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1、胰腺癌MDCT: I 诊断与鉴别 II 手术切除性判断 III 磁共振价值,曾蒙苏 教授 复旦大学附属中山医院 放射诊断科 复旦大学上海医学院影像学系 上海市影像医学研究所,zeng.mengsuzs-,2012-6-3 浙江绍兴讲课,MDCT检查方法,口服水+低张，充盈胃和十二指肠 增强 单期法(45s) 双期法(45s/85s) 三期法(20/45s/85s) 薄层（5mm或6 .5mm）、屏气 对比剂 90ml/3ml/s (120ml/5ml/s) 必须包括肝脏扫描 16层CT为常规配置 3D reformation,根据多层螺旋CT扫描时像常分为: 动脉期: 20-25s (动脉血管
2、) 胰腺期: 40-50s (胰腺强化高峰) 门脉期: 80-90s (肝脏强化高峰),研究表明： 胰腺血供丰富，胰腺期强化峰值最高，而 胰腺癌一般为少血供肿瘤， 该期两者之密度差异最大， 易于显示。 同时该期可同时显示胰腺周围动、静脉血管。,李卉、曾蒙苏 中华放射学杂志 2004（3）：38；287 李卉、曾蒙苏 临床放射学杂志 2004（7）：23；593,胰腺癌螺旋CT表现,直接征象： 占位表现（强化不明显） 间接征象：1、胰腺管扩张，胰腺萎缩（80-90%） 2、胆道扩张（胰头、颈）（70-80） 3、侵犯周围血管及脏器 4、脏器和淋巴结转移 -偶见上消化道梗阻表现伴腰背疼痛 重要生物
3、学特性 围管性浸润、嗜神经生长、少血供肿瘤,CA19-9 升高 （70-80%）,动脉期和胰腺期意义,小胰腺癌（1.5 or 2cm）的早期检出 富血供的胰岛细胞瘤的检出 显示周围动脉血管，有利于MSCT三维重建（CTA） -手术切除性判断,6 cases (2.0cm) 特点,1、动脉期强化明显 （2）或等密度（4） 2、门脉期强化等密度（4）或低密度（2） 3、远端胰腺管扩张,CT和MRI互补， 短期随访十分重要,等密度胰腺癌- 指动脉和门脉期肉眼上与正常胰腺密度一样,1 incidence 5.4% （35 of 644) 2 tumor size (1.5-4 cm, median,
4、3cm) 3CA19-9 elevated 51.5% 4 IgG or IgG4 elevated 8.3% 5 MR and PET/CT may be useful as subsequent examination, when the patient is suspected of having the lesion at CT.,From Radiology 2010;Vol257:No.1(October) 87-96,门脉期意义,一小部分病例肿瘤的显示反而清楚 显示转移淋巴结 显示肝内转移灶,动脉期+胰腺期+门脉期意义,利于 小肿瘤（少血供及富血供）的检出 手术切除性的判断 分期
5、 各种三维重建,胰腺癌术前诊断“金标准”,16 MDCT,Accuracy 95.5%,Accuracy 98% + CA199、CEA and symptom,中山 156 pats ( 98 heads and 58 body- tail）,1Suspected lesion of pancreas , first choice is MDCT 2standard for non-surgical treatment without pathological results,Clinical Value,胰腺癌与慢性胰腺炎症局部肿块鉴别,支持慢性炎症的征象 胰头增大，但不能显示低密度占位
6、肿块3cm，周围血管无侵犯 CBD下端显示结石 胰管内结石 胰头部增大，内见粗大钙化或假性囊肿 肾旁筋膜增厚 MRCP、ERCP示CBD移行狭窄 临床病史,Chronic Mass-Forming Pancreatitis, CMFP,胰腺癌与慢性胰腺炎症局部肿块鉴别,支持慢性炎症的征象 胰头增大，但不能显示低密度占位 肿块3cm，周围血管无侵犯 CBD下端显示结石 胰管内结石 胰头部增大，内见粗大钙化或假性囊肿 肾旁筋膜增厚 MRCP、ERCP示CBD移行狭窄 临床病史,AIP: 蜡肠征；胰腺管狭窄； 临床症状和实验室检查,Chronic Mass-Forming Pancreatitis,
7、 CMFP,胰腺癌与慢性胰腺炎症局部肿块鉴别,支持慢性炎症的征象 胰头增大，但不能显示低密度占位 肿块3cm，周围血管无侵犯 CBD下端显示结石 胰管内结石 胰头部增大，内见粗大钙化或假性囊肿 肾旁筋膜增厚 MRCP、ERCP示CBD移行狭窄 临床病史,Groove pancreatitis- specific chronic pancreatitis,Chronic Mass-Forming Pancreatitis, CMFP,手术切除性判断-MDCT,胰腺癌，特别胰头癌手术切除性判断,外科手术切除,肠系膜上动脉 肠系膜上静脉 肝外门静脉 腹腔动脉干和分支 下腔静脉 主动脉,不可切除性的判
8、断准确率 MSCT 98.3%(57 / 58） SSCT 95% 可切除性的判断准确率 MSCT 85.5%（65/76) SSCT 70.3%,术前胰腺癌手术切除性判断,国外文献：不可切除 95% ；可切除75-80% by CT source from 88th Annual Clinical Congress American College of Surgeons October6-10,2002 San Francisco, CA, USA.,血管侵犯,意义：分期和手术切除性的判断 有利于明确肿瘤的诊断 判断标准： A 肿瘤包绕血管：周径范围和距离长短， B 血管腔狭窄、闭塞，血管
9、腔不规则， C 脂肪层面消失（部分、完全）， D 肿瘤与血管间尚有正常胰腺组织 显示血管方法：动脉期+胰腺期增强(Axial I)， MPRs（动脉、胰腺）,Li Hui,Zeng Mengsu. JCAT 2005;29:170-176,Staging of Vessel Infiltration Type Criteria Significance A Tumor is separated from adjacent Tumor is resectable without venous resection in 95% of patients vessel by intact fat pl
10、ane B Tumor is separated from adjacent vessel Tumor is resectable without venous resection in 95% of patients by normal pancreatic parenchyma C Hypodense tumor has convex point of Tumor involvement of vessel cannot be reliable predicted contact with adjacent vessel D Hypodense tumor has concave poin
11、t of Tumor cannot be removed without partial resection of vessel contact with,or partially encircles, adjacent vessel E Hypodense tumor ebcircles adjacent vessel Not possible to resection tumor with negative margin F Tumor occludes adjacent vessel No possible to resect tumor with nagative margin Loy
12、er E et al. Abdom Imading 1996;21:202-2-6,TNM staging of pancreatic adenocarcinoma - Stage Definition -Primary tumor Tis Carcinoma in situ T1 Tumor limited to pancreas, 2 cm in any direction T2 Tumor limited to pancreas, 2 cm in any direction T3 Infiltration into peripancreatic tissue, duodenum, and
13、/or common bile duct T4 Infiltration into peripancreatic vessels, stomach, spleen, large bowel - Regional lymph nodes N0 No lymph node metastases N1 Metastases in peripancreatic lymph nodes Nx Unknown - Distant metastases M0 No distant metastases M1 Distant metastases present Mx Unknown -,The New En
14、gland Journal of Medicine Table. 1 Staging of Pancreatic Cancer Stage Tumor Nodal Distant Median Characteristics Grade Status Metastasis Survival (mo) IA T1 N0 M0 24.1 Tumor limited to the pancreas,2.0cm in longest dimension IIA T3 N0 M0 15.4 Tumor extend beyond the pancreas but dose not involve the
15、 celiac axis or superior mesenteric artery IIB T1 T2 or T3 N1 M0 12.7 Regional lymph-node metastasis III T4 N0 or N1 M0 10.6 Tumor involves the celiac axis or the superior mesenteric artery (unresectable disease) IV T1 T2 T3 or T4 N0 or N1 M1 4.5 Distant metastasis, N denotes reginal lymph nodes, an
16、d T primary tumor; # Data are from Bilimoria et al . 45 Tumor involving the superior mesenteric vein, portal veins or splenic veins are classified as T3 45. Bilimoria KY, Bentrem DJ, Ko CY, et al. Validation of the 6th edition AJCC pancreatic cancer staging system: resport from the National Cancer D
17、atabase. Cancer 2007;10:738-744.,the pylorus-preserving pancreaticoduodenectomy (PPPD), A recent study showed no difference between a standard Whipple procedure and PPPD with regard to postoperative mortality, morbidity, and long-term survivalRates。 Patients who undergo resection for nonmetastatic d
18、isease have a 5-year survival rate of 725%, with a median survival of 1120 months . The highest survival rate is achieved in patients with small tumors (2 cm) and negative lymph nodes at resection . Patients with nonresectable, locally advanced, nonmetastatic disease have a median survival of 611 mo
19、nths, and those with metastatic disease have a median survival of 26 months. Most patients develop disease recurrence within 2 years of resection, usually after a mean time of 912 months in the retroperitoneum (3487%), the peritoneum(1953%), the liver (3873%), extraabdominal sites (829%). Liver meta
20、stases frequently develop earlier(at approximately 511 months postsurgery), indicating the presence of micrometastases at the time of surgery, whereas local recurrences tend to appear a little later (about 13 months postsurgery) .,Should known for the Radiologists,肿瘤侵犯血管不可切除,Limited Criteria: 血管周径1/
21、2 + 血管长径2 cm,Other factors: operators skill and patients condition,肿瘤TNM分期 手术切除性判断,2D + 3D more accuracy in determining the resectebility,Artery differs from venous,高端MRI (1.5T)的价值,补充 MDCT （特别疑难病例） 无辐射效应，可短期多次检查 病人必须配合 技术要求高 图象解释较复杂 更依赖设备优劣 经验丰富的放射科医生,MRI检查方法,一、SE序列： T1WI+ T2WI+DWI T1WI+FS 由于胰腺腺泡组织含
22、较高的水样蛋白成份，信号，显示胰腺轮廓十分清晰，与肿瘤的信号差异扩大，该技术被普遍应用。 二、GRE 序列: 动态增强：动脉期，胰腺期和门脉期(axial and coronal scans for detection and MRA)。 Gd+ 15-20 ml Vol, 10s hand injection time of images= delay time(10s)+injection time (10s)+half time of K space 三、 MRCP检查: 显示CBD及PD。,CT 和 MRI 比较,胰腺癌首选CT(主要双期或三期增强扫描) 对疑难病例，MRI可补充 发现肝脏转移灶，MRI敏感，尤其 T2WI 发现淋巴结转移，CT敏感 肿瘤切除性判断，CT较优 MRCP必须结合T1、T2WI和增强GRE,CT和MRI互为补充,Acknowledgements,Radiology General Surgery 殷允娟 硕士 靳大勇 教授 王冬青 博士 楼文辉 副教授 李 卉 博士 王单松 副教授 史 讯 硕士 陈伟中 硕士 姚秀忠 博士 饶圣祥 博士,Thanks for your attention welcome to Zhongshan Hospital,