Three-dimensional volume-rendered multidetector CT imaging of the posterior inferior pancreaticoduodenal artery: its anatomy and role in diagnosing extrapancreatic perineural invasion

Bhavik N Patel, Craig Giacomini, R Brooke Jeffrey, Juergen K Willmann, Eric Olcott, Bhavik N Patel, Craig Giacomini, R Brooke Jeffrey, Juergen K Willmann, Eric Olcott

Abstract

Extrapancreatic perineural spread in pancreatic adenocarcinoma contributes to poor outcomes, as it is known to be a major contributor to positive surgical margins and disease recurrence. However, current staging classifications have not yet taken extrapancreatic perineural spread into account. Four pathways of extrapancreatic perineural spread have been described that conveniently follow small defined arterial pathways. Small field of view three-dimensional (3D) volume-rendered multidetector computed tomography (MDCT) images allow visualization of small peripancreatic vessels and thus perineural invasion that may be associated with them. One such vessel, the posterior inferior pancreaticoduodenal artery (PIPDA), serves as a surrogate for extrapancreatic perineural spread by pancreatic adenocarcinoma arising in the uncinate process. This pictorial review presents the normal and variant anatomy of the PIPDA with 3D volume-rendered MDCT imaging, and emphasizes its role as a vascular landmark for the diagnosis of extrapancreatic perineural invasion from uncinate adenocarcinomas. Familiarity with the anatomy of PIPDA will allow accurate detection of extrapancreatic perineural spread by pancreatic adenocarcinoma involving the uncinate process, and may potentially have important staging implications as neoadjuvant therapy improves.

Figures

Figure 1
Figure 1
Histological evidence of perineural invasion in a patient with pancreatic adenocarcinoma. The nerve fascicle (N) in cross section is surrounded by adenocarcinoma cells (arrows) infiltrating the perineural space.
Figure 2
Figure 2
Schematic (A) shows the normal origin of the posterior inferior pancreaticoduodenal artery (PIPDA) (green) and anterior inferior pancreaticoduodenal artery (AIPDA) arising from the inferior pancreaticoduodenal artery (IPDA) (curved arrow). A normal pancreaticoduodenal arcade is also shown with an anastomotic network between the branches of the superior pancreaticoduodenal artery (SPDA) and IPDA (black arrows). The anterior arcade (open arrows) is formed by the anterior superior pancreaticoduodenal and anterior inferior pancreaticoduodenal arteries. The posterior arcade (solid arrows) is formed by the posterior superior pancreaticoduodenal and posterior inferior pancreaticoduodenal arteries. Axial (B) and coronal (C) three-dimensional (3D) volume-rendered computed tomography (CT) images show the posterior pancreaticoduodenal arcade (arrows).
Figure 3
Figure 3
Normal origin of the IPDA and branching pattern. Axial (B) and coronal (C) 3D volume-rendered multidetector CT (MDCT) images from a 78-year-old man with obstructive jaundice shows the IPDA (solid arrow) originating from the SMA and giving rise to AIPDA (open arrow) and PIPDA (curved arrow).
Figure 4
Figure 4
IPDA prominence in celiac artery stenosis in a 60-year-old man, status post distal pancreatectomy and splenectomy for a pancreatic neuroendocrine tumor. Sagittal (A) arterial-phase CT image shows a significant celiac axis stenosis (arrow). Axial 3D volume-rendered image (B) shows the PIPDA (curved arrow) and the AIPDA (short arrow).
Figure 5
Figure 5
Variations in origin of IPDA. Coronal schematics show variations in the PIPDA (shown in green) origin, including origination from the common pancreaticoduodenal-jejunal trunk (A), separate origins of the AIPDA and PIPDA (B), and single pancreaticoduodenal arcade (C, arrows).
Figure 6
Figure 6
Normal PIPDA anatomy. Axial schematic (A), axial 3D volume-rendered image (B), and coronal 3D volume-rendered image (C) show the PIPDA (curved arrow) and AIPDA (open arrow) originating off the IPDA (solid arrow). SMA, superior mesenteric artery; SMV, superior mesenteric vein.
Figure 7
Figure 7
Origin of the IPDA as a common trunk with the first jejunal branch. Axial (A) and coronal (B) 3D volume-rendered MDCT images show a common trunk (solid arrow) giving rise to the IPDA (curved arrow) and the first jejunal branch (open arrow).
Figure 8
Figure 8
Variation in the origin of the IPDA in a 59-year-old woman undergoing workup for a pancreatic mass. Axial (A) and coronal (B) 3D volume-rendered MDCT images show a replaced right hepatic artery (solid arrow) off the SMA (open arrow) that gives rise to the IPDA (curved arrow).
Figure 9
Figure 9
Four pathways of extrapancreatic perineural spread. Coronal schematic (A) shows the 4 pathways of extrapancreatic perineural spread. Plexus pancreaticus capitalis 1 (PPC1) extends posterior to the portal vein (PV) from the pancreatic head to the celiac ganglion (CG). Plexus pancreaticus capitalis 2 (PPC2) spreads along the posterior inferior pancreaticoduodenal artery (PIPDA) toward the mesenteric ganglion. Root of mesentery (RoM) involves spread along the PIPDA but extends caudally along the superior mesenteric artery (SMA) to the mesenteric root. The anterior or gastroduodenal artery (GDA) pathway extends along the GDA and common hepatic artery (CHA), ultimately toward the CG. Axial schematic (B) shows an uncinate mass (M) with perineural spread along the PIPDA (curved arrow) and IPDA (solid arrow) toward the SMA, typical of the PPC2 pathway. SMV, superior mesenteric vein.
Figure 10
Figure 10
Extrapancreatic perineural invasion along the PIPDA. Axial (A) and coronal (B) 3D volume-rendered images in a patient with a pancreatic head adenocarcinoma (M) shows perineural invasion along the PIPDA (solid arrow) and a biliary stent in place (open arrow). Additional axial (C) and coronal (D) images from different patients show pancreatic head adenocarcinoma (M) with perineural invasion (arrow) along the PIPDA extending up to the SMA.
Figure 11
Figure 11
Extrapancreatic perineural invasion along the PIPDA. Axial (A, B, C) and coronal (D) 3D volume-rendered images in different patients with pancreatic uncinate adenocarcinoma (M) shows perineural invasion along the PIPDA (solid arrow).

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