locoregional lymphnodes
Tumor + resection margins
Differentiation grade tumor
Diameter tumor
Kuhlmann et al, Eur.J.Cancer 2004
Therapy
Curative:
pylorus preserving pancreaticoduodenectomy
(Whipple or PPPD)
Palliative:
Biliary stenting
Pain relief
double by-pass
(chemotherapy/radiation)
,
100 pts with pancreatic carcinoma
40 pts (40%)
40 pts (40%)
locally irresectable
distant metastases
20 pts (20%) laparotomy with curative intent
20 pts laparotomy with curative intent
13 á 14 (± 65%) pts:
resection
6 á 7 (± 35%) pts
irresectable in OR:
-local invasion
± 50% “radical R0”
resectie
PPPD
-metastases
Double by-pass
R1 versus R0
Survival 1-yr
(%)
R0
69
3-yr
5-yr
28
11
R1
9
6
60
P=0.02
Kuhlmann et al, Surgery 2006;139:188-96
R1 versus locally advanced disease
Survival
Median
1-yr
3-yr
R1
15.8
59.9
8.9
5-jyr
5.7
34.4
2.2
0
N=80
Loc. adv 9.4
disease
N=90
Kuhlmann et al, Surgery 2006;139:188-96
R1 versus locally advanced disease
Survival
Median
1-yr
3-yr
5-yr
R1
15.8
59.9
8.9
5.7
34.4
2.2
0
N=80
Loc. adv 9.4
disease
N=90
P < 0.01
Kuhlmann et al, Surgery 2006;139:188-96
Partial resection PV/SMV
215 resections (‘92-’98)
34 PV/SMV resection
20 (59%) pos. margin
Median survival:
Pos. margin: 14 m
Neg. margin: 11 m
van Geenen et al, Surgery 2001;129:158-63
Partial resection PV/SMV
52 studies with 1646 pts
Median survival 13 m
5-yr survival 7%
Peri-operative mortality 5.9%
Positive nodes 67.4%
Positive margins 39.8%
Conclusion:
involvement of PV/SMV precludes curative resection
Siriwardana et al, Br J Surg 2006;93:662-73
What CT-technique ?
Desired:
maximal arterial enhancement
maximal portal enhancement
maximal tumor-pancreas contrast
Optimal timing ?
arterial phase (AP)
±25 sec. scan delay
pancreatic phase (PPP)
±50 sec. scan delay
portal-venous phase (PVP)
±70 sec. scan
delay
Enhancement portal veins and
visceral arteries
SMV
Portal
vein
AP
52
PPP PVP
140 171
50
147 180
Coel
trunk
SMA
McNulty et al. Radiology 2001; 220: 97
AP PPP PVP
228 293 157
245 299 158
maximal contrast
Pancreas parenchyma-tumor
AP
PPP
PVP
Pancreas
70
122
109
Difference
with tumor
16
49
44
McNulty et al. Radiology 2001; 220: 97
CT Protocol?
No: early arterial phase
Yes: dual-phase, i.e. pancreatic phase
+ portal phase
Alterative: one phase, late pancreatic /
early-portal phase
Slice thickness: < 5 mm (2 à 3 mm).
Contrast: always, ≥130ml, 3-5 ml/sec.
What imaging modality?
Ultrasound ?
CT ?
MRI ?
How good are US, CT and MRI for tumor
detection?
datasets /
N ptt
sensitivity
specificity
US
14/2909
76 (69-82)* 75 (51-89)
CT
23/959
91 (86-94)
MRI
11/583
84 (78-89)* 82 (67-92)
85 (76-91)
*significantly lower as compared to CT
Bipat et al, J Comput Assist Tomogr 2005;29:438-45
How good are US, CT and MRI for
assessment of resectability?
datasets /
N patt
sensitivity
specificity
US
6/1233
83 (68-91)
63 (45-79)*
CT
32/1823
81 (76-85)
82 (77-87)
MRI
7/516
82 (69-91)
78 (63-87)
*significantly lower as compared to CT
Bipat et al, J Comput Assist Tomogr 2005;29:438-45
Algorithm imaging pancreatic lesion
US
Tumor / suspection of solid
tumor
CT
No tumor
resectable
EUS
irresectable
borderline
PA / neo-adjuvant
chemoradiation
exploration
PA / palliation
MRI Pancreas
No primary role in solid tumors
Useful in cystic pancreatic tumors
MRI protocol (30 min)
T2 TSE FS ax (6mm) RT
T2 3D cor (1 mm) met ax. reconstr.
T2 HASTE (40 mm) cor
EP 2D Diff (4 mm): b50/400/800
T1 FS ax (3 mm) before and dyn after
gado (0/30/60 sec)
Reporting
Presence/absence of tumor
size tumor
obstruction CBD/PD
relation tumor with surrounding organs and portovenous and
arterial vessels
Presence/absence of liver metastases
Presence/absence locoregional or distant nodes (trunc/paraaortal/mesenterial)
Presence/absence peritoneal metastases
anatomical variants vessels and stenosis coel trunc/SMA
ascites
Conclusions 1
without therapy: median survival 4-6 m
curative resection: 10-20% 5-yr survival
6-7% R0 resection
R1 resection ↑ median survival 9 → 16 m
involvement PV/SMV: no curative resection
Conclusions 2
Staging CT with dual phase series PPP en PVP
1 phase CT with late-pancreatic/early-portal phase
2 -3 mm slices with ≥130ml, 3-5 ml/sec
Tumor detection: CT > MRI
Tumor resectability: CT = MRI
Cystic lesions: MR > CT