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
References
- Deshmukh SD, Willmann JK, Jeffrey RB. Pathways of extrapancreatic perineural invasion by pancreatic adenocarcinoma: evaluation with 3D volume-rendered MDCT imaging. AJR Am J Roentgenol. 2010;194:668–674. doi: 10.2214/AJR.09.3285.
- Yoshioka H, Wakabayashi T. Therapeutic neurotomy on head of pancreas for relief of pain due to chronic pancreatitis; a new technical procedure and its results. AMA Arch Surg. 1958;76:546–554.
- Miyazaki I. [Perineural invasion and surgical treatment of the pancreas head cancer] Nihon Geka Gakkai Zasshi. 1997;98:646–648.
- Verbeke CS. Resection margins and R1 rates in pancreatic cancer—are we there yet? Histopathology. 2008;52:787–796. doi: 10.1111/j.1365-2559.2007.02935.x.
- Nakao A, Harada A, Nonami T, Kaneko T, Takagi H. Clinical significance of carcinoma invasion of the extrapancreatic nerve plexus in pancreatic cancer. Pancreas. 1996;12:357–361.
- Tian H, Mori H, Matsumoto S, et al. Extrapancreatic neural plexus invasion by carcinomas of the pancreatic head region: evaluation using thin-section helical CT. Radiat Med. 2007;25:141–147. doi: 10.1007/s11604-006-0115-1.
- Dang C, Zhang Y, Ma Q, Shimahara Y. Expression of nerve growth factor receptors is correlated with progression and prognosis of human pancreatic cancer. J Gastroenterol Hepatol. 2006;21:850–858. doi: 10.1111/j.1440-1746.2006.04074.x.
- Zhu Z, Friess H, diMola FF, et al. Nerve growth factor expression correlates with perineural invasion and pain in human pancreatic cancer. J Clin Oncol. 1999;17:2419–2428.
- Makino I, Kitagawa H, Ohta T, et al. Nerve plexus invasion in pancreatic cancer: spread patterns on histopathologic and embryological analyses. Pancreas. 2008;37:358–365.
- Bertelli E, Di Gregorio F, Bertelli L, Civeli L, Mosca S. The arterial blood supply of the pancreas: a review. III. The inferior pancreaticoduodenal artery. An anatomical review and a radiological study. Surg Radiol Anat. 1996;18:67–74.
- Sakaguchi T, Suzuki S, Inaba K, Takehara Y, Nasu H, Konno H. Peripancreatic arterial anatomy analyzed by 3-dimensional multidetector-row computed tomography. Hepatogastroenterology. 2012;59:1986–1989. doi: 10.5754/hge11787.
- Chong M, Freeny PC, Schmiedl UP. Pancreatic arterial anatomy: depiction with dual-phase helical CT. Radiology. 1998;208:537–542.
- Song SY, Chung JW, Kwon JW, et al. Collateral pathways in patients with celiac axis stenosis: angiographic-spiral CT correlation. Radiographics. 2002;22:881–893.
- Kallamadi R, Demoya MA, Kalva SP. Inferior pancreaticoduodenal artery aneurysms in association with celiac stenosis/occlusion. Semin Intervent Radiol. 2009;26:215–223. doi: 10.1055/s-0029-1225671.
- Zuo HD, Zhang XM, Li CJ, et al. CT and MR imaging patterns for pancreatic carcinoma invading the extrapancreatic neural plexus (part I): anatomy, imaging of the extrapancreatic nerve. World J Radiol. 2012;4:36–43. doi: 10.4329/wjr.v4.i2.36.
- Padilla-Thornton AE, Willmann JK, Jeffrey RB. Adenocarcinoma of the uncinate process of the pancreas: MDCT patterns of local invasion and clinical features at presentation. Eur Radiol. 2012;22:1067–1074. doi: 10.1007/s00330-011-2339-4.
- Pham DT, Hura SA, Willmann JK, Nino-Murcia M, Jeffrey RB., Jr Evaluation of periampullary pathology with CT volumetric oblique coronal reformations. AJR Am J Roentgenol. 2009;193:W202–208. doi: 10.2214/AJR.08.2069.
- Mochizuki K, Gabata T, Kozaka K, et al. MDCT findings of extrapancreatic nerve plexus invasion by pancreas head carcinoma: correlation with en bloc pathological specimens and diagnostic accuracy. Eur Radiol. 2010;20:1757–1767. doi: 10.1007/s00330-010-1727-5.
- Sai M, Mori H, Kiyonaga M, Kosen K, Yamada Y, Matsumoto S. Peripancreatic lymphatic invasion by pancreatic carcinoma: evaluation with multi-detector row CT. Abdom Imaging. 2010;35:154–162. doi: 10.1007/s00261-008-9461-z.
- Zhang XM, Mitchell DG, Witkiewicz A, Verma S, Bergin D. Extrapancreatic neural plexus invasion by pancreatic carcinoma: characteristics on magnetic resonance imaging. Abdom Imaging. 2009;34:634–641. doi: 10.1007/s00261-008-9440-4.
- Brennan DD, Zamboni GA, Raptopoulos VD, Kruskal JB. Comprehensive preoperative assessment of pancreatic adenocarcinoma with 64-section volumetric CT. Radiographics. 2007;27:1653–1666. doi: 10.1148/rg.276075034.
- National Comprehensive Cancer Network. Pancreatic adenocarcinoma. NCCN clinical practice guidelines in oncology (NCCN Guidelines) 2011
- Tamm EP, Silverman PM, Charnsangavej C, Evans DB. Diagnosis, staging, and surveillance of pancreatic cancer. AJR Am J Roentgenol. 2003;180:1311–1323. doi: 10.2214/ajr.180.5.1801311.
Source: PubMed