OBSERVATIONS ON THE DEVELOPMENTAL PATTERNS AND THE CONSEQUENCES OF PANCREATIC EXOCRINE ADENOCARCINOMA - FINDINGS OF 154 AUTOPSIES

Objective: To improve our future care of the patient with exocrine pan creatic cancer by seeking, within the limitations of our present appro aches, additional information an the growth and spread of the cancer a nd its influences on the patient. Design: Consecutive autopsies fall p atients with exocrine pancreatic cancer were reviewed retrospectively by two surgeons and three pathologists. Settings: Three teaching hospi tals of the Medical College of Ohio, Toledo. Materials: One hundred fi fty-four consecutive autopsies of patients with exocrine pancreatic ca ncer during the period between 1952 and 1992. Results: Intrapancreatic metastases or multicentric cancers were found in 12 patients. In 32 p atients, pancreatic cancer skipped the lymph nodes, primarily draining the respective areas of the pancreas to metastasize to the secondary chain of nodes. In 13 patients, pulmonary metastases occurred without hepatic metastasis. Intrapancreatic contiguous extension was:as identi fied in 34 patients. Carcinoma of the body and/or tail of the pancreas was characterized by transperitoneal as well as hematogenous dissemin ation to a greater extent than was carcinoma of the head of the pancre as. Seven of 11 small tumors (<2 cm in diameter) were associated with remote metastases. Relatively severe chronic obstructive pancreatitis was found to have resulted from pancreatic carcinoma in 18 cases, wher eas in seven patients, pancreatic carcinoma probably developed in pree xisting chronic pancreatitis. Thromboembolic disease was found in 30 p atients, more frequently in the patients with the mucin-producing tumo rs of the pancreatic body and tail. In 21 patients, the amount of asci tes was not proportional to the severity of peritoneal dissemination, vessel invasion, or recognizable hepatic dysfunction. Thromboembolic d isease, severe infection, stress ulcer, and acute hemorrhagic erosive gastroenteritis were frequent systemic complications contributing to d eath. Malnutrition in the form of cachexia was undoubtedly a major, ev en dominant, feature in many patients that could not he quantitated fr om this data. Conclusions: Metastasizing cells frequently bypass the i nitial filters in lymph nodes, liver, or lung to become established in secondary or tertiary sites. Intrapancreatic metastases or multicentr ic tumors also may develop more frequently than generally has been rec ognized. Small cancers (<2 cm in diameter) are often associated at aut opsy with remote metastases. These facts would appear to limit the use fulness of the current staging of resected cancers of the pancreas. Ca ncers of the bud!; or tail are characterized by transperitoneal and he matogenous spread to a greater extent than are those of the head. Anat omical studies often do not explain the cause or the extent of ascites associated with pancreatic adenocarcinoma. As previously indicated, c hronic pancreatitis appears to be further confirmed as a precursor of pancreatic cancer.