Pancreatic cancer

Initiation of pancreatic development in ventral and dorsal pancreatic bud. Day E9.5 mouse embryo stained for Pdx1 to visualize ventral (vb) and dorsal (db) pancreatic buds. At this stage, only small numbers of differentiated endocrine cell types are present, and Pdx1 is expressed in all undifferentiated precursor cells.

Four different types of neoplastic pancreatic disease. Microscopic appearance of infiltrating ductal adenocarcinoma (A), microscopic appearance of PanIN-3 (B), microscopic appearance of a mucinous cystadenoma (C), and gross appearance of an intraductal papillary mucinous neoplasm with in situ carcinoma. Note the ovarian-like stroma in the mucinous cystadenoma (C). The intraductal papillary mucinous neoplasm (D) fills the main pancreatic duct.

Histologic-genetic progression model of infiltrating pancreatic ductal adenocarcinoma from PanIN. Printed with permission from Wilentz RE et al. Cancer Res 2000;60:2002–6.

Representative spectrum examples of SELDI analysis of pancreatic juice samples bound to IMAC-3 cupper ProteinChip array. A peak of <16,570 Da (arrow) was present in the 4 pancreatic juice samples from patients with pancreatic adenocarcinoma (PC4, PC8, PC18, PC24) but absent in the 4 patients with other pancreatic diseases [IPMN; islet cell tumor (ICT); serous cystadenoma (SC)].

Late arterial phase of spiral CT scan, with contrast used as oral agent. The kidneys and aorta are contrast enhanced, as is the inferior vena cava. Dilated bile ducts are seen in the liver, and the gallbladder is distended. A large (5 cm) hypodense mass is seen in the head of the pancreas, and the superior mesenteric vein (SMV) is not seen. Additional caudal images confirmed occlusion of the SMV, with numerous mesenteric venous collaterals. This tumor was deemed unresectable, on the basis of the advanced local disease.

Arterial phase of multidetector CT scan, with water used as oral agent. The kidneys and aorta are contrast enhanced. A 3-cm hypodense tumor mass is seen in the pancreatic uncinate process, anterior to the aorta and inferior vena cava. The tumor abuts the right lateral aspect of the superior mesenteric vein. The superior mesenteric artery is contrast-enhanced, patent and not approached by tumor. This tumor was resected via pancreaticoduodenectomy, with negative resection margins.

Multidetector CT images from patient with small cancer in head of pancreas. (Top) Sagital 3-dimensional reconstruction shows normal aorta, celiac axis, and superior mesenteric artery. (Bottom) Coronal 3-dimensional reconstruction shows normal liver, gastric fundus, portal vein, as well as intact superior mesenteric artery and vein.

Two T₁-weighted MR images with contrast enhancement with gadolinium. A mass in the head of the pancreas appears as a hypointense area. (From Yeo CJ, Cameron JL. Pancreatic Cancer. Curr Prob Surg 1999;36:57–152, Fig 17).

Single shot, spin echo MRI-cholangiopancreatogram in patient with obstructive jaundice. Both the common bile duct and the pancreatic duct are dilated, and a hypointense area of tumor is apparent in the periampullary region. (From Yeo CJ, Cameron JL. Pancreatic Cancer. Curr Prob Surg 1999;36:57–152, Figure 18).

ERCP in patient with obstructive jaundice reveals classic “double-duct” sign. There is evidence of tumor at the genu of the common bile duct and pancreatic duct. (From Yeo CJ, Cameron JL. Pancreatic Cancer. Curr Prob Surg 1999;36:57–152, Figure 19).

EUS image with linear array echoendoscope, revealing a mass in the head of the pancreas with no vascular invasion of the superior mesenteric artery (SMA), superior mesenteric vein (SMV), or portal vein (portal). (From Yeo CJ, Cameron JL. Pancreatic Cancer. Curr Prob Surg 1999;36:57–152, Figure 24).

FNA of pancreatic adenocarcinoma: cluster of malignant cells with coarse nuclear chromatin, variable nuclear size and shape, and disorderly nuclear crowding. (Original magnification × 400.) (From Tsiotos GG, Sarr MG. Diagnosis and clinical staging of pancreatic cancer. In: Howard JM, Idezuki Y, Ihse I, Prinz RA, editors. Surgical diseases of the pancreas. 3rd ed. Baltimore: Williams and Wilkins; 1998. p. 504, Fig 52.5).

Image obtained at ERCP, with guide wire passed cephalad through distal common bile duct obstruction caused by cancer in head of pancreas. (From Yeo CJ, Cameron JL. Pancreatic Cancer. Curr Prob Surg 1999;36:57–152, Figure 26).

Image obtained immediately after successful ERCP. A 10F plastic endoprosthesis has been placed across a malignant distal bile duct obstruction. A markedly dilated intrahepatic biliary tree is visualized. (From Yeo CJ, Cameron JL. Pancreatic Cancer. Curr Prob Surg 1999;36:57–152, Figure 27).

Percutaneous transhepatic cholangiogram in patient with obstructive jaundice. There is a malignant obstruction of the biliary tree at the level of the junction of the common hepatic duct and cystic duct. Staples are visible from a remote laparotomy for peptic ulcer disease. (From Yeo CJ, Cameron JL. Pancreatic Cancer. Curr Prob Surg 1999;36:57–152, Figure 28).

Cholangiogram obtained after placement of internal-external percutaneous transhepatic biliary drainage catheter. The catheter transverses the obstruction in the head of the pancreas. The tip of the catheter resides in the duodenum, distal to the ampulla. (From Yeo CJ, Cameron JL. Pancreatic Cancer. Curr Prob Surg 1999;36:57–152, Figure 29).

Illustration depicts anatomy after one method of palliative intervention. The biliary-enteric anastomosis is shown as a retrocolic end-to-side hepaticojejunostomy with a jejunal loop. A jejunojejunostomy is performed below the transverse mesocolon, to divert the enteric stream away from the biliary-enteric anastomosis. Also shown is a retrocolic gastrojejunostomy. (From Cameron JL, Atlas of Surgery, Volume 1, B.C. Decker, Toronto, 1990, p 427, Image V).

Technique of alcohol celiac nerve block. Twenty milliliters of 50% alcohol are injected on each side of the aorta (Ao) at the level of the celiac axis. IVC, Inferior vena cava. (From Lillemoe KD et al. Ann Surg 1993;217:447–57).

Pylorus-preserving pancreaticoduodenectomy. Top left: The structures resected include the duodenum (except for the initial 1 to 2 cm beyond the pylorus); head, neck and uncinate process of the pancreas, with tumor (black); gallbladder; and distal extrahepatic biliary tree. Top right: The structures retained include the entire stomach, pylorus, proximal 1 to 2 cm of duodenum, body and tail of the pancreas, proximal biliary tree, and jejunum distal to the ligament of Treitz. Bottom: The reconstruction is shown as a proximal end-to-end pancreaticojejunostomy, hepaticojejunostomy decompressed via a percutaneous transhepatic catheter and a distal duodenojejunostomy. (From Yeo CJ, Cameron JL. The pancreas. In: Hardy JD, editor. Hardy's textbook of surgery. 2nd ed. Philadelphia: JB Lippincott; 1988. p 718, Fig 28-9).

Illustration near completion of distal pancreatectomy and splenectomy for large tumor in body of pancreas. The spleen and tail of the pancreas have been mobilized out of the retroperitoneum. The pancreatic parenchyma is being divided by use of electrocautery. (From Cameron JL. Atlas of surgery. Vol 1. Toronto: BC Decker; 1990. p. 435, Image H).