壶腹部肿块影像学检查技巧

John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 March 2013 Atlas of Radiological Modalities in the Evaluation of Ampullary Masses John B. Moore, MSc, HMSIII Gillian Lieberman, MD John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 Agenda • Patient Presentation • Normal anatomy of the hepato-pancreatico-biliary system • Differential diagnosis for a periampullary mass • Menu of tests • Radiological evaluation of the ampulla of Vater • Categorizing the lesion with imaging • Discussion of ampullary carcinoma • Correlating findings with prognosis March 2013 2 John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 Patient 1: HPI • 58 yo M who presented with symptomatic obstructive jaundice. Developed pruritus and dark urine of 3 weeks duration before presentation. Mild weight loss over past 3 months. No abdominal pain, nausea, vomiting, alcohol use. – PMH significant only for glaucoma – takes timolol – Father passed away from unknown GI malignancy • Labs were significant for following: – ALT: 192 IU/L – AST: 133 IU/L – Total bilirubin: 1.9 mg/dl – Lipase: 1498 IU/L – CA 19-9: 36 (normal < 34 U/ml) 3 John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 CBD Pancreatic duct Pancreas Splenic artery Celiac artery SMV IVC Aorta C+ axial CT abdomen & pelvis BIDMC, PACS Patient 1: Initial CT+ contrast 4 John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 5 The common bile duct and the pancreatic duct are dilated. This finding is known as the “double duct sign” C+ axial CT abdomen & pelvis BIDMC, PACS Patient 1: Initial CT+ contrast John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 6 C+ coronal CT abdomen & pelvis C+ coronal CT abdomen & pelvis BIDMC, PACS BIDMC, PACS Dilated common bile duct and pancreatic duct on coronal imaging Distended gallbladder in absence of clear obstructing lesions or stones Patient 1: Initial CT+ contrast John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 7 Duodenum with pancreatic duct and CBD converging in periampullary region. No overt mass seen C+ coronal CT abdomen & pelvis BIDMC, PACS C+ coronal CT abdomen & pelvis BIDMC, PACS Patient 1: Initial CT+ contrast John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 Anatomy of the periampullary region 8 John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 Anatomy of the ampulla From Martin & Moser, Ampullary carcinoma, UpToDate 9 John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 Differential Diagnosis • Benign periampullary masses – Duodenal adenoma – Ampullary adenoma – Gallstones (choledocholithiasis or gallstone pancreatitis) • Periampullary cancers – Pancreatic ductal adenocarcinoma – Carcinoma of the bile duct • Cholangiocarcinoma (extra-hepatic) – Carcinoma of the ampulla itself – Carcinoma of the periampullary duodenum March 2013 10 John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 Let’s continue with several CT images of companion patients with other periampullary cancers. 11 John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 12 Companion Patient 2: Cholangiocarcinoma on CT Ill-defined hypodense mass seen near common bile duct stent with a dilated gastroduodenal artery. The pancreas is atrophic. C+ axial CT abdomen & pelvis BIDMC, PACS John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 Companion Patient 3: Pancreatic adenocarcinoma on CT Hypoenhancing mass in pancreatic head consistent with pancreatic adenocarcinoma. C+ axial CT abdomen & pelvis BIDMC, PACS 13 John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 Menu of tests • Transabdominal US • Abdominal CT • MR and MRCP • ERCP • EUS • IDUS • Percutaneous transhepatic cholangiography (PTC) March 2013 14 John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 Transabdominal US • First imaging technique in pts with jaundice • Can potentially assess vascular involvement, biliary dilation, liver lesions • Overall accuracy in finding ampullary masses only 15% – If no gallstones or obvious pancreatic head mass → proceed to other modality • For patient 1, US was not initially done – No abdominal pain, low suspicion for stones March 2013 15 John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 CT – abdominal • Once ampullary mass suspected → order “pancreatic mass protocol” • Water as “oral contrast” and IV contrast – water distends duodenum but w/o high attenuation of usual contrast • allows vessels to be clearly visualized – contrast allows for arterial- and venous-phase imaging • Acquire images 1.0 to 2.5 mm intervals (helps see pancreas) March 2013 16 John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 CT – abdominal (cont’d.) March 2013 17 • Pros: – More sensitive than US in assessing periampullary region – Can pick up distant mets – Visualize regional lymph nodes, liver, peritoneum, lungs, and bone • Cons: – Inadequate for staging because lacks spatial resolution for invasion of nearby structures – Can not see small ampullary neoplasms • Detection as low as 20% • For patient 1, he subsequently had CTA abdomen & pelvis several days after initial CT abdomen John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 18 Patient 1: CTA abdomen Ampullary mass BIDMC, PACS C+/- coronal CTA abdomen CBD Stent John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 19 Patient 1: CTA abdomen BIDMC, PACS C+/- coronal CTA abdomen PANC DUCT MINIP Pneumobilia Air in central intrahepatic ducts Air in central intrahepatic ducts and pneumobilia secondary to CBD stent placement John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 20 MR and MR cholangiopancreatography (MRCP) • Usually, in patients where ERCP contraindicated • Masses usually appear isointense or hypointense on T1- and T2-weighted images • When mass not seen on MR, bulging duodenal papilla may be only indication of ampullary cancer – Bulging caused by dilated pancreatic and bile ducts • MRCP – noninvasive way to visualize pancreaticobiliary tree • Some signs that differentiate one periampullary cancer from another – So-called “four segment sign” on MR in pancreatic adenocarcinoma John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 21 MR and MR cholangiopancreatography (MRCP) From Kim JH et al., Differential Diagnosis of Periampullary Carcinomas at MR, 2002 MRCP Hypointense mass Axial T2 Coronal T2 Companion Patient 4 John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 • Combines endoscopy and fluoroscopy • Visualizes stomach, duodenum, ampulla – Cannot evaluate extent of local tumor invasion • Fluoroscopy with contrast allows for radiographic visualization of bile ducts and pancreatic duct • Diagnostic and therapeutic – Removal of some stones – Insertion of stent (retrograde) – Dilation of strictures – Biopsy • Does have some contraindications, complications Endoscopic retrograde cholangiopancreatography (ERCP) 22 John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 Normal ERCP From Greenberger NJ, Blumberg RS, Burakoff R, CURRENT Diagnosis & Treatment, 2nd Edition Endoscope Gallbladder Cystic Duct Common Hepatic Duct Common Bile Duct Pancreatic Duct Ampulla Duodenum 23 John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 Patient 1: Ampullary lesion on ERCP Ampullary mass Sphincterotomy with stent placement • Mass was visualized and biopsied. – Stent placed → obstruction relieved Nodular ampullary carcinoma (reference case) From Martin & Moser, Ampullary carcinoma, UpToDate 24 BIDMC, ERCP Companion Patient 5 John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 Patient 1: ERCP Results (cont’d.) • Fluoroscopy image sequence: – Stent placed → obstruction relieved Dilated common bile duct on cholangiogram Stricture of distal CBD due to ampullary mass Stent being placed Stricture, obstruction, and dilation relieved 25 BIDMC, ERCP John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 Endoscopic Ultrasound (EUS) • Pros: – Higher spatial resolution than CT/MRI – Can show surrounding anatomy including lymph nodes – Discerns duodenal wall and pancreas interface – More accurate in detecting ampullary tumors than US and CT • As in 100% accurate – FNA ability – Great for preop planning and T-stage • 70-90% accurate in T-stage March 2013 • Cons: – Technically challenging – Operator dependent – No stent ability – Less adept at nodal-staging in comparison to tumor-staging 26 Especially useful when ERCP has found low-grade dysplasia → Could allow for local resection John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 27 Companion Patient 6: Tumor on EUS DL: duodenal lumen T: tumor mass CBD: common bile duct m: muscularis propria nLN: non-metastatic lymph node P: pancreas From Skordilis P et al., Is endosonography an effective method for detection and local staging of the ampullary carcinoma?, 2002 John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 Intraductal ultrasound (IDUS) • Small miniprobes ~2mm • From endoscope into biliary or pancreatic duct • Only modality that can differentiate sphincter of Oddi muscle from papilla • Useful in identifying tumor strictures when no mass seen on imaging or indeterminate strictures – Increases accuracy of ERCP March 2013 28 Malignant stricture Benign stricture From: Stavropoulos S et al., Intraductal ultrasound for the evaluation of patients with biliary strictures , 2005 Companion Patient 7 Companion Patient 8 John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 Patient 1: Diagnosis & Surgery • Cytology sent from ERCP brushings – “Adenomatous mucosa with villous and papillary features, and at least high grade dysplasia” – Path Report BIDMC • Given HGD → surgery – Whipple: pancreaticoduodenectomy – In this case, Robot-assisted, pylorus-preserving 29 John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 Carcinoma of ampulla of Vater: Some facts • 6-35% of pancreaticoduodenal malignancies – But, rare: 4-6 cases per million people – Average age of diagnosis for sporadic cases → 60-70 • Can be earlier in genetic syndromes, e.g. FAP w/increased risk – Male-to-female ratio 2:1 • Papillary orifice of ampulla commonly involved by tumor – Means symptoms appear early – Abdominal pain, pruritus, obstructive jaundice, steatorrhea, weight loss • Survival is ~25% at 5 years for pts with +LNs and 50% in those without involved nodes – 80% thought to be resectable at Dx March 2013 30 John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 Ampullary carcinoma: location correlates with prognosis 31 Large overall size, small invasive component, best overall prognosis. 3-y survival, 73% → which correlates with histology From: Adsay V, et al., Ampullary Region Carcinomas, 2012 John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 32 Ampullary carcinoma: location correlates with prognosis → which correlates with histology From: Adsay V, et al., Ampullary Region Carcinomas, 2012 Largest, highest incidence of LN mets. Minimal intra-amp lumen. Mostly intestinal histology (75%). 3-y survival, 69% John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 33 Ampullary carcinoma: location correlates with prognosis → which correlates with histology From: Adsay V, et al., Ampullary Region Carcinomas, 2012 Ulcero-nodular tumors, does not show features of other subtypes. Intermediate tumor size. 3-y survival, 54% John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 34 Ampullary carcinoma: location correlates with prognosis → which correlates with histology From: Adsay V, et al., Ampullary Region Carcinomas, 2012 Smallest but worst prognosis, presumably due to the pancreatic histology or origin (in 86%). 3-y survival, 41% John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 35 Ampullary carcinoma: location correlates with prognosis → which correlates with histology From: Adsay V, et al., Ampullary Region Carcinomas, 2012 John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 36 Patient 1: Subsequent course • Final path of mass: – Ampullary adenocarcinoma, moderately differentiated, 1+ node of 29 – T1N1 → tumor limited to Ampulla of Vater w/regional LN met. Negative margins • Unfortunately, pancreaticobiliary histology – Cytokeratin 7 (CK7) and CK20 have recently (2013) been shown to differentiate between pancreaticobiliary and intestinal ampullary histology – CK20 → intestinal type; CK7 → pancreaticobiliary type – Patient 1 was CK7+/CK20 – , which is pancreaticobiliary • Now, receiving adjuvant chemo – Still experimental: gemcitabine 1000 mg x2 weekly, 3 weeks on, 1 week off for 4-6 months • He will f/u with surgeon in 3 months for staging John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 Diagnostic-Therapeutic Algorithm 37 From: Roberts KJ, et al., Endoscopic ultrasound assessment of lesions of the ampulla of Vater, 2013. John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 Summary 38 • Ampullary masses can be difficult to assess on cross- sectional imaging • CT and trans-abdominal US will usually be done to r/o other processes • ERCP is first-line modality for suspected malignant strictures, supplemented by EUS • MR with MRCP and IDUS in special circumstances • Future refinement of radiological modalities to help correlate with new path subdivisions which predict prognosis John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 1) Adsay V, Ohike N, Tajiri T, et al. Ampullary Region Carcinomas: Definition and Site Specific Classification with Delineation of Four Clinicopathologically and Prognostically Distinct Subsets in an Analysis of 249 Cases. The American Journal of Surgical Pathology 2012; 36(11): 1592-1608. 2) Albores‐Saavedra, Jorge, et al. Cancers of the ampulla of Vater: demographics, morphology, and survival based on 5,625 cases from the SEER program. Journal of surgical oncology 2009; 100(7): 598-605. 3) Carr BI. Chapter 92. Tumors of the Liver and Biliary Tree. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 18th ed. New York: McGraw-Hill; 2012. http://www.accessmedicine.com.ezp-prod1.hul.harvard.edu/content.aspx?aID=9116154. Accessed March 24, 2013. 4) Greenberger NJ, Blumberg RS, Burakoff R. CURRENT Diagnosis & Treatment: Gastroenterology, Hepatology, & Endoscopy, 2nd Edition: www.accessmedicine.com. Accessed 24 March 2013. 5) Kim JH, Kim, MJ, Chung JJ, et al. Differential Diagnosis of Periampullary Carcinomas at MR Imaging. Radiographics 2002; 22(6): 1335-1352. 6) Martin JA, Moser AJ. Ampullary carcinoma: Epidemiology, clinical manifestations, diagnosis and staging. http://www.uptodate.com/contents/ampullary-carcinoma-epidemiology-clinical-manifestations-diagnosis-and- staging?source=search_result&search=ampullary+carcinoma&selectedTitle=2~21#. UpToDate. Accessed 22 March 2013. 7) Morini S, Perrone G, Borzomati D, et al. Carcinoma of the Ampulla of Vater: Morphological and Immunophenotypical Classification Predicts Overall Survival. Pancreas 2013; 42: 60-66. 8) Rivadeneira DE, Pochapin M, Grobmyer SR, et al. "Comparison of linear array endoscopic ultrasound and helical computed tomography for the staging of periampullary malignancies." Annals of surgical oncology (2003; 10(8): 890-897. 9) Roberts KJ, McCulloch N, Sutcliffe R, et al. Endoscopic ultrasound assessment of lesions of the ampulla of Vater is of particular value in low‐grade dysplasia. HPB 2013; 15; 18–23. 10) Skordilis P, Mouzas IA, Dimoulios PD, et al. Is endosonography an effective method for detection and local staging of the ampullary carcinoma? A prospective study. BMC surgery 2002; 2(1): 1-8. 11) Stavropoulos S, Larghi A, Verna E, et al. Intraductal ultrasound for the evaluation of patients with biliary strictures and no abdominal mass on computed tomography. Endoscopy 2005; 37(8): 715-721. 12) Talamini MA, Moesinger RC, Pitt HA, et al. Adenocarcinoma of the ampulla of Vater. A 28-year experience. Annals of surgery 1997; 225(5): 590. References 39 John B. Moore, MSc, MS3 Gillian Lieberman, MD March 2013 • Dr. Gunjan Senapati • Dr. Arthur J. Moser • Dr. Gillian Lieberman • Claire Odom • Victoria Van Voorhees 40 Acknowledgments