Pathways of Regional Spread in Pancreatic Cancer

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1 Pathways of Regional Spread in Pancreatic Cancer 12 Chusilp Charnsangavej, M.D. Regional spread of pancreatic ductal adenocarcinoma is common at the time of diagnosis, and it is often associated with poor prognosis. 1 4 This is because the pancreas is an organ that is located in the retroperitoneum adjacent to many structures and organs, and there is no fibrous capsule or fascial plane to confine the organ. The pathways of regional spread include local organ or structure invasion, perineural spread, vascular invasion, and lymph node metastasis. Diagnosis of regional spread of pancreatic ductal adenocarcinoma is important for surgical planning because the prognosis of patients undergoing pancreatic resection with a positive margin and lymph node metastases is very poor. Conventional imaging modalities such as CT, MR imaging, and ultrasonography often understage locally advanced disease at pretreatment staging. However, new imaging techniques, such as helical CT with thin-section collimation and fast MR imaging with intravenous dynamic contrast enhancement, have improved the ability to define locally advanced disease. This chapter defines the pathways of regional spread of pancreatic ductal adenocarcinoma on imaging studies based on the anatomic relationship between the pancreas and its surrounding structures, organs and adjacent blood vessels, lymphatic vessels and nodes, and nerves. Anatomy of the Pancreas The pancreas lies transversely along its long axis in the anterior pararenal space of the retroperitoneum. 5,6 The head of the pancreas lies within the C-loop of the second portion of the duodenum. The lateral surface of the head is against the serosa of the duodenum. The posterior surface of the head is separated from the inferior vena cava by only retroperitoneal fat and on occasion small posterior peripancreatic nodes. Medially, the head of the pancreas is closely related to the superior mesenteric artery (SMA) and superior mesenteric vein (SMV). At the caudal portion of the head, a small portion of the pancreas extends behind the SMA and SMV, forming an uncinate process. It is connected to the SMA and SMV by small twigs of vessels that are branches of the jejunal artery and vein or that arise directly from the posterior wall of the SMA and SMV and a plexus of nerves between the head of the pancreas and the SMA. The cranial portion of the head of the pancreas is located on the right side of the SMA and SMV. As the SMV joins the splenic vein to form the portal vein, it courses behind the head of the pancreas, and from that point, extending to the left retroperitoneum, the head of the pancreas becomes the body. The body and tail of the pancreas course transversely to the left side of the retroperitoneum toward the splenic hilum. After passing in front of the abdominal aorta and celiac axis, it curves posteriorly and in the cranial direction. In most cases, it follows the course of the splenic artery and vein, staying anterior and slightly caudal to those vessels. Anteriorly, the pancreas is covered by posterior peritoneal layers that form the posterior wall of the lesser sac and the inframesocolic compartment of the peritoneal cavity. Just at the caudal margin along the body and tail of the pancreas, the root of the transverse mesocolon, which is formed by those two posterior peritoneal layers, merges anteriorly to suspend the transverse colon into the peritoneal cavity. The root of the transverse

2 Pathways of Regional Spread in Pancreatic Cancer Fig Illustration of the arterial anatomy of the pancreas. 1 = common hepatic artery; 2 = splenic artery; 3 = gastroduodenal artery; 4 = dorsal pancreatic artery; 5 = posterior superior pancreaticoduodenal artery (SPDA); 6 = anterior SPDA; 7 = inferior pancreaticoduodenal artery; 8 = superior mesenteric artery; D = duodenum. mesocolon extends to the right, traversing across the head of the pancreas and second portion of the duodenum. The transverse mesocolon forms the inferior boundary of the lesser sac. Vascular Anatomy The pancreas receives blood supply from multiple branches of the celiac axis and the SMA. 5 8 The head of the pancreas is supplied by a network of arteries that originates from three major arteries (Fig. 12 1). The gastroduodenal artery (GDA) descends from the common hepatic artery (CHA) in the retropyloric space between the pylorus and the cranial portion of the head of the pancreas. Proximally, it gives off a branch posteriorly that runs along the posterior lateral surface of the pancreatic head along the common bile duct, the posterior superior pancreaticoduodenal artery (SPDA). The GDA continues its course in the craniocaudal direction anterior to the head of the pancreas and then bifurcates to form a branch coursing anteriorly in the gastrocolic ligament to become the right gastroepiploic artery, which runs along the greater curvature of the pylorus. The other branch continues in the craniocaudal direction close to the anterior surface of the pancreas as the anterior SPDA. The posterior and anterior SPDAs then form an anastomotic network around the head of the pancreas with the inferior pancreaticoduodenal artery (IPDA) and a branch of the dorsal pancreatic artery. The IPDA arises from the proximal jejunal artery or directly from the SMA. These arteries usually originate from the posterior wall of the SMA. The IPDA gives off a few small branches to the uncinate process and gives off a branch posteriorly to join the posterior SPDA and another branch anteriorly to join the anterior SPDA. The dorsal pancreatic artery originates from the posterior or caudal surface of the celiac axis or the proximal 1 2 cm of the common hepatic or splenic artery. It can be identified behind the proximal portion of the body of the pancreas. It usually gives off a branch to the right, medial to the cranial portion of the head of the pancreas and the portal vein. This branch runs medially along the head of the pancreas and anastomoses with the peripancreatic arcade around the head of the pancreas. The body and tail of the pancreas receive their blood supply from the dorsal pancreatic artery and multiple branches along the course of the splenic artery. The dorsal pancreatic artery courses along the body and tail and anastomoses with small branches from the splenic artery. The venous drainage of the head of the pancreas forms a network around the head and follows a branching pattern similar to the artery (Fig. 12 2). The anatomy of these veins is relatively constant, but the course of the veins and their drainage patterns differ from the artery. The confluence of the SMV and the splenic vein forms the portal vein. The relationship of these three veins with the pancreas is most important in pancreatic surgery. The segment of the SMV at the caudal portion of the head of the pancreas receives two important

3 Anatomy of the Pancreas 597 Fig Illustration of the venous anatomy of the pancreas. 1 = portal vein; 2 = splenic vein; 3 = superior mesenteric vein; 4 = inferior mesenteric vein; 5 = posterior superior pancreaticoduodenal vein (SPDV); 6 = anterior SPDV; 7 = inferior pancreaticoduodenal vein; 8 = right colic vein. branches that are closely associated with the uncinate process and the head, the proximal jejunal vein, and the gastrocolic trunk. The proximal jejunal vein that drains the proximal segment of the jejunum frequently drains into the SMV posteriorly. Before it enters into the SMV, it picks up the drainage from the inferior pancreaticoduodenal vein (IPDV). The gastrocolic trunk, which is formed by the right gastroepiploic vein, the middle colic vein, and the right colic vein, runs in the gastrocolic ligament and drains into the SMV anteriorly. The posterior superior pancreaticoduodenal vein (SPDV) follows the bile duct and drains into the caudal surface of the main portal vein within 2 cm of the confluence of the SMV and splenic vein, in most cases. The anterior SPDV is a smaller vein that runs horizontally along the anterior surface of the head of the pancreas before joining the gastrocolic trunk and draining into the SMV. At the confluence of the SMV and the splenic vein that forms the portal vein, the inferior mesenteric vein may join the portal vein in this region; 60 70% join the splenic vein and 30 40% join the SMV. The portal vein then ascends behind the head of the pancreas to enter into the hepatoduodenal ligament. This segment of the SMV and portal vein is in close contact with the pancreas. Venous drainage of the body and tail of the pancreas is more variable, but it consists of multiple small branches draining into the splenic vein that courses along the tail and body of the pancreas. Lymphatic Anatomy Lymphatic vessels of the pancreas originate from the interlobular network in the pancreatic parenchyma. 5,6 They form collecting trunks that follow the pancreatic and peripancreatic blood vessels and drain into the regional lymph nodes according to the pancreatic regions. 9 Lymphatic drainage of the body and the tail of the pancreas drains into the nodes at the splenic hilum and follows the splenic artery to the celiac node, which is the principal nodal group. The lymphatic drainage of the anterior cephalad portion of the head of the pancreas follows lymphatic vessels along the anterior SPDA to the pyloric (or subpyloric ) nodal group, which consist of several lymph nodes along the GDA where it originates from the CHA. This nodal group is located behind the pylorus and anteriosuperior to the head of the pancreas. Posteriorly, the lymphatic drainage of the cephalad portion follows the bile duct to drain into the nodes along the bile duct posterior to the portal vein in the hepatoduodenal ligament and can continue to the hepatic hilar node. The alternate route is to follow the posterior SPDA to the pyloric node. These pathways can also be defined as the superior or ascending pathways, and they drain into the celiac node as their principal node. 9 The lymphatic drainage of the caudal portion of the head of the pancreas and the uncinate process follows the inferior pancreaticoduodenal vessels to the superior mesenteric artery lymph node and drains into the ret-

4 Pathways of Regional Spread in Pancreatic Cancer roperitoneal paraaortic lymph node. This pathway can be defined as the inferior or descending pathway. 9 Several classification systems, including those from the Japanese Pancreatic Society 4 and our institution, 10 have been adopted to define the precise location of nodal stations based on surgical pathologic specimens. The systems usually describe nodal station in relationship to the pancreas and the peripancreatic vessels. The anterior and posterior pancreaticoduodenal nodes are those nodes near the pancreaticoduodenal groove anterior and posterior to the pancreas. The superior nodes are those nodes cephalad to the plane of the main pancreatic duct from the neck of the pancreas to the ampulla, and caudal to that plane are the inferior nodes. These systems are not practical to apply on crosssectional imaging studies such as CT because the plane of the pancreatic duct is oriented obliquely. However, nodal groups along the GDA, pancreaticoduodenal arcades, and IPDA can be defined with a proper helical scanning technique. Pancreatic Nerve Plexus The pancreas is innervated by the networks of the sympathetic and parasympathetic chain that pass through the celiac ganglia and superior mesenteric ganglia. The nerves from the celiac and superior mesenteric plexus generally follow the arteries supplying the pancreas. Imaging Studies Advances in thin-section helical CT have improved the ability to demonstrate precise pancreatic anatomy. With proper intravenous contrast enhancement techniques, small vessels around the pancreas can readily be shown in most patients The relationships between the pancreas and surrounding structure and organs are easily defined. However, nerve plexi, lymphatic vessels, and normal lymph nodes are still not regularly defined with current imaging technology. In this section, I define the anatomy of the pancreas and peripancreatic vessels based on the vascular anatomy as seen on thin-section helical CT. CT Anatomy of the Pancreatic Head The vessels around the head of the pancreas can be identified on CT by following the course of the SMV, the gastrocolic trunk, the gastroduodenal artery, the posterior SPDA and SPDV, the anterior SPDA and SPDV, the proximal jejunal vessels, and the IPDA and IPDV (Fig. 12 3). These vessels form excellent anatomic landmarks around the head of the pancreas. At the level of the cranial portion of the head of the pancreas, the gastroduodenal artery is located in the retropyloric space at the anterolateral surface and can be seen in almost every case. The posterior SPDA and SPDV can be identified along the posterior lateral surface accompanying the bile duct in 72 88% of CT scans The posterior SPDV can be followed cranially, and it drains into the caudal surface of the suprapancreatic segment of the portal vein. Medial to the pancreatic head and behind the pancreatic neck, the SMV is routinely seen here, and on occasion, the branch of the dorsal pancreatic artery to the head of the pancreas may be seen. The 1MV can be seen draining into the left side of the SMV in this location in 50 70%. At the midlevel of the head of the pancreas, the anatomic landmark is the gastrocolic trunk where it enters into the SMV. 15 Although the branching patterns that form the gastrocolic trunk may vary, the site where it enters into the SMV and the position of the SMV in relationship to the head of the pancreas are constant. The gastrocolic trunk enters into the SMV anteriorly, and the SMV is usually anterior and medial to the head. The position of the posterior SPDV and the bile duct remains the same at the posterolateral surface of the head of the pancreas. The anterior SPDA continues the same course of the gastroduodenal artery at the anterolateral surface of the head, but the anterior SPDV can be seen draining into the gastrocolic trunk. The anterior SPDV is a small vein that is closely approximated to the head. Its course can be similar to a larger right colic vein that is located at the root of the transverse mesocolon and also drains into the gastrocolic trunk. This may explain the difference in the ability to identify this vein, as reported by Crabo et al. and Ibukuro et al. (98% vs. 50%, respectively). 11,12 At this same level of the head of the pancreas, the branches of the IPDV may be identified at the posterior surface of the head as it forms a network with the posterior SPDV. At the level of the caudal portion of the head and the uncinate process, the IPDV can be identified medial to the head as it connects with the proximal jejunal vein before entering into the posterior wall of the SMV. This type of anatomy can be seen in 66 90% of cases. The branching pattern of the IPDA and proximal jejunal artery is similar to that of the veins.

5 Pathways of Regional Spread in Pancreatic Cancer 599 Fig Arterial anatomy of the pancreas (see text). (a) The gastroduodenal artery (arrow) is behind the pylorus (P). The posterior superior pancreaticoduodenal artery (PSA) accompanies the bile duct (BD). The dorsal pancreatic artery (arrowhead) gives off a branch medial to the pancreatic head. D = duodenum. (b) The gastroepiploic artery (large white arrow) is branching out from the gastroduodenal artery (small white arrow), (c) The anterior superior pancreaticoduodenal artery (large white arrow) and posterior inferior pancreaticoduodenal artery (small white arrow) form an arcade around the head of the pancreas. (d) Anterior to the uncinate process is the jejunal vein (small white arrow) draining into the SMW (large white arrow). Pathways of Regional Spread in Pancreatic Cancer Local Organ Invasion Pancreatic ductal adenocarcinoma has a propensity to invade adjacent organs and structures surrounding the pancreas, depending on the site of the primary tumor. The tumors in the tail and body of the pancreas often present at an advanced stage because of the lack of symptoms (Fig. 12 4). The tumors may involve the spleen, stomach, and the splenic flexure of the colon, and not infrequently, they invade the surrounding retroperitoneal organs such as the left adrenal gland, the upper pole of the left kidney, and the left renal vein and spread along the transverse mesocolon (Fig. 12 4). This locally advanced disease is usually associated with vascular involvement along the celiac axis (Figs and 12 5) and the superior mesenteric artery and with distant metastasis to the liver and peritoneum, which makes it unlikely that patients will be operable candidates.

6 Pathways of Regional Spread in Pancreatic Cancer Fig Locally advanced pancreatic carcinoma with invasion of the splenic artery and the stomach and metastases in the transverse mesocolon. (a) Large tumor (T) from body of pancreas with invasion of the posterior wall of stomach (St) and encasement of the splenic artery (arrow), (b) CT 4 cm caudal to a shows multiple tumor deposits (arrows) in the transverse mesocolon. Fig Locally advanced pancreatic carcinoma (T) of body of pancreas with perivascular and perineural involvement of celiac plexus (arrow). The primary tumors in the head of the pancreas, on the other hand, present earlier because of the high potential of obstructive jaundice. Yet, most of the tumors, even though they are small, extend beyond the contour of the pancreas at presentation. Local organ involvement such as the duodenum by carcinoma of the head of the pancreas is common (Fig. 12 6), but it does not have impact on resectability because both the pancreas and duodenum are removed together at pancreaticoduodenectomy. Involvement of the inferior vena cava and the transverse mesocolon is rare (Fig. 12 6), but their involvement are not absolute criteria of unresectability and will be considered on an individual basis. At our institution, pancreatic surgeons use the following criteria as guidelines for resectability of pancreatic carcinoma at the head of the pancreas: (a) lack of distant metastasis such as hepatic and peritoneal metastasis; (b) no involvement of the superior mesenteric artery or

7 Pathways of Regional Spread in Pancreatic Cancer 601 Fig Ductal adenocarcinoma of head of pancreas with local invasion to duodenum, stomach and transverse mesocolon. (a) CT shows hypodense tumor (T) involving the duodenum (D) and posterior wall of antrum of stomach (St). (b) CT 2 cm caudal to a shows tumor (T) extending into the transverse mesocolon along the gastroepiploic (large white arrow) and middle colic veins (small white arrows). celiac axis; and (c) the superior mesenteric and portal venous confluence must be patent. 17 Vascular involvement is described in the next section. Vascular Involvement Identification of pathways of tumor spread is important for surgical planning in order to achieve a marginnegative resection, particularly when the tumor spreads beyond the usual extent of pancreaticoduodenectomy or when the tumor is located in the retroperitoneum behind the SMA where direct intraoperative assessment is not possible until the final stage of resection (Figs and 12 8). However, tumors arising from the pancreas adjacent to the duodenum tend to infiltrate along the anterior SPDA toward the gastroduodenal artery behind the pylorus (Fig. 12 9) and the proper hepatic artery in the hepatoduodenal ligament or along the posterior SPDV toward the inferior surface of the portal vein. Tumors arising in the cranial portion of the pancreatic head near the neck may infiltrate superiorly toward the CHA (Fig ) or infiltrate inferiorly into the mesentery and transverse mesocolon and along the SMV. Tumors arising from the uncinate process may infiltrate along the IPDA or IPDV toward the posterior surface of the SMA (Fig. 12 8) or into the jejunal mesentery where the IPDA originates from. Tumors arising from the head of the pancreas near the confluence of the gas trocolic trunk where it drains into the SMV may infiltrate into the base of the transverse mesocolon along the middle colic artery or vein (Fig. 12 6). Knowledge of this anatomy and of the potential pathways of local tumor invasion is important for surgical planning when an aggressive surgical approach is planned. We defined CT criteria of vascular involvement and used these criteria to assess vascular involvement in 56 patients with pancreatic ductal adenocarcinoma who underwent surgical exploration. 18,19 When there was a fat plane (type A) or normal pancreatic parenchyma (type B) separating the tumor from adjacent vessels, the tumor was resected without venous resection in 21 of 22 patients (95%). When the tumor was inseparable from the vessels but the points of contact formed a convexity against the vessel (type C), it was not reliable to predict whether the tumor was fixed against the vessel (Fig ). When the tumor was partially encircling (type D), the tumor was fixed against the vessels in most cases (Figs and 12 12). The resectable rate was 47%, but resection also required venous resection. When the tumor was completely encircling (type E) or

8 Pathways of Regional Spread in Pancreatic Cancer Fig Tumor (T) involving the head of the pancreas. Note tumor infiltrate (t) along the superior mesenteric artery (arrow). It is not possible to distinguish perivascular or perineural invasion in this case because the nerve plexus also accompanies the artery. The lesion is not resectable. Fig Tumor (T) involving the uncinate process. Note hypodense tumor infiltrate along the inferior pancreaticoduodenal artery (small arrow) behind the superior mesenteric artery (large arrow). This lesion is not resectable. Fig Tumor in cephalad portion of head of pancreas. Tumor (T) involves the gastroduodenal artery (large arrow) and the replaced right hepatic artery (small arrows) from the SMA.

9 Pathways of Regional Spread in Pancreatic Cancer 603 Fig Tumor (T) at neck of pancreas with direct involvement of the common hepatic artery (arrow). Fig Ductal adenocarcinoma of head of pancreas. Medial extension of tumor (small arrow) just abuts the SMA (large arrow), a type C vascular involvement. Patient did not undergo resection because metastatic disease in liver was found on follow-up study. occluding (type F) the vessel, all tumors were not resectable with a negative margin. We believe that these improved results are largely due to scanning with thin sections during the bolus phase of intravenous contrast enhancement, when the lesion and its extent along the vessels are easier to identify. With our scanning technique described earlier, we have shown that CT accurately defines the extent of vascular involvement and correctly predicts resectability in 88% of patients. Nodal Metastasis Lymph node metastases are common in pancreatic tumors because of rich lymphatic networks around the pancreas. They are found in 40 75% of patients with tumors larger than 2 cm on pathologic examinations. 4 The majority of lymph node metastases are found at the peripancreatic nodal group, including the anterior and posterior peripancreatic nodes, pancreaticoduodenal lymph nodes, pyloric nodes (Fig ), and inferior

10 Pathways of Regional Spread in Pancreatic Cancer Fig Ductal adenocarcinoma of head of pancreas. Tumor (T) involves the superior mesenteric vein (large arrow), a type D involvement. Tumor was resected with venous resection. The small hypodense nodule (small arrow) between the SMV and SMA was confirmed to be a metastatic node. Fig Pancreatic ductal adenocarcinoma involving body and cephalad portion of head of pancreas. Note node (n) anterior to the gastroduodenal artery (arrow) and behind the gastric antrum (St). A metastatic node was confirmed at surgery. T = tumor in body of pancreas. nodes along the IPDA (Fig ). Metastases to the nodes in the hepatoduodenal ligament, common hepatic nodes, and celiac node are rare (less than 10%). 4 Currently, preoperative assessment of nodal metastasis by CT or MR is not accurate enough to make an impact on surgical planning because no better criteria of nodal metastasis can be applied other than the size MR may provide a better potential because metastatic nodes may be hyperintense on T2-weighted images, but this potential has yet to be proved. The Radiology Diagnostic Oncology Group study has shown that the sensitivity to predict nodal metastasis was only 37% by CT and 34% by MR, and the specificity was 60% by CT and 76% by MR, with the positive and negative predictive values ranging between 47% and 57%. 21 The results from our unpublished data using the thin-section CT scanning technique are similar to this study. We believe that these poor results are due to several factors, including (a) the inability to diagnose microscopic metastasis in small nodes (3 5 mm); (b) the large inflammatory nodes mistaken as metastasis; (c) poor understanding of the pathways of nodal metastasis in pancreatic tumors in crosssectional imaging; and (d) possibly misinterpreting tumor infiltration as a nonnodal disease. It should be emphasized that nodal metastasis around the pancreas would not impact surgical planning because metastatic nodes are mostly removed in the specimen of pancreaticoduodenectomy; however, its presence would influ-

11 References 605 Fig Large tumor (T) involving head of pancreas. Multiple hypodense nodes are shown along the SMA and jejunal mesentery (short arrows) and the upper paraaortic region (long arrow). This is the descending or inferior pathway of nodal metastasis. ence the outcome of surgery. It is more important to recognize nodal metastasis in the nodal groups, such as the mesenteric nodes, the common hepatic artery node, and the celiac node, that may not be included in the resected specimen because metastasis to these nodes would preclude patients from surgery. Recently, we developed new criteria to try to improve the sensitivity and specificity in predicting nodal metastasis in patients with pancreatic carcinoma. 23 We have observed that (a) low-density nodes with irregular margins are highly specific for metastatic disease but they are not sensitive enough to detect the majority of metastatic nodes (Figs and 12 14); (b) using the size of lymph node larger than 5 mm in the inferior pancreatic nodal group increases the sensitivity to detect nodal metastasis; and (c) enlarged nodes in the periportal and common hepatic nodal groups are nonspecific and can be seen in patients with chronic pancreatitis or nodenegative pancreatic cancer. Perineural Invasion Perineural invasion is common in pancreatic ductal adenocarcinoma. However, the diagnosis is made on histologic examination and rarely by imaging studies because of the inability to define nerves around the pancreas. There are no objective criteria to define perineural invasion by imaging studies. It is also possible that perivascular invasion along the arteries around the pancreas is, in fact, perineural invasion because most of the peripancreatic nerves accompany the peripancreatic vessels (Figs and 12 7). Conclusion Identification of pathways of tumor spread is important for surgical planning in order to achieve a marginnegative resection, particularly when the tumor spreads beyond the usual extent of pancreaticoduodenectomy. The anatomic relationship between the pancreas and peripancreatic vessels and the knowledge of the pathways of lymphatic drainage of the pancreas are important to define the extent of the disease before definitive surgery, which carries a high risk and a marginal longterm result. References 1. Warshaw AL, Fernandez-del Castillo C: Pancreatic carcinoma. N Engl J Med 1992; 326: Evans DB, Abbruzzese JL, Rich TA: Cancer of the pancreas. In Cancer Principles and Practice of Oncology. Edited by VT DeVita Jr, S Hellman, SA Rosenberg. Lippincott-Raven, Philadelphia, 1997, pp Yeo CJ, Cameron JL, Lillemoe KD, et al: Pancreaticoduodenectomy for cancer of the head of the pancreas. Ann Surg 1995; 221: Kobari M, Matsuno S, Ohashi O, et al: Staging systems for pancreatic cancer and distribution of metastases. In Pancreatic Cancer: Problems in General

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