Interesting X-rays 1
1) Carcinoma of the head of the pancreas
Finding : Pancreatic protocol helical computed tomography scan. The scan demonstrates a
lesion in the head of the pancreas. The coronal reconstruction demonstrates possible
involvement of the portal vein by the lesion.
Surgical point :
The single most valuable study to stage patients with pancreatic cancer is the helical
computerized tomographic (CT) scan performed as a pancreatic protocol scan . The pancreatic
protocol CT requires that 2–3 mm cuts be performed through the pancreas itself during the
administration of intravenous contrast and that separate scans for both the pancreas and the
liver during the arterial and venous phases be performed. Appropriate software permits the
creation of images that provide extraordinary detail of the tumor and its relationship to
important adjacent structures.
The information provided by a pancreatic protocol CT allows for correct prediction of
resectability approximately 85% of the time. Signs of unresectability includs
loss of the normal fat plane between the superior mesenteric or portal vein and the tumor of
more than 50% of the circumference of the vein, portal vien and or superior mesenteric vein
oclusion or encasement, extra pancreatic extension, presence of liver or peritoneal metastesis.
Patients with metastatic disease are not operative candidates. Locally advanced disease that
includes involvement of the hepatic, celiac, or superior mesenteric arteries or involvement of
the superior mesenteric or portal vein is generally felt to be unresectable by most pancreatic
surgeons.
However, a growing experience with patients who have superior mesenteric or portal vein
involvement suggests that vein resection can be performed safely. Although the survival rate
for these patients is similar to that of resected patients without vein involvement, no patients
are cured.
Patients with involved celiac or periaortic nodes (not normally resected as part of a
pancreaticoduodenectomy) are considered unresectable. However, because enlarged lymph
nodes identified on preoperative imaging studies may be either inflammatory or neoplastic,
large nodes should not be a reason to deny a patient an operation and the chance for a
resection.
Staging :
Patients with tumor confined to the pancreas and lymph nodes that will be included in the
resection and who have no vascular invasion are candidates for resection.
Table- The American Joint Committee on Cancer 6th Edition Staging System—
Pancreatic Cancer
Primary
Tumor (T)
T1
Tumor limited to the pancreas, ≤2 cm
T2
Tumor limited to the pancreas, >2 cm
T3
Tumor extends beyond the pancreas but without
involvement of the celiac axis or the superior mesenteric
artery
T4
Tumor involves the celiac axis or the superior mesenteric
artery (unresectable primary tumor)
Regional Lymph Nodes (N)
N0
No regional lymph node metastasis
N1
Regional lymph node metastasis
Distant Metastasis (M)
M0
No distant metastasis
M1
Distant metastasis
Stage Grouping
Stage Grouping
0
Tis
N0
M0
T1- T2
N0
M0
T3
N0
M0
T1,2,3
N1
M0
III
T4
Any N
M0
IV
Any T
Any N
M1
I
II