转移性胰腺癌影像学表现

11 Michele A. Levin, HMS III Gillian Lieberman, MD Metastatic Pancreatic Cancer:Metastatic Pancreatic Cancer: An Abdominal An Abdominal Occham’sOccham’s RazorRazor November 13th, 2006 Michele A. Levin, HMS III Gillian Lieberman, M.D. 22 Michele A. Levin, HMS III Gillian Lieberman, MD „„ HPI: The patient is a 60 year old man with HPI: The patient is a 60 year old man with T2DM and a 50 packT2DM and a 50 pack--year smoking history who year smoking history who presents with a presents with a petechialpetechial rash on both shins.rash on both shins. –– rash: purple, palpable, pruritic, plaquerash: purple, palpable, pruritic, plaque--likelike –– increasing fatigue and SOB on exertionincreasing fatigue and SOB on exertion –– subjective fever that “comes and goes”subjective fever that “comes and goes” –– abdominal pain and bloatingabdominal pain and bloating –– lower extremity swelling bilaterallylower extremity swelling bilaterally –– calf pain, increased with walkingcalf pain, increased with walking Initial ED Patient PresentationInitial ED Patient Presentation Image source: www.uklupus.co.uk/purp.jpg 33 Michele A. Levin, HMS III Gillian Lieberman, MD Lower extremity USLower extremity US Initial outside hospital workInitial outside hospital work--upup Non-compressible vein (left image) Echogenic thrombus in the popliteal vein Lack of venous blood flow on Doppler Diagnosis: Bilateral DVTs Images courtesy of Dr. Karen Lee, BIDMC PACS vein artery vein thrombus 44 Michele A. Levin, HMS III Gillian Lieberman, MD Chest CTA:Chest CTA: Multiple filling defectsMultiple filling defects Diagnosis: segmental and Diagnosis: segmental and subsegmentalsubsegmental PEsPEs segmental subsegmental Image source: www.lumen.luc.edu/.../Pulmonary/PE16.jpg effusion atelectasis Axial CTA with arterial contrast 55 Michele A. Levin, HMS III Gillian Lieberman, MD They also ran a few labs…They also ran a few labs… „„ CBC with differentialCBC with differential „„ Chem 7, Ca, Mg, PhosChem 7, Ca, Mg, Phos „„ PT, PTT, INRPT, PTT, INR „„ HaptoglobinHaptoglobin „„ B12B12 „„ FolateFolate „„ Reticulocyte countReticulocyte count „„ MCVMCV „„ RDWRDW „„ FerritinFerritin „„ TIBCTIBC „„ ESRESR „„ AST/ALTAST/ALT „„ Alkaline PhosphataseAlkaline Phosphatase „„ LDHLDH „„ Total bilirubinTotal bilirubin „„ Hepatitis B and CHepatitis B and C „„ HCVHCV „„ HIVHIV „„ BabesiosisBabesiosis „„ LymeLyme „„ ErlichiaErlichia „„ Parvovirus B19Parvovirus B19 „„ EBVEBV …which still provided no clear diagnosis! 66 Michele A. Levin, HMS III Gillian Lieberman, MD The patient was transferred to The patient was transferred to BIDMC for further workBIDMC for further work--upup First step: Abdominal CT!First step: Abdominal CT! 77 Michele A. Levin, HMS III Gillian Lieberman, MD Abdominal CT: splenic abnormalitiesAbdominal CT: splenic abnormalities „„ Numerous wedgeNumerous wedge--shaped shaped perfusion defectsperfusion defects „„ Preservation of Preservation of capsular enhancementcapsular enhancement „„ Thrombosis of the Thrombosis of the splenic veinsplenic vein Ddx:Ddx: -- Venous thrombiVenous thrombi -- Arterial emboliArterial emboli -- Infection, ex: fungalInfection, ex: fungal -- MetastasesMetastases -- LymphomaLymphoma PACS, BIDMC Coronal CT with contrast Axial CT with contrast 88 Michele A. Levin, HMS III Gillian Lieberman, MD Key point: Key point: splenic capsule enhancementsplenic capsule enhancement „„ The splenic capsule has a different blood The splenic capsule has a different blood supply than the splenic parenchymasupply than the splenic parenchyma „„ Preserved enhancement is highly specific Preserved enhancement is highly specific for for infarctioninfarction 99 Michele A. Levin, HMS III Gillian Lieberman, MD Abdominal CT: liver lesionsAbdominal CT: liver lesions „„ Innumerable Innumerable low density lesionslow density lesions „„ Extensive Extensive arterial shuntingarterial shunting Ddx:Ddx: -- MetastasesMetastases -- Infection/Infection/MicroabscessesMicroabscesses -- Amoebic, Fungal, BacterialAmoebic, Fungal, Bacterial -- Septic emboliSeptic emboli -- Hepatic hemangiomasHepatic hemangiomas -- Biliary hamartomasBiliary hamartomas -- Primary hepatic neoplasmPrimary hepatic neoplasm Axial CT arterial contrast phase PACS, BIDMC 1010 Michele A. Levin, HMS III Gillian Lieberman, MD Key points: liver lesion ddxKey points: liver lesion ddx 1.1. Arterial shuntingArterial shunting -- lesions cause obstruction of flow from low pressure lesions cause obstruction of flow from low pressure portal venous systemportal venous system -- preferential arterial supply (hepatic artery)preferential arterial supply (hepatic artery) -- nonnon--specific (metastases, abscesses, emboli, etc.)specific (metastases, abscesses, emboli, etc.) 2.2. “Wash out”“Wash out” of contrast during delay phaseof contrast during delay phase -- often seen with primary hepatic neoplasmoften seen with primary hepatic neoplasm -- these metastases get more enhancing over timethese metastases get more enhancing over time 1111 Michele A. Levin, HMS III Gillian Lieberman, MD Abdominal CT: renal perfusion defectsAbdominal CT: renal perfusion defects „„ WedgeWedge--shaped shaped perfusion defectsperfusion defects „„ BilateralBilateral „„ Extension to capsuleExtension to capsule Ddx:Ddx: -- Infarcts Infarcts (likely (likely arterialarterial emboli)emboli) -- Renal metastasesRenal metastases Axial CT scan cortical medullary phase PACS, BIDMC 1212 Michele A. Levin, HMS III Gillian Lieberman, MD Key point:Key point: Arterial Arterial andand venous thrombosisvenous thrombosis „„ Differential diagnosis:Differential diagnosis: –– Genetic: Protein C/S, Factor V Leiden, ThrombinGenetic: Protein C/S, Factor V Leiden, Thrombin –– Paradoxical emboli due to cardiac Paradoxical emboli due to cardiac septalseptal defectdefect –– HeparinHeparin--induced thrombocytopenia (HIT)induced thrombocytopenia (HIT) –– Hypercoagulability of malignancyHypercoagulability of malignancy „„ Further workFurther work--up:up: -- Echo bubble study (evaluates for Echo bubble study (evaluates for septalseptal defect): negative defect): negative -- HIT: PF4 Ab screen was positive, started on argatrobanHIT: PF4 Ab screen was positive, started on argatroban 1313 Michele A. Levin, HMS III Gillian Lieberman, MD Abdominal CT: pancreatic massAbdominal CT: pancreatic mass „„ Heterogeneous massHeterogeneous mass „„ Tail of the pancreasTail of the pancreas „„ Low attenuationLow attenuation Ddx:Ddx: -- AdenocarcinomaAdenocarcinoma -- NeuroendocrineNeuroendocrine// Islet cell tumorIslet cell tumor -- ThrombosisThrombosis 19 mm x 39 mm PACS, BIDMC 1414 Michele A. Levin, HMS III Gillian Lieberman, MD Key point: Key point: Pancreatic carcinoma on CTPancreatic carcinoma on CT HypoenhancingHypoenhancing in arterial phase:in arterial phase: -- Indicates adenocarcinomaIndicates adenocarcinoma -- Most common type of pancreatic cancer (90%)Most common type of pancreatic cancer (90%) Hyperenhancing Hyperenhancing in arterial phase: in arterial phase: -- Indicates Indicates neuroendocrineneuroendocrine tumortumor -- Examples include Examples include insulinomainsulinoma, , gastrinomagastrinoma, , somatostatinomasomatostatinoma 1515 Michele A. Levin, HMS III Gillian Lieberman, MD Abdominal CT: diffuse lymphadenopathyAbdominal CT: diffuse lymphadenopathy „„ Enlarged lymph nodes Enlarged lymph nodes present throughout present throughout thorax and abdomenthorax and abdomen -- pericardial, peripancreatic, lesser pericardial, peripancreatic, lesser sac, porta hepatis, retroperitonealsac, porta hepatis, retroperitoneal „„ Central necrosisCentral necrosis DdxDdx:: -- MetastasesMetastases -- Infection (ex: TB, MAI)Infection (ex: TB, MAI) -- Lymphoma (less likely)Lymphoma (less likely) retrocrural paraaortic PACS, BIDMC Axial CT with contrast Axial CT with contrast 1616 Michele A. Levin, HMS III Gillian Lieberman, MD Summary of CT findings:Summary of CT findings: 1.1. Geographic splenic infarctsGeographic splenic infarcts 2.2. Numerous hypodense liver lesionsNumerous hypodense liver lesions 3.3. WedgeWedge--shaped renal perfusion defectsshaped renal perfusion defects 4.4. HypoenhancingHypoenhancing pancreatic tail masspancreatic tail mass 5.5. Diffuse Diffuse lymphadenopathylymphadenopathy 1717 Michele A. Levin, HMS III Gillian Lieberman, MD Next step: liver biopsyNext step: liver biopsy „„ Guidance methods: Guidance methods: –– U/S: preferredU/S: preferred –– CT: secondary choice if poorly CT: secondary choice if poorly visualized on U/Svisualized on U/S „„ Biopsy gun tissue sampleBiopsy gun tissue sample Result of pathology:Result of pathology: -- Poorly differentiated Poorly differentiated adenocarcinomaadenocarcinoma -- ImmunohistochemistryImmunohistochemistry positive for tumor markers positive for tumor markers CDCD--7 and CD7 and CD--2020 Diagnosis: metastatic pancreatic adenocarcinoma PACS, BIDMC 1818 Michele A. Levin, HMS III Gillian Lieberman, MD Pulling it all together:Pulling it all together: Metastatic pancreatic adenocarcinomaMetastatic pancreatic adenocarcinoma ƒƒ Menu ofMenu of imaging techniques:imaging techniques: ƒƒ CT w/ contrast: best sensitivity (90%) and CT w/ contrast: best sensitivity (90%) and specificity (95%)specificity (95%) ƒƒ Best imaging technique useful for stagingBest imaging technique useful for staging ƒƒ U/S: decreased sensitivity (80%) and specificity U/S: decreased sensitivity (80%) and specificity (90%)(90%) ƒƒ ERCP: useful if CT and U/S inconclusive and ERCP: useful if CT and U/S inconclusive and possible chronic pancreatitispossible chronic pancreatitis ƒƒ MRI/MRCP: good for anatomy of biliary tract and MRI/MRCP: good for anatomy of biliary tract and pancreatic ductpancreatic duct Source: UpToDate 1919 Michele A. Levin, HMS III Gillian Lieberman, MD Presentation and prognosisPresentation and prognosis ƒƒ HypercoagulabilityHypercoagulability of malignancyof malignancy ƒƒ Common with GI, ovarian, prostate, lung Common with GI, ovarian, prostate, lung neoplasmsneoplasms ƒƒ Trousseau’s syndromeTrousseau’s syndrome: migratory superficial : migratory superficial thrombophlebitisthrombophlebitis (10% pancreatic adenocarcinoma)(10% pancreatic adenocarcinoma) ƒƒ PatientPatient prognosisprognosis ƒƒ Pancreatic tail masses have a worse prognosis given Pancreatic tail masses have a worse prognosis given later presentationlater presentation ƒƒ 52% of patients have stage IV disease at diagnosis52% of patients have stage IV disease at diagnosis ƒƒ 6%6% 5 year survival with metastatic disease5 year survival with metastatic disease Source: UpToDate 2020 Michele A. Levin, HMS III Gillian Lieberman, MD AcknowledgementsAcknowledgements „„ Dr. Gillian LiebermanDr. Gillian Lieberman „„ Pamela LepkowskiPamela Lepkowski „„ Dr. Karen LeeDr. Karen Lee „„ Dr. Eric Dr. Eric ZeikusZeikus „„ Dr. Moritz Dr. Moritz KircherKircher „„ Dr. Howard Dr. Howard LibmanLibman 2121 Michele A. Levin, HMS III Gillian Lieberman, MD ReferencesReferences AGA technical review: Epidemiology, diagnosis, and treatment of pancreatic ductal adenocarcinoma. In: UpToDate. Rose, B.D., Ed. UpToDate: Waltham, MA, 2006. Bauer, K.A. Hypercoagulable disorders associated with malignancy. In: UpToDate. Rose, B.D., Ed. UpToDate: Waltham, MA, 2006. Juhl, J.H. and Crummy, A.B. Essentials of Radiologic Imaging. 6th edition. Philadelphia: J.B. Lippincott Company, 1993, pp. 539-544. Prokesch, R.W. et al. “Multidetector CT of pancreatic adenocarcinoma: diagnostic advances and therapeutic relevance.” Eur Radiology 13 (2003): 2147-2154. Reader, M.M. and Bradley, Jr., W.G. Gamuts in Radiology: Comprehensive Lists of Roentgen Differential Diagnosis. 3rd edition. New York: Springer-Verlag, 1993. Smith, S.L and Rajan, P.S. “Imaging of pancreatic adenocarcinoma with emphasis on multidetector CT.” Clinical Radiology 59 (2004): 26-38. Steer, M.L. Clinical manifestations, diagnosis, and surgical staging of exocrine pancreatic cancer. In: UpToDate. Rose, B.D., Ed. UpToDate: Waltham, MA, 2006. To’o, K.J. et al. “Pancreatic and peripancreatic diseases mimiking primary pancreatic neoplasia.” Radiographics 25 (2005): 949-965, www.rsna.org. All radiographic images are from BIDMC PACS unless otherwise noted Metastatic Pancreatic Cancer:�An Abdominal Occham’s Razor Initial ED Patient Presentation Lower extremity US Chest CTA: They also ran a few labs… � Abdominal CT: splenic abnormalities Key point: �splenic capsule enhancement Abdominal CT: liver lesions Key points: liver lesion ddx Abdominal CT: renal perfusion defects Key point:�Arterial and venous thrombosis Abdominal CT: pancreatic mass Key point: �Pancreatic carcinoma on CT Abdominal CT: diffuse lymphadenopathy Summary of CT findings: Next step: liver biopsy Pulling it all together:�Metastatic pancreatic adenocarcinoma� Presentation and prognosis Acknowledgements References