Part II: Roentgen-Diagnosis of Carcinoma of the Pancreas

Transcription

1 Acta Radiologica: Diagnosis ISSN: (Print) (Online) Journal homepage: Part II: Roentgen-Diagnosis of Carcinoma of the Pancreas To cite this article: (1965) Part II: Roentgen-Diagnosis of Carcinoma of the Pancreas, Acta Radiologica: Diagnosis, 3:sup235, To link to this article: Published online: 4 Jan 21. Submit your article to this journal Article views: 1 View related articles Full Terms & Conditions of access and use can be found at

2 PART II ROENTGEN-DIAGNOSIS OF CARCINOMA OF THE PANCREAS

3

4 I I I. P REV1 U S I NVE STI GAT1 ON S CONVENTIONAL METHODS The roentgen diagnosis of tumours of the pancreas has been based on indirect evidence, i. e., information from methods that demonstrate disease of the pancreas by changes produced in adjacent organs. The method most widely used is roentgen examination of the stomach and duodenum following ingestion of barium. Since more than 8 O/o of all malignant tumours of the pancreas are situated in the head of this organ (BERK 1941)~ they often involve the duodenum fairly early. The duodenal loop may be widened, and there may be an impression on or infiltration in the lesser curvature. (RIGLER 1933, FROSTBERG 1938). If the tumour is large the prepyloric area of the stomach is displaced upward, forward or downward according to the position of the stomach relative to the tumour. A tumour of the body of the pancreas can produce similar changes, while tumours of the tail do not cause any demonstrable change in the appearance of the stomach until they have attained a considerable size. Judging from reports based on large series of patients, roentgen examination following ingestion of barium will produce conclusive evidence of tumour in only about half of all cases. CERNEY & WALLACE (1955) diagnosed 23 Yo of 139 carcinomas of the pancreas with this method, BEELER & KIRKLIN (1952) 42 O/o of 167, and BROADBENT & KERNIAN (1951) 54 O/o of 76. SALIK (1961) reported a correct diagnosis in 77 Yo of 67 patients examined by the same method. In some of his cases, however, the diagnosis appeared to be based on subtle mucosal changes often difficult to distinguish from normal variations. Demonstration of small abnormalities in the duodenal mucosa requires investigation of the motility of the duodenum, preferably by cineradiography (JORGENS et coll. 1962). Such an examination can reveal smaller impressions or infiltrates better than conventional studies after ingestion of barium. Ordinary roentgen examination of the stomach and duodenum can be supplemented by pharmacoduodenography (LIOTTA I 955). According to this method, duodenal hypotonia is produced by the administration of an anticholinergic drug. The duodenum then fits more closely to adjacent organs, and changes in the papilla of Vater or the head of the pancreas can be more easily detected.

5 58 ENGEL & LYSHOLM (1934) described a method for diagnosing tumours of the pancreas by inflation of the stomach with gas. They found that a normal pancreas produced an impression in the posterior wall of the distended stomach and that any increase in the size of the pancreas caused a corresponding increase in the size of the impression. Critical analysis of the method by HOLM (1941)~ however, showed that a pancreatic mass could be simulated by other retroperitoneal tumours, tumours of the liver, ascites, or fat. In other words, the impression in the distended stomach is not pathognomonic of a pancreatic tumour. The method is more reliable in the diagnosis of well-defined tumours in the anterior part of the pancreas, which are, however, rare (OLLE OLSSON In the roentgen examination of patients for tumours of the pancreas, inflation of the stomach with gas can be combined with retroperitoneal pneumography and body section roentgenography in different planes (MACARINI & OLIVA 1957). In the absence of disease, this method will often outline the pancreas. In the presence of inflammatory changes or tumour, however, oedema or adhesions may occur between the pancreas and adjacent tissue and thereby interfere with the anatomic relationships prerequisite to the examination. Cancer of the head of the pancreas often affects the common bile duct early. Such involvement is reflected by irregular stenosis of the caudal part of the common bile duct. The stenosis can be diagnosed preoperatively by cholegraphy in the preicteric or subicteric stage of the disease (WISE et coll. 1957, EVANS & MUJAHED I 959) or by percutaneous transhepatic cholangiography in the icteric stage (NURICK et coll. 1953, WIECHEL 1964). All of the previously mentioned diagnostic methods are based on changes produced in neighbouring organs. Such abnormalities are frequently not characteristic. In concluding this review of the conventional methods, the following quotations hold true: the pancreas still presents the physician with one of his most perplexing pursuits (RIGLER 1g45), and as long as we must depend on indirect technique, our accuracy in the diagnosis of pancreatic disease will not be at a satisfactory level (MOSELEY 1961). ANGIOGRAPHIC DIAGNOSIS Splenoportography may be used to diagnose pancreatic tumours. Tumours of the body or tail of the pancreas may displace or infiltrate the splenic vein (LEROUX & DE SCOVILLE 1954, CATALANO & GIARDIELLO 1955, ANACKER et coll. 1957, CACCIARI et coll. 1958, RBSCH 1959, BERGSTRAND 1961, ROSCH & HERFORT I 962). The method will, however, not often allow differentiation between malignant tumour, non-malignant tumour, and pancreatitis.

6 In most cases of carcinoma, angiography will reveal positive evidence of the tumour, i. e., vascular infiltration and newly-formed pathologic vessels within the tumour. The pancreas is richly vascularized. Therefore, tumours of the pancreas may produce vascular changes demonstrable by angiography. Tumours of the pancreas has occasionally been diagnosed by abdominal aortography (SMITH et coll. 1952, CREEVY et coll. 1953, GOLLMAN 1956, PYRAH & COWIE 199, BIEBER & ALBO 1963)~ but this method appears to be capable of demonstrating only large or very richly vascularized tumours. Therefore only a few neoplasms are discovered by this method, and the findings reported have not been the result of systematic investigations. In abdominal aortography the concentration of the contrast medium in the pancreatic vessels is too low to properly define the fine vessels running from the coeliac and superior mesenteric arteries to the pancreas. Moreover, these fine vessels are difficult to differentiate from the superimposed lumbar and renal arteries. The contrast medium filling the aorta obscures part of the body of the pancreas, and this area can therefore not be examined. The method can, however, demonstrate displacement of the larger vessels around the pancreas (CREEVY et coll. 1953, GOLLMANN 1956, BIEBER & ALBO 1963), and, if the tumour is richly vascularised, also pathologic vessels (PYRAH& COWIE 1957, BIEBER & ALBO 1963). At the Roentgendiagnostic Department, University Hospital, Lund, it is considered necessary to obtain as selective a filling as possible in all types of angiography. Judging from the experience at our department, angiography of the pancreas requires selective injection of contrast medium into the coeliac and superior mesenteric arteries simultaneously. BIERMAN et coll. (1951) described antegrade catheterisation of the coeliac and superior mesenteric arteries via the carotid and brachial arteries. Because of a number of serious complications using the carotid approach, this method has never been widely used. MORINO & TARQUINI (1956) performed antegrade catheterisation of the coeliac and superior mesenteric vessels by introducing a catheter through the exposed brachial artery, while TILLANDER (1956) of our department used the same route, but guided the catheter electromagnetically. That year ODMAN described a technique for percutaneous retrograde catheterisation of the coeliac and superior mesenteric arteries via the femoral artery. He directed a radiopaque catheter with a pre-formed curve at the tip into the artery to be examined. These methods have since been further developed and modified by other workers in this field. Because of these improvements and the availability of less toxic contrast media, complications are now rare. A valuable modification of ODMAN S method in the examination of the pancreas was described by BOIJSEN & OLIN (1961) and OLLE OLSSON, BOIJSEN & OLIN (1962). Via the femoral arteries they introduced one catheter into the 59

7 6 coeliac artery and a second into the superior mesenteric artery. Contrast medium was then injected simultaneously through both catheters. Selective angiography (UDMAN 1958, 1961, BOIJSEN & OLIN 1961, ROSCH & BRET 1963) has been used in the diagnosis of pancreatic cysts, which displace the vessels in and around the pancreas. Cystadenoma of the pancreas can be recognized not only from displacement of these vessels, but also from the rich pathologic vascularization ( SWANSON I 963, GLENN et coll. I 964). Insuloma may also be richly vascularized and the case published by OLLE OLSON (1963) showed a fairly long retention of the contrast medium in the tumour. Selective angiography in the diagnosis of carcinoma of the pancreas has been described in only a few case reports apart from the cases of the Roentgendiagnostic Department, University Hospital, Lund. At the annual meeting of Scandinavian Ass. for Med. Radiol. in 1961, BOIJSEN & OLIN presented a surgically confirmed case of carcinoma of the pancreas containing numerous pathologic vessels and a second case without such vascularization but with irregular narrowing of the gastroduodenal artery. At a meeting of Swedish Ass. for Med. radiol. in 1962, LUNDERQUIST reported the first 12 cases of carcinoma of the pancreas demonstrated by selective angiography at our department. He stressed the diagnostic importance of irregular narrowing of vessels affected by the tumour in addition to displacement of normally occurring vessels and the presence of newly-formed pathologic vessels. Such changes have since been described by CORTESINI (1963), who found stenosis progressing to occlusion of the gastroduodenal artery in one case of cancer of the head of the pancreas, and by MEANEY et coll. (1963), who demonstrated stenosis of the coeliac, splenic and hepatic arteries when the tumour was situated in the body of pancreas. ROSCH & BRET (1963) reported one case with a poorly vascularized tumour and one with a richly vascularized tumour of the pancreas, but they did not mention the histopathologic nature of the growths. BOIJSEN & OLIN (I 964) referring to LUNDERQUIST, stressed that irregular narrowing of the lumina of the pancreatic vessels in association with displacement of vessels within the pancreas is sometimes alone sufficient to warrant a diagnosis of cancer of the pancreas, i. e., even when no tumour vessels can be demonstrated. In one case of carcinoma of the head of the pancreas, GLENN et coll. (1964) described displacement of the pancreatic vessels but mentioned nothing about pathologic vessels or narrowing of the vessels.

8 diabetes IV. PRESENT INVESTIGATION MATERIAL AND METHODS Carcinoma of the pancreas may originate in the epithelium of the excretory ducts or in the acini. The duct tumour is the commoner type. Tumours of the common bile duct and the papilla of Vater have the same microscopic appearance as the duct tumour of the pancreas. It is, therefore, only the macroscopic site of the tumour that decides to which type it should be assigned. The origin of a duct tumour infiltrating both the head of the pancreas and the common bile duct can thus not be decided from the microscopic findings (HENKE& LUBARSCH I 929). Carcinomas of the caudal part of the common bile duct and of the papilla of Vater were, therefore, included in this material of carcinoma of the pancreas. But since the macroscopic site of these tumours was usually readily recognized, they were allocated to a separate group. Selective arteriography of the coeliac and superior mesenteric arteries was done in thirty-six patients with carcinoma of the pancreas, of the caudal part of the common bile duct and of the papilla of Vater. The malignant tumour was situated in the pancreas in thirty cases, in the papilla of Vater in four, and in the caudal part of the common bile duct in two. The patients ages ranged from 4 to 82 years (average 63 years). Seventeen of the patients were Table 5. Distribution of symptoms ~~~~~ Patients with: Number Site of tumour of abdo- loss of patients jaundice minal body pain weight Head of pancreas I 4 Body and tail of pancreas Pap. of Vater and caudal common bile duct I

9 62 females and nineteen males. The patients had had symptoms for z weeks to I year, (average 3.6 months) before the operation. The commonest symptoms were jaundice, abdominal pain, and loss of bodyweight (Table 5). In only three cases was a tumour palpated in the abdomen. Roentgen examination of the stomach and duodenum of 32 of the patients after ingestion of barium showed changes suggestive of tumour of the pancreas in thirteen (41 Yo). In sixteen cases the examination revealed no abnormalities and in two a non-characteristic deformation of the duodenal bulb. In one patient with cancer of the caudal part of the common bile duct, the examination disclosed a hiatus hernia but otherwise nothing abnormal. CARCINOMA O F THE HEAD OF THE PANCREAS In twenty-three patients the tumour was situated in the head of the pancreas. They had had symptoms from 2 weeks to 12 months. The commonest symptom was jaundice (Table 5). In one case it was difficult to ascertain the site of the tumour because of peritoneal carcinosis and adhesions, but, judging from the angiographic examination, the tumour was situated in the head of the pancreas. Roentgen examination of the stomach showed changes suggestive of tumour of the pancreas in nine (6-8, 1, 13, 14, 16, 21, 22) of twenty patients studied. In nineteen cases angiography was a part of the preoperative investigation, while four patients were examined after some palliative operation, such as cholecysto-jejunostomy because of jaundice. Selective angiography of both the coeliac artery and the superior mesenteric artery was performed in fifteen cases, while in six (11, 12, 16, 17, 22, 23) only the coeliac artery was catheterised, and in two (2, IS) only the superior mesenteric artery. In thirteen cases no attempt was made to remove the tumour, usually because it had already metastasised or because of its relationship to the larger vessels. One patient was judged as operable, but after a palliative operation with cholecysto-jejunostomy she developed renal insufficiency with uraemia and died. Another patient was considered too old for radical pancreatectomy and was therefore subjected to cholecysto-jejunostomy only. Pancreatectomy was done in seven cases, and resection of the head of the pancreas in one. ANG IOG RAPH IC EXAM NATION Displacement of arteries. The tumours caused only slight displacement of the arteries around and in the pancreas. The normal range of variation of the

10 course of the common hepatic artery, gastroduodenal artery, and pancreatic arcades is so wide that it was difficult to recognise any slight displacement. Displacement of the arteries around and in the pancreas by the tumour was observed in all together eleven cases (Figs. 11, 12, 15, 16, 18-2, 22, 23, 25, 28). In four cases (3, 7, 16, 18) the tumour caused a slight curvature of the gastroduodenal artery, while the gastroduodenal artery was displaced to the left by an enlarged liver in three cases (I, 5, 2) and by an enlarged gallbladder in two (4, 12). When the tumour affected the pancreatic arcades the latter were either straightened out or displaced in a slight bow. Such displacement of the posterior superior pancreaticoduodenal artery was seen in seven cases (I, 6, 7, 9, 1, 14, 21) and of the anterior superior pancreaticoduodenal artery in six (6, 7, 11, 14, 16, 21). A tumour of the head of the pancreas had also displaced the transverse pancreatic artery in one case (16) and the superior mesenteric artery in two (14, 21). In twelve cases (2, 4, 5, 8, 12, 13, 15, 17, 19, 2, 22, 23) no arterial displacement ascribable to the tumour could be observed. Irregular arterial stenosis. Irregular stenosis of arteries involved by the tumours was common and was seen in sixteen cases (Figs. 11, 12, 14, 17, 18, 2-3). Such narrowing of the lumen of the gastroduodenal artery was noted in six cases (13, 17, 19, 2, 22, 23), of the posterior superior pancreaticoduodenal artery in nine (I, 3, 8, 9, 13, 14, 17, 18, zo), and of the anterior superior pancreaticoduodenal artery in ten (8, 11, 13, 14, 16, 17, 19-22). Other arteries affected in the same way by the tumour were: the transverse pancreatic artery (case IS), the first jejunal branch from the superior mesenteric artery with its inferior pancreaticoduodenal artery (case 5), the right gastroepiploic artery (case IS), the superior mesenteric artery and the hepatic artery originating from it (case zo), a branch of the dorsal pancreatic artery (case IS), the splenic artery (case 23) and a pancreatic branch arising from the splenic artery (case 13). Newly-formed pathologic vessels were seen in seventeen cases (Figs. I 1-19, 21, 22, 24-27, 29). These vessels were usually very narrow and difficult to recognise. They were often impossible to recognise from a single film, but had to be judged from the whole series. In three cases (I, 4, 7) they were fairly wide. The pathologic vessels were characterised by their marked variation in width and their tortuosity. Pathologic vessels were sometimes seen in only part of a tumour. In six cases (2, 12, 15, 16, 21, 23) no pathologic vessels were seen. In five of these the examination was incomplete because only the coeliac or superior mesenteric artery had been catheterised and in one case barium in the distended duodenum obscured the site of the tumour. Accumulation of contrast medium in the tumour during the capillary phase occurred in only six cases (5, 8, 9, 14, 16, 18). In these cases the accumulation 63

11 64 of the contrast medium in the tumour occurred somewhat earlier than in the adjacent tissue. The accumulation of contrast medium was usually slightly irregular. Veins. Neither pathologic communications between arteries and veins nor early filling of veins were observed. In four cases one of the large veins around the pancreas was stenosed. In two cases (17, 18) a narrowing of the portal vein was seen. The narrowing, which was about 3 cm. long, began at the origin of the vein from the splenic and superior mesenteric veins. In one case [14) the superior mesenteric vein was slightly stenosed at the level of the tumour, and in another (2) the splenic vein was stenosed in that segment crossing the spine [Fig. 27). In five cases the concentration of the contrast medium in the splenic and portal veins was too low to allow evaluation of these vessels. Size of turnour. The diameters of the tumours, as estimated at operation were: 2-3 cm. in three cases (I, 2, 3); 4-6 cm. in thirteen (4-16); and 7-1 cm. in six (17-22). In one case (23) massive adhesions and peritoneal carcinosis precluded estimation of the size of the tumour at operation. In one case (2) with a small tumour in the head of the pancreas, the angiogram was of normal appearance. But the investigation had not been complete, only the superior mesenteric artery having been catheterised. In the other two cases (I, 3) with small tumours, the examination had been complete and had shown vascular displacement, as well as irregular stenosis of the pancreatic arteries and newly-formed pathologic vessels. Nine patients with tumours 4-6 cm. in diameter were examined by the combined method. Newly-formed pathologic vessels were seen in all nine, vascular displacement in five, irregular stenosis of the arteries in four, accumulation of contrast medium in the tumour in four, and slight stenosis of the superior mesenteric vein in one. In four cases with a tumour 4-6 cm. in diameter in the head of the pancreas, only the coeliac artery (I I, 12, 16) or the superior mesenteric artery [IS) had been catheterised. Of these cases, vascular displacement was noted in two cases, irregular stenosis of the pancreatic arteries in two, newly-formed pathologic vessels in one, and accumulation of contrast medium in the tumour in one. Four of the patients with a pancreatic tumour 7-1 cm. in diameter had been examined by the combined method. Irregular stenosis of the pancreatic arteries was found in all four of them, newly-formed pathologic vessels in three, vascular displacement in two, stenosis of one of the large veins around the pancreas in two, and accumulation of contrast medium in the tumour in one. In the remaining two patients (17, 22) with such a large tumour, only the coeliac artery had been catheterised. Both cases showed irregular stenosis of the pancreatic arteries and newly-formed pathologic vessels. In one of the

12 cases the portal vein was also stenosed. No vascular displacement or accumulation of contrast medium in the tumour was observed. 65 HI STOLOCIC EXAMINATION Histologic examination of the tumour of the head of the pancreas showed adenocarcinoma in all seventeen cases studied in this way. These tumours were mucoid adenocarcinomas in six (2, 5, 7, 8, 13, 18) and a well differentiated adenocarcinoma in one (17). Microscopic section in one case showed arteries with thickened walls surrounded by scirrhous cancer (Fig. I 8). In two cases (I I, 23) the histologic diagnosis of adenocarcinoma was based on the microscopic appearance of a metastasis removed from the peritoneal cavity. Four cases were not verified histologically (4, 12, 19, 2). 5 - Lunderquist

13 66 Fig. 11 a

14 67 Fig. 11 ti Fig. 11 a. Case I. Carcinoma (z by 3 cm.) of the head of the pancreas. Gastroduodenal art. and superior mesenteric art. displaced to the left by an enlarged liver. Irregular lumen of the upper part of the posterior sup. pancr. duod. art. Newly-formed pathologic vessels in the tumour. Fig. 11 b. Tracing of the angiogram in case I. Gastroduodenal art. (I), posterior sup. pancr. duod. art. (2), anterior sup. pancr. duod. art. (3), splenic branch to the tail of the pancreas (73, splenic and portal veins (grey), newly-formed pathologic vessels (+I.

15 68 Fig. IZ a

16 69 Fig. 12 b Fig. 12 a. Case 3. Carcinoma (3 by 3 cm.) of the head of the pancreas. Slight displacement to the right of the lower part of gastroduodenal art. Irregular lumen of the upper part of posterior sup. pancr. duod. art. Newly-formed pathologic vessels in the tumour. Fig. 12 b. Tracing of the angiogram in case 3. Gastroduodenal art. (I], posterior sup. pancr. duod. art. (2), anterior sup. pancr. duod. art. (31, transverse pancr. art. (6), duodenal branches (6), newly-formed pathologic vessels (+).

17 7 Fig. 138

18 71 Fig. 13 tl Fig. 13 a. Case 4. Tumour (4 by 4 cm.) of the head of the pancreas. Numerous newlyformed pathologic vessels in the tumour. Fig. x3 b. Tracing of the angiogram in case 4. Gastroduodenal art. (I), posterior sup. pancr. duod. art. (23, anterior sup. pancr. duod. art. [3), duodenal branches (81, newly-formed pathologic vessels (+).

19 72 Fig. 14 a

20 73 Fig. 14 b Fig. 14 a. Case 5. Carcinoma (5 by 5 cm.) of the head of the pancreas. Gastroduodenal art. and superior mes. art. displaced to the left by an enlarged liver. Irregular lumen of the inferior pancr. duod. art. Newly-formed pathologic vessels in the tumour. Fig. 14 b. Tracing of the angiogram in case 5. Gastroduodenal art. (I), posterior sup. pancr. duod. art. [z), anterior sup. pancr. duod. art. (33, inferior pancr. duod. art. (41, splenic branch to the tail of the pancreas [7), newly-formed pathologic vessels (-3, splenic and portal veins [grey).

21 74 Fig. 15 a Fig. 15. Case 6. Carcinoma (5 by 5 cm.) of the head of the pancreas. Displacement of the posterior sup. pancr. duod. art. and anterior sup. pancr. duod. art. Newly-formed pathologic vessels in the tumour. a. Frontal view. b. Oblique view with tracing of the angiogram to the right. Gastroduodenal art. (I), posterior sup. pancr. duod. art. (z), anterior sup. pancr. duod. art. (33, inferior pancr. duod. art. (43, duodenal branches (8) and newly-formed pathologic vessels (+). c. Surgical specimen,

22 75 Fig. 15 b Fig. 15 c

23 76 Fig. 16 a

24 77 Fig. 16 b Fig. 16 a. Case 7. Carcinoma (5 by 5 cm.) of the head of the pancreas. Displacement of the gastroduodenal art., posterior sup. pancr. duod. art. and anterior sup. pancr. duod. art. Newly-formed pathologic vessels in the turnour. Fig. 16 b. Tracing of the angiogram in case 7. Gastroduodenal art. [I), posterior sup. pancr. duod. art. (23, anterior sup. pancr. duod. art. (33, dorsal pancr. art. (51, splenic branch to the body of the pancreas (71, middle colic art. (13, newly-formed pathologic vessels (-3.

25 78 Fig. 17a Fig. 17 a. Case 8. Carcinoma (5 by 5 cm.) of the head of the pancreas. Irregular lumina of the posterior sup. pancr. duod. art. and anterior sup. pancr. duod. art. Newly-formed pathologic vessels in the tumour. Fig. 17 b. Tracing of the angiogram in case 8. Gastroduodenal art. (13, posterior sup. pancr. duod. art. (21, anterior sup. pancr. duod. art. (3), dorsal pancr. art. (51, transverse pancr. art. [6), splenic branches to the body and tail of the pancreas (7), newly-formed pathologic vessels [+). Fig. 17 c. Case 8. Surgical specimen. The tumour of the head of the pancreas (+I.

26 Fig. 17c 79

27 8 Fig. 18 a Fig. 18 a. Case 9. Carcinoma (5 by 5 cm.) of the head of the pancreas. Displacement of posterior sup. panu. duod. art. with irregular lumen of the lower part. Newly-formed pathologic vessels in the tumour. Fig. 18 b. Tracing of the angiogram in case 9. Gastroduodenal art. (I], posterior sup. pancr. duod. art. (23, anterior sup. pancr. duod. art. (3), inferior pancr. duod. art. (41, dorsal pancr. art. (51, newly-formed pathologic vessels (+I. Fig. 18 c. Case 9. Microscopic section showing two arteries with thickened walls surrounded by scirrhous cancer, htx-eosin. X 63.

28 81 Fig. 18 b Fig. 18 c G - Lunderquisi

29 82 Fig. rg a

30 83 Fig. 19 b Fig. 19 a. Case KO. Carcinoma (5 by 5 cm.) of the head of the pancreas. Slight displacement of posterior sup. pancr. duod. art. Newly-formed pathologic vessels in the tumour. Fig. 19 b. Tracing of the angiogram in case 1. Gastroduodenal art. (I), posterior sup. pancr. duod. art. [z), anterior sup. pancr. duod. art. [3), inferior pancr. duod. art. (4), transverse pancr. art. [S), splenic branch to the tail of the pancreas (73, newly-formed pathologic vessels [+).

31 84 Fig. 2 a Fig. 2 a. Case 11. Carcinoma (5 by 5 cm.) of the head of the pancreas. Displacement of anterior sup. pancr. duod. art. with irregular lumen. Stenosis of the common hepatic art. at its origin-spasm? Fig. 2 b. Tracing of the angiogram in case 11. Gastroduodenal art. (I), posterior sup. pancr. duod. art. (23, anterior sup. pancr. duod. art. (31, transverse pancr. art. [S), splenic branches to the body and tail of the pancreas (73, duodenal branches (8). Fig. 2 c. Case 11. Antegrade catheterisation of the common hep. art. Irregular lumen of gastroduodenal art. caused by spasm.

32 85 Fig. 2b Fig. 2 c

33 86 Fig. 21 tl Fig. 21. Case 13. Carcinoma (5 by 5 cm.) of the head of the pancreas. Irregular stenosis and occlusion of gastroduodenal art. Irregular lumen of posterior sup. pancr. duod. art. and anterior sup. pancr. duod. art. Newly-formed pathologic vessels in the tumour. a. Frontal view. Fig. 21 b. Case 13. Oblique view with tracing of the angiogram. Gastroduodenal art. (I), posterior sup. pancr. duod. art. (2), anterior sup. pancr. duod. art. (31, inferior pancr. duod. art. (43, newly-formed pathologic vessels (+).

34 87

35 88 Fig. 22 a

36 89 Fig. 22 b Fig. 22 a. Case 14. Carcinoma (4 by 6 cm.) of the head of the pancreas. Displacement of posterior sup. pancr. duod. art., anterior sup. pancr. duod. art. and superior mes. art. Irregular lurnina of posterior and anterior sup. pancr. duod. art. Newly-formed pathologic vessels in the tumour. Fig. 22 b. Tracing of the angiogram in case 14. Gastroduodenal art. (I), posterior sup. pancr. duod. art. [2), anterior sup. pancr. duod. art. (3), dorsal pancr. art. (53, splenic branch to the tail of the pancreas [;I], splenic and portal veins (grey), newly-formed pathologic vessels [+).

37 9 Fig. 23. Case 16. Carcinoma (6 by 6 cm.) of the head of the pancreas. Slight displacement of gastroduodenal art. (I). Anterior sup. pancr. duod. art. (3) and transverse pancr. art. (6) are somewhat streched and their lumina irregular. Duodenal branches (81, splenic and portal veins (grey).

38 91 Fig. 24. Case 17. Carcinoma (7 by 7 cm.) of the head of the pancreas. Irregular lumina of gastroduodenal art. [I), posterior sup. pancr. duod. art. (2) and anterior sup. pancr. duod. art. (3). Dorsal pancr. art. (5), splenic branch to the tail of the pancreas (7). Splenic and portal veins (grey), newly-formed pathologic vessels (-1.

39 92 Fig. 25 a

40 93 Fig. 25 b Fig. 25 a. Case 18. Carcinoma (5 by 8 cm.) of the head of the pancreas. Gastroduodenal art. slightly displaced. Posterior sup. pancr. duod. art. is occluded. The lumen of dorsal pancr. art. is irregular. Newly-formed pathologic vessels in the tumour. Fig, 25 b. Tracing of the angiogram in case 18. Gastroduodenal art. [I), posterior sup. pancr. duod. art. [2), anterior sup. pancr. duod. art. (33, dorsal pancr. art. (5), newly-formed pathologic vessels [+), splenic and portal veins [grey).

41 94 Fig. 26 a

42 95 Fig. 26 a. Case 19. Tumour (1 by 1 cm.) of the head of the pancreas. Gastroduodenal art., anterior sup. pancr. duod. art. and first part of right gastroepiploic art. with irregular lumen. Newly-formed pathologic vessels in the tumour. Fig. 26 b. Tracing of the angiogram in case 19. Gastroduodenal art. (I), anterior sup. pancr. duod. art. (3), inferior pancr. duod. art. (43, dorsal pancr. art. (51, newly-formed pathologic vessels [+), splenic and portal veins [grey).

43 96

44 97 Fig. 27 b Fig. 27. Case 2. Tumour (1 by 1 cm.) of the head of the pancreas. Common hep. art. originates from superior mes. art. Superior mes. art. is displaced to the left by an enlarged liver. Irregular stenosis of gastroduodenal art., posterior sup. pancr. duod. art. and anterior sup. pancr. duod. art. Slight stenosis of superior mes. art. and the aberrant common hep. art. at its origin. Newly-formed pathologic vessels in the tumour. a. Frontal view. Fig. 27 b. Tracing of the angiogram in [a). Gastroduodenal art. [I), posterior sup. pancr. duod. art. [z), anterior sup. pancr. duod. art. (31, inferior pancr. duod. art. [4), dorsal pancr. art. (5), newly-formed pathologic vessels [+), splenic and portal veins [grey). 7 - Lunderquist

45 98 Fig. 27 c

46 99 Fig. 27 d Fig. 27 c. Case 2. Oblique view. Fig. 27 d. Case 2. Venous phase shows stenosis of the splenic vein.

47 1 Fig. 28 a

48 11 Fig. 28 a. Case 21. Carcinoma (1 by 1 cm.) of the head of the pancreas. Retained barium suspension in the duodenal loop makes interpretation difficult. Displacement of posterior sup. pancr. duod. art., anterior sup. pancr. duod. art. and superior mes. art. Irregular lumen of anterior sup. pancr. duod. art. Fig. 28 b. Tracing of the angiogram in case 21. Gastroduodenal art. (13, posterior sup. pancr. duod. art. (23, anterior sup. pancr. duod. art. (33, dorsal pancr. art. (53, splenic branch to the tail of the pancreas (73, splenic and portal veins [grey).

49 12 Fig. ZQ a

50 13 Fig. 29 b Fig. zg. Case zz. Carcinoma( 1 by 1 cm.) of the head of the pancreas. Irregular lumen of the lower part of gastroduodenal art. and anterior sup. pancr. duod. art. Newly-formed pathologic vessels in the tumour. a. Oblique view. Fig. zg b. Tracing of the angiogram in (a). Gastroduodenal art. (I), posterior sup. pancr. duod. art. (2), anterior sup. pancr. duod. art. (33, dorsal pancr. art. (5), duodenal branches (83, newly-formed pathologic vessels (+), splenic and portal veins (grey).

51 14 Fig. 29 c Fig. zg c. Case 22. Frontal view.

52 15 Fig. 3. Case 23. Carcinoma of the head of the pancreas. Gastroduodenal art. [I), Irregular stenosis of the first part of the splenic art. is stenosed.

53 16 CARCINOMA O F THE BODY AND TAIL OF THE PANCREAS This group contains seven cases. No sharp line of demarcation can be drawn between the body and the tail of the pancreas. Tumours of these two parts of the pancreas were, therefore, considered together as a single group. As judged from gross examination at operation or necropsy, four of the tumours were situated mainly in the body (25, 28-3), and three mainly in the tail of the pancreas (24, 26, 27). The interval between the onset of symptoms and operation ranged from 3 weeks to I year. The commonest symptoms were epigastric pain and loss of bodyweight. In two of the patients an abnormal mass in the abdomen was palpated before operation. Roentgen examination of the stomach and duodenum did not reveal any signs suggestive of tumour of the pancreas in any of these patients. In one case the stomach was displaced to the left by an enlarged liver. ANGIOGRAPHIC, OPERATIVE, AND POSTMORTEM FINDINGS In five cases in which the carcinoma was situated in the body or tail of the pancreas angiography was performed with simultaneous injection of contrast medium into the coeliac and superior mesenteric artery. The examination showed displacement of the arteries around or in the pancreas in one case, irregular stenosis of the arteries in all cases, newly-formed pathologic vessels in one case, and accumulation of contrast medium in the tumour during the capillary phase in one case. In two cases the splenic vein was occluded. The concentration of the contrast medium in the veins in the other cases was too low to allow evaluation of the vessels. In two cases (24, 27) only the coeliac artery was examined. In both cases postmortem examination showed the tumour to be situated in the tail of the pancreas. The tumour had not displaced any arteries around or in the pancreas. Irregular stenosis of the splenic artery was seen in both cases. No other arteries were seen to be involved in this manner. Newly-formed pathologic vessels were demonstrated in one case. No accumulation of contrast medium occurred within the tumour during the capillary phase. The concentration of the contrast medium in the large veins around the pancreas was not high enough to allow evaluation of these vessels. Case 25. Stenosis of a short segment of the coeliac artery and the first part of hepatic artery (Fig. 31). The splenic artery showed extensive and irregular stenosis commencing about 3 cm. from the origin of the vessel. One splenic branch to the tail of the pancreas was irregularly stenosed, as was the adjacent

54 part of the transverse pancreatic artery. The right hepatic artery arose from the superior mesenteric artery, but showed no changes despite its proximity to the body of the pancreas. Immediately below the stenosed long segment of the splenic artery, narrow newly-formed pathologic vessels were seen in the region of the tumour, and later, accumulation of contrast medium in the tumour followed during the capillary phase. No abnormally early passage of contrast medium into the veins. Faint filling of the splenic and portal veins without demonstrable changes. Eleven days later the patient died. Autopsy: Tumour (4 by 4 cm.) in the body and tail of the pancreas. The splenic artery ran along the upper border of the tumour. It was irregular in course, but showed no macroscopic signs of infiltration. Liver metastases. Microscopic examination: poorly differentiated adenocarcinoma. One pancreatic artery with thickened wall surrounded by cancer (Fig. 31 d). Case 28. Irregular stenosis of the first 4 cm. of the splenic artery [Fig. 32). Dorsal pancreatic artery irregularly stenosed. Superior mesenteric artery showed no mural changes but appeared to be somewhat displaced to the right from its very origin. No newly-formed pathologic vessels and no accumulation of contrast medium in the tumour. The splenic vein ran along the lower part of the tail and body of the pancreas. No mural changes were seen in the portal vein or that segment of the splenic vein that could be demonstrated. Operation 26 days later revealed a large inoperable tumour (about 1 by 1 cm.) in the body of the pancreas and liver metastases. The patient died 6 months later. Microscopic examination : mucus-secreting adenocarcinoma. Case 29. The splenic artery was markedly and irregularly stenosed along the first z cm. of its length (Fig. 33). The first segment of the hepatic artery was also stenosed, but not so irregularly as the splenic artery. The right hepatic artery, which was the first branch given off by the superior mesenteric artery, showed no mural changes. One artery, which ran caudally after its origin from the right hepatic artery, had an irregular lumen. Its contrast filling was, however, poor. At the level of the origin of the right hepatic artery, the left posterior aspect of the superior mesenteric artery showed a gentle impression about I cm. long. The lower part of the posterior superior pancreaticoduodenal artery was very irregular. No newly-formed pathologic vessels were seen, and no accumulation of contrast medium in the tumour occurred. To the left of the spine the splenic vein was obstructed, and the short gastric veins to the splenic vein were wide. Operation 14 days later revealed a tumour (about 1 by 1 cm.) of the body of the pancreas. Microscopic examination: well differentiated adenocarcinoma. Case 3. Marked stenosis along the first 3 cm. of the splenic artery. The right 17

55 18 hepatic artery arose from the first part of the superior mesenteric artery. It was markedly stenosed along the first z cm. of its length. The gastroduodenal artery originated from the superior mesenteric artery, and the posterior superior pancreaticoduodenal artery, from the left hepatic artery (Fig. 34). Lumbar aortography also showed irregular stenosis of the aorta and both renal arteries at the level of the tumour. No newly-formed pathologic vessels or accumulation of contrast medium in the tumour. No filling was obtained of the splenic vein, but wide tortuous veins were demonstrated near the hilus of the spleen suggesting occlusion of the splenic vein. Operation 14 days later revealed a tumour (about 1 by 1 cm.), which appeared to involve the entire pancreas, as well as liver metastases. Biopsy was not done, but a previously excised lymph node from the left supraclavicular fossa had shown mucus-secreting adenocarcinoma. Case 24. Selective angiographic examination of the coeliac artery only. (The catheter in the superior mesenteric artery was unsteady, and on injection of the contrast medium it recoiled back into the aorta). Irregular stenosis, about 3 cm. long, of the distal segment of the splenic artery (Fig. 35). No newly-formed pathologic vessels, no accumulation of contrast medium in the tumour. The splenic and portal veins could not be defined. The spleen was larger than ordinarily. The patient died 3 weeks later. Autopsy: In the tail of the pancreas, a tumour (about 3 by 4 cm.) caused narrowing of the splenic artery and occluded the splenic vein. Postmortem injection of barium into the coeliac and superior mesenteric arteries [Fig. 35 b and c) again showed the severe stenosis of the splenic artery and striking paucity of vessels in the tumour. The wall of the stenosed segment of the splenic artery was markedly thickened but had not been invaded by the tumour. Microscopic examination : adenocarcinoma. Case 26. The splenic artery was irregularly stenosed from a few centimetres from its origin to the hilus of the spleen. The spleen was displaced somewhat caudally and, thereby, also the splenic artery. The anterior upper part of the superior mesenteric artery was slightly stenosed (Fig. 36). No newly-formed pathologic vessels or accumulation of contrast medium in the tumour and no abnormally early passage of contrast medium into the veins. The concentration of contrast medium in the splenic and portal veins was too low to allow evaluation of these vessels. Operation 4 days later revealed peritoneal carcinosis and liver metastases. The entire pancreas felt hard out to the hilus of the spleen. The patient died one day later. Post-mortem examination showed a tumour (4 by 7 cm.) in the tail of the pancreas. The gross, as well as the microscopic appearance of the head and body of the pancreas was normal. The tumour had invaded the walls

56 19 of the small arteries in the pancreas, and in some areas it had grown intraluminally. The splenic artery was stenosed by scirrhous carcinoma. Microscpic examination : mucus-secreting adenocarcinoma. Case 27. Only the coeliac artery was catheterised (Fig. 37). This artery as well as the common hepatic artery and the gastroduodenal artery were displaced to the left by the markedly enlarged liver. About z cm. from its origin the splenic artery showed a small aneurysmatic change. ImmediateIy distal to the aneurysm the splenic artery was markedly stenosed out to the hilus of the spleen. The dorsal pancreatic artery and the splenic branches to the tail of the pancreas could not be recognised. The posterior superior pancreaticoduodenal artery could be followed only a short distance, and the anterior superior pancreaticoduodenal artery was not visible at all. The transverse pancreatic artery arose from the gastroduodenal artery and could be followed about 7 cm., to the region of the body of the pancreas. It showed no change. Small newly-formed pathologic vessels were seen immediately above the aneurysmatic dilatation of the splenic artery. No accumulation of contrast medium in the tumour. Operation 2 days later revealed a tumour (1 by 1 cm.) in the tail of the pancreas. The liver and the omentum were full of metastases. The patient died g days later. Post mortem examination: the tumour of the tail of the pancreas had grown around the splenic artery, which it severely stenosed. The aneurysm was situated immediately adjacent the right border of the tumour. Microscopic examination : adenocarcinoma.

57 11 Fig. 31 a

58 111 Fig. 31 b Fig. 31 c Fig. 31. Case 25. Carcinoma (4 by 4 cm.) of the left part of the body of the pancreas. Stenosis of the coeliac art. and left hepatic art. at their origin. Irregular stenosis of the splenic art., left part of transverse pancr. art. (61, and one splenic branch to the body of the pancreas (7). Gastroduodenal art. [I), posterior sup. pancr. duod. art. (2), anterior sup. pancr. duod. art. (31, newly-formed pathologic vessels (+), splenic and portal veins [grey). a. Frontal, b. oblique view. c. Microscopic section showing one pancreatic artery with thickened wall surrounded by infiltrating cancer. Htx-eosin. X 63.

59 112 Fig. 32 Fig. 32. Case 28. Carcinoma (1 by 1 cm.] of the body of the pancreas. The first part of the splenic art. is irregularly stenosed. Irregular lumen of the dorsal pana. art.

60 113 Fig. 33. Case zg. Carcinoma [ro by 1 cm.) of the body of the pancreas. Aberrant right hep. art. from superior mes. art. The first part of the splenic art. is irregularly stenosed. Slight stenosis of the upper part of superior mes. art. and left hep. art. at its origin. 8 - Lundcrquist

61 114 Fig. 34 a Fig. 34. Case 3. Carcinoma (1 by 1 cm.) of the body of the pancreas. Stenosis of the splenic art. at its origin. Stenosis of right hepatic art. at its origin from superior mes. art: a. Frontal view.

62 115 Fig. 34 b Fig. 34 b. Case 3. Oblique view.

63 116 Fig. 35 a Fig. 35 a. Case 24. Carcinoma (3 by 4 cm.) of the tail of the pancreas. Irregular stenosis of the splenic art. Fig. 35 b. Post-mortem angiograrn in case 24. Marked irregular stenosis of the splenic art. at the site of the tumour. Fig. 35 c. Case 24. The pancreas dissected free.

64 117 Fig. 35 b Fig. 35 c

65 118 Fig. 36 Fig. 36. Case 26. Carcinoma (4 by 7 crn.) of the tail of the pancreas. Irregular stenosis of the splenic artery and upper part of the superior mes. art.

66 Fig. 37. Case 27. Carcinoma (1 by 1 cm.) of the tail of the pancreas. An enlarged liver displaces common hep. art. to the left. Stenosis of splenic art. distal to the aneurysm. Newlyformed pathologic vessels immediately above the aneurysmatic dilatation. 119

67 12 CARCINOMA OF THE CAUDAL PART OF THE COMMON BILE DUCT AND THE PAPILLA OF VATER In six cases (31-36) the tumour was situated in the caudal part of the common bile duct or in the papilla of Vater. The interval between the onset of symptoms and the operation varied from 3 weeks to 12 months. All the patients were jaundiced except one, who had been operated upon 5 years previously with removal of a small carcinoma of the papilla of Vater and choledocho-duodenostomy was performed. The patient was now examined because of a suspected recurrence. Roentgen examination of the stomach and duodenum was performed on five of the patients. No changes were seen in three (32. 33, 36) of them. In one (34) the stomach was deformed by a large hiatus hernia, but neither the stomach nor the duodenum showed signs of infiltration. In case 35 the examination revealed narrowing of the descending duodenum, which was believed to be secondary to malignant infiltration. ANGIOGRAPHIC AND OPERATIVE FINDINGS Both the coeliac and the superior mesenteric artery were examined in all six cases. Displacement of the arteries around or in the head of the pancreas was seen in two cases and irregular stenosis of the arteries involved by the tumour in three. In one case with the tumour in the caudal part of the common bile duct the arteries in and around the head of the pancreas were displaced, and their lumina were irregular. This was presumably not due to extension of the tumour but to pancreatitis. Newly-formed pathologic vessels and accumulation of contrast medium within the tumour were demonstrated in each of two cases. The portal vein was stenosed in the case in which the tumour had the greatest extension. In the two patients with the smallest tumours (2 by 2 cm.) the angiographic appearance was normal. Case 31. No displacement of arteries around or in the pancreas, no irregular stenosis of the arteries, no newly-formed pathologic vessels and no accumulation of contrast medium in the tumour. The large veins around the pancreas were normal in appearance. The angiographic examination thus showed nothing abnormal. Operation because of jaundice 26 days before the angiographic examination disclosed no stone in the common bile duct but tumour masses in its caudal segment. Drainage of the common bile duct. Re-operation 14 days after the angiographic examination revealed a tumour (about 2 by 2 cm.) of the papilla

68 of Vater. The tumour had not invaded the pancreas. Microscopic examination: adenocarcinoma. Case 32. Angiographic examination revealed nothing abnormal. Operation z months later because of jaundice, which was originally believed to have been due to hepatitis. Cholecysto-jejunostomy was established. A small tumour was palpated in the caudal part of the common bile duct. Re-operation one month later revealed a tumour (about z by z cm.) of the papilla of Vater which did not invade the pancreas. Microscopic examination: adenocarcinoma. Case 33. No changes in the arteries around or in the pancreas. Accumulation of contrast medium during the late arterial phase in small areas in the region of the tumour (Fig. 38). This irregular accumulation of contrast medium in the tumour was later more homogenous. The veins around the pancreas appeared normal. Operation one month before the angiographic examination because of jaundice. Cholecysto-jejunostomy was performed. A tumour (about 2 by 3 cm.) was palpated in the region of the papilla of Vater. The patient was re-operated upon z weeks after the angiographic examination. The tumour, which was assumed to be situated in the papilla of Vater, had infiltrated the adjacent part of the head of the pancreas and the duodenum. Microscopic examination: poorly differentiated adenocarcinoma. Case 34. The coeliac, splenic, common hepatic and superior mesenteric arteries were of normal appearance. The first segment of the posterior superior pancreaticoduodenal artery described a somewhat widened arch, but its course lay within the normal range of variation. Other pancreatic arteries appeared normal. The right hepatic artery in the hilus of the liver showed a slightly irregular narrowing (Fig. 39). No newly-formed pathologic vessels or accumulation of contrast medium in the tumour. The splenic and portal veins were of normal appearance. At operation 26 days later a tumour (about 3 by 3 cm.) was palpated distally in the hepatoduodenal ligament. Extension of the tumour was palpated along the posterior aspect of the common bile duct and the hepatic duct up into the hilus of the liver. Liver metastases. Microscopic examination of a metastasis in a lymph node in the hepatoduodenal ligament showed well differentiated adenocarcinoma. Case 35. The gastroduodenal artery was angulated. The.posterior superior pancreaticoduodenal artery was stretched and its lumen was irregular. The transverse pancreatic artery, which arose from the distal part of the gastroduodenal artery together with the anterior superior pancreaticoduodenal artery, was moderately stenosed along its first segment. Irregular pathologic vessels were seen at the site of the tumour in the posterior right part of the head of 121

69 122 the pancreas and in the adjacent part of the duodenum (Fig. 4). In the late arterial phase an accumulation of contrast medium was seen within the tumour. The splenic and portal veins were normal. Five years previously the patient had been operated upon because of a small adenocarcinoma of the papilla of Vater, at which choledocho-duodenostomy had been performed. Operation 27 days after the angiographic examination revealed a tumour (3 by 4 cm.) at the site of the previous choledocho-duodenostomy with infiltration into the head of the pancreas. Microscopic examination : poorly differentiated adenocarcinoma. Case 36. Severe stenosis of the common and proper hepatic arteries (Fig 41). The proximal segment of the gastroduodenal artery was stenosed, and the rest of the artery was irregular. The lower part of the gastroduodenal artery was arcuate with the convexity forward and to the right corresponding to the anterior part of the head of the pancreas. The posterior and anterior superior pancreaticoduodenal arteries were stretched, and their lumina were irregularly stenosed. The uncinate branch of the dorsal pancreatic artery showed similar changes. Narrow, newly-formed pathologic vessels were seen within a small area in the lower part of the tumour. No accumulation of contrast medium within the tumour. Stenosis of the portal vein at the same level as the stenosis of the hepatic artery. Operation one week later revealed a tumour (about 3 by 5 cm.) in the caudal part of the hepatoduodenal ligament. The tumour surrounded the hepatic artery and portal vein. It extended to the upper border of the head of the pancreas which, however, felt normal. No liver metastases. Biopsy of the tumour was not performed.

70

71 124 Fig. 38 a Fig. 38. Case 33. Carcinoma (2 by 3 cm.) in the region of papilla of Vater. a. Early arterial phase. Fig. 38 b. Case 33. Late arterial phase shows irregular accumulation of contrast medium within the tumour. Tracing of the angiogram: Gastroduodenal art. (I), posterior sup. pancr. duod. art. (21, anterior sup. pancr. duod. art. (33, dorsal pancr. art. (53, irregular accumulation of contrast medium within the tumour (-3. Splenic and portal veins, (grey).

72 125 1 Fig. 38 b

73 126 Fig. 39 a

74 127 Fig. 39 b Fig. 39 a. Case 34. Carcinoma (3 by 3 cm.) in the caudal part of common bile duct with metastases in the lymph nodes in the hilus of the liver. Right hep. art. is irregularly stenosed. Fig. 39 b. Tracing of the angiogram in case 34. Gastroduodenal art. (I), posterior sup. pancr. duod. art. (23, anterior sup. pancr. duod. art. (3), splenic branch to the body of the pancreas (7), right hep. art. irregularly stenosed (+), splenic, superior mes. and portal veins (grey).

75 128 Fig. 4a

76 129 Fig. 4 b Fig. 4 a. Case 35. Carcinoma (3 by 4 cm.) in the region of papilla of Vater. Displaced posterior sup. pancr. duod. art. Irregular lumen of posterior sup. pancr. duod. art., anterior sup. pancr. duod. art. and transverse pancr. art. Newly-formed pathologic vessels in the tumour. Fig. 4 b. Tracing of the angiogram in case 35. Gastroduodenal art. (I], posterior sup. pancr. duod. art. (21, anterior sup. pancr. duod. art. (31, transverse pancr. art. (61, splenic branch to the body of the pancreas (7), newly-formed pathologic vessels [+), splenic and portal veins [grey]. 9 - Lunderquirt

77 13 Fig. 41 a

78 131 Y Fig. 41 b Fig. 41 a. Case 36. Carcinoma (3 by 5 cm.) in the caudal part of the common bile duct. Displacement of the lower part of gastroduodenal art., posterior sup. pancr. duod. art. and anterior sup. pancr. duod. art. Stenosis of common hep. art., proper hep. art. and upper part of gastroduodenal art. Irregular lumen of posterior and anterior sup. pancr. duod. art. and dorsal pancr. art. Newly-formed pathologic vessels in the tumour. Fig. 41 b. Tracing of the angiogram in case 36. Gastroduodenal art. (I), posterior sup. pancr. duod. art. (z), anterior sup. pancr. duod. art. (3), dorsal pancr. art. [5), newly-formed pathologic vessels (+), splenic and portal veins (grey).

79 132 Table 6. Angiographic findings in patients with carcinoma of the head of the pancreas (cases 1-23), of the body and tail of the pancreas (cases 24-3) and of the caudal part of the common bile duct and papilla of Vater (cases 31-36) Displa- Case cement of arteries I I I1 I2 I3 ' I PSPA GDA PSPA, ASPA GDA, PSPA, ASPA PSPA PSPA ASPA PSPA, ASPA, SMA ASPA, TPA, GDA GDA PSPA, ASPA, SMA SMA PSPA PSPA, ASPA, GDA Irregular stenosis of arteries PSPA PSPA IPA PSPA, ASPA PSPA ASPA GDA, PSPA, ASPA Spl. br. PSPA, ASPA ASPA, TPA GDA, PSPA, ASPA PSPA, DPA GDA, RGA, ASPA GDA, PSPA, ASPA SMA, ab. HA ASPA GDA, ASPA GDA, SA SA CA, LHA, SA, Spl. br. TPA SA, SMA SA SA, DPA SA, LHA, PSPA, SMA SA, ab. HA RHA PSPA, ASPA, TPA CHA, PHA, GDA, PSPA, ASPA, DPA Newly- Accumulation stenosls Size of f:z:,d of contrast tumours medium in Of (-1 the tumour i SMV PV PV sv sv sv PV 2x3 3x3 3x3 4x4 5x5 5x5 5x5 5x5 5x5 5x5 5x5 5x5 5x5 4x6 5x6 6x6 7x7 5x8 1 I I x I I x I 1 x I? 3x4 4x4 4x7 I x I I I I x I I x I 2x2 2x2 2x3 3x3 3x4 3x5

80 133 DISCUSSION The angiographic diagnosis of tumours is based on various signs, viz. displacement of vessels, irregular arterial stenosis, demonstration of newly-formed pathologic vessels, accumulation of contrast medium in the tumour during the capillary phase, and early passage of contrast medium into the veins. Displacement of vessels. The infiltrative mode of growth of the tumours can explain why even large carcinomas of the pancreas caused only slight displacement of the large arteries around the pancreas, i. e., the coeliac, hepatic, splenic and superior mesenteric arteries. The normal course of these arteries varies so widely that any slight displacement is difficult to recognise. On the other hand, tumours which grow expansively, such as cysts and cystadenomas, can cause considerable displacement of the above-mentioned arteries (UDMAN I 958, ROSCH & BRET 1963, BOIJSEN & OLIN 1964, GLENN et coll. 1964). Though the gastroduodenal artery closely follows the anterior surface of the head of the pancreas, it was only slightly affected (Table 6.). In only five of twenty-nine cases in which the tumour was situated in the head of the pancreas, in the papilla of Vater or in the caudal part of the common bile duct, was displacement of the gastroduodenal artery due to the tumour demonstrable. In some other cases, on the other hand, the gastroduodenal artery was displaced by a distended gallbladder or by an enlarged liver. Displacement of the gastroduodenal artery was also difficult to recognise because of the wide normal variations of the course of this vessel and was of diagnostic value only when seen in association with other signs of tumour. Barely one third of the cases showed any change, and then usually a straightening, of the course of the posterior or anterior superior pancreaticoduodenal artery. When the tumour was situated in the body or the tail of the pancreas, it never caused any demonstrable displacement of the pancreatic vessels. It would thus appear that displacement of vessels is only a sign of subordinate importance in the diagnosis of carcinoma of the pancreas. Irregular arterial stenosis. Irregular stenosis of arteries affected by the tumour was seen in 26 patients [Table 6.). These changes consisted either of an even or a very irregular narrowing of the lumen of the vessel. The large arteries (thse Abbreviations used in table 6: CA-coeliac art., CHA-common hepatic art., PHA-proper hepatic art., LHA-left hepatic art., RHA-right hepatic art., ab. HA-aberrant hepatic art., SA-splenic art., GDA-gastroduodenal art., PSPA-posterior superior pancreaticoduodenal art., ASPA-anterior superior pancreaticoduodenal art., RGA-right gastroepiploic art., TPAtransverse pancreatic art., IPA-inferior pancreaticoduodenal art., Spl. br.-splenic branches to the left part of the body and the tail of the pancreas, DPA-dorsal pancreatic art., SMAsuperior mesenteric art., SV-splenic vein, PV-portal vein, SMV-superior mesenteric vein.

81 134 coeliac artery, the hepatic artery, the splenic and the superior mesenteric artery) as well as the smaller arteries (the gastroduodenal artery and the pancreatic arteries) could be affected in the same way. The changes were demonstrable even in parts of fairly fine vessels. In cases of small tumours of the head of the pancreas or of the papilla of Vater, only a small segment of the posterior or anterior superior pancreaticoduodenal artery was involved, depending on whether the tumour was situated in the posterior or anterior part of the head of the pancreas. The larger the tumour the longer the segment of the arcades involved. The large tumours sometimes caused stenosis of both the anterior and posterior arcades, of the gastroduodenal artery, of the inferior pancreaticoduodenal artery, and of that part of the superior mesenteric artery passing the head of the pancreas. When the carcinoma was situated in the right part of the body of the pancreas, it involved the coeliac, common hepatic, or right part of the splenic artery. Sometimes the dorsal pancreatic artery or the upper part of the superior mesenteric artery was involved in the same way. When the tumour was situated in the left part of the body or in the tail of the pancreas, it stenosed the splenic artery and sometimes also splenic branches to the pancreas in the corresponding area. Such changes of the pancreatic arteries have been described previously by LUNDERQUIST (1962 and 1963)~ by MEANEY et coll. (1963), CORTESINI (1963) and BOIJSEN & OLIN (1964). In two cases microscopic examination was focused in particular on the appearance of the stenosed arteries. In these cases the wall of the arteries in the stenosed segments were markedly thickened but showed no infiltration of carcinoma through the arterial walls. Check-examination of the microscopic preparations from a third case showed a large artery which appeared to be stenosed by surrounding scirrhous masses of carcinoma. In some other cases check-examination of histological preparations revealed marked changes of atherosclerotic appearance in the arteries within the tumour. The histo-pathologic basis of the stenosing arterial changes thus appears to vary and deserves further investigation. Newly-formed pathologic vessels were seen in 21 of the 36 cases (Table 6.). They were difficult to recognize in a single film from the arterial phase, and had to be judged from the whole series. When these vessels were numerous, the change they produced in the roentgenogram was striking. This was seen in only 6 cases. In the remaining cases only a few pathologic vessels were seen in part of the tumour. The pathologic vessels were usually very narrow, they varied in width, they changed abruptly in course, and they were often arranged in an arcuate fashion. No large arteries were seen to supply the tumours, and

82 no early passage of contrast medium into the veins could be demonstrated. Since the pathologic vessels were very narrow, they could only be demonstrated in high quality roentgenograms. In three cases (I, 4, 7) the pathologic vessels were fairly wide and easy to recognise. The microscopic diagnosis of two of these tumours was mucusforming adenocarcinoma, while the third case was not verified microscopically. The series also contained other cases with mucusforming adenocarcinoma, including some in which the pathologic vessels were very narrow and others in which no pathologic vessels could be demonstrated. In all of the cases with pathologic vessels then, the appearance of the vessels would not allow any conclusion about the microscopic picture. The absence of pathologic vessels in the roentgenogram does not mean that no such vessels exist. Such vessels may be too fine to be demonstrable, as sometimes in intestinal carcinoma. BILLING & L~NDCREN (1944) found the pathologic vessels in gastric carcinoma to be at most.2 mm. in width, which means that they are too narrow to be demonstrated by available angiographic methods in uiuo. Gastric carcinoma with wider pathologic vessels demonstrable by angiography are, however, sometimes seen (BOIJSEN & OLIN 1964, BOIJSEN, WALLACE & KANTER I 964). What was said above concerning gastric carcinoma holds also for carcinoma of the colon, where both narrow and wide pathologic vessels have been demonstrated (SCHOBINGER I 959, MARCULIS & HEINBECKER 1961, MCALISTER et coll. 1962, STRBM & WINBERG 1962). Accumulation of contrast medium in the tumour. UDMAN (1958) found that enlargement, if any, of the pancreas could be demonstrated during the capillary phase of angiography, particularly in pancreatitis. In the present material of carcinoma of the pancreas, of the papilla Vater, and of the caudal part of the common bile duct the accumulation of the contrast medium in the parenchyma of the pancreas never proved of any use in the diagnosis of tumour. Accumulation of the contrast medium in the pancreas during the capillary phase seldom allowed demarcation of the organ. This was probably because the amount of contrast medium injected into each main artery (the coeliac artery and the superior mesenteric artery) was smaller than that used by UDMAN. He, however, injected contrast medium only into the coeliac artery. On the other hand, irregular accumulation of the contrast medium within the actual tumour, because of the presence of pathologic vascularization, enabled delineation of the tumour during the capillary phase in g of the 36 cases examined (Table 6.). Veins. RBSCH & BRET (1963) described a patient with a tumour of the body of the pancreas (microscopic diagnosis not given) in which selective angiography of the coeliac artery and the superior mesenteric artery had demonstrated arteriovenous shunting of contrast medium to the draining veins. No 135

83 136 such shunting was seen in any of the cases in the present material. Neither in the controls nor in the patients with tumours could pancreatic veins be demonstrated. In some cases this may have been due to accumulation of contrast medium in the gastric and duodenal mucosa, making interpretation difficult, and in other cases because pancreatic veins filled with contrast medium could not be distinguished from other intestinal veins. Displacement, deformation, and occlusion of the splenic and portal veins in patients with carcinoma of the pancreas have been described by previous workers in this field (LEROUX& de SCOVILLE 1954, CATALANO & GIARDIELLO 1955, ANACKER et coll. 1957, MOSELEY 1958, CACCIARI et coll. 1958, BERGSTRAND 1961, FRIMANN-DAHL 1961, ROSCH & HERFORT x962, ROSCH 1964). Such changes are, however, not pathognomonic of carcinoma of the pancreas since they can also be produced by other retroperitoneal tumours, retroperitoneal metastases, and pancreatitis. Involvement of the splenic and portal veins is usually regarded as a late sign of carcinoma of the pancreas and also indicates inoperability of the tumour. According to ROSCH, however, even small tumours can be demonstrated by splenoportography if they are situated in the posterior part of the tail of the pancreas. In only three of the present cases the tumour was situated in the tail of the pancreas, and in all three the concentration of the contrast medium in the splenic vein during the venous phase was too low to allow reliable evaluation. In two patients with carcinoma of the body of the pancreas and one with carcinoma of the head of the pancreas, the splenic vein was found to be stenosed. The tumours were large in all of the cases, and only one was operable. I I I Complete examination, i. e., simultaneous injection of contrast medium into the coeliac and superior mesenteric arteries, was performed in twenty-six cases. Changes known from the present investigation to indicate carcinoma were noted in twenty-four (92 O/o) of these examinations. These changes consisted of irregular arterial stenosis in nineteen cases, newly-formed pathologic vessels in seventeen cases, displacement of vessels in twelve cases, accumulation of contrast medium in the tumours in eight cases, and stenosis of some of the veins around the pancreas in six cases. In the two cases in which angiography revealed no abnormalities, the tumours were small (2 by 2 cm.) and situated in the papilla of Vater. In five of the thirty-six cases of tumour of the pancreas, papilla of Vater or caudal part of the common bile duct, angiography failed to demonstrate any changes with certainty. Incomplete examination, i. e. injection of contrast

84 137 medium only into either the coeliac or the superior mesenteric artery, could explain the negative result in three of the five cases. Large tumours or tumours situated favourably from an angiographic point of view were, however, sometimes demonstrated even when only one of these arteries was catheterised. Judging from this analysis, the diagnosis of carcinoma of the pancreas, can be improved considerably by simultaneous selective angiography of the coeliac and superior mesenteric arteries. Promising investigations with pharmaco-angiography (ABRAMS, BOIJSEN & BORGSTRBM 1962, ABRAMS 1964) suggest that the abnormal reaction of the pathologic vessels to neurohumoral stimuli may increase the possibility of demonstrating the pathologic vessels. Some differentia2-diagnostic considerations. It is at present hardly justified to use the aforementioned angiographic tumour changes independently in the diagnoses of pancreatic tumours. A detailed evaluation of the differentialdiagnostic value of these signs is in progress. The number of surgically verified cases available for such an investigation is still too small. The problem will, however, be taken up as soon as sufficient cases have become available. Only a few differential diagnostic aspects will be considered below. Tumours situated in the area examined but not belonging to the pancreas, such as retroperitoneal urologic tumours, gastric tumours, and tumours of the small intestine, can be deduced from the origin of the arteries supplying it. Pancreatic tumours other than carcinoma, such as cysts, cystadenomas, and insulomas, produce a different angiographic appearance. Cysts are characterised by avascular areas with marked displacement of pancreatic arteries to the periphery. Cystadenomas and insulomas are richly vascularised and in insuloma a very persistent accumulation of the contrast medium in the tumour has been described ( OLSSON, OLLE I 963). Chronic pancreatitis probably offers the greatest differential-diagnostic difficulties. The present material was, however, not large enough to warrant a discussion of this problem. Irregular arterial lumina sometimes occur in pancreatitis (UDMAN 1958, 1961; ROB 1962, BOIJSEN & OLIN 1964). As previously mentioned, however, pancreatitis tends to produce displacement of the arteries in and around the pancreas to a degree not seen in carcinoma. Arterial spasm (LINDBOM I 957, WICKBOM & BARTLEY 1957)~ arteriosclerosis (REINER et coll. 1962)~ periarteritis nodosa (PUGH& STRINGER 1956), and fibromuscular hyperplasia ( WYLIE et coll. I 962) can produce irregular arterial stenosis. The angiographic appearance of stenosis in arterial spasm and arteriosclerosis, however, differs clearly from that produced by carcinoma of the pancreas. It would appear that no visceral angiograms of patients with stenosis due to periarteritis nodosa have been published. Fibromuscular hyperplasia can

85 138 produce arterial stenosis resembling those of carcinoma of the pancreas. The condition is, however, rarely seen except in the renal arteries, and only one case has been published in which the changes affected the coeliac artery (PALUBINSKAS & RIPLEY I 964). The sometimes subtle arterial changes produced by carcinoma of the pancreas can readily lead to overdiagnosis. Incomplete filling of the arteries can produce an impression of arterial stenosis. This resulted in an overdiagnosis in one patient in whom a pancreatectomy was performed and later microscopic examination of the specimen revealed nothing abnormal. SUMMARY The results of selective angiography of the coeliac and superior mesenteric arteries in 36 patients with surgically verified carcinoma of the pancreas, of the papilla of Vater or caudal part of the common bile duct were analysed. Angiographic signs of tumour, i. e., displacement and irregular stenosis of vessels, pathologic vessels, accumulation of contrast medium within the tumours during the capillary phase, and early filling of draining veins, were studied. Displacement of vessels was not a prominent sign. The course of the pancreatic arteries, like that of the coeliac, splenic, hepatic and superior mesenteric arteries, which was in the immediate proximity of the pancreas, were only slightly affected even by large tumours. This may be explained by the infiltrative mode of growth of the tumours. Vascular displacement, possibly due to the tumour, was seen in 14 cases but it was generally so slight that it was of diagnostic value only when seen in association with other signs of tumour. Irregular stenosis of the arteries involved by the tumour was the commonest arteriographic change and was seen in 26 cases. It might affect the large arteries immediately adjacent the pancreas, the coeliac, splenic, hepatic, gastroduodenal or superior mesenteric artery as well as the pancreatic arteries. The changes were often characteristic. No such changes were seen in the controls. Pathologic vessels were observed in 21 cases. These vessels were usually very narrow and were therefore demonstrable only in roentgenograms of high quality. In some cases, however, no pathologic vessels were seen, even in films of exceptionally good quality. Accumulation of contrast medium within the tumour during the capillary phase was noted in only g cases. In no instance was early passage of contrast medium into the veins observed. One or more of the angiographic changes described above were seen in 31 of the 36 cases studied. If only those 26 cases of carcinoma which were examined completely, i. e., with injection of contrast medium simultaneously into the coe-