HHHoldorf

Staging Pancreatic Carcinomaand Liver Carcinoma

using CT SCAN

CT ScanComputed tomography (CT or CAT scan) is

a noninvasive diagnostic imaging procedure that uses a combination of X-rays 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 ScanCT 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 PreparationPreparation 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 PreparationNotify 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 PreparationYOU MAY RECEIVE AN INJECTION OF IV CONTRAST

(X-RAY DYE) DURING YOUR EXAMIf 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 PatientsFor 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 ScanningA 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

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.

RADIATION AMOUNT*CT scan, full body 10–12 mSvCT scan, chest 7 mSvCardiac Catheterization Up to 22.7 mSvNuclear Stress Test - Technician 9.4 mSvNuclear Stress Test - Thallium 40.7 mSvCT scan, brain 2.0 mSvCT scan, abdomen  8 mSvCT scan, abdomen (liver) 15 mSvCT Scan, pelvis 6mSvCT Scan, abdomen pelvis 14 mSvCT scan, Chest abdomen Pelvis 18 mSv

Pancreatic Carcinoma

Anatomy of the PancreasThe 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

NormalBody 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 carcinomasquamous cell carcinomasgiant 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 diabetesPeople with long-term

inflammation of the pancreas (chronic pancreatitis)

SmokersA small number of cases

are related to genetic syndromes that are passed down through families.

Stages of Pancreatic CancerUsing 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 StatisticsThe 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 stoolsFatigue and weakness Jaundice (a yellow color in the skin, mucus membranes, or eyes)Loss of appetite and weight lossNausea and vomitingPain or discomfort in the upper part of the belly or abdomen

Other possible symptoms are:Back painBlood clotsDiarrhea Indigestion

Blood testBlood 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 CA19-9 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 ProtocolDepending 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 3D-information on the anatomy of the mesenteric arteries this phase is included.

Early Portal PhaseThe 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 PhaseThe '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 AnatomyThe 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 arterynutrient-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 liverAKA primary liver cancer or hepatomaThe liver is made up of different cells types

including bile duct, blood vessels, and fat storing cells.

Hepatocytes make up 80% of liver tissueTherefore the majority of primary liver

cancers arise from these cells (Hepatocellular carcinoma)

Liver Carcinoma StatisticsFrequency 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 StatisticsThe 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 SymptomsUnexplained weight loss and fevers are

warning signs for patients with cirrhosisSudden complications including ascites,

jaundice, or muscle wastingEsophageal 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 SymptomsOn physical examination: an enlarged and

tender liverSince cancers are very vascular, increased

amounts of blood to the hepatic artery which will cause turbulent flow

Nausea and vomitingEnlarged spleenAbdominal pain or pain near the right

shoulder blade

Clinical SymptomsHigh blood calcium levels

(nausea)Low blood sugar levelsHigh red blood cell countHigh 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 WorkAFP:

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 WorkBlood 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 accessibleQuickly performedIf 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 CTContrast is routinely used for imaging the liverImproves contrast to noise ratio between

lesions and normal liver tissueLimitations: 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 CTPre contrast of Liver CT :Used to detect:

CalcificationsHemorrhage from trauma

Arterial Phase:Performed approximately 30 seconds

after the injection (bolus)Hypervascular lesions will enhance

during this phase and appear hyperdenseUsed as preoperative evaluation

Imaging to Enhance Liver CTPortal Venous phase

60-65 seconds post contrastHypovascular 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 ImagingMRI has emerged as the

best imaging test for liver lesion detection and characterization

This modality provides high lesion-to-liver contrast

No ionizing radiationRecent 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 Abnormal CT Scan

Normal liver on CT scan,

with smooth liver contours;

normal size spleen

Cirrhotic liver with smallnodular appearance,

enlarged spleen,ascites around the liver

Incidental FindingsWhen scanning through the abdomen,

incidental findings in surrounding anatomy can occur.

Some locations include:LiverGallbladderPancreasAdrenalsKidneysStomachIVC/AO

Incidental Findings

Gallblader, Liver, or Pancreas, including:Acute cholecystitisAlcoholic liver diseaseCholelithiasisPancreatic abscessPancreatic pseudocystPancreatitisSclerosing 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

The abdominal CT scan may show problems in the:

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 FindingsThe 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/pancreatic-disorders/

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/