Adenocarcinoma of the uncinate process of the pancreas: MDCT patterns of local invasion and clinical features at presentation

ArticleinEuropean Radiology 22(5):1067-74 · November 2011with30 Reads
DOI: 10.1007/s00330-011-2339-4 · Source: PubMed
To compare the multidetector CT (MDCT) patterns of local invasion and clinical findings at presentation in patients with adenocarcinoma of the uncinate process of the pancreas to patients with adenocarcinomas in the non-uncinate head of the pancreas. We evaluated the two cohorts for common duct and pancreatic duct dilatation, mesenteric vascular encasement, root of mesentery invasion, perineural invasion and duodenal invasion. In addition, we compared the clinical findings at presentation in both groups. Common duct (P < 0.001) and pancreatic duct dilatation (P = 0.001) were significantly less common in uncinate process adenocarcinomas than in the non-uncinate head of the pancreas. Clinical findings of jaundice (P = 0.01) and pruritis (P = 0.004) were significantly more common in patients with lesions in the non-uncinate head of the pancreas. Superior mesenteric artery encasement (P = 0.02) and perineural invasion (P = 0.001) were significantly more common with uncinate process adenocarcinomas. Owing to its unique anatomic location, adenocarcinomas within the uncinate process of the pancreas have significantly different patterns of both local invasion and clinical presentation compared to patients with carcinomas in the non-uncinate head of the pancreas. Key Points • SMA encasement and perineural invasion were more common with uncinate process adenocarcinomas. • Common bile duct and pancreatic duct dilatation were less common in uncinate process adenocarcinomas • Jaundice and pruritis were more common with lesions elsewhere in the pancreatic head.
    • "Scrolling through the cut-plane VR images allows excellent depiction of the course of the PIPDA along the posterior inferior margin of the uncinate process and pancreatic head. Tumors of the uncinate process typically result in hypodense masses that enlarge the uncinate and cause its contours to extend in a convex margin, giving it a rounded appearance [16] . Current guidelines for the staging of ductal adenocarcinoma do not take into consideration extrapancreatic spread along perineural pathways [21—23] . "
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  • [Show abstract] [Hide abstract] ABSTRACT: Pancreatic duct (PD) dilation proximal to a solid focal pancreatic lesion on computed tomography (CT) scan is considered highly suggestive of pancreatic adenocarcinoma. There is, however, no published data on the differential diagnosis of focal non-cystic pancreatic lesions with and without PD dilation. We assessed the diagnostic utility of this radiologic finding. This is a retrospective analysis of a prospectively maintained database of university-based clinical practice. A total of 445 non-jaundiced patients who underwent endoscopic ultrasound (EUS) (2002-2010) for evaluation of solid pancreatic lesions noted on CT scan were included. Final diagnosis was based on surgical pathology or definitive cytology with supporting clinical follow-up of ≥12 months. Main outcome measurements included (1) differential diagnoses and (2) performance characteristics of EUS-fine needle aspiration (FNA) for diagnosing neoplasm in patients with non-cystic pancreatic lesions with and without PD dilation. A neoplasm was finally diagnosed in 152 of 187 patients with and 87 of 258 patients without PD dilation on CT scan. Chronic pancreatitis (diffuse and focal) was the predominant non-malignant diagnosis in patients with PD dilation. In patients without PD dilation, malignant lesions included neuroendocrine tumor, adenocarcinoma, metastasis, PEComa (perivascular epitheloid cell tumor), and lymphoma; and the non-neoplastic diagnosis included chronic pancreatitis, intrapancreatic lymph nodes, and infected pancreatic fluid collection. EUS-FNA had 97.6% accuracy for diagnosing a neoplasm in these patients. Dilation PD proximal to a focal solid pancreatic lesion increases the likelihood of malignancy but the performance characteristics of this radiologic finding are probably inadequate to guide clinical management. Neoplasms without dilated PD often require immunostaining for a definitive diagnosis.
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  • [Show abstract] [Hide abstract] ABSTRACT: This literature review aimed to critically analyze oncological results of vascular resection during pancreatectomy for adenocarcinoma in the light of the concept evolution of locally advanced tumors and microscopic complete resection. The literature search was conducted in PubMed and Medline for the period June 1994 to December 2012, retaining English as the language of publication. The review of 12 publications indicated that mortality and morbidity rates were not significantly different for pancreatectomy with or without venous resection (VR). Six comparative studies showed worse long-term survival in the VR group, though one meta-analysis, albeit with a significant population heterogeneity, demonstrated that the overall survival between VR and the control group was similar (12% vs. 17%). The compilation of 13 comparative studies showed a significantly lower rate of complete microscopic resection in the VR patient group compared to controls (63% vs. 77%; P = 0.001). Concerning pancreatectomy combined to arterial resection, the literature review indicated a significantly greater mortality and morbidity rate and a lower survival rate compared to pancreatic resection alone. Conflicting results concerning the long-term outcome of VR was due to the heterogeneity of the patient population. Since the only chance to cure patients of pancreatic adenocarcinoma is to obtain free resection margins, VR is a valid therapeutic option. But combined arterial resection to pancreatic resection does not appear to be recommended.
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