C A R C I N O M A O F H E A D O F P A N C R E A S 439

AN UNUSUAL CASE OF CARCINOMA OF THE HEAD OF THE PANCREAS BY E. M. NANSON

IROM THE DEPARTMhNT OE SURGERY, BRISTOL UNIVERSITY

IN 1951 Loggan and Kleinsasser made a very compre- hensive review of the surgery of the pancreas. They collected 123 cases i n which a radical pancreatico- duodenal resection had been performed for carcinoma of either the duodenum, ampulla of Vater, or head of the pancreas. Therefore this ground will not be covered again in this communication ; but a case of carcinoma of the head of the pancreas will be recorded which presents none of the usual features of the disease.

T h e special points of interest in this case are :- I. The age of the patient-17 years. 2. T h e absence of any obstruction of the common

bile-duct or of the pancreatic duct ; therefore the absence of jaundice.

3. That the presenting symptom was intestinal haemorrhage producing profound anaemia.

4. That the carcinoma of the head of the pancreas had produced a punched-out ulcer of the second part of the duodenum from which the haemorrhage had occurred.

stool. Her haemoglobin dropped to 35 per cent at this time, but it improved rapidly with treatment.

On July 10 she was admitted to the Yeovil Hospital because of the sudden recurrence of breathlessness and palpitation, associated with melaena. Her hiemoglobin was 60 per cent and the benzedine reaction on her stool

CASE REPORT HISToRY.-The patient was a single girl, aged 17

years, who was working in the Women's Royal Air Force. She had been perfectly well up to the onset of her illness

FIG. 523.-Showing method of reconstruction of gastro-intestinal tract.

FIG. 5zz.-Tumour size of common

of head of pancreas showing normal bile-duct and limits of excision.

8 months before her admission to the Bristol Royal Infirmary on Aug. 15, 1951, under Dr. A. M. G. Campbell. In January, 195 I, she suddenly developed breathlessness and palpitations over a period of 3 days, and had a melaena

was strongly positive on three separate occasions. A barium meal was reported to be normal on this occasion. The barium enema was also normal.

She was admitted to the Bristol Royal Infirmary for the purpose of further investigation on Aug. 15. She was symptom-free, and at no time had she had any abdominal pain or discomfort. Her hiemoglobin was 93 per cent and the red blood-cell count was 4.9 million per c.mm. Three consecutive stool examinations were negative for occult blood. The barium meal was repeated on Sept. 3 by Dr. R. H. Owen. It revealed no demonstrable abnormality in the oesophagus, stomach, duodenum, or small bowel. A fractional test-meal on Sept. 2 was also normal. She was discharged with no diagnosis made, but ulceration in a Meckel's diverticulum was considered the most likely.

She was re-admitted to the Bristol Royal Infirmary on Aug. 19, 1952, having been well up to one week prior to admission. She then again developed lassitude, breathlessness, and pallor. Her haemoglobin was found to be 50 per cent by her general practitioner and on the day of admission it was 35 per cent. The B.S.R. was 24 mm./I hour and the appearance of the blood-film was

440 T H E B R I T I S H J O U R N A L O F S U R G E R Y

that of an iron-deficiency anzmia secondary to haemor- THE OPERATION.-oII Aug. 28 a laparotomy was per- rhage. Two days after admission she had a melaena formed by the author, through a mid right paramedian stool. On clinical examination no abnormality was incision. A smooth mobile rounded swelling about found other than pallor. She responded well to the the size of a tennis ball was found in the head of the

A B

D

A

C

FIG. c21.-Gross soecimen of carcinoma of head of ~=~~~~~~~~~ .~ ~ - ~ ~ ~ ~ ~ ~ ~ ~ ~ . ~~ ~~ >-- . ._ pancreas. The tumour has been bisected and turned back. A black rod has been passed from tumour through ulcer into duodenum. A light-coloured probe has been passed into the common bile-duct. A, Black rod passing through ulcer into

FIG. gzg.-Gross appearance of portion of duodenum excised. The lumen has been laid open, and a probe has been inserted in the common bile-duct. The ulcer was I cm. in diameter. A, Probe in common bile-duct ; 6, Tumour ulcer- ating into duodenum ; C, Ampulla of Vater ; D, Pylorus.

duodenum ; of tumour well encapsulated.

6, Probe in common bile-duct ; C l Cut surface (Approximately half scale.)

oral administration of iron and by Aug. 25 her hzmo- globin was back to 72 per cent. The author was then asked to see her and advised laparotomy with the expecta- tion of finding a Meckel's diverticulum.

FIG. 526.-Section of tumour edge showing normal pancreas capsule, and turnour, with tumour-cell collections infiltrating capsule (lower inset). ( . 45.5.)

An interesting point in her family history was that her father, aged 52 years, had a cerebral tumour explored three years previously and the histology confirmed by biopsy. This was treated by deep X rays with complete relief of symptoms.

pancreas. The common bile-duct was not obstructed, nor was the pancreatic duct of Wirsung (Fig. 522) . There were no obvious metastases in the liver or the adjacent lymph-nodes. The tumour felt semicystic but aspiration failed to find any fluid. There was a round punched-out ulcer I cm. in diameter on the medial wall of the second part of the duodenum 5 cm. above the ampulla of Vater (Figs. 522, 525) . This ulcer com- municated with the tumour mass and was the obvious source of the bleeding. The remainder of the abdominal and retroperitoneal organs were normal. The duodenum was opened, the ulcer inspected, and a finger passed through it into the tumour. A radical pancreatico- duodenal resection was then performed. Continuity was restored by dividing the jejunum across at the apex of its second loop, and making a Roux-en-Y loop. The end of the Roux loop was closed and this was passed up through the transverse mesocolon. The common bile- duct was then implanted into the antimesenteric border of the Roux loop, using interrupted thread sutures in a single layer. The stump of the pancreas was implanted into the posterior wall of the stomach as recommended by Wells, Shepherd, and Gibbon (1952) and Dill-Russell (1952). The stomach was anastomosed to the Roux loop distal to the common bile- duct. The stump of the fourth part of the duodenum was closed (Fig. 523). Four pints of blood were given in the course of the operation.

PRoGREss.-The patient made a smooth recovery without any leakage from the various anastomoses, until the twelfth post-operative day, when she developed signs of sudden intestinal obstruction. The abdomen was re-opened and the Roux loop was found to be kinked and obstructed where it passed through the transversc mesocolon. This was freed up, and following this,

C A R C I N O M A O F H E A D O F P A N C R E A S 44 I

convalescence was remarkably smooth. Her appetite has 2. Female, aged 2 years. Carcinoma of head of bccn good, and her bowel motions normal. Dr. G. K. Metastases in liver, lungs, and lymph-nodes. McGowan kindly carried out an estimation of the trypsin 3. Male, aged 4 years. Carcinoma of head of in her gastric juice and also on her stools and found it to Metastases in liver and lymph-nodes.

pancreas.

pancreas.

FIG. 527.-Higher powered view of top inset in Fig. 526, showing tumour cells. ( x 420.)

be present in small quantities, and an estimation of her fat absorption showed that 95 per cent was being absorbed, so that it can be assumed that the pancreatic stump is secreting into the stomach.

THE SPECIMEN.-Dr. Oliver Lloyd reported that the head of the pancreas was occupied by a well-encapsulated rounded solid tumour 5 cm. in diameter (Fig. 524). Some. normal pancreatic tissue appeared to be stretched over it. The common bile-duct was not dilated nor was the pancreatic duct. There was a round punched- out ulcer of the second part of the duodenum, I cm. in diameter, connecting the centre of the tumour with the lumen of the duodenum. This ulcer was 4 cm. above the ampulla of Vater (Fig. 525). There were no obviously involved adjacent lymph-nodes.

Microscopical sections of the tumour showed it to be of glandular origin. Its cells were round and rather small. They had small neat central nuclei. They were arranged in a distinctly perivascular pattern, with a tendency to tubular formation in other parts. The tumour was invading its capsule (Figs. 526-528) ; mitoses were rare. The diagnosis was that of adenocarcinoma of low-grade malignancy possibly arising in the duct of Santorini.

DISCUSSION Mielcarek (1935) reviewed the authenticated

cases of carcinoma of the pancreas in people under 20 years of age. He found only 5 and added I case of his own. T h e details of these 6 cases are as follows :-

Carcinoma of head of pancreas.

I. Female, aged 7 months. Metastases in liver and lymph-nodes.

FIG. 528.- Higher powered view of lower inset in Fig. 526, showing undifferentiated turnour cells merging into acini formation invading capsule. ( x 195.)

4. Male, aged 13 years. Carcinoma of head of pancreas infiltrating duodenum. Metastases in liver, kidneys, and lymph-nodes.

5. Male, aged 15 years. Carcinoma of head of pancreas 7 cm. in diameter, producing biliary and pancreatic obstruction.

6. Female, aged 19 years. Carcinoma of tail of pancreas, with metastases in liver and lungs.

All these cases had the usual symptomatology of obstructive jaundice except for the last case. No case similar to the one recorded above has been found in the literature, in which a successful resec- tion has been performed.

SUMMARY I. A case of carcinoma of the head of the pancreas

in a girl of 17 years of age is recorded. 2. T h e presenting symptoms were three episodes

of intestinal haemorrhage producing profound anzmia. 3. Obstruction of the pancreatic and biliary ducts

was absent. 4. Successful pancreatico-duodenal resection was

performed.

REFERENCES DILL-RUSSELL, A. S. (1952), Lancet, I, 589. LOGGAN, P. B., and KLEINSASSER, L. J. (I95I), Surg.

Gynec. Obstet. [Int. Abst. Surg.], 93, 521. MIELCAREK, P. A. (I935), Ann. J . Path., I I, 527. WELLS, C., SHEPHERD, J. A., and GIBBON, N. (1952),

Lancet, I, 588.