Skip to main content
SpringerLink
Log in

Computertomographie bei Pankreastumoren

Computed tomography of pancreatic tumors

  • Leitthema
  • Published:
Der Radiologe Aims and scope Submit manuscript

Zusammenfassung

Die Computertomographie (CT), v. a. mit Mehrzeilentechnologie – syn. Multidetektor-CT (MDCT), Multislice-CT (MSCT) – ist aufgrund der hohen Ortsauflösung ideal zur Detektion von Pankreastumoren geeignet.

Technik der Wahl ist dabei die „Hydro-CT“. Hierzu wird unter medikamentöser Spasmolyse der Magen durch Gabe von 1–1,5 l Wasser als „negatives“ Kontrastmittel maximal distendiert, der Patient in 45° Rechtsseitenlage verbracht, um insbesondere die engen anatomischen Lagebeziehungen zum Pankreaskopf artefaktfrei darstellen zu können. Ergänzend werden zur therapieentscheidenden Darstellung der Lagebeziehung der Tumoren zum viszeralen Gefäßsystem „curved MPR“ und in Einzelfällen auch 3D-Darstellungen durchgeführt.

Zum Zeitpunkt der Diagnosestellung eines Pankreaskarzinoms können nur noch etwa 20% der Patienten operiert werden. Da dies allerdings in Kombination mit den modernen multimodalen Therapieverfahren die einzige Möglichkeit ist, ein signifikant längeres Überleben zu ermöglichen, kommt der Beurteilung der Karzinomresektabilität eine wesentliche Bedeutung zu. Aktuell können mit der MDCT nahezu alle Pankreaskarzinome sicher detektiert werden. Die Nachweisraten variieren zwischen 70 und 100% (in der neueren Literatur Sensitivitäten von 89%/Spezifitäten bis zu 99%). Im Einzelfall ist die Differenzierung zwischen fokaler Pankreatitis und Karzinom möglicherweise schwierig. Die Resektabilität kann mit Sensitivitäten von 94% und Spezifitäten bis zu 89% der Fälle richtig erfasst werden.

Die MDCT ist darüber hinaus ideal zur Detektion neuroendokriner Tumoren, Metastasen und zur Differenzierung zystischer Tumoren wie Pseudozysten, mikrozystischen Zystadenomen und intraduktalen papillär-muzinösen Neoplasien (IPMN). Zwar ist die sichere Einschätzung letzterer zwischen benigne, Borderline und maligner Transformation nicht immer möglich, allerdings können indirekte Hinweise aufgrund der hohen Ortsauflösung wie Wandknötchen, Gangweite und Verbindungen zum Ductus pancreaticus oft detektiert werden, die so vergleichbare Ergebnisse zur MRT mit der Magnetresonanz-Cholangiopankreatikographie (MRCP) liefern.

Die MDCT ist zusätzlich ein ideales Verfahren zur Beurteilung der lokalen Tumorsituation unter neoadjuvanter oder adjuvanter Therapie.

Abstract

Computed tomography (CT) and in particular multi-detector row computed tomography (MDCT), also known as multislice CT (MSCT), is ideally suited for detecting pancreatic tumors because of the high spatial resolution.

The method of choice is hydro-CT which involves distension of the stomach and duodenum by administration of 1–1.5 l water as a negative contrast medium under medically induced hypotension by administration of buscopan. The patient is laid on the right side at an angle of 30–45° in order to obtain an artefact-free image of the close anatomical relationship around the pancreas head. In addition, curved MPRs or in rare cases 3D reconstructions could be very helpful in identifying the critical anatomic tumor site in the neighbourhood of the visceral vessel system.

After the correct diagnosis of an adenocarcinoma has been made only 20% of all patients are shown to have a surgically resectable disease, but the overall survival rate is significantly higher after resection in combination with a multimodal tumor therapy strategy. The reason is that the correct diagnosis of the resectability of the tumor is one of the main criteria for overall survival of these patients. Currently practically all pancreatic tumors can be detected using MDCT and the detection rate varies between 70% and 100% (most recent literature references give a sensitivity of 89% and specificity up to 99%). In some rare cases the differentiation between focal necrotizing pancreatitis and pancreatic carcinoma can be difficult even with sophisticated protocols. Resectability can be correctly diagnosed with MDCT with a sensitivity of 94% and a specificity of 89%.

MDCT is an ideal tool for the detection of neuroendocrine tumors, metastases and for the differentiation of cystic pancreatic lesions such as pseudocysts, microcystic adenomas or intraductal papillary mucinous neoplasms (IPMN). Particularly, the differentiation of the latter into benign, borderline or malignant transformation is not always possible, but indirect signs, such as small nodules adjacent to the ductal wall, the diameter of the pancreatic duct, or a direct communication between cystic lesions and duct can be detected because of the high spatial resolution and is comparable to the findings in MRI. Moreover MD-CT is an ideal procedure for the differentiation of local tumor stages in patients under neoadjuvant or adjuvant chemotherapy.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1
Abb. 2
Abb. 3
Abb. 4
Abb. 5
Abb. 6
Abb. 7
Abb. 8
Abb. 9
Abb. 10
Abb. 11
Abb. 12
Abb. 13
Abb. 14
Abb. 15
Abb. 16
Abb. 17
Abb. 18
Abb. 19
Abb. 20
Abb. 21
Abb. 22

Literatur

  1. Schima W, Ba-Ssalamah A, Kolblinger C et al (2007) Pancreatic adenocarcinoma. Eur Radiol 17:638–649

    Article  PubMed  Google Scholar 

  2. Schima W, Ba-Ssalamah A, Plank C et al (2006) Pancreas. Part II: Tumors. Radiologe 46:421–437

    Article  PubMed  CAS  Google Scholar 

  3. Catalano C, Laghi A, Fraioli F et al (2003) Pancreatic carcinoma: the role of high-resolution multislice spiral CT in the diagnosis and assessment of resectability. Eur Radiol 13:149–156

    Article  PubMed  Google Scholar 

  4. Brugel M, Link TM, Rummeny EJ et al (2004) Assessment of vascular invasion in pancreatic head cancer with multislice spiral CT: value of multiplanar reconstructions. Eur Radiol 14:1188–1195

    Article  PubMed  Google Scholar 

  5. Klauss M, Mohr A, von Tengg-Kobligk H et al (2008) A new invasion score for determining the resectability of pancreatic carcinomas with contrast-enhanced multidetector computed tomography. Pancreatology 8:204–210

    Article  PubMed  CAS  Google Scholar 

  6. Ichikawa T, Erturk SM, Sou H et al (2006) MDCT of pancreatic adenocarcinoma: optimal imaging phases and multiplanar reformatted imaging. AJR Am J Roentgenol 187:1513–1520

    Article  PubMed  Google Scholar 

  7. Fukushima H, Itoh S, Takada A et al (2006) Diagnostic value of curved multiplanar reformatted images in multislice CT for the detection of resectable pancreatic ductal adenocarcinoma. Eur Radiol 16:1709–1718

    Article  PubMed  Google Scholar 

  8. Richter GM, Simon C, Hoffmann V et al (1996) Hydrospiral CT of the pancreas in thin section technique. Radiologe 36:397–405

    Article  PubMed  CAS  Google Scholar 

  9. Richter GM, Wunsch C, Schneider B et al (1998) Hydro-CT in detection and staging of pancreatic carcinoma. Radiologe 38:279–286

    Article  PubMed  CAS  Google Scholar 

  10. Happel B, Niederle B, Puespoek A et al (2008) Benign neuroendocrine and other rare benign tumors of the pancreas. Radiologe 48:752–763

    Article  PubMed  CAS  Google Scholar 

  11. Rha SE, Jung SE, Lee KH et al (2007) CT and MR imaging findings of endocrine tumor of the pancreas according to WHO classification. Eur J Radiol 62:371–377

    Article  PubMed  Google Scholar 

  12. Jemal A, Siegel R, Ward E et al (2006) Cancer statistics. CA Cancer J Clin 56:106–130

    Article  PubMed  Google Scholar 

  13. Kleeff J, Michalski C, Friess H, Buchler MW (2006) Pancreatic cancer: from bench to 5-year survival. Pancreas 33:111–118

    Article  PubMed  CAS  Google Scholar 

  14. Kim R, Saif MW (2007) Is there an optimal neoadjuvant therapy for locally advanced pancreatic cancer? JOP 8:279–288

    PubMed  Google Scholar 

  15. Neoptolemos JP, Stocken DD, Friess H et al (2004) A randomized trial of chemoradiotherapy and chemotherapy after resection of pancreatic cancer. N Engl J Med 350:1200–1210

    Article  PubMed  CAS  Google Scholar 

  16. Tamm EP, Silverman PM, Charnsangavej C, Evans DB (2003) Diagnosis, staging and surveillance of pancreatic cancer. AJR Am J Roentgenol 180:1311–1323

    PubMed  Google Scholar 

  17. Schima W, Ba-Ssalamah A, Plank C et al (2006) Pancreas. Part II: tumors. Radiologe 46:421–438

    Article  PubMed  CAS  Google Scholar 

  18. Bold RJ, Charnsangavej C, Cleary KR et al (1999) Major vascular resection as part of pancreaticoduodenectomy for cancer: radiologic, intraoperative and pathologic analysis. J Gastrointest Surg 3:233–243

    Article  PubMed  CAS  Google Scholar 

  19. Kleeff J, Friess H, Buchler MW (2007) Neoadjuvant therapy for pancreatic cancer. Br J Surg 94:261–262

    Article  PubMed  CAS  Google Scholar 

  20. NCCN. NCCN guidelines for treatment of pancreatic cancer (2006). http://www.nccn.org/professionals/physician_gls/PDF/pancreatic.pdf

  21. Furukawa H, Kosuge T, Mukai K et al (1998) Helical computed tomography in the diagnosis of portal vein invasion by pancreatic head carcinoma: usefulness for selecting surgical procedures and predicting the outcome. Arch Surg 133:61–65

    Article  PubMed  CAS  Google Scholar 

  22. Lehmann KJ, Diehl SJ, Lachmann R, Georgi M (1998) Value of dual-phase-helical CT in the preoperative diagnosis of pancreatic cancer – a prospective study. Rofo 168:211–216

    PubMed  CAS  Google Scholar 

  23. Bipat S, Phoa SS, van Delden OM et al (2005) Ultrasonography, computed tomography and magnetic resonance imaging for diagnosis and determining resectability of pancreatic adenocarcinoma: a meta-analysis. J Comput Assist Tomogr 29:438–445

    Article  PubMed  Google Scholar 

  24. Zeman RK, Cooper C, Zeiberg AS et al (1997) TNM staging of pancreatic carcinoma using helical CT. AJR Am J Roentgenol 169:459–464

    PubMed  CAS  Google Scholar 

  25. Li H, Zeng MS, Zhou KR et al (2005) Pancreatic adenocarcinoma: the different CT criteria for peripancreatic major arterial and venous invasion. J Comput Assist Tomogr 29:170–175

    Article  PubMed  Google Scholar 

  26. Li H, Zeng MS, Zhou KR et al (2006) Pancreatic adenocarcinoma: signs of vascular invasion determined by multi-detector row CT. Br J Radiol 79:880–887

    Article  PubMed  CAS  Google Scholar 

  27. Roche CJ, Hughes ML, Garvey CJ et al (2003) CT and pathologic assessment of prospective nodal staging in patients with ductal adenocarcinoma of the head of the pancreas. AJR Am J Roentgenol 180:475–480

    PubMed  Google Scholar 

  28. Warshaw AL, Fernandez-del Castillo C (1992) Pancreatic carcinoma. N Engl J Med 326:455–465

    PubMed  CAS  Google Scholar 

  29. Schima W, Fugger R, Schober E et al (2002) Diagnosis and staging of pancreatic cancer: comparison of mangafodipir trisodium-enhanced MR imaging and contrast-enhanced helical hydro-CT. AJR Am J Roentgenol 179:717–724

    PubMed  Google Scholar 

  30. Trede M, Rumstadt B, Wendl K et al (1997) Ultrafast magnetic resonance imaging improves the staging of pancreatic tumors. Ann Surg 226:393–405 (discussion 405–397)

    Article  PubMed  CAS  Google Scholar 

  31. Chao C, Hoffman JP, Ross EA et al (2000) Pancreatic carcinoma deemed unresectable at exploration may be resected for cure: an institutional experience. Am Surg 66:378–385 (discussion 386)

    PubMed  CAS  Google Scholar 

  32. Beger HG, Poch B, Schwarz M, Gansauge F (2003) Pancreatic cancer. The relative importance of neoadjuvant therapy. Chirurg 74:202–207

    Article  PubMed  CAS  Google Scholar 

  33. Seufferlein T, von Wichert G, Adler G (2007) Palliative treatment of pancreatic cancer. Dtsch Med Wochenschr 132:813–817

    Article  PubMed  CAS  Google Scholar 

  34. Tamm EP, Loyer EM, Faria S et al (2006) Staging of pancreatic cancer with multidetector CT in the setting of preoperative chemoradiation therapy. Abdom Imaging 31:568–574

    Article  PubMed  CAS  Google Scholar 

  35. Klauß M, Welzel T, Werner J et al (2008) Multidetector CT evaluation of the course of nonresectable pancreatic carcinomas with neoadjuvant therapy. Pancreatology 704, DOI 10.1159/000

  36. Vick C, Zech CJ, Hopfner S et al (2003) Imaging of neuroendocrine tumors of the pancreas. Radiologe 43:293–300

    Article  PubMed  CAS  Google Scholar 

  37. Phan GQ, Yeo CJ, Hruban RH et al (1998) Surgical experience with pancreatic and peripancreatic neuroendocrine tumors: review of 125 patients. J Gastrointest Surg 2:472–482

    Article  PubMed  CAS  Google Scholar 

  38. Smith TR, Koenigsberg M (1990) Low-density insulinoma on dynamic CT. AJR Am J Roentgenol 155:995–996

    PubMed  CAS  Google Scholar 

  39. Ichikawa T, Peterson MS, Federle MP et al (2000) Islet cell tumor of the pancreas: biphasic CT versus MR imaging in tumor detection. Radiology 216:163–171

    PubMed  CAS  Google Scholar 

  40. Semelka RC, Cumming MJ, Shoenut JP et al (1993) Islet cell tumors: comparison of dynamic contrast-enhanced CT and MR imaging with dynamic gadolinium enhancement and fat suppression. Radiology 186:799–802

    PubMed  CAS  Google Scholar 

  41. Fernandez-del Castillo C, Warshaw AL (1995) Cystic tumors of the pancreas. Surg Clin North Am 75:1001–1016

    Google Scholar 

  42. Sahani DV, Kadavigere R, Saokar A et al (2005) Cystic pancreatic lesions: a simple imaging-based classification system for guiding management. Radiographics 25:1471–1484

    Article  PubMed  Google Scholar 

  43. Sahani DV, Saokar A, Hahn PF et al (2006) Pancreatic cysts 3 cm or smaller: how aggressive should treatment be? Radiology 238:912–919

    Article  PubMed  Google Scholar 

  44. Brugge WR, Lauwers GY, Sahani D et al (2004) Cystic neoplasms of the pancreas. N Engl J Med 351:1218–1226

    Article  PubMed  CAS  Google Scholar 

  45. Strobel O, Z’Graggen K, Schmitz-Winnenthal FH et al (2003) Risk of malignancy in serous cystic neoplasms of the pancreas. Digestion 68:24–33

    Article  PubMed  Google Scholar 

  46. Colonna J, Plaza JA, Frankel WL et al (2008) Serous cystadenoma of the pancreas: clinical and pathological features in 33 patients. Pancreatology 8:135–141

    Article  PubMed  Google Scholar 

  47. Garcea G, Ong SL, Rajesh A et al (2008) Cystic lesions of the pancreas. A diagnostic and management dilemma. Pancreatology 8:236–251

    Article  PubMed  CAS  Google Scholar 

  48. Tseng JF, Warshaw AL, Sahani DV et al (2005) Serous cystadenoma of the pancreas: tumor growth rates and recommendations for treatment. Ann Surg 242:413–419 (discussion 419–421)

    PubMed  Google Scholar 

  49. Goh BK, Tan YM, Yap WM et al (2006) Pancreatic serous oligocystic adenomas: clinicopathologic features and a comparison with serous microcystic adenomas and mucinous cystic neoplasms. World J Surg 30:1553–1559

    Article  PubMed  Google Scholar 

  50. Campbell F, Azadeh B (2008) Cystic neoplasms of the exocrine pancreas. Histopathology 52:539–551

    Article  PubMed  CAS  Google Scholar 

  51. Tanaka M, Chari S, Adsay V et al (2006) International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas. Pancreatology 6:17–32

    Article  PubMed  Google Scholar 

  52. Belyaev O, Seelig MH, Muller CA et al (2008) Intraductal papillary mucinous neoplasms of the pancreas. J Clin Gastroenterol 42:284–294

    PubMed  Google Scholar 

  53. Ogawa H, Itoh S, Ikeda M et al (2008) Intraductal papillary mucinous neoplasm of the pancreas: Assessment of the likelihood of invasiveness with multisection CT. Radiology 248:876–886

    Article  PubMed  Google Scholar 

  54. Michaels PJ, Brachtel EF, Bounds BC et al (2006) Intraductal papillary mucinous neoplasm of the pancreas: cytologic features predict histologic grade. Cancer 108:163–173

    Article  PubMed  Google Scholar 

  55. D’Angelica M, Brennan MF, Suriawinata AA et al (2004) Intraductal papillary mucinous neoplasms of the pancreas: an analysis of clinicopathologic features and outcome. Ann Surg 239:400–408

    Article  Google Scholar 

  56. Salvia R, Fernandez-del Castillo C, Bassi C et al (2004) Main-duct intraductal papillary mucinous neoplasms of the pancreas: clinical predictors of malignancy and long-term survival following resection. Ann Surg 239:678–685 (discussion 685–677)

    Article  PubMed  Google Scholar 

  57. Sohn TA, Yeo CJ, Cameron JL et al (2004) Intraductal papillary mucinous neoplasms of the pancreas: an updated experience. Ann Surg 239:788–797 (discussion 797–789)

    Article  PubMed  Google Scholar 

  58. Gourgiotis S, Ridolfini MP, Germanos S (2007) Intraductal papillary mucinous neoplasms of the pancreas. Eur J Surg Oncol 33:678–684

    PubMed  CAS  Google Scholar 

  59. Murakami Y, Uemura K, Hayashidani Y et al (2007) Predictive factors of malignant or invasive intraductal papillary-mucinous neoplasms of the pancreas. J Gastrointest Surg 11:338–344

    Article  PubMed  Google Scholar 

  60. Sugiyama M, Izumisato Y, Abe N et al (2003) Predictive factors for malignancy in intraductal papillary-mucinous tumours of the pancreas. Br J Surg 90:1244–1249

    Article  PubMed  CAS  Google Scholar 

  61. Schmidt CM, White PB, Waters JA et al (2007) Intraductal papillary mucinous neoplasms: predictors of malignant and invasive pathology. Ann Surg 246:644–651 (discussion 651–644)

    Article  PubMed  Google Scholar 

  62. Song SJ, Lee JM, Kim YJ et al (2007) Differentiation of intraductal papillary mucinous neoplasms from other pancreatic cystic masses: comparison of multirow-detector CT and MR imaging using ROC analysis. J Magn Reson Imaging 26:86–93

    Article  PubMed  Google Scholar 

  63. Waters JA, Schmidt CM, Pinchot JW et al (2008) CT vs MRCP: optimal classification of IPMN type and extent. J Gastrointest Surg 12:101–109

    Article  PubMed  Google Scholar 

  64. Kloppel G, Kosmahl M (2001) Cystic lesions and neoplasms of the pancreas. The features are becoming clearer. Pancreatology 1:648–655

    Article  PubMed  CAS  Google Scholar 

  65. Tipton SG, Smyrk TC, Sarr MG, Thompson GB (2006) Malignant potential of solid pseudopapillary neoplasm of the pancreas. Br J Surg 93:733–737

    Article  PubMed  CAS  Google Scholar 

  66. Bachmann J, Michalski CW, Bergmann F et al (2007) Metastasis of rectal adenocarcinoma to the pancreas. Two case reports and a review of the literature. JOP 8:214–222

    PubMed  Google Scholar 

  67. Sellner F, Tykalsky N, De Santis M et al (2006) Solitary and multiple isolated metastases of clear cell renal carcinoma to the pancreas: an indication for pancreatic surgery. Ann Surg Oncol 13:75–85

    Article  PubMed  Google Scholar 

  68. Wente MN, Kleeff J, Esposito I et al (2005) Renal cancer cell metastasis into the pancreas: a single-center experience and overview of the literature. Pancreas 30:218–222

    Article  PubMed  Google Scholar 

  69. Palmowski M, Hacke N, Satzl S et al (2008) Metastasis to the pancreas: characterization by morphology and contrast enhancement features on CT and MRI. Pancreatology 8:199–203

    Article  PubMed  Google Scholar 

  70. Tillmann BN (2005) Atlas der Anatomie. Springer, Berlin Heidelberg New York

  71. Nöldge G, Weber M-A, Ritzel RA et al (2009) Invasive Diagnostik bei Insulinomen. Radiologe, epub ahead of print

Download references

Interessenkonflikt

Der korrespondierende Autor gibt an, dass kein Interessenkonflikt besteht.

Author information

Authors and Affiliations

  1. Abt. Diagnostische und Interventionelle Radiologie, Radiologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Deutschland

    L. Grenacher & M. Klauß

Authors
  1. L. Grenacher
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. M. Klauß
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to L. Grenacher.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Grenacher, L., Klauß, M. Computertomographie bei Pankreastumoren. Radiologe 49, 107–123 (2009). https://doi.org/10.1007/s00117-008-1755-1

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00117-008-1755-1

Schlüsselwörter

Keywords

Search

Navigation