Computed tomography-based diagnostics might be insufficient in the determination of pancreatic cancer unresectability

Figure 4 In this 64-year-old woman (case 7), circular encasement of the celiac, common hepatic, left gastric, left hepatic and splenic arteries by PDA on the background of aberrant arterial anatomy; a replaced right hepatic artery (rRHA, Michels, type VIIIb) was identified on CT (A-D). E. Photograph of operating field after distal pancreatectomy (R0 resection), with excision of the celiac, common, left gastric, left hepatic arteries and gastroduodenal artery resection in the absence of any evidence for major arterial invasion, either during surgery or on histopathology; the blood supply to the stomach was routed from the SMA via pancreaticodudenal arcades and then through the GDA with the latter’s proximal segment being resected and ligated. F-I: Removed specimen under microscope. The tumor (DA) was smaller than 2 cm and was surrounded by a thick layer of fibrotic tissue (H,I). There were no signs of involvement of the major peripancreatic (CHA, GDA, LHA) arteries; H: CHA section obtained from close to the point of its transection (white arrow) in the fibrotic zone (black arrow) along the pancreas margin. No evidence of tumor growth x 5. G: Celiac plexus and trunk area of diffuse fibrosis (F) x 5; A: Artery; N: Nerve plexus with large ganglion; H: Pancreatic tissue with apparent diffuse fibrosis (F), groups of islets remaining (I) and groups of glandular formations of ductal adenocarcinoma (DA) of the pancreas x 50. d: Structures of DA throughout the fibrotic tissue (F) containing remnants of pancreatic tissue (atrophic islets and ductules) x 50, hematoxylin + eosin. PV: Portal vein; T: Tumor; CA: CT-celiac artery (celiac trunk); SMA: Superior mesenteric artery; GDA: Gastroduodenal artery; rRHA: Replaced right hepatic artery; PDA: Pancreato-duodenal arcade; LRV: Left renal vein; PV: Portal vein; SMV: Superior mesenteric vein; LAV: Left adrenal vein.