ANTICANCER RESEARCH 27: 1733-1736 (2007)
Pancreatic Head Resection for Invasive
Colon Cancer Apropos of a Case
ANDREAS MEYER and MATTHIAS BEHREND
Klinik fr Viszeral-, Thorax- und Gefchirurgie, Klinikum Deggendorf,
Perlasberger Strasse 41, 94469 Deggendorf, Germany
Abstract. Background: Despite the possibilities for early
detection of colon cancer, some patients present with locally
advanced cancer with invasion of adjacent organs. A case of
right colonic cancer with infiltration of the duodenum and
pancreas that was treated with hemicolectomy and duodeno-
pancreatectomy (DP) en bloc is reported. Case report: A 76-
year-old man was admitted to the local hospital due to
anaemia, loss of weight and worsening clinical condition.
Clinical examination, including upper and lower intestinoscopy
and computed tomography of the abdomen, revealed right-
sided colonic cancer with infiltration of the duodenum and the
pancreas causing a bleeding duodenal ulcer that was the origin
of the anaemia. The patient was transferred to our hospital for
surgical therapy. The primary colon cancer seemed to be
resectable without suspicion of hepatic metastases or peritoneal
seeding, and a right-sided hemicolectomy with en bloc
duodeno-pancreatectomy was carried out. Histopathological
examination classified the tumour as pT4 pN1 (3/24) M0 G3
R0 according to stage III of the UICC classification. The
patient recovered uneventfully. Conclusion: This case
demonstrates that even common diseases such as colonic
cancer may require a careful preoperative diagnosis so that a
patient with a locally advanced tumour may be transferred to a
specialist centre. With colorectal carcinoma, monobloc
resection is standard, but a monobloc hemicolectomy on the
right side and pancreatic head resection can only be performed
in hospitals having sufficient expertise in pancreatic surgery.
Colorectal cancer is one of the most common malignancies
of the Western world, and radical surgery with adequate
Correspondence to: Professor Dr. med. Matthias Behrend,
Klinikum Deggendorf, Klinik fr Viszeral-, Thorax-und
Gefchirurgie, Perlasberger Strasse 41, 94469 Deggendorf,
Germany. Tel: +49 991 380 3000, Fax: +49 991 380 3010, e-mail:
matthias.behrend@ klinikum-deggendorf.de
Key Words: Invasive colonic cancer, bleeding duodenal infiltration,
duodeno-pancreatectomy, en bloc resection.
0250-7005/2007 $2.00+.40
margins and regional lymph node resection is the standard
therapeutic modality (1-3). Despite the possibilities for early
detection of a colonic carcinoma provided by regular lower
intestinoscopies, some patients present with locally
advanced colon cancer. Right-sided colonic carcinomas
which invade the adjacent pancreas and duodenum pose a
surgical challenge because such locally infiltrative tumours
are often considered to be unresectable. In addition,
whether an organ is infiltrated or just adherent due to
inflammatory disease is often identified for the first time
intra-operatively when the patient and surgeon might not be
fully prepared for a surgical resection of such magnitude
(4). A case of infiltration of the duodenum and head of the
pancreas with right colonic cancer that was treated
successfully with duodeno-pancreatectomy (DP) is reported.
Case Report
A 76-year-old man was admitted due to loss of weight and
worsening clinical condition. During basic clinical
examination pale skin and mucosa of the mouth could be
seen, no abdominal palpable mass or pressure pain was
noticed. During the routine blood test, hypochromic
microcytic anaemia was detected with a haemoglobin level of
8.4 g/dl and a CRP level of 2.24 mg/dl (normal <0.50 mg/dl).
The CEA level was 5.32 mmol/l (normal <2.5 mmol/l), and
the CA 19-9 level was 3.6 kU/l (normal <37 kU/l). An upper
intestinoscopy was carried out showing a fresh pyloric ulcer
next to a healing gastric ulcer in the antrum. The occurrence
of stool in the duodenal bulb was striking. A biopsy was taken
of the ulcer and histopathological examination indicated an
invasive adenocarcinoma. A lower intestinoscopy showed a
circular growing cancer of the right colonic flexure with
subtotal stenosis that was not passable by intestinoscopy.
Histopathological examination showed the same histology as
the tissue specimen of the duodenal ulcer. Computed
tomography of the abdomen showed a swelling of the wall of
the right colonic flexure with stenosis and reaction of the
surrounding tissue. The head of the pancreas appeared to lie
next to this conglomerate tumour and could not be clearly
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 ANTICANCER RESEARCH 27: 1733-1736 (2007)
separated from the tumour formation. Additionally, two
hypodense intrahepatic lesions could be seen by computed
tomography, but abdominal ultrasound excluded intrahepatic
metastases. The patient was transferred to our unit for
surgical therapy.
During the explorative median laparotomy, the primary
colonic cancer seemed to be resectable and the liver appeared
to be normal without suspicion of intrahepatic metastasis or
peritoneal tumour seeding. The colonic cancer was located at
the right flexure with firm adhesions to the duodenum and
pancreas. A right hemicolectomy en bloc with partial DP,
cholecystectomy and lymphonodectomy were carried out. The
alimentary tract was reconstructed via end-to-end
ileotransversostomy, end-to-side pancreaticojejunostomy, end-
to-side hepaticojejunostomy, end-to-side gastrojejunostomy and
end-to-side jejunojejunostomy. The operation was carried out
in 3 hours and 45 minutes. The patient recovered uneventfully.
Histopathological examination indicated a poorly
differentiated adenocarcinoma of the colon, with a maximum
diameter of 7.8 cm, with invasion through the colonic wall
and penetration into the serosa, and infiltration of the
duodenum with perforation into the lumen. In the resected
head of the pancreas and the gall bladder signs of infiltration
could be seen. Of the 24 resected lymph nodes, three
contained cancer tissue, the tumour was classified as pT4 pN1
(3/24) M0 G3 R0 according to stage III of the UICC
classification. Postoperatively, chemotherapy was
administered with capecitabine 2000 mg/m2 on days 1-14 and
repeated after 3 weeks for over 24 weeks. Now, 18 months
after the operation, the patient is alive and free of disease.
Discussion
Approximately 5% of the population in the Western world
are affected by colonic cancer (5). Although in recent years
many programs have been established, such as public
education with mass screening strategies and endoscopic
imaging to detect colonic cancer at an early stage, even
today the disease is seen at an advanced stage in some
patients. Colonic cancer with invasion of adjacent organs
occurs in approximately 5-16% of all colorectal
malignancies (1, 6, 7). Although extracolonic spread is
common in rectosigmoid tumours, it is seen less often in
right-sided colonic cancer (8). Tumours of the right-sided
colon may infiltrate the liver, the duodenum, the pancreas
and the right kidney. Duodenal or pancreatic involvement
from primary carcinoma of the colon can be difficult to
define preoperatively because the results of preoperative
imaging are often unreliable in predicting adjacent organ
spread, as seen in our patient. Upper gastrointestinal
endoscopy may also fail to identify duodenal infiltration
because tumour infiltration may be limited to the muscle
layer without invasion of the duodenal mucosa. Therefore
1734
extracolonic spread is often discovered for the first time
during laparotomy. However, in our patient the cancerous
infiltration of the duodenum had caused a bleeding
duodenal ulcer, and the correct diagnosis of tumour
infiltration could have been established preoperatively by
biopsy. In retrospective studies it has been demonstrated
that in approximately 40% of cases adherence of the
carcinoma to adjacent organs is caused by inflammatory
disease and only in approximately 55-70% by direct tumour
invasion (9). The use of palliative bypass surgery resulted in
a median survival of only nine months (9). The only curative
surgical approach is en bloc resection of all involved organs
(4). Any separation of the colonic cancer from the adherent
organs should be avoided because this may lead to spillage
and dissemination of cancer cells leaving behind residual
disease that may result in early local recurrence. An
incomplete resection leads to diminished survival of only
eleven months (9). The impact of en bloc resection has been
demonstrated (4, 9).
Although operative resection of primary carcinoma of
the pancreas is commonly carried out, little information is
available about the mortality, morbidity and outcome after
enbloc DP for right colonic carcinomas. The first duodenal
resection for colonic cancer was published in 1929 (10),
whereas Van Prohaska et al. performed the first DP for
direct colonic cancer invasion in 1953 (11). However, in
recent decades most surgeons have avoided performing a
hemicolectomy with en bloc resection of the duodenum and
the pancreas due to the historically high rates of
perioperative morbidity and mortality of DP in patients
with primary pancreatic adenocarcinoma and the expected
poor prognosis of these patients. Therefore the impact of
DP and right-sided hemicolectomy has only been
demonstrated in case reports and in some series dealing
with surgery of locally advanced colorectal cancer with
enbloc resection of adjacent organs including solitary cases
with DP (3, 4, 8, 9, 12-31). These authors have reported
survival times, with no evidence of disease, of up to 40
months making PD for locally invasive colon cancer a
therapeutic and curative option (Table I). However, there
might be a publication bias because only successful cases
are published. In contrast, the median survival for
pancreatic cancer for all patient groups reported in the
literature only ranges between 12 and 18 months (32-35).
During the past two decades the results from DP have
gradually improved and the Whipple operation and its
modifications have clearly evolved to become safe and
effective procedures for several indications. In addition to
advances in surgical techniques and a better understanding
of pancreatic diseases, numerous improvements in
diagnostic and interventional radiology, intensive and
perioperative care and management of complications have
contributed to the currently low mortality of DP (32). In
 Meyer and Behrend: Pancreatic Head Resection for Invasive CRC

Table I. Overview of the existing publications with PD for locally invasive 5 Boring CC, Squires TS, Tong T and Montgomery S: Cancer
right-sided colon cancer. statistics, 1994. CA Cancer J Clin 44: 7-26, 1994.
6 Eldar S, Kemeny MM and Terz JJ: Extended resections for
Author Number of Perioperative carcinoma of the colon and rectum. Surg Gynecol Obstet 161:
(ref.) patients mortality 319-322, 1985.
(identified/ 7 Staniunas RJ and Schoetz DJ Jr: Extended resection for
resected) carcinoma of colon and rectum. Surg Clin North Am 73: 117-
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Izumi 1993 (31) 1 NED 20 months 0
8 Heslov SF and Frost DB: Extended resection for primary
Curley 1994 (17) 7/12 OS 32 months for all 0
colorectal carcinoma involving adjacent organs or structures.
Suzaki 1996 (23) 1 NED 30 months 0
Harrison 1997 (30) 7/18 OS 40 months 1 Cancer 62: 1637-1640, 1988.
for all patients 9 Curley SA, Carlson GW, Shumate CR, Wishnow KI and Ames
Yoshimi 1999 (24) 2 NED 37 months/ FC: Extended resection for locally advanced colorectal
1 death after 24 months 0 carcinoma. Am J Surg 163: 553-559, 1992.
Koea 2000 (14) 4/8 NED 24-30 months/ 10 Turner GG: Cancer of the colon. Lancet 1: 1017-1023, 1929.
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Kama 2001 (19) 4 NED 14-41 months 0 resection for advanced carcinoma of the colon and rectum. Surg
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Pingpank 2002 (26) 4/17 OS 56 months for all 12 Gall FP, Tonak J and Altendorf A: Multivisceral resections in
Perez 2005 (27) 1 NED 24 months 0 colorectal cancer. Dis Colon Rectum 30: 337-341, 1987.
Kapoor 2006 (28) 6/11 NED 52 months for all 1 13 McGlone TP, Bernie WA and Elliott DW: Survival following
extended operations for extracolonic invasion by colon cancer.
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14 Koea JB, Conlon K, Paty PB, Guillem JG and Cohen AM:
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15 Berrospi F, Celis J, Ruiz E and Payet E: En bloc
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Received January 14, 2007
Revised March 22, 2007
Accepted March 23, 2007