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 symp toms (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. 12-4 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.

Splenic Tumor

Fig. 12—4. 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. 12—4. 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. 12—5. 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 pancreaticoduode-

nectomy. 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

Tumor Invasion Into Skull

Fig. 12—6. 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).

Fig. 12—6. 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.

Baby Sleeping

Baby Sleeping

Everything You Need To Know About Baby Sleeping. Your baby is going to be sleeping a lot. During the first few months, your baby will sleep for most of theday. You may not get any real interaction, or reactions other than sleep and crying.

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