0:01

So next, we are going to deal with adenocarcinoma,

0:03

which is the most important pathology we deal

0:05

in real life, and, uh, these tumors are, uh,

0:08

really aggressive, and progressions are not

0:10

great, and that's why the staging, uh, is

0:14

very important for the surgeon, and we have to

0:16

determine whether the tumor is susceptible or not.

0:19

So, just to give a, give you a quick idea,

0:21

these ductal tumors, adenocarcinomas, are

0:24

ductal tumors, and they arise from the

0:26

duct, mostly from the pancreatic head.

0:28

About 70 percent arise from the pancreatic head.

0:31

20 percent from the pancreatic body and

0:34

about 10 percent from the pancreatic tail.

0:36

So as they grow, they expand and they involve

0:39

the ductal system and cause obstruction.

0:41

And as soon as the obstruction

0:42

starts, the duct proximal to that or

0:45

distal to that is actually dilated.

0:47

And slowly, because of the pressure effect,

0:49

overlying parenchyma becomes atrophic.

0:52

So this is a very important concept to

0:54

understand because it is a process which

0:57

occurs in weeks or few, few months.

1:01

And that leads to dilated duct and

1:03

atrophy of overlying pancreas, pancreas.

1:07

This is a very diagnostic point because we

1:09

can differentiate, uh, adenocarcinoma from the

1:12

chronic pancreatitis based on certain signs.

1:14

And this is one of them.

1:16

And it is an aggressive tumor that

1:18

will also lead to obstruction of

1:20

the CBD at the major papilla.

1:22

And that will lead to obstructive jaundice.

1:25

So the pancreatic head masses are going

1:26

to deal with ductile system dilatation

1:29

from the pancreatic duct itself.

1:31

And dilated CBD as well.

1:33

That is called the double duct sign.

1:35

And as we think that the double duct

1:36

sign is very, very, very specific for

1:38

the malignancy, actually, it is not.

1:41

So about 60 to 80 percent of patients with the double

1:45

duct sign will be presenting with the real cancer,

1:48

but the rest of them will be benign pathologies.

1:49

So make sure that you are aware that seeing double

1:51

duct sign is not a diagnostic sign of cancer.

1:55

It can be seen with other pathologies as well.

1:58

And then we can have

1:59

retroperitoneal lymphadenopathy.

2:01

Any, any tumor, any aggressive tumor

2:03

will lead to lymphadenopathy, okay?

2:05

And then, as we have atrophy of the pancreas,

2:08

the ductal system, which is dilated, and

2:11

if we take the ratio of the ductal system from

2:13

the parenchyma, so duct-to-parenchyma ratio,

2:16

that will be, uh, increased more than 0.

2:20

59 00:02:20,375 --> 00:02:22,614 So if you have more ductal dilatation and less

2:22

parenchyma, that will lead to altered ratio.

2:25

Usually, parenchyma is thicker than the duct is.

2:27

And as we discussed earlier, the

2:29

duct should measure less than 3

2:31

millimeters in most of the patients.

2:33

In adult patients, if the patient becomes

2:35

like more than 60 or 70 years old,

2:37

that duct can increase in size up to 5

2:39

millimeters in the pancreatic head region.

2:42

And as we go further towards the tail,

2:43

the duct becomes smaller, smaller in size.

2:46

So let's deal with some of the

2:47

important aspect of the adenocarcinoma.

2:50

What are the features of

2:52

unresectability for adenocarcinoma?

2:54

If you see the liver

2:55

metastasis, that is number one.

2:58

And then if you see vascular encasement,

3:00

so you should be very much clear about

3:02

this term "encasement" versus "abutment."

3:06

If you have abutment, the tumor is

3:08

invading the vessel and it is encircling

3:10

the vessel less than 180 degrees.

3:12

It can happen the tumor has not even

3:14

reached to the vessel but there is

3:16

some fatty standing around that.

3:18

And those are not called as encasement.

3:20

Encasement is the real tumor present

3:22

along with the vessel more than 180

3:24

degree along with the circumference.

3:27

So we have to be very cautious

3:28

about calling encasement because

3:29

it can be different than abutment.

3:31

And abutment makes the tumor partially

3:34

resectable or borderline resectable.

3:36

But if you have encasement, that means

3:37

the tumor is not resectable at all.

3:39

And we have to evaluate 5 vessels.

3:42

Be sure that we see all these 5 vessels.

3:43

Celiac truncate and its bifurcation,

3:47

SMA, common hepatic artery.

3:49

So there are 3 arteries and 2 veins.

3:51

SMV and portal vein.

3:53

So portal vein continues as

3:54

a SMV beyond the confluence.

3:56

And usually once you have the pancreatic

3:58

head tumor, it's going to involve

3:59

the SMV and confluence, most likely.

4:02

And what about the splenic

4:04

artery and splenic vein?

4:05

They are not important because if they are

4:07

even involved, surgeons can resect them.

4:09

And some of the people, some of

4:11

the surgeons are very aggressive.

4:12

They can actually talk about resecting the portion

4:15

or part of the portal vein and SMV as well.

4:17

So involvement of these veins

4:18

may not be contraindication for

4:20

resectability for certain surgeons.

4:22

But we have to deal with all these five

4:23

vessels once we are dealing with the report.

4:26

And adenocarcinoma.

4:27

And then the next point will be,

4:29

are there any peritoneal implants?

4:31

If there are implants in the mesenteric

4:32

root, in the neighborhood of the pancreatic

4:34

parenchyma, and there is peripancreatic

4:36

spread, that is again a sign of unresetability.

4:38

If the lesion measures more than 3 centimeters,

4:40

that's again a kind of borderline, a sign

4:43

that patient may not have a resetable tumor.

4:46

And presence of adenopathy, and then most

4:48

important one is invasion of neural plexuses.

4:52

So perineural tumor is not a part of conventional

4:57

description we describe in our reports.

4:59

It has not been the part of the,

5:01

the staging system which has been

5:02

described by the surgery as well.

5:04

But invasion of neural plexus is a very,

5:06

very important aspect we have to deal

5:08

with and we often miss this because

5:10

we don't know what exactly it is.

5:11

Perineural invasion or PNI.

5:14

Is very important aspect to be reported

5:16

on all cases of adenocarcinoma.

5:19

Just to give you a quick glimpses, CA99

5:22

is usually elevated in adenocarcinoma

5:24

and more than 40 is the, the limit

5:26

we should be relying most, most upon.

5:29

So if the CA99 is about 40 or more, the patient

5:33

might be having adenocarcinoma somewhere.

5:35

Specifically in the pancreas or GI origin, it

5:37

can be sometime, uh, cholangiocarcinoma as well.

5:39

And it usually present in patient

5:41

with more than 60 year age, majority

5:43

present between 70 to 80 years.

5:45

And 70 percent in head, 20 percent

5:47

in body, 10 percent in tail.

5:49

Depending on the location of the

5:50

tumor, you can have the symptoms.

5:53

And obstructive jaundice will be the most

5:54

common symptoms in the head pancreatic lesions.

5:57

And body and tail will present

5:58

with pain abdomen and weight loss.

6:01

And seeing the obliteration of fat surrounding

6:03

the vessel in less than 5 mm may suggest the

6:06

tumor is infiltrating along with the vessel.

6:08

But remember, we have to be very careful about 180

6:11

encasement to be called as it is encased or not.

6:14

And usually in that situation, when

6:16

it is encased, there will be some

6:18

reduced caliber of the vessel as well.

6:20

And vascular encasement is a very peculiar

6:22

feature of adenocarcinoma of pancreas because

6:24

none of the other tumor is going to do that.

6:26

If you have a question between chronic

6:28

pancreatitis versus adenocarcinoma,

6:30

And if you see the encasement, it's

6:32

going to be adenocarcinoma for sure.

6:34

And the same thing applies

6:34

to autoimmune pancreatitis.

6:37

Pancreatitis can lead to some dirtiness

6:38

or haziness of the peripancreatic

6:40

fat, but it will never, never, never

6:42

encase with a soft tissue there.

6:43

So seeing encasement is a very

6:45

diagnostic sign of the adenocarcinoma.

6:47

Lymph nodes, we always think that

6:50

measuring a lymph node in the shortest

6:51

access about 1 cm should be the criteria.

6:55

But that doesn't apply here.

6:56

Any lymph node which is present

6:58

in the peripancatic region should

6:59

be described in our report.

7:00

Because even a small lymph node up

7:02

to 1 2 mm can harbor cells there.

7:06

And as I said earlier, abutment

7:08

is less than 180 degree.

7:09

An encasement is more than

7:10

180 degree of the vessel.

7:13

We should be very careful about

7:14

borderline resectable tumor.

7:16

Any tumor which reaches to the, the

7:19

celiac axis bifurcation may not be

7:22

resectable to some of the surgeons.

7:23

So talk about that, that encasement up

7:26

to the bifurcation of the celiac axis.

7:28

So we should be very, very cautious about

7:30

when we are talking about perineural invasion.

7:33

And most of the people are not aware how it

7:35

looks and what to see and where to see exactly.

7:38

So perineural invasion can occur

7:39

from the pancreatic head lesions.

7:41

And from the uncinate process, and it has

7:42

four different pathways to be involving,

7:45

uh, the plexuses in the retroperitoneum.

7:48

So the two pathways, the commonest pathway

7:50

is basically the one which I'm showing you

7:51

on the left hand side here, and that starts

7:54

from the posterior aspect of the portal

7:57

vein, and these plexuses are draining the

7:59

pancreatic head, and they actually drain

8:01

to the celiac plexus on the right side.

8:03

Same kind of pathway can happen from

8:06

the anterior pathway along with the GDA.

8:08

So gastro duodenal artery, which drains

8:10

eventually to the common hepatic artery and

8:13

that drains towards the right celiac plexus.

8:16

So tumor can start from the pancreatic head or

8:18

uncinate process can involve from two different

8:20

pathway to involve right side of celiac plexus.

8:23

The left side is possibly involved once the

8:26

disease progresses beyond certain point.

8:29

Second most common pathway is going along with the

8:32

posterior inferior pancreatic or duodenal artery.

8:34

And this pathway goes and involves

8:37

the plexus along with the SMA.

8:39

But the same pathway can involve the

8:40

mesenteric neural plexuses here and

8:43

can cause deposits in this location.

8:46

So, just to be clear, that once we see a

8:48

lesion in the pancreatic head specifically or

8:50

uncinate process, that can lead to perineural

8:52

invasion that will be deposited either in

8:55

the celiac plexus on the right side or along

8:57

with the SMA or along with the mesentery.

9:00

And there are different kinds of pathways;

9:02

they are called PPC1, this is called

9:04

PPC2, but these are different pathways here.