Pankreas kanseri -karaciğer metastazlarında difüzyon ağırlıklı manyetik rezonans görüntüleme

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 kanseri tanılı 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.

Diffusion weighted magnetic resonance imaging of hepatic metastasis of pancreatic cancer

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.

Kaynakça

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