Role of Angiography in the Diagnosis of Pancreatic Neoplasms
Bimal C. Ghosh, MD, FACS, Chicago, Illinois Kamal Mojab, MD, Chicago, Illinois Fraydon Esfahani, MD, Chicago, Illinois Gerald S. Moss, MD, FACS, Chicago, Illinois Tapas K. Das Gupta, MD, PhD, FACS, Chicago, Illinois
The treatment of carcinoma of the pancreas continues to present a dismal outlook, apparently because of the late appearance of clinical symptoms associated with tumors of the pancreas and the precarious anatomic position occupied by the gland. After the initial wave of enthusiasm for radical resection for carcinoma of the pancreas popularized by Whipple et al [I] and Brunschwig [2], that method was almost abandoned because of its failure to cure the patients. Bowden and Pack [3] reported a cure rate of 1.1 per cent in a series of 190 patients with a mean survival time of 9 months. The vast majority of pancreatic tumors are found at exploration to be unresectable, primarily because of inadequate preoperative knowledge of the extent of the disease. Despite recent advances in the surgical technique, the results of treatment of carcinoma of the pancreas continue to be discouraging. The vascular architecture of the pancreas has been described in the past, but very few reports indicate any preoperative accuracy. Angiography is a promising method for diagnosing disorders of the endocrine glands. Since the pancreas is rich in vascularity, ample information can be obtained by outlining the vessels using the selective technique of injecting contrast medium directly into the superior and inferior pancreaticoduodenal and dorsal pancreatic arteries. The purpose of this study was to find out the importance of angiography in evaluating various disorders of the pancreas and to evaluate its role in the diagnostic workup for suspected neoplasm. Material and Methods During the period July 1974 to June 1977, selected celiac and superior mesenteric angiography was performed in 471 From the Department of Surgery, University of Illinoisat the Abraham Lincoln School of Medicine and the Division of Angiography, Cook County Hospital, Chicaoo. Illinois. Re&t requests should be addressed to Bimal C. Ghosh, MD, Division of Surgical DnCOlogy,Cook County Hospital, 1825 West Harrison, Chicago, Illinois 60612.
Volume 138, November 1979
patients. In 35 of the patients additional selective angiography was performed to reveal the detailed vascular patterns of the pancreas and its surrounding structures. A no. 7 French taper tip double curve catheter was used. With the injection of 2 to 6 cc of 75 per cent contrast medium for 2 seconds to the superior and inferior pancreaticoduodenal
arteries, a series of anteroposterior radiographs of the abdomen were obtained. The subtraction technique was performed to permit better evaluation of the smaller vessels. Of the 35 patients who had additional selective pancreatic angiography, 15 had carcinoma of the pancreas, 2 had islet cell tumors, 7 had chronic pancreatitis, and 7 had pseudocysts of the pancreas. Four subjects with normal pancreatic glands were studied as control subjects (Figure 1). Exploratory surgery was performed in all patients except the control subjects, and the findings were compared. Results
The angiographic findings reflect poorly vascularized, infiltrating lesions with invasion of the blood vessels and the serpiginous encasements (Figure 2). In early pancreatitis, the pancreas is swollen with increased vascularity and occasional stretched vessels. In more advanced disease, the pancreatic arterial branches become prominent and irregular with an increased parenchymal accumulation of contrast medium in the capillary phase (Figure 3). In pancreatic pseudocysts, the angiogram shows primarily a stretching of the arteries around the lesion. The vessels that are stretched depend on the site and the positions of the cysts. Large cysts involve various anatomic vessels such as the hepatic, gastroduodenal, splenic, or mesenteric arteries (Figure 4). In adenoma, the angiographic abnormality depends on the site of the tumor. In small lesions, the finding is well circumscribed around the area of contrast accumulation in the capillary and venous phases. The vessels are increased in number, but no malignant vessels are evident (Figure 5). As the tumor becomes large, the tumor vessels increase in size and number. A well 675
Ghosh et al
Figure 1. Normal pancreatic angiogram. da = dorsal arcade; GO = gastroduodenal artery; gep = gastroepiploic artery; I = inferior pancreaticoduodenal artery; S = superior pancreaticoduodenal artery; t = transverse pancreatic artery; va = ventral arcade.
Figure 2. Carcinoma of the head of the pancreas. The arrows indicate encasement of the gastroduodenal artery. Note obstruction of the superior pancreaticoduodenal and retroduodenal arteries.
circumscribed lesion with increased contrast medium in the capillary and venous phases indicates pancreatic adenoma. Comments
Angiography has been developed in recent years and has demonstrated its advantage over other available investigations in the disorders of the pancreas. Since Odman [4] described the potential of angiography for the diagnosis of pancreatic disorders, Baghery et al [5] and Herlinger [6] reported the an676
Figure 3. Pancreatitis and abscess involving the h?tYkidney. The arrows show irregular increased parenchymal accumulation of contrast medium exfending from the pancreas.
giographic characteristics of insulomas. Published studies have reported little accuracy in the angiographic evaluation of other disorders, particularly pseudocysts and pancreatitis. The major problem in surgical eradication of pancreatic tumors is the lack of preoperative accuracy about the extent of the disease and, in many cases, the inability to differentiate tumors from other pancreatic disorders. Although many of these tumors are still localized regionally, it is technically impossible to resect tumors of the pancreas. Fortner [7] has proposed a technique of extended resection of the pancreas in which the tumors, many of which are thought to be unresectaThe American Journal of Surgery
Angiography
Figure 4. Pseudocysts of the head of the pancreas. The arrows show bowing and lateral displacement of the gastroepiploic artery, surrounding a pseudocyst.
ble, can be resected by removing the superior mesenteric and celiac vascular axis with immediate vascular reconstruction. It is too early to judge these extensive surgical maneuvers for the treatment of carcinoma of the pancreas. In some patients with suspected carcinoma of the pancreas, a mass is found on exploration either in the body or the head of the pancreas, and it is not always possible to determine accurately whether the mass is a tumor or chronic pancreatitis. In most of these patients, the diagnosis is confirmed after the pancreas is removed. Any test that can suggest closely an accurate diagnosis of the suspected pancreatic mass is important. Angiography is quite accurate in evaluating pancreatic neoplasms because the vascular patterns of various pancreatic disorders differ. In the patients in this study, we performed exploratory surgery and confirmed the diagnosis with preoperative angiographic findings. We believe that pancreatic angiography, along with other available laboratory examinations, is a great help in the evaluation of pancreatic disorders. Summary
The vascular architecture of the pancreas has been described, but few reports indicate preoperative accuracy. During the last 3 years, selective superior mesenteric and celiac angiography was performed in 471 patients. In 35 of these patients, additional selective angiography of the superior pancreaticoduodenal and inferior pancreaticoduodenal arteries was performed to reveal the detailed vascular pattern of the pancreas and its surrounding structures. ExVolume 138, November 1979
for Pancreatic
Neoplasms
Figure 5. Adenoma of the head of the pancreas. The large arrows show prominent vessels arising from the inferior pancreaticoduodenal artery (small arrow).
ploratory surgery was performed in all patients except the four control subjects. The angiographic findings reflected a poorly vascularized infiltrating lesion with invasion of the blood vessels and serpiginous encasements. Peripancreatic extension of the tumor indicated nonresectability. In early pancreatitis, the pancreas showed increased vascularity and occasional stretched vessels. In more advanced pancreatitis, the arteries were prominent and irregular with increased parenchymal accumulation of contrast medium in the capillary phase. In pseudocysts of the pancreas, the only finding was stretching of the vessels around the lesion. A well circumscribed lesion with increased contrast medium in the capillary and venous phases is diagnostic of pancreatic adenoma. Pancreatic angiography is an important diagnostic tool in evaluating and staging pancreatic neoplasms. References 1. Whipple AO, Persons WB, Mullins CR: Treatment of carcinoma of the ampulla of Vater. Ann Surg 102: 763, 1935. 2. Brunschwig A: Surgery of pancreatic tumors. St. Louis, CV Mosby, 1942. 3. Bowden L, Pack GT: Cancer of the head of the pancreas. GEN 23: 339, 1969. 4. Odman P: Percutaneous selective angiography of the celiac artery. Acfa Radial Suppl 159: 1-168. 1958. 5. Baghery S, Alfidi FJ, Zelch MG: Angiography of nonfunctioning islet cell tumors of the pancreas. Radiology 120: 57, 1976. 6. Herlinger H: The angiographic diagnosis of insulinoma. Proc R Sot Med 69: 618, 1976. 7. Fortner JG: Regional resection of cancer of the pancreas. A new surgical approach. Surgery 73: 307, 1973.
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Bimal C. Ghosh, MD, FACS, Chicago, Illinois Kamal Mojab, MD, Chicago, Illinois Fraydon Esfahani, MD, Chicago, Illinois Gerald S. Moss, MD, FACS, Chicago, Illinois Tapas K. Das Gupta, MD, PhD, FACS, Chicago, Illinois
The treatment of carcinoma of the pancreas continues to present a dismal outlook, apparently because of the late appearance of clinical symptoms associated with tumors of the pancreas and the precarious anatomic position occupied by the gland. After the initial wave of enthusiasm for radical resection for carcinoma of the pancreas popularized by Whipple et al [I] and Brunschwig [2], that method was almost abandoned because of its failure to cure the patients. Bowden and Pack [3] reported a cure rate of 1.1 per cent in a series of 190 patients with a mean survival time of 9 months. The vast majority of pancreatic tumors are found at exploration to be unresectable, primarily because of inadequate preoperative knowledge of the extent of the disease. Despite recent advances in the surgical technique, the results of treatment of carcinoma of the pancreas continue to be discouraging. The vascular architecture of the pancreas has been described in the past, but very few reports indicate any preoperative accuracy. Angiography is a promising method for diagnosing disorders of the endocrine glands. Since the pancreas is rich in vascularity, ample information can be obtained by outlining the vessels using the selective technique of injecting contrast medium directly into the superior and inferior pancreaticoduodenal and dorsal pancreatic arteries. The purpose of this study was to find out the importance of angiography in evaluating various disorders of the pancreas and to evaluate its role in the diagnostic workup for suspected neoplasm. Material and Methods During the period July 1974 to June 1977, selected celiac and superior mesenteric angiography was performed in 471 From the Department of Surgery, University of Illinoisat the Abraham Lincoln School of Medicine and the Division of Angiography, Cook County Hospital, Chicaoo. Illinois. Re&t requests should be addressed to Bimal C. Ghosh, MD, Division of Surgical DnCOlogy,Cook County Hospital, 1825 West Harrison, Chicago, Illinois 60612.
Volume 138, November 1979
patients. In 35 of the patients additional selective angiography was performed to reveal the detailed vascular patterns of the pancreas and its surrounding structures. A no. 7 French taper tip double curve catheter was used. With the injection of 2 to 6 cc of 75 per cent contrast medium for 2 seconds to the superior and inferior pancreaticoduodenal
arteries, a series of anteroposterior radiographs of the abdomen were obtained. The subtraction technique was performed to permit better evaluation of the smaller vessels. Of the 35 patients who had additional selective pancreatic angiography, 15 had carcinoma of the pancreas, 2 had islet cell tumors, 7 had chronic pancreatitis, and 7 had pseudocysts of the pancreas. Four subjects with normal pancreatic glands were studied as control subjects (Figure 1). Exploratory surgery was performed in all patients except the control subjects, and the findings were compared. Results
The angiographic findings reflect poorly vascularized, infiltrating lesions with invasion of the blood vessels and the serpiginous encasements (Figure 2). In early pancreatitis, the pancreas is swollen with increased vascularity and occasional stretched vessels. In more advanced disease, the pancreatic arterial branches become prominent and irregular with an increased parenchymal accumulation of contrast medium in the capillary phase (Figure 3). In pancreatic pseudocysts, the angiogram shows primarily a stretching of the arteries around the lesion. The vessels that are stretched depend on the site and the positions of the cysts. Large cysts involve various anatomic vessels such as the hepatic, gastroduodenal, splenic, or mesenteric arteries (Figure 4). In adenoma, the angiographic abnormality depends on the site of the tumor. In small lesions, the finding is well circumscribed around the area of contrast accumulation in the capillary and venous phases. The vessels are increased in number, but no malignant vessels are evident (Figure 5). As the tumor becomes large, the tumor vessels increase in size and number. A well 675
Ghosh et al
Figure 1. Normal pancreatic angiogram. da = dorsal arcade; GO = gastroduodenal artery; gep = gastroepiploic artery; I = inferior pancreaticoduodenal artery; S = superior pancreaticoduodenal artery; t = transverse pancreatic artery; va = ventral arcade.
Figure 2. Carcinoma of the head of the pancreas. The arrows indicate encasement of the gastroduodenal artery. Note obstruction of the superior pancreaticoduodenal and retroduodenal arteries.
circumscribed lesion with increased contrast medium in the capillary and venous phases indicates pancreatic adenoma. Comments
Angiography has been developed in recent years and has demonstrated its advantage over other available investigations in the disorders of the pancreas. Since Odman [4] described the potential of angiography for the diagnosis of pancreatic disorders, Baghery et al [5] and Herlinger [6] reported the an676
Figure 3. Pancreatitis and abscess involving the h?tYkidney. The arrows show irregular increased parenchymal accumulation of contrast medium exfending from the pancreas.
giographic characteristics of insulomas. Published studies have reported little accuracy in the angiographic evaluation of other disorders, particularly pseudocysts and pancreatitis. The major problem in surgical eradication of pancreatic tumors is the lack of preoperative accuracy about the extent of the disease and, in many cases, the inability to differentiate tumors from other pancreatic disorders. Although many of these tumors are still localized regionally, it is technically impossible to resect tumors of the pancreas. Fortner [7] has proposed a technique of extended resection of the pancreas in which the tumors, many of which are thought to be unresectaThe American Journal of Surgery
Angiography
Figure 4. Pseudocysts of the head of the pancreas. The arrows show bowing and lateral displacement of the gastroepiploic artery, surrounding a pseudocyst.
ble, can be resected by removing the superior mesenteric and celiac vascular axis with immediate vascular reconstruction. It is too early to judge these extensive surgical maneuvers for the treatment of carcinoma of the pancreas. In some patients with suspected carcinoma of the pancreas, a mass is found on exploration either in the body or the head of the pancreas, and it is not always possible to determine accurately whether the mass is a tumor or chronic pancreatitis. In most of these patients, the diagnosis is confirmed after the pancreas is removed. Any test that can suggest closely an accurate diagnosis of the suspected pancreatic mass is important. Angiography is quite accurate in evaluating pancreatic neoplasms because the vascular patterns of various pancreatic disorders differ. In the patients in this study, we performed exploratory surgery and confirmed the diagnosis with preoperative angiographic findings. We believe that pancreatic angiography, along with other available laboratory examinations, is a great help in the evaluation of pancreatic disorders. Summary
The vascular architecture of the pancreas has been described, but few reports indicate preoperative accuracy. During the last 3 years, selective superior mesenteric and celiac angiography was performed in 471 patients. In 35 of these patients, additional selective angiography of the superior pancreaticoduodenal and inferior pancreaticoduodenal arteries was performed to reveal the detailed vascular pattern of the pancreas and its surrounding structures. ExVolume 138, November 1979
for Pancreatic
Neoplasms
Figure 5. Adenoma of the head of the pancreas. The large arrows show prominent vessels arising from the inferior pancreaticoduodenal artery (small arrow).
ploratory surgery was performed in all patients except the four control subjects. The angiographic findings reflected a poorly vascularized infiltrating lesion with invasion of the blood vessels and serpiginous encasements. Peripancreatic extension of the tumor indicated nonresectability. In early pancreatitis, the pancreas showed increased vascularity and occasional stretched vessels. In more advanced pancreatitis, the arteries were prominent and irregular with increased parenchymal accumulation of contrast medium in the capillary phase. In pseudocysts of the pancreas, the only finding was stretching of the vessels around the lesion. A well circumscribed lesion with increased contrast medium in the capillary and venous phases is diagnostic of pancreatic adenoma. Pancreatic angiography is an important diagnostic tool in evaluating and staging pancreatic neoplasms. References 1. Whipple AO, Persons WB, Mullins CR: Treatment of carcinoma of the ampulla of Vater. Ann Surg 102: 763, 1935. 2. Brunschwig A: Surgery of pancreatic tumors. St. Louis, CV Mosby, 1942. 3. Bowden L, Pack GT: Cancer of the head of the pancreas. GEN 23: 339, 1969. 4. Odman P: Percutaneous selective angiography of the celiac artery. Acfa Radial Suppl 159: 1-168. 1958. 5. Baghery S, Alfidi FJ, Zelch MG: Angiography of nonfunctioning islet cell tumors of the pancreas. Radiology 120: 57, 1976. 6. Herlinger H: The angiographic diagnosis of insulinoma. Proc R Sot Med 69: 618, 1976. 7. Fortner JG: Regional resection of cancer of the pancreas. A new surgical approach. Surgery 73: 307, 1973.
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