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New Concepts in Staging and Treatment of Locally Advanced Pancreatic Head Cancer

Chandana G. Lall1, Thomas J. Howard2, Arunan Skandarajah1, John M. DeWitt3, Alex M. Aisen1 and Kumaresan Sandrasegaran1

1 Department of Radiology, Indiana University Medical Center, UH 0279, 550 N University Blvd., Indianapolis, IN 46202.
2 Department of Surgery, Indiana University Medical Center, Indianapolis, IN.
3 Department of Medicine, Indiana University Medical Center, Indianapolis, IN.


Figure 1
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  		Fig. 1 —Diagram shows pylorus-preserving pancreaticoduodenectomy (classic Whipple procedure is shown in inset). This procedure entails radical dissection of pancreatic head, adjacent nodes, gallbladder, common bile duct, and most or all of duodenum followed by gastrojejunostomy or duodenojejunostomy, pancreaticojejunostomy, and hepaticojejunostomy.

 

Figure 2
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  		Fig. 2 —Diagram shows sites of venous invasion that may be potentially resectable; v = vein, vv = veins. Most common anatomic configuration of portal vein is shown. Early invasion of venous segment marked in purple is potentially resectable, with subsequent vein reconstruction. Invasion of superior mesenteric vein proximal (away from liver) to its jejunal tributaries is not resectable due to difficulty with vascular control in this area and potential for bowel infarction.

 

Figure 3
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  		Fig. 3A —62-year-old man with locally advanced pancreatic cancer. Intraoperative photograph before tumor resection shows portal vein confluence (arrowhead) involved by tumor (arrows) arising from superior aspect of pancreatic head.

 

Figure 4
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  		Fig. 3B —62-year-old man with locally advanced pancreatic cancer. Intraoperative photograph after tumor resection shows portal and superior mesenteric veins reconstructed over segment marked by sutures (arrows).

 

Figure 5
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  		Fig. 4A —58-year-old man with pancreatic cancer. Noncircumferential distal superior mesenteric vein involvement is potentially resectable with vein reconstruction. Coronal CT reformation images show invasion of proximal portal vein (straight arrow, A) by tumor in superior head of pancreas (arrowhead, A). Superior mesenteric vein was not involved at level of its most distal jejunal tributary (arrow, B). Hepatic artery (arrowhead, B), superior mesenteric artery (dashed arrow, A), and splenic vein (curved arrow, A) were clear of tumor. Whipple procedure with portal vein reconstruction was performed.

 

Figure 6
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  		Fig. 4B —58-year-old man with pancreatic cancer. Noncircumferential distal superior mesenteric vein involvement is potentially resectable with vein reconstruction. Coronal CT reformation images show invasion of proximal portal vein (straight arrow, A) by tumor in superior head of pancreas (arrowhead, A). Superior mesenteric vein was not involved at level of its most distal jejunal tributary (arrow, B). Hepatic artery (arrowhead, B), superior mesenteric artery (dashed arrow, A), and splenic vein (curved arrow, A) were clear of tumor. Whipple procedure with portal vein reconstruction was performed.

 

Figure 7
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  		Fig. 5 —83-year-old man with resectable pancreatic cancer. This case shows value of coronal reformation in determining length of venous invasion. Coronal reformation image shows that tumor abuts portal confluence over 1-cm segment (double arrow). Vertical length of involvement was easier to determine on coronal reformation images than on axial images (not shown). Superior mesenteric vein was involved above insertion of first jejunal branch (black arrow). Note anomalous venous anatomy with inferior mesenteric vein (white arrow) joining superior mesenteric vein and biliary (arrowhead) and pancreatic stents. Whipple procedure with vein reconstruction was performed.

 

Figure 8
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  		Fig. 6 —58-year-old man with unresectable pancreatic cancer. Coronal slab maximum-intensity-projection image shows cancer arising in head of pancreas (arrowhead) encircling and constricting portal vein (P). Even though length of involvement (double arrow) was short, surgery was not contemplated in view of likelihood of positive margins. Advanced venous invasion is usually not resectable for cure.

 

Figure 9
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  		Fig. 7 —65-year-old man with unresectable pancreatic cancer. Inferiorly positioned pancreatic head and uncinate process cancers are usually unresectable if they locally invade superior mesenteric vein or transverse mesocolon. Axial CT image shows small inferior pancreatic head–uncinate process tumor (solid black arrow) applied over 90° arc to superior mesenteric vein (black arrowhead). Note jejunal branch (dashed arrow) entering superior mesenteric vein at this level. Despite CT findings, surgery was attempted, but adequate vascular control of superior mesenteric vein could not be performed safely. Palliative surgery was performed. In addition, transverse mesocolon was invaded. This finding was not called preoperatively, but, in retrospect, there was wispiness of mesocolic fat (white arrow). Note proximity of fine veins (white arrowheads) in mesocolon.

 

Figure 10
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  		Fig. 8 —72-year-old man with unresectable pancreatic cancer. Invasion of transverse mesocolon signals unresectability. Coronal reformation image shows barely visible tumor abutting superior mesenteric vein over 1.5-cm segment (double arrow). This finding per se was not considered contraindication to pancreaticoduodenectomy. However, there was soft tissue in transverse mesocolon (arrowhead), which was suspected to be invasive cancer and proven on subsequent diagnostic laparoscopy. Patient did not have curative resection. Tumor is closely abutting and probably invades third part of duodenum (white arrow). Duodenal invasion does not preclude pancreaticoduodenectomy because almost all of duodenum is removed at surgery.

 

Figure 11
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  		Fig. 9A —69-year-old woman with pancreatic cancer. Invasion or occlusion of gastroduodenal artery is not contraindication to surgery. Axial CT image shows constriction of gastroduodenal artery (white arrowhead) by tumor (white arrow). Superior mesenteric vein (black arrow) was free of tumor. Note common bile duct stent (black arrowhead).

 

Figure 12
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  		Fig. 9B —69-year-old woman with pancreatic cancer. Invasion or occlusion of gastroduodenal artery is not contraindication to surgery. Endoscopic color Doppler sonogram (reproduced here in gray-scale) obtained before common bile duct (CBD) stent insertion showed dilated CBD and encased but patent gastroduodenal artery (GDA). Common hepatic artery (not shown) was uninvolved by tumor. Echogenic fat (arrowhead) was seen between tumor (TU) and superior mesenteric vein (SMV), indicating this vessel was free of tumor.

 

Figure 13
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  		Fig. 10A —76-year-old woman with small tumor in head of pancreas. Variant anatomy makes otherwise resectable cancer unresectable. Axial (A) and coronal (B) reformation images of small tumor (black arrows) in head of pancreas show that cancer was unresectable for cure because common hepatic artery (black arrowheads) had very low course, inferior in relation to portal vein (white arrow, B) and was encased by tumor. Note biliary stent (white arrowheads).

 

Figure 14
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  		Fig. 10B —76-year-old woman with small tumor in head of pancreas. Variant anatomy makes otherwise resectable cancer unresectable. Axial (A) and coronal (B) reformation images of small tumor (black arrows) in head of pancreas show that cancer was unresectable for cure because common hepatic artery (black arrowheads) had very low course, inferior in relation to portal vein (white arrow, B) and was encased by tumor. Note biliary stent (white arrowheads).

 

Figure 15
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  		Fig. 11A —59-year-old man with pancreatic cancer. Variant anatomy may make an otherwise unresectable cancer potentially resectable. A is most superior and C is most inferior of these images. Axial CT image shows mass arising from neck of pancreas (solid arrow) and invading distal celiac (arrowhead) and splenic (dashed arrow) arteries.

 

Figure 16
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  		Fig. 11B —59-year-old man with pancreatic cancer. Variant anatomy may make an otherwise unresectable cancer potentially resectable. A is most superior and C is most inferior of these images. Axial CT image shows hepatic artery (white arrow) branching almost immediately from celiac trunk and not involved by tumor (black arrow).

 

Figure 17
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  		Fig. 11C —59-year-old man with pancreatic cancer. Variant anatomy may make an otherwise unresectable cancer potentially resectable. A is most superior and C is most inferior of these images. Axial CT image shows replaced right hepatic artery (arrowhead) from superior mesenteric artery (dashed arrow) also clear of tumor. Because hepatic arterial supply was spared despite celiac artery involvement, curative resection was attempted but abandoned because of unexpected peritoneal metastases.

 

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