Tumour spread and staging

It is an exception to find a resected carcinoma that is still limited to the pancreas {1414}. In head carcinomas, peripancre-

Fig. 10.03 Ductal adenocarcinoma. A Well differentiated tumour with desmoplasia and irregular gland formation. B Well differentiated neoplasm involving a normal duct (right part).

Fig. 10.04 Poorly differentiated ductal adenocarcinoma.

atic tumour invasion, often via perineural sheaths, primarily involves the retroperitoneal fatty tissue. Subsequently, retro-peritoneal veins and nerves are invaded. Direct extension into neighbouring organs and/or the peritoneum is seen in advanced cases. In carcinomas of the body and tail, local extension is usually greater, because of delayed tumour detection, and includes invasion of the spleen, stomach, left adrenal gland, colon, and peritoneum {359, 941}. Lymphatic spread of pancreatic head carcinomas involves, in descending order of frequency, the retroduodenal (posterior pancreaticoduodenal) and the superior pancreatic head groups, the inferior head and the superior body groups, and the anterior pancreaticoduodenal and the inferior body groups {359}. This lymph node compartment is usually resected together with the head of the pancreas, using a standard Whipple procedure {1955}. More distal nodal metastases may occur in the ligamentum hepatoduodenal, at the coeliac trunk, the root of the superior mesenteric artery, and in paraaortic nodes at the level of the renal arteries. These lymph node compartments are only removed if an extended Whipple procedure is performed. Carcinomas of the body and tail metastasise especially to the superior and inferior body and tail lymph node groups and the splenic hilus lymph nodes. They may also spread via lymphatic channels to pleura and lung. Haematogenous metastasis occurs, in approximate order of frequency, to the liver, lungs, adrenals, kidneys, bones, brain, and skin {359, 941, 1231}.

Staging

The 1997 TNM classification {66} is presented on page 220. Another staging system has been published by the Japan Pancreas Society {832}.

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