Embed Size (px)
Citation preview
CARCINOMA OF T H E PANCREAS ARISING IN T H E REGION OF T H E UNCINATE PROCESS
TAKASHI SUZUKI, MD," HITOSHI KURATSUKA, MD, * K G T A R ~ UCHIDA, MD, * YOSHIRG MATSUMOTO, MD," AND ICHIO HONJO, MD+
Of 54 patients with carcinoma of the head of the pancreas, six were confirmed to have lesions arising in region of the uncinate process. The present study was initiated in an attempt to clarify the particular clinical features exhibited by these lesions. As compared with patients with periampullary carcinoma, those with uncinate carcinoma revealed the following characteristics: jaun- dice, abdominal mass, and severe pain were rare; the preoperative identification of the lesion was very difficult, even with cholangiography, scintigraphy, and the pancreozymin secretin test in addition to routine laboratory studies; the most helpful information could be obtained from selective arteriography and hypotonic duodenography; because of its topographic relationship with the portal vein system and mesentery, the lesion became unresectable even in a comparatively early stage; and long survival after surgery could not be ex- pected, even when the lesion was resectable.
HE UNCINATE PROCESS IS A HOOK-LIKE EX- T tension of the lower part of the head of the pancreas. Anatomically, i t lies just pos- terior to the superior mesenteric vessels along the upper border of the third portion of the duodenum, Compared with other parts of the pancreas, this region is more closely connected to the mesentery and is situated at some dis- tance from the course of both bile and pan- creatic ducts. These topographic relationships account for the special clinical features of carcinoma in this portion of the pancreas. Few reports, however, have referred to the peculiar aspects of carcinoma of the uncinate process. This study describes a group of pa- tients suffering from carcinoma in the region of the uncinate process. Their symptoms and clinical course are discussed, and some rep- resentative cases are illustrated in detail.
CLINICAL MATERIALS
Among 54 patients with carcinoma of the head of the pancreas who underwent laparot- omy in our clinic from April 1965 to Decem- ber 1971, six were confirmed to have lesions
From the First Department of Surgery, Kyoto Uni- versity Medical School, Kyoto, Japan.
* Staffs of the First Department of Surgery, Kyoto University Medical School.
t Professor of the First Department of Surgcry, Kyoto University Medical School.
Address for reprints: T. Suzuki, MD, First Depart- ment of Surgery, Kyoto University Medical School, Sak- yo-ku, Kyoto, Japan.
Received for publication March 29, 1972.
arising in the region of the uncinate proc- ess-four men and two women aged 45 to 66.
SYMPTOM s
Vague distress in the abdomen was the ini- tial symptom in five of the six patients. In one patient, loss of weight was initiated. The du- ration of symptoms prior to surgery ranged from 2 to 9 months, with a mean value of 5 months. The most frequent preoperative symptom was loss of weight, which averaged 8 kg. Dull pain in the abdomen accurred in five patients and lumbar pain in four. None had severe pain. Jaundice was noted in only one patient on admission. One other patient be- came jaundiced during hospitalization for di- agnostic evaluation. No patients complained of chills, fever, vomiting, diarrhea, prurigo, etc.
DIAGNOSTIC STUDIES
The routine laboratory data were almost within normal range. Anemia and leukocyto- sis were absent or very mild. In four of the six, the icterus index was normal; in the re- maining two, i t was 52 and 120 units. In the latter case, compression by metastatic lymph nodes, not by the original tumor, was found at operation. The amylase and fasting blood sugar levels were within normal range, except in one patient. In three patients, the exocrine function of the pancreas was examined by the
796
No. 3 CANCER OF UNCINATE PROCESS - Si i z i i l t i et (11. 797
pancreozymin secretin test and proved to be normal. Arteriography, performed in five pa- tients, showed abnormal findings: invasion of the root of the superior mesenteric artery in all five and of inferior pancreaticoduodenal artery in three. One patient showed slightly proliferated tumor vessels. No tumor stain was demonstrated. Hypotonic duodenography was carried out in all six patients. In five of them, the inner margin of the third portion of the duodenum was invaded irregularly, suggesting extension of the tumor towards the tliio- denum. In one patient, no abnormal findings were demonstrable. In three patients, scintig- raphy with 75Se-selenomethionine was at- tempted, but lesions could not be identified.
SURGICAL TREATMENT AND
FOLLOW-UP RESULTS
Only one of six patients could be treated by pancreatoduodenectomy, wliich showed the tumor to be 5 x 3 cm on cut section. In the remaining five patients, the tumors had di- rectly invaded the superior mesenteric vessels and formed cancerous cores in the mesentery, so that bypass operations alone were per- formed. These tumors were estimated to be the size of hen or goose eggs. Remarkable lymph node metastases were present in all the cases. No patients, however, showed evidence of liver metastasis. Histologically, all the tii-
mors were confirmed to be adenocarcinoma. Follow-up studies showed that all the pa-
tients died of cachexia within 6 months after surgery. The one patient whose lesion could be resected survived only 5 months. Of the (five patients treated by palliative operation, three died within 3 months after surgery (Table 1).
CASE REPORTS
Of the present series, one unresectable and one resectable case are described in detail.
Case 1. A 61-year-old man was admitted to our clinic with complaints of vague abdomi- nal distress and weight loss of 4 months’ dura- tion. One and a half months prior to admis- sion, he first noticed a painless mass in the left supraclavicular region, which gradually in- creased in size. Upon physical examination, a hard immovable mass 6 x 5 cm was palpated in the left supraclavicular region, suggesting distant lymph node metastasis. Except for tu- mor-like resistance in the epigastic region, no abnormal findings were noted in the abdo-
men. Routine 1)lootl studies and liver function tests were all within normal range. The values for serum bilirubin, amylase, and blood sugar were also noncontributory. The function and size of the gallbladder were shown to be nor- mal by oral cliolecystograpliy. The pancreo- zymin sccrctin test showed normal volume, amylase output, and bicarbonate level of the pancreatic juice. Selective angiography of the superior mesenteric artery showed amputation of its main stem, suggesting the invasion by a malignant tumor arising from the uncinate process (Fig. 1 A). The pancreaticoduotlenal arteries which took off from a variant right hepatic artery showed no abnormality. Hypo- tonic tluotlenograph y showed a n irregular ron- tour of the inner margin of the third portion of the duodenum. Celiotomy indicated that a large mass extended from the uncinate process into the root of the mesentery, and fixed the third portion of the duodenum (Fig. 1B). The body, tail, and upper part of the head of the pancreas remained in- tact, and the gallbladder, common bile duct, and pancreatic duct were not dilated. Operative cholangiography showed no ab- normal findings such as stenosis, displace- ment, or dilatation anywhere along the biliary system (Fig. 1C). Neither liver metastasis nor peritoneal dissemination was noted. Gastroje- junotomy was performed for the impending obstruction of the duodenum. After surgery, the supraclavicular tumor and abdominal dis- tress gradually increased in degree despite in- travenous administration of anticancer agents. The patient died of cachexia 21/, months after surgery, but had no symptoms clue to obstruc- tion of the bile or pancreatic duct.
In this patient, jaundice and other signs of c-arcinoma of the head of the pancreas failed to develop during the course of his illness. The absence of biliary obstruction and the topographic relationship of the lesion with the portal vein system and mesentery are surely an obstacle in the early detection and satisfactory treatment of patients with carci- noma of the uncinate process.
Case 2. A 66-year-old man came to our hos- pital because of lumbar pain, weight loss, and dull epigastric pain. The laboratory studies at the time of his admission showed no signifi- cant abnormalities except for hyperglycemia. On palpation, slight tenderness was noted in the epigastric region. No mass was palpable. After admission, he gradually developed jaun- dice, and blood studies showed an icterus index of 22, a C O T of 364, and a G P T of 882 units. One week later, the icterus index was 52. Hypotonic duodenography taken just prior to surgery showed irregularity of the inner margin of the third portion of the duo-
TA
BL
E
1.
Res
ults
of
Six
Pat
ient
s w
ith
Car
cino
ma
Ari
sing
in
the
Reg
ion
of t
he I
'nci
nate
Pro
cess
~
~~~~
~~~
Sym
ptom
pri
or t
o ad
mis
sion
(+
: Pos
itiv
e fi
ndin
gs, - :
Neg
ativ
e fi
ndin
gs)
____
____
__
Abd
omin
al
Lum
bar
Palp
able
LT
'eig
ht
Dur
atio
n of
sym
ptom
C
ase
Xge
!sex
pa11
1 pa
in
J a ti
ndic
e m
ass
loss
D
iarr
hea
Fev
er
Prur
igo
prio
r to
sur
gery
(ni
os.)
+ h'I
H
6611
1 +
+ +
+ E
O
62M
+
+ H
N
45F
+ +
+ +
TY
58
F
+ M
Y
51M
+
+ T
S 61
M
+ +
+ +
4.0
60
4.0
-
2.0
9 .O
5.0
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- -
-
-
- -
-
-
-
-
-
-
Dia
gnos
tic
data
pri
or to
surg
ery
n
> z S
erum
F
asti
ng
Pa nc
re-
Surv
ival
n
Ic
teru
s am
ylas
e bl
ood
suga
r oz
ytni
n af
ter
5;i in
dex
(Sm
ith-
Roe
; (S
omog
yi;
Hyp
oton
ic
secr
etin
Sc
inti
gram
wit
h su
rger
y co
duod
enog
rain
Se
lect
ive a
rter
iogr
am
test
7~
Se-S
elen
omet
hion
iiie
O
pera
tive
pro
ced
tire
(mos
.)
r3
'K
Caz
e (u
nits
) un
its)
m
g/dl
) M
I1
52
110
186
EO
12
10
4 96
HK
12
0 90
11
5
TY
4
132
104
MY
3
98
110
TS
3 1.5
0 90
Inva
sion
of
the
thir
d du
oden
al p
orti
on
No
rem
arka
ble
chan
ge
Inva
sion
of
the
seco
nd a
nd th
ird
duod
enal
por
tion
Inva
sion
of
the
thir
d du
oden
al p
orti
on
Inva
sion
of
the
thir
d du
oden
al p
orti
on
Inva
sion
of
the
thir
d du
oden
al p
orti
on
Inva
sion
of
the
infe
rior
pa
ncre
atic
oduo
dena
l an
d th
e su
peri
or
mes
ente
ric
arte
ry
Inva
sion
of
the
infe
rior
pa
ncre
atic
oduo
dena
l an
d th
e su
peri
or
mes
ente
ric
arte
ry
Inva
sion
of
the
infe
rior
pa
ncre
atic
od u
oden
al
and
the
supe
rior
m
esen
teri
c ar
tery
; tu
mor
ves
sels
Inva
sion
of
the
dors
al
panc
reat
ic a
nd t
he
supe
rior
mes
ente
ric
arte
ry
Am
puta
tion
of
the
supe
rior
mes
ente
ric
-
Tio
rmal
re
spon
se
Nor
mal
re
spon
se
-
-
Nor
mal
re
spon
se
- -
Panc
reat
oduo
dene
ctom
y 5 0
2 3
-
Exp
lora
tory
lapa
roto
my
60
2 Q
- - cc 4 I0 -
Ext
erna
l in
trah
epat
o-
30
du
ctos
tom
y
No
rem
arka
ble
chan
ge
Gas
troj
ejun
osto
my
and
27
ch
olec
ysto
jej u
nost
omy
Dec
reas
ed u
ptak
e in
G
astr
ojej
unos
tom
y an
d 5
.0
the
enti
re p
ancr
eas
chol
ecys
toje
juno
stom
y
No
rem
arka
ble
chan
ge
Gas
troj
ejun
osto
my
2.6
5
arte
ry
w
0
No. 3 CANCER OF UNCINATE PROCESS * Sirzriki et 01. 799
FIG. 1. An uriresectable case with carcinoma of the iincinatc process. A. Preoperative aiigiograni o f thc supci-ior mcsentcric artely. Ampiit;ction of its main stein, suggesting the pescncc of a inalignant tutlior aiising froin tlic uncinate proccss, is S ~ C I I ( a ~ ~ . o w ) .
denum (Fig. 2 ) . At laparotomy, 2 wccks after the onset of jaundice, a hard mass was found in the region of the uncinate process. Grossly, the lesion was confined to the gland, and no portal involvement was noted by digital exam- ination of the posterior surface of the head of the pancreas. Consequently, pancreatotluo- denectomy was performed in the usual fash- ion. The postoperative course was quite unev- entful, but he soon complained of abdominal distress and died of recurrent tumor as early as 5 months after surgery.
This is the only patient with carcinoma of the uncinate process who could be treated by pancreatoduodenectomy. Growth of the tumor towards the center of the gland, not towards the mesentery or portal vein system, probably makes it possible to resect the lesion. How- ever, recurrence developed shortly after sur- gery. Among all the cases treated by pancrea- toduodenectomy, this patient had the shortest survival, if the immediate postoperative deaths are excluded.
FK.. 1 B. Findings observed at operation. Cancerous cote is fotmetl in the root of the mesentcry.
pel inmpullary carcinoma depends largely on the time of appearance of jaundice. In this se- ries, only one patient showed jaundice prior to atlniis,ion which, however, was due not to the primary tumor but to metastasis in the pel icholedothal llmpli nodes. T ~ L I S , one of the principal reasons for the poor results in uncinate carcinoma is the lack of symptoms of biliary retention. In a rekiew of signs and symptoms in patients with carcinoma of the head of the pancreas, Jordan6 reported that 12 of 95 patients showed no jaundice on admis-
DISCUSSION
Throughout the study, stress was laid on the peculiar aspects o f carcinoma of the uncinate process, which can be summarized as follows: paucity of distinctive signs and symptoms such as jaundice, severe pain, and abdominal mass; no evidence of abnormality in laboratory stud- ies; preservation of biliary and pancreatic func- tion until the latest stage; low percentage of resectability of the lesion; and short survival after surgery, even when the tumor can be re- sected. The possibility of early detection of
FIG. 1C. Operative cholangiogram. No abnormal findings such as stenosis, displacement, or dilatation are noted anywhere along the hiliary sistem.
800 CANCER September 1972 Vol. 30
FIG. 2. A rexctable case with carcinoma of the uncinate process. Preoperative hypotonic duodenog- raphy shows irregularity of the inner margin of the third portion of the duodenum.
sion to the hospital and in Glenn's series5 8 of 126 patients were not jaundiced. In the series of Berg3 and Be11,Z nearly 20% were not jaun- diced throughout their course. Most of these lesions may have been in the uncinate process. Patients with carcinoma of the body or tail of the pancreas d o not develop jaundice, but they often complain of severe pain. The pain due to uncinate carcinoma is, however, dull and not severe, so far as we observed, which causes further difficulty in establishing an ac- curate diagnosis.
A comparatively reliable diagnostic proce- dure for identification of this disease is selec-
tive arteriography and hypotonic duodenogra- phy. The superior mesenteric artery originates in the dorsal surface of the pancreas and runs downwards in a groove formed by the uncin- ate process. T h e inferior pancreaticoduodenal artery, although anatomic variations are fre- quently noted,8 most commonly arises from this artery in the region of the uncinate proc- ess. In uncinate carcinoma, these arteries often appear abnormal on roentgenograms, showing encasement, irregular narrowing, or amputa- tion. Baron1 stated that carcinoma of the un- cinate process was apt to displace the dorsal pancreatic artery, but, in our series, this was not a constant finding. Hypotonic duodenog- raphy was also very useful in the evaluation of these lesions. In almost all the cases, an irregu- larity and/or a filling defect was seen in the third portion of the duodenum. In order to delineate such tumors more accurately, we have attempted combined arteriography and duodenography, the details of which will be reported in another paper.' I n a recent report, Blatt4 noted that uncinate carcinoma showed the atypical appearing ulcer of the duodenum, which was postbulbar in location.
T h e uncinate process is closely connected to the mesentery as well as to the superior mesen- teric vessels, as emphasized above. These topo- graphic relationships surely prevent curative resection of lesions involving this portion. Al- most all the lesions showed direct invasion into the portal vein system associated with core formation in the mesentery, which re- sulted in an extremely low percentage of re- sectability. Follow-up results of the patients with uncinate carcinoma were ultimately dis- couraging. All the patients died shortly after surgery. Even a patient who could be treated by pancreatoduodenectomy died of recurrence as early as 5 months following resection. Therefore, we now prefer local infusion chem- otherapy, the value of which is yet to be deter- mined.
REFERENCES
1. Baron, M. G., Mitty, H. A,, and Wolf, B. S.: Thc 5. Glenn, F., and Thorhjarnarson, B.: Carcinoma of arteriographic appearance of carcinoma of the uncinate the pancreas. Ann. Surg. 159:945-955, 1964. process of the pancreas. A m . J. Roentgenol. 101:649- 6. Jordan, G. L.: Benign and malignant tumors of 655, 1967. the pancreas and the periampullary region. I n Surgical
2. Bell, E. T.: Carcinoma of the pancreas. I . A c h i - Diseases of the Pancreas. Philadelphia, J. B. Lippincott cal and pathologic study of 609 necropsied cases 11. Re- Company, 1960; pp. 462-463. lation of carcinoma of pancreas to diabetes mellitus. 7, suzuki, T., uchida, K,, ~ ~ ~ ~ t ~ ~ k ~ , H,, ~ ~ ~ ~ h ~ , K., Am. J. Pathol. 33:499-523, 1957. Imamura, M., and Honjo, I.: Usefulness of combined
3. Berg, J. E.: Diagnosis of carcinoma of the pan- selective arteriography and hypotonic duodenography creas. Arch. Intern. Med. 68:525-599, 1941. in evaluation of carcinoma of the pancreas. Ann. Surg.
4. Blatt, C. J., Bernstein, R. G . , and Lopez, F.: Un- In Press. common roentgenologic manifestation of pancreatic 8. Woodhurne, R. T., and Olsen, L. L.: T h e artery carcinoma. A m . I . Roentgeenol. 113:119-124, 1971. of the pancreas. Anat. Rec. 31255-270, 1951.
