Transcript Pancreatic Carcinoma and Liver Carcinoma

Staging Pancreatic Carcinoma
and Liver Carcinoma
using CT SCAN
HHHoldorf
CT Scan
 Computed tomography (CT or CAT scan) is a noninvasive
diagnostic imaging procedure that uses a combination of Xrays and computer technology to produce horizontal, or
axial, images (often called slices) of the body.
 A CT scan shows detailed images of any part of the body,
including the bones, muscles, fat, and organs. CT scans are
more detailed than standard X-rays.
CT Scan
 CT scans may be done with or without "contrast." Contrast
refers to a substance taken by mouth and/or injected into an
intravenous (IV) line that causes the particular organ or tissue
under study to be seen more clearly.
 Contrast examinations may require you to fast for a certain
period of time before the procedure.Your doctor will notify
you of this prior to the procedure.
Coronal Image
Axial Image
Patient Preparation
 Preparation for a CT scan can vary from patient to patient. The X-
ray department, your doctor or nurse will tell you what you need
to do before you go along for your scan.
 If your procedure involves the use of contrast dye, you will be
asked to sign a consent form that gives permission to do the
procedure. Read the form carefully and ask questions if something
is not clear.
 Notify the radiologic technologist if you have ever had a reaction
to any contrast dye, or if you are allergic to iodine.
Patient Preparation
 Notify your doctor of all medications (prescribed and over-the-
counter) and herbal supplements that you are taking.
 Notify the technologist if you have any body piercing on your
chest and/or abdomen.
 Based on your medical condition, your doctor may request other
specific preparation.
Patient Preparation
YOU MAY RECEIVE AN INJECTION OF IV CONTRAST (X-RAY DYE)
DURING YOUR EXAM
 If your CT scan is scheduled for the morning:
 You may have a normal diet until midnight of the day before your test.
 On the day of the test, you should have clear liquids; no solid foods.
 We encourage you to drink clear liquids prior to the test.
 If your CT scan is scheduled for the afternoon or evening:
 You may have a normal diet until 4 hours prior to your appointment, then you
should only have clear liquids until the test is performed.
 We encourage you to drink clear liquids prior to the test.
Diabetic Patients
 For patients on Metformin * therapy and undergoing procedures
involving intravenous administration of contrast, the information,
released by the drug manufacturers state that they "should be
stopped at the time of, or prior to the procedure."
 Then, they should be withheld for 48 hours after the procedure. Once
renal function is found to be normal, medication therapy can be started
again.
 Your referring physician will be informed of these conditions prior to
your study.You should then refer to your physician's instructions for
restarting this medication therapy.
 * Diabetic Patients on METFORMIN therapy which includes
brand names such as: ACTOplus, AVANDIMET, AVANDAMET,
FORTAMET, GLUCOPHAGE, GLUCOPHAGE XR,
GLUCOVANCE, GLUMETZA, METAGLIP, RIOMET
Pre-Diagnosis Imaging: US
 Sound waves and echoes are used to
produce a picture of internal organs or
masses.
 This test can show masses (tumors) which
can then be tested for cancer, if needed.
 Very simple exam and uses no radiation
 For most ultrasound exams, you simply lie
on a table while the transducer (which is
shaped like a wand) is moved around on
the area being looked at.
 This test is used in people with certain
cancer risk factors to help find cancers
earlier. Many experts recommend that the
test be done every 6 to 12 months.
Limitations of CT Scanning
 A person who is very large may not fit into the opening of a
conventional CT scanner or may be over the weight limit—
usually 450 pounds—for the moving table. For very large
patients, some facilities have extra-large bariatric-capable CT
scanners. If this is necessary, contact your doctor for more
information.
 For some conditions, including but not limited to some liver,
adrenal, kidney, pancreatic, uterine or ovarian abnormalities,
the evaluation and diagnosis with MRI may be preferable over
CT scanning.
Average Radiation dose
RADIATION
CT scan, full body
CT scan, chest
Cardiac Catheterization
Nuclear Stress Test - Technician
Nuclear Stress Test - Thallium
CT scan, brain
CT scan, abdomen
CT scan, abdomen (liver)
CT Scan, pelvis
CT Scan, abdomen pelvis
CT scan, Chest abdomen Pelvis
AMOUNT*
10–12 mSv
7 mSv
Up to 22.7 mSv
9.4 mSv
40.7 mSv
2.0 mSv
8 mSv
15 mSv
6mSv
14 mSv
18 mSv
We absorb radiation from a variety of sources.
How much is too much?
Experts say 3 mSv per year is probably OK for most of us;
20 mSv for those who must have medical tests.
Pancreatic Carcinoma
Anatomy of the Pancreas
 The pancreas is an elongated, tapered organ located across
the back of the abdomen, and behind the stomach.
• The right side of the organ
(called the head) is the widest
part of the organ and lies in
the curve of the duodenum
(the first section of the small
intestine).
• The tapered left side extends
slightly upward (called the
body of the pancreas) and
ends near the spleen (called
the tail).
Anatomy of the Pancreas
 The pancreas is made up of two types of glands:
 Exocrine. The exocrine gland secretes digestive enzymes. These enzymes are
secreted into a network of ducts that join the main pancreatic duct, which runs
the length of the pancreas.
 Endocrine. The endocrine gland, which consists of the islets of Langerhans,
secretes hormones into the bloodstream.
Normal pancreas
Normal
Body of Pancreas, Tail of Pancreas,
Splenic Flexure, Splenic Vein
What is Pancreatic Carcinoma?
 Cancer that arises in the pancreas
 Tumors that affect the exocrine functions are the most common type of
pancreatic cancer. Sometimes these tumors or cysts are benign, called
cystadenomas.
 It is more likely to find malignant tumors called adenocarcinomas, which
account for 95% of exocrine pancreatic cancers.
 Other types of pancreatic cancers that are associated with exocrine functions
include
 adenosquamous carcinoma
 squamous cell carcinomas
 giant cell carcinomas
 Tumors that affect the endocrine functions of the pancreas are called
neuroendocrine or islet cell tumors, but these are fairly uncommon. These
tumors are named for the type of hormone-producing cell that is initially
affected.
Causes of Pancreatic Carcinoma
 The exact cause of pancreatic
cancer is unknown. It is more
common in:
 People with diabetes
 People with long-term
inflammation of the pancreas
(chronic pancreatitis)
 Smokers
 A small number of cases are
related to genetic syndromes
that are passed down through
families.
Stages of Pancreatic Cancer
Using information from staging tests, your doctor assigns your
pancreatic cancer a stage. The stages of pancreatic cancer are:
 Stage I. Cancer is confined to the pancreas.
 Stage II. Cancer has spread beyond the pancreas to nearby
tissues and organs and may have spread to the lymph nodes.
 Stage III. Cancer has spread beyond the pancreas to the
major blood vessels around the pancreas and may have spread
to the lymph nodes.
 Stage IV. Cancer has spread to distant sites beyond the
pancreas, such as the liver, lungs and the lining that surrounds
your abdominal organs (peritoneum).
Pancreatic Carcinoma Statistics
 Pancreatic cancer is the fourth leading
cause of cancer-related death in the
United States.
 In 2010, there were over 43,000
estimated new cases of pancreatic cancer
and over 36,000 deaths attributed to it
in the United States.
 It comprises about 2.5 % of all newly
diagnosed tumors and 5% of all cancer.
 The estimated lifetime risk of
developing Pancreatic Carcinoma is
about 1 in 71 (1.41%).
Pancreatic Carcinoma Statistics
 The disease is rare before age 45 but incidence rises rapidly after that
and peaks in the seventh decade of life.
 It is more common in men (1.5:1) between the age of 60 and 70 years.
 Pancreatic cancer has a poor prognosis:
 for all stages combined, the 1- and 5-year relative survival rates are
25% and 6%, respectively
 for local disease the 5-year survival is approximately 20%
 the median survival for locally advanced and for metastatic disease,
which collectively represent over 80% of individuals, is about 10 and
6 months respectively
Clinical Symptoms
 A tumor or cancer in the pancreas may grow without any symptoms at first. This means
pancreatic cancer is often advanced when it is first found.
 Early symptoms of pancreatic cancer include:
 Dark urine and clay-colored stools
 Fatigue and weakness
 Jaundice (a yellow color in the skin,
 mucus membranes, or eyes)
 Loss of appetite and weight loss
 Nausea and vomiting
 Pain or discomfort in the upper part
 of the belly or abdomen
 Other possible symptoms are:
 Back pain
 Blood clots
 Diarrhea
 Indigestion
Blood test
 Blood test.Your doctor may test your blood for specific
proteins (tumor markers) shed by pancreatic cancer cells.
 One tumor marker test used in pancreatic cancer is called
CA19-9. Some research indicates that the more elevated your
level of CA19-9 is, the more advanced the cancer. But the test
isn't always reliable, and it isn't clear how best to use the CA199 test results. Some doctors measure your levels before, during
and after treatment. Others use it to gauge your prognosis.
Why is CT important to Pancreatic CA?
 CT is the test of choice to help diagnose pancreatic
cancer.
 A CT scan can locate small tumors in the pancreas
that might be missed by ultrasound.
 A CT scan can accurately show whether the mass has
extended beyond the pancreas and what the relation is
to nearby blood vessels and organs - information vital
to a surgeon planning an operation to remove the
cancer.
 If a pancreatic tumor is suspected, then a specialized
CT scan, called a pancreatic protocol scan, is
preferred prior to surgery.
CT Protocol
 Depending on the type of multidetector CT, 120 - 150 ml
contrast is given at an injection rate of 3-5 ml/s.
 Slice thickness depends on the type of scanner that is used,
but should be preferentially 2-3 mm or less.
 An early arterial phase-scan (delay 30 sec) does not add
significant information on the staging of the pancreas tumor,
since there is not enough contrast in the pancreas.
 Only if the surgeons want to get optimal pre-operative 3Dinformation on the anatomy of the mesenteric arteries this
phase is included.
Early Portal Phase
 The early-portal phase is also called the pancreatic phase.




It has a scan-delay of 40-50 sec.
This is the most important phase for detecting and staging a
pancreatic tumor.
At that moment the normal pancreatic parenchyma will enhance
optimally, because it gets all of its blood supply through the
arterial and capillary system.
In this phase there is optimal attenuation difference between the
hypodense tumor and the normal enhancing pancreatic
parenchyma.
This phase helps in the differentiation of liver lesions and usually
the mesenteric arteries and veins are well opacified.
Late Portal Phase
 The 'late portal' or hepatic phase has a scan-delay of 70-80 sec.
 At that moment the normal liver parenchyma will enhance
optimally, because normal liver cells get 80% of their blood supply
through the portal venous system.
 Liver metastases do not get their blood supply from the portal
venous system and will be seen in this phase as hypovascular or
hypodense lesions.
 This phase is performed for the overall assessment of the abdomen
to look for liver metastases, lymphnodes and peritoneal implants.
 This phase is also helpful for local staging of the tumor and
detection of venous ingrowth.
CT of Pancreatic Carcinoma
 As pancreatic carcinoma is a hypovascular
tumor, it presents as a hypodense mass on a
CECT (contrast enhanced CT)
 The mass is usually ill-defined.
 In 10 - 15% the tumor is isodense 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).
CT of Abnormal Pancreas
Dynamic contrast enhanced axial CT image of a 55-year-old man with known
pancreatic adenocarcinoma.
A hypodense, mildly enhancing mass is seen in the pancreatic head and neck
involving the common bile duct and proximal portal vein.
CT of Abnormal Pancreas
CT of Abnormal Pancreas
Results of CT with contrast, including evidence of a mass in the pancreas just anterior to the
portal vein (2.8cm maximum diameter) and a second mass in the pancreas head (3.5cm
maximum diameter)
CT of Abnormal Pancreas
CT scan of the abdomen, axial section,
showing pancreatic cancer
CT of Pancreas
Treatment
 Options for treatment include
 Surgical removal (called resection)
 Chemotherapy (treatment with drugs that kill the cancer cells)
 Radiotherapy (using radiation to kill cancer cells)
 As well as treatment for pain and other symptoms and
complications of the disease.
Liver Carcinoma
Liver Anatomy
The liver is located in the upper right-hand portion of the abdominal cavity, beneath the
diaphragm, and on top of the stomach, right kidney, and intestines.
 Shaped like a cone
 dark reddish-brown organ, weighs 3 pounds
There are two distinct sources that supply blood to the liver, including the following:
 oxygenated blood flows in from the hepatic artery
 nutrient-rich blood flows in from the hepatic portal vein
The liver consists of two main lobes, both of
which are made up
of thousands of lobules.
The hepatic duct transports the bile
produced by the liver cells
to the gallbladder and duodenum
CT LIVER Anatomy
CT Liver Anatomy
What is Liver Carcinoma?
 Cancer that arises from the liver
 AKA primary liver cancer or hepatoma
 The liver is made up of different cells types including bile
duct, blood vessels, and fat storing cells.
 Hepatocytes make up 80% of liver tissue
 Therefore the majority of primary liver cancers arise from
these cells (Hepatocellular carcinoma)
Liver Carcinoma Statistics
 Frequency in Southeast Asia and Sub-Saharan Africa is greater
than 100 cases per 100,000 population.
 Frequency in North American and Europe is less than five
cases per 100,000 population
 This reflects the prevalence of hepatitis B which is the most
common cause of liver cancer worldwide.
Liver Carcinoma Statistics
 The frequency of liver carcinoma in the U.S. is rising due to
an increase in obesity, diabetes, hepatitis C, and other liver
infections
 Frequently spreads to lung through bloodstream
 Rarely can spread to brain or bone
Clinical Symptoms
 Unexplained weight loss and fevers are warning signs for
patients with cirrhosis
 Sudden complications including ascites, jaundice, or muscle
wasting
 Esophageal Varices (When CA invades and blocks portal vein
there is an increased pressure in the vein which causes them
to become dilated which may result in esophageal varices)
Clinical Symptoms
 On physical examination: an enlarged and tender liver
 Since cancers are very vascular, increased amounts of blood
to the hepatic artery which will cause turbulent flow
 Nausea and vomiting
 Enlarged spleen
 Abdominal pain or pain near the right shoulder blade
Clinical Symptoms
 High blood calcium levels (nausea)
 Low blood sugar levels
 High red blood cell count
 High cholesterol levels
LAB Work: Why do we use it?
 To help diagnose liver cancer
 To help determine what might have caused your liver cancer
 To learn how well the liver is working, which may affect
what types of treatments you can have
 To get an idea of your general health and how well your other
organs are working, which also may affect what types of
treatments you can have
 To see how well treatment is working
 To look for signs that the cancer has come back after
treatment
Blood Work
AFP:
It can be helpful in determining if a liver mass might be cancer.
- A low or normal value on this test means it is less likely you have liver
cancer
- high value makes it more likely
 The test can be used after treatment as well, to look for possible signs that the
cancer has come back (recurred).
 Kidney function tests: Tests of blood urea nitrogen (BUN) and creatinine
levels are often done to assess how well your kidneys are working.
 Complete blood count (CBC): This test measures levels of red blood cells,
white blood cells (which fight infections), and platelets (which help the blood
clot). It gives an idea of how well the bone marrow, where new blood cells are
made, is functioning.
Blood Work
 Liver function tests (LFTs): A series of blood tests that
can help assess the condition of the part of your liver not
affected by the cancer. It measures levels of certain
substances in your blood that show how well your liver is
working.
 If your liver is not healthy, you might not be able to have
surgery to try to cure the cancer, as the surgery might
require removal of a large part of your liver. This is a
common problem in people with liver cancer.
Blood Work
 Blood clotting tests: The liver also makes proteins that
help blood clot when you are bleeding. A damaged liver may
not make enough of these clotting factors, which could
increase your risk of bleeding.Your doctor may order blood
tests such as a prothrombin time (PT) to help assess this risk.
 Tests for viral hepatitis: If liver cancer has not yet been
diagnosed, your doctor may order blood tests to check for
hepatitis B and C. Results showing you have been infected
with either of these viruses may make it more likely that you
have liver cancer.
Why is CT important to Liver
Carcinoma?
 CT has a high sensibility and specificity for detecting liver





carcinoma
Most accurate modality for detecting liver carcinoma
when contrast is used
CT is preferred because it out performs US and MRI
Easily accessible
Quickly performed
If contrasts cannot be administered due to an allergy or renal
insufficiency the accuracy of the CT will be poor and an MRI
should be performed.
Imaging to Enhance Liver CT
 Contrast is routinely used for imaging the liver
 Improves contrast to noise ratio between lesions and normal
liver tissue
 Limitations: need for radiation dose and low sensitivity for
the detections and characterization of lesions small than 1cm
 Four phases:
- pre contrast
- arterial phase
- portal venous phase
- delayed phase
Imaging to Enhance Liver CT
 Pre contrast of Liver CT :
 Used to detect:
 Calcifications
 Hemorrhage from trauma
 Arterial Phase:
 Performed approximately 30 seconds after the injection
(bolus)
 Hypervascular lesions will enhance during this phase and
appear hyperdense
 Used as preoperative evaluation
Imaging to Enhance Liver CT
 Portal Venous phase
 60-65 seconds post contrast
 Hypovascular lesions appear as hypodense
 Hypervascular lesions appear as isodense (same as surrounding liver)
 Delayed Phase
 -5 -10 minutes post contrast
 -used to further characterize lesions
Post Diagnosis Imaging
 MRI has emerged as the best
imaging test for liver lesion
detection and characterization
 This modality provides high
lesion-to-liver contrast
 No ionizing radiation
 Recent advances: breath-hold 3D
imaging and rapid half-Fourier
acquisition help image the liver in
a single breath-hold with a high
spatial resolution
CT Imaging
CT scan in the hepatic arterial phase of contrast enhancement showing neo-vascularity in a
low-density hepatic mass.
CT of Abnormal Liver
CT Imaging
Normal CT Scan
Normal liver on CT scan,
with smooth liver contours;
normal size spleen
Abnormal CT Scan
Cirrhotic liver with small
nodular appearance,
enlarged spleen,
ascites around the liver
Incidental Findings
 When scanning through the abdomen, incidental findings in
surrounding anatomy can occur.
Some locations include:
 Liver
 Gallbladder
 Pancreas
 Adrenals
 Kidneys
 Stomach
 IVC/AO
Incidental Findings
The abdominal CT scan may show problems in the:
 Gallblader, Liver, or Pancreas,
including:
 Acute cholecystitis
 Alcoholic liver disease
 Cholelithiasis
 Pancreatic abscess
 Pancreatic pseudocyst
 Pancreatitis
 Sclerosing cholangitis
•Kidney including:
•Acute bilateral obstructive uropathy
•Acute unilateral obstructive uropathy
•Chronic bilateral obstructive uropathy
•Chronic unilateral obstructive uropathy
•Complicated UTI (pyelonephritis)
•Kidney stones
•Kidney Cysts
•Kidney swelling (hydronephrosis)
•Kidney or ureter damage
•Polycystic kidney disease
•Uterocele
Incidental findings
 Contrast-enhanced CT:
Incidental finding of
multiple small focal
hypodense cysts in both
lobes of the liver with
variable density and size,
indistinguishable from
small hypovascular
metastases that may have a
similar appearance
Incidental Findings
 CT of liver with contrast shows low attenuation lesions in the
liver and a mass within the left kidney, with some low
attenuation within it.
Incidental Findings
 The CT scan showed an
incidental finding of a
herniation of the stomach,
small bowel, and colon into
the thoracic cavity (type IV
hiatal hernia).
Incidental Findings
The following image is
a computerized
tomogram
study with contrast
demonstrating a
simple renal cyst
and its
characteristic lack
of enhancement
Incidental Findings
 Acute pancreatitis (AP) is an
inflammatory condition of the
pancreas that can extend to
extrapancreatic tissues.
 AP is broadly classified as mild or
severe.
 Mild AP is often referred to as
interstitial pancreatitis, based on its
radiographic appearance. The
pancreatic blood supply is preserved in
interstital pancreatitis.
 Severe AP implies organ failure, local
complications, or pancreatic necrosis.
There is disruption of the pancreatic
blood supply in necrotizing
pancreatitis, with resulting ischemia.
Abdominal computed tomography scan
of acute pancreatitis. Pseudocyst
formation can be noted (arrowheads)
References











Abdominal Ct Scan. (2012, November 21). Retrieved November 2012, from PubMed Health:
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004248/
Pavan Tummala, O. J. (2011, September). Retrieved from Imaging of pancreatic cancer: An overview:
http://www.thejgo.org/article/view/213/427
Smithuis, O. v. (n.d.). Pancreatic Carcinoma. Retrieved from The Radiology Assistant:
http://www.radiologyassistant.nl/en/p43848b63def9d/pancreas-carcinoma.html
Stevens, T. (n.d.). Pancreatic Disorders. Retrieved 2012, from The Cleveland Clinic Foundation:
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/gastroenterology/pancreaticdisorders/
http://www.mayoclinic.com/health/pancreatic-cancer/DS00357/DSECTION=tests-and-diagnosis
http://www.hopkinsmedicine.org/healthlibrary/test_procedures/gastroenterology/computed_tomography_ct
_or_cat_scan_of_the_pancreas_92,P07692/
http://www.virtualmedicalcentre.com/diseases/pancreatic-cancer-adenocarcinoma-of-the-pancreas/590
http://www.sekmchd.org/cms/Services/ChronicDiseaseControl/Cancer/PancreaticCancerFAQs/tabid/1340/
Default.aspx
http://www.nlm.nih.gov/medlineplus/ency/article/003789.htm
http://www.webmd.com/a-to-z-guides/computed-tomography-ct-scan-of-the-body
http://www.nationaljewish.org/programs/tests/imaging/ct-scan-of-the-abdomen-liver-pancreas-with-contrast/