Pankreas kanseri -karaciğer metastazlarında diffüzyon ağırlıklı manyetik rezonans görüntüleme

Öz

Giriş ve Amaç: Pankreas kanseri günümüzde sık görülen, medikal tedaviye dirençli ve kötü prognozlu tümörlerden biridir. Görüntüleme yöntemleri ile hem primer tümörün hem de metastazlarının saptanmasında güçlükler yaşanmaktadır. Bu çalışmanın amacı pankreas kanserinde operabilite kriterlerinden olan karaciğer metastazlarının saptanmasında çok kesitli bilgisayarlı tomografi ve difüzyon ağırlıklı görüntüleme sekansları ile birlikte manyetik rezonans görüntülemenin katkılarını karşılaştırmaktır. Gereç ve Yöntem: 2012-2017 yılları arasında merkezimizde pankreas kanseri tanısı alan 79 hastaya ait çok kesitli bilgisayarlı tomografi ve difüzyon ağırlıklı manyetik rezonans görüntüleri retrospektif olarak değerlendirildi. Çalışmaya dahil ettiğimiz 63 hastanın 45’i adenokanser, 18’i pankreatik nöroendokrin tümör tanısı alan hasta idi. Çok kesitli bilgisayarlı tomografi ve difüzyon ağırlıklı manyetik rezonans görüntülemede tespit edilen karaciğer metastazları sayı olarak karşılaştırıldı. Ayrıca manyetik rezonans görüntüleme ile her iki grup primer tümörlerinden yapılan görünür difüzyon katsayısı ölçümleri arasında anlamlı fark olup olmadığı ve her iki gruba ait metastatik kitleler arasındaki görünür difüzyon katsayı değerlerinin farkı incelendi. Bulgular: Difüzyon ağırlıklı manyetik rezonans görüntülemede çok kesitli bilgisayarlı tomografiye kıyasla daha fazla sayıda metastaz tespit edildi (%38,10). Adenokanser ve pankreatik nöroendokrin tümörlerde primer tümörlerden yapılan ölçümlerde görünür difüzyon katsayı değerleri dağılımları istatistiksel olarak önemli bir farklılık göstermedi (p=0.976 ). Aynı şekilde her iki gruba ait metastazlardan yapılan görünür difüzyon katsayı ölçümlerinde istatistiksel olarak anlamlı fark saptanmadı (p=0.140). Tartışma: Pankreas kanseri hastalarında tek tedavi yönteminin cerrahi olduğu düşünüldüğünde evreleme ve tümör tipinin belirlenebilmesi açısından hem primer kitlelerin hem de metastazlarının görüntüleme yöntemleriyle tanısının ne kadar önemli olduğu anlaşılmaktadır. Günümüzde henüz pankreas kanseri hastalarında karaciğer metastazlarının tespit ve spesifiye edilmesinde kullanılan uluslararası bir kılavuz yayınlanmamıştır. Ancak kontrastlı çok kesitli bilgisayarlı tomografi incelemelerinde tespit edilen fakat spesifiye edilemeyen karaciğer kitlelerinde manyetik rezonans görüntülemeye başvurulmaktadır. Konvansiyonel manyetik rezonans görüntüleme incelemelerinde de benzer sıkıntılar yaşanabilmektedir. Difüzyon ağırlıklı manyetik rezonans görüntüleme ile inceleme konvansiyonel manyetik rezonans görüntüleme sekanslarına ek sekans olarak aynı oturumda ve kısa sürede yapılabilmektedir. Bu çalışmada pankreas kanseritanılı hasta serimizde hastaların %38,10’nunda; difüzyon ağırlıklı manyetik rezonans görüntüleme ile incelemede çok kesitli bilgisayarlı tomografiden daha fazla karaciğer metastazı saptandı. Bu nedenle gereksiz cerrahi ve cerrahinin neden olduğu morbidite ve mortaliteden korunmak amacıyla pankreas kanseri tanılı hastalarda karaciğer metastazı saptanması ve dolayısıyla evrelemede difüzyon ağırlıklı manyetik rezonans görüntülemenin tarama amaçlı gerçekleştirilmesi gerektiğini düşünmekteyiz.

Anahtar Kelimeler

• Pankreatik kanser,difüzyon ağırlıklı manyetik rezonans,çok kesitli bilgisayarlı tomografi,karaciğer metastazı

Diffusion weighted magnetic resonance imaging of hepatic metastasis of pancreatic cancer

Öz

 

Background and Aims: Pancreatic cancer is one of the tumors that occurs most commonly, is resistant to medical treatment, and has a poor prognosis. Imaging methods present difficulties in detecting both primary and metastatic tumors. The aim of this study was to compare the contribution of diffusion-weighted magnetic resonance imaging with that of multiple detector computed tomography in the detection of liver metastases based on the operability criteria of pancreatic cancer. Materials and Methods: Multiple detector computed tomography and diffusion-weighted magnetic resonance imaging images of 79 patients diagnosed with pancreatic cancer in our center during 2012-2017 were evaluated retrospectively. Of the 63 patients included in the study, 45 had adenocarcinoma and 18 had pancreatic neuroendocrine tumor. The liver metastases detected via multiple detector computed tomography and diffusion-weighted magnetic resonance imaging images were compared. The liver metastases detected in multiple detector computed tomography and diffusion-weighted magnetic resonance imaging were compared in numbers. In addition, the difference between the apparent diffusion coefficient measurements between the two groups of primer tumors in magnetic resonance imaging and the difference between the apparent diffusion coefficient values between the metastatic masses in both groups were examined. Results: A larger number of metastases were detected in diffusion-weighted magnetic resonance imaging than in multiple detector computed tomography images (38.10%). The distributions of apparent diffusion coefficient values of the measurements made from primary tumors in patients with adenocarcinoma and pancreatic neuroendocrine tumor were not statistically significant (p=0.976). Similarly, there was no statistically significant difference between the apparent diffusion coefficient measurements obtained from the metastases of both groups (p=0.140). Discussion: When we consider the fact that the only treatment method for pancreatic cancers is surgery, it is understood how important it is to recognize both primary masses and metastases using imaging methods to determine the staging and tumor type. Currently, there are no published international guidelines for the identification and specification of liver metastases in patients with pancreatic cancer. However, magnetic resonance imaging has been applied to detect liver masses in contrast-enhanced multiple detector computed tomography, though not specifically. Similar problems can be experienced in conventional magnetic resonance examinations. Diffusion-weighted magnetic resonance imaging examination can be performed in the same session and in a short time as an additional sequence to conventional magnetic resonance sequences. In this study, more metastases were detected in diffusion-weighted magnetic resonance imaging than multiple detector computed tomography in %38,10 of the patients diagnosed with pancreas cancer. To prevent morbidity and mortality caused due to unnecessary surgeries, we believe that liver metastasis should be detected in patients with pancreatic cancer, and therefore, diffusion-weighted magnetic resonance imaging should be performed for screening purposes.

Anahtar Kelimeler

• Pancreatic cancer,diffusion weighted magnetic resonance imaging,multiple detector computed tomography,hepatic metastasis

Kaynakça

1. 1. Amin MB, Edge S, Greene F, et al. AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer; 20172.
2. 2. Carpelan-Holmström M, Nordling S, Pukka E, et al. Does anyone survive pancreatic ductal carcinoma? A nationwide study re-evaluating the data of the Finnish Cancer Registry. Gut 2005;54:385-7.
3. 3. Kazanjian KK, Hines OJ, Duffy JP, et al. Improved survival following pancreaticoduodenectomy to treat adenocarcinoma of the pancreas: the influence of operative blood loss. Arch Surg 2008;143:1166-71.
4. 4. Tempero MA, Malafa MP, Al-Hawary M, et al. Pancreatic Adenocarcinoma. Version 2.2017, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2017;15:1028-61.
5. 5. Treadwell JR, Mitchell MD, Eatmon K, et al. Imaging Tests for the Diagnosis and Staging of Pancreatic Adenocarcinoma. Comparative Effectiveness Review No. 141. (Prepared by the ECRI Institute-Penn Medicine Evidence-based Practice Center under Contract No. 290-2012-00011-I.) AHRQ Publication No.14-EHC045-EF. Rockville, MD: Agency for Healthcare Research and Quality. September 2014. Available at: https://www.effectivehealthcare.ahrq.gov/ehc/products/513/1973/cancer-pancreasexecutive-140923.pdf
6. 6. Expert Panel on Gastrointestinal Imaging, Qayyum A, Tamm EP, Kamel IR, et al. ACR Appropriateness Criteria® Staging of Pancreatic Ductal Adenocarcinoma.J Am Coll Radiol 2017;14:S560-S569.
7. 7. Ma C, Guo X, Liu L, et al. Effect of region of interest size on ADC measurements in pancreatic adenocarcinoma. Cancer Imaging 2017;17:13.
8. 8. Poot DH, den Dekker AJ, Achten E, et al. Optimal experimental design for diffusion kurtosis imaging. IEEE Trans Med Imaging 2010;29:819-29.

9. 9. Yao X, Kuang T, Wu L, et al. Optimization of MR diffusion-weighted imaging acquisitions for pancreatic cancer at 3.0T. Magn Reson Imaging 2014;32:875-9.
10. 10. Keogan MT, McDermott VG, Paulson EK, et al. Pancreatic malignancy: effect of dual-phase helical CT in tumor detection and vascular opacification. Radiology 1997;205:513-8.
11. 11. Richter GM, Wunsch C, Schneider B, et al. Hydro-CT in detection and staging of pancreatic carcinoma [in German]. Radiologe 1998;38:279-86.
12. 12. Nishiharu T, Yamashita Y, Abe Y, et al. Local extension of pancreatic carcinoma: assessment with thin-section helical CT versus with breath-hold fast MR imaging—ROC analysis. Radiology 1999;212:445-52.
13. 13. Schima W, Függer R, Schober E, et al. Diagnosis and staging of pancreatic cancer: comparison of mangafodipir trisodium-enhanced MR imaging and contrast-enhanced helical hydro-CT. AJR Am J Roentgenol. 2002;179:717-24.
14. 14. De Robertis R, Tinazzi Martini P, Demozzi E, et al. Prognostication and response assessment in liver and pancreatic tumors: The new imaging World J Gastroenterol 2015;21:6794-808.
15. 15. Koong AC, Mehta VK, Le QT, et al. Pancreatic tumors show high levels of hypoxia. Int J Radiat Oncol Biol Phys 2000;48:919-22.
16. 16. Chang Q, Jurisica I, Do T, Hedley DW. Hypoxia predicts aggressive growth and spontaneous metastasis formation from orthotopically grown primary xenografts of human pancreatic cancer. Cancer Res 2011;71:3110-20.
17. 17. Pizzi S, Porzionato A, Pasquali C, et al. Glucose transporter-1 expression and prognostic significance in pancreatic carcinogenesis. Histol Histopathol 2009;24:175-85.
18. 18. Wang Y, Chen ZE, Nikolaidis P, et al. Diffusion-weighted magnetic resonance imaging of pancreatic adenocarcinomas:association with histopathology and tumor grade. J Magn Reson Imaging 2011;33:136-42.
19. 19. Legrand L, Duchatelle V, Molinié V, et al. Pancreatic adenocarcinoma: MRI conspicuity and pathologic correlations. Abdom Imaging 2015;40:85-94.
20. 20. Rosenkrantz AB, Matza BW, Sabach A, et al. Pancreatic cancer: lack of association between apparent diffusion coefficient values and adverse pathological features. Clin Radiol 2013;68:e191-7.
21. 21. Niwa T, Ueno M, Ohkawa S, et al. Advanced pancreatic cancer: the use of the apparent diffusion coefficient to predict response to chemotherapy. Br J Radiol 2009;82:28-34.
22. 22. Holzapfel K, Reiser-Erkan C, Fingerle AA, et al. Comparison of diffusion-weighted MR imaging and multidetector-row CT in the detection of liver metastases in patients operated for pancreatic cancer. Abdom Imaging 2011;36:179-84.
23. 23. Miller FH, Hammond N, Siddiqi AJ, et al. Utility of diffusion-weighted MRI in distinguishing benign and malignant hepatic lesions. J Magn Reson Imaging 2010;32:138-47.
24. 24. Chew C, O’Dwyer PJ. The value of liver magnetic resonance imaging in patients with findings of resectable pancreatic cancer on computed tomography. Singapore Med J. 2016;57:334-8.
25. 25. Bosman FT, World Health Organization, International Agency for Research on Cancer. WHO classification of tumours of the digestive system. 4th ed. Lyon, France: IARC press, 2010.
26. 26. Wang Y, Chen ZE, Yaghmai V, et al. Diffusion-weighted MR imaging inpancreatic endocrine tumors correlated with histopathologic characteristics. J Magn Reson Imaging 2011;33:1071-9.
27. 27. Jang KM, Kim SH, Lee SJ, Choi D. The value of gadoxetic acidenhanced and diffusion-weighted MRI for prediction of grading of pancreatic neuroendocrine tumors. Acta Radiol 2014;55:140-8.
28. 28. Hwang EJ, Lee JM, Yoon JH, et al. Intravoxel incoherent motion diffusion-weighted imaging of pancreatic neuroendocrine tumors: prediction of the histologic grade using pure diffusion coefficient and tumor size. Invest Radiol 2014;49:396-402.
29. 29. Couvelard A, Deschamps L, Ravaud P, et al. Heterogeneity of tumor prognostic markers: a reproducibility study applied to liver metastases of pancreatic endocrine tumors. Mod Pathol 2009;22:273-81.
30. 30. d’Assignies G, Fina P, Bruno O, et alHigh sensitivity of diffusion-weighted MR imaging for the detection of liver metastases from neuroendocrine tumors: comparison with T2 weighted and dynamic gadolinium-enhanced MR imaging. Radiology 2013;268:390-9.
31. 31. Singh N, Telles S. High frequency yoga breathing can increase alveolar dead space. Comment to: Gastroesophageal reflux disease and pulmonary function: a potential role of the dead space extension, Damir Bonacin, Damir Fabijanic´ , Mislav Radic´ , Zv eljko Puljiz, Gorana Trgo, Andre Bratanic´ , Izet Hozo, Jadranka Tocilj, Med Sci Monit, 2012; 18(5): CR271-275. Med Sci Monit 2012; 18: LE5-L6; author reply LE5-L6.