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Ultrasound and computed tomographic findings in pancreatic metastases
European Journal of Radiology, 12 (1991) 41-44 41
Elsevier
EJR 0011 I
Ultrasound and computed tomographic findings in pancreatic metastases J.M. Biset, F. Laurent, G. de Verbizier, B. Houang, Department of Radiology, H6pital Haut Leveque,
(Received
Key words: Pancreas,
ultrasound
and J. Drouillard
Centre Hospitalier Universitaire de Bordeaux.
12 March 1990; accepted
CT; Pancreas,
G. Constantes
France
after revision 1 August 1990)
study; Pancreas,
metastases;
Computed
tomography,
pancreas
Abstract
This is a retrospective study of a series of seven patients with pancreatic metastases studied by ultrasonography and computed tomography. They were detected during tumor staging, or in the follow-up period of over 10 years of patients with advanced known malignancy. Lesions were multiple in two patients and solitary in five; solid in six cases and cystic in one. Clinically, four cases were asymptomatic and three cases presented with jaundice or epigastric pain. Ultrasonography and computed tomography findings were non-specific. Consequently it was not possible to differentiate solitary metastases from primary solid adenocarcinoma and cystadenocarcinoma of the pancreas. In these cases, computed tomography- or ultrasonography-guided biopsies had to be performed to obtain histological proof. However, multiple lesions discovered in a patient with a known malignancy can be assumed to be due to metastases.
Introduction
patients from US and CT guided biopsies, in two from surgical resection and in one from necropsy.
Metastases localized in the pancreas are seldom reported [ l-51. However, the frequency of these lesions at autopsy is approximately estimated at 3 y0 [6]. Improvement in the treatment of patients with diffuse metastases and their follow-up with new imaging techniques lead to more frequent detection of pancreatic metastases. Our purpose is to describe ultrasonography (US) and computed tomography (CT) findings of pancreatic metastases in seven patients. Patients and Methods Between 1984 and 1989, we found in the charts of our institution seven patients with pancreatic metastases discovered by US or CT during follow up in a population of approximately 4000 cases with a known malignancy. All these patients underwent a CT examination and four of them had US as well. Patients with pancreatic lymphoma were excluded. Clinical data are reported in Table 1. Histological proof was obtained in four Address for reprints: J.M. Biset, M.D. Department of Radiology H8pital Haut-Leveque, Avenue de Magellan 33604 Pessac France. 0720-048X/91/$03.50
0 1991 Elsevier Science Publishers
Results US and CT findings are reported in Table 1. Pancreatic metastases were solitary in five patients and multiple in two. The size of the lesions ranged from 1.5 to 8 cm. Among the solitary metastases, three were located in the head of the gland (Fig. l), and two in body or tail. US findings in two cases were hypoechoic, well delineated, round or lobulated masses. In two other cases the lesions were hyperechoic (Fig. 2a). On CT, they appeared as solid masses (Fig. 2b) in six patients, well defined in four and ill defined in two. Dynamic CT showed enhancement of the lesion during the arterial phase in two cases (Fig. 3). In one of those (case l), a duplex examination confirmed the hypervascularity of the lesions. In one patient, the pancreatic lesion was a cystic mass with a thin wall which enhanced after i.v. contrast. This resembled a primary cystic tumor of the pancreas (Fig. 4). In two cases (2 and 7), US and CT derponstrated retropancreatic and porta hepatis adenopathy (Fig. 4).
B.V. (Biomedical
Division)
Liver, bones, lung, muscles. Retroperitoneal and mediastinal nodes Lung
Liver and lung
Lung
Squamous bronchogenic carcinoma Small cell carcinoma of the lung
Renal cell carcinoma
Renal cell carcinoma
Squamous cell carcinoma of pharyngeal tonsils
Abdominal pain jaundice 6 months
During the staging
Staging of a pulmonary metastase 9 years
Abdominal pain and mass 6 years
M/55
M/38
M/65
M/85
M/62
3
4
5
6
7
Jaundice 6 years
Lung and brain
Squamous cell oesophageal carcinoma
Retro-pancreatic adenopathies
im-
During the staging
2
Peritoneal plants
M/58
F/63
1
Renal cell carcinema
organ
Incidental discovery 10 years
Additional metastases
Primary malignancy
Sex/age
Case
Circumstances of discovery, delay of diagnosis
Clinical and imaging findings of the seven patients
TABLE 1
’
Single hypoechoic mass on head (3.5 cm). Biliary duct obstruction. Porta hepatitis nodes
Two echoic lobulated masses on head and body (3-6.5 cm)
Single hypoechoic mass (1 cm) on head. Biliary and pancreatic duct obstruction
Multiple echoic lobulated masses disseminated on the pancreas (1.5 cm to 6 cm) High velocity biphasic signal on Duplex US
US findings
Soft tissue mass hypodense on head. Biliary duct obstruction, Porta hepatitis nodes
Hypervascular bulging mass (8 cm) on tail with retroperitoneal involvement
Two hypervascular soft tissue masses during dynamic CT on head and body
Low density infiltrative mass on the head (2.5 cm)
biopsy
biopsy
Percutaneous
biopsy
biopsy
Percutaneous
Percutaneous
Necropsy
Percutaneous
Surgical biopsy
Cystic like mass (2.5 cm) on the isthmus with retropancreatic duct obstruction Single low density mass on head with biliary and pancreatic duct obstruction
Pancreatectomy
Verification of pancreatic metastases
Lobulated solid masses spontaneously hypodense disseminated on the pancreas
CT findings
R
43
Fig. 1. (case 3) Solitary metastasis of epidermoid bronchial carcino maL.Initial CT (a) shows a 1.5 cm sized hypodense pancreatic head with considerable increa se in size 3 months later (control scan (b)).
nodule (arrow) on
Fig. 2 (case 1) Multiple pancreatic metastases of renal cell carcinon ia. US (a) and plain (b) CT. US sagittal section (a) showing a lobulated hyperechoic mass (star) anterior to the superior mesenteric vein (a rrow). Multiple hypodense nodules (stars) within the pancreas on #L T( ,b).
Fig. 3 (case 5) Metastases of a renal cell carcinoma. Dynamic CT shows hyperdense masses compressing the uncinate process (u) and the mesenteric W:ssels. Another localisation
(arrowhead) in the head of pancreas in the body of the pancreas (b).
(a)
Fig. 4 (case 2) Pancreatic metastasis of epidermoid oesophageal carcinoma. Enhanced CT shows a well-defined cystic-like mass with a peripheral rim enhancement (arrowhead) bulging on the pancreatic isthmus. Necrotic retropancreatic nodes (arrow).
Discussion Pancreatic metastases are rarely reported in imaging studies though their reported incidence in autopsies is 3% [6] and even higher in bronchogenic carcinoma (8.4%) and melanoma (37.5%) [4,7]. Less often, carcinomas of ovary, breast, prostate and kidney can metastasize to pancreas. Pancreatic metastases may be discovered as the first manifestation of a malignancy, incidentally during tumor staging or during follow-up of a known primary malignancy. The latter is the most frequent and can occur very late particularly for renal cell carcinoma [l-3,8,9], (up to 10 years for one of our patients). Quite often, pancreatic metastases are simultaneously detected with secondaries elsewhere (six cases in our series). Pancreatic metastases are often asymptomatic lesions [4,7]. However, clinical findings like jaundice or pancreatitis due to main pancreatic and/or bile duct obstruction can occur [ 10,111. Gastrointestinal hemorrhage can be due to secondary duodenal extension or portal hypertension [ 31. US and CT findings are pleiomorphic, non-specific and cannot differentiate a primary pancreatic neoplasm from a secondary tumor [ 1,4,5,7]. Moreover, metastases may compress the main bile and pancreatic ducts [4]. Wemecke et al. report US to be the most sensitive technique for the detection of small lesions [4], but dynamic CT is very sensitive in detecting a pancreatic lesion particularly in the tail, not always visible with US. Pancreatic tumors with retropancreatic nodes are usually considered to be primary lesions. However, this is non-specific, since these findings were present in two of our cases of pancreatic metastases. In these latter cases, the explanation could be the local spread of metastatic retroperitoneal nodes in the pancreas. A cystic appearance of pancreatic metastases seems to be relatively rare. One of the cases showed this
appearance (case 2), and another has also been reported by Freeny et al. [7]. Metastases from a renal cell carcinoma are often hypervascular [2,3]. In our experience, they appear hyperechoic on US and are enhanced during the arterial phase of dynamic CT (Fig. 3). Other imaging techniques than US and CT do not add any additional information to differentiate primary from secondary tumor. Angiograms can demonstrate hypervascularity which is mostly observed in metastases from renal adenocarcinomas. Endoscopic retrograde cholangiopancreatography (ERCP) is very sensitive (but not specific) and can show displacement, stenosis, or involvement of bile and pancreatic ducts [ 7,111. When a solitary pancreatic mass is discovered in a patient with a known primary malignancy, guided biopsy has to be done to exclude synchronous primary malignant tumors. However, in patients with known malignant disease and multiple pancreatic masses on US or CT associated with metastases to other organs, pancreatic metastases must be considered to be the diagnosis [4]. Conclusion US and CT findings of pancreatic metastases are pleiomorphic and non-specific. In a patient with an advanced primary cancer and multiple pancreatic masses, pancreatic metastases should be considered as the most likely cause for this. References 1 Rumancik WM, Megibow AJ, Bosniak MA, Hilton S. Metastatic disease to the pancreas: evaluation by computed tomography. J Comput Assist Tomogr 1984; 8: 829-834. 2 Strijk SP. Pancreatic metastases of renal cell carcinoma. Report of two cases. Gastrointest Radio1 1989; 14: 123-126. 3 Tongio J, Peruta 0, Wenger JJ, Warter P. Metastases duodenalis et pancreatiques du nephroepitheliome. A propos de quatre observations. Ann Radio1 1977; 20: 641-647. 4 Wernecke K, Peters PE, Galanski M. Pancreatic metastases: US evaluation. Radiology 1986; 160: 399-402. 5 Whittington R, Moylan DL, Dobelbower RR, Kramer S. Pancreatic tumours in patients with previous malignancy. Clin Radio1 1982; 33: 297-299. 6 Willis RA. The spread of tumors in the human body. London: Butterworths, 1952; 217- 218. 7 Freeny PC, Lawson TL. Radiology of the pancreas. New York: Springer-Verlag, 1982; 580-582. 8 Ritchie AWS, Chisholm GD. The natural history of renal carcinoma. Semin Oncol 1983; 10: 390-400. 9 Marquand J, Giraud B, Maliakas S. Metastase pancreatique rtvelatrice d’un cancer du rein. Chirurgie 1971; 97: 52-56. 10 Niccolini DG, Graham JH, Banks PA. Tumor-induced acute pancreatitis. Gastroenterology 1976; 71: 142-145. 11 Swensen T, Osnes M, Serck-Hanssen A. Endoscopic retrograde cholangio-pancreatography in primary and secondary tumours of the pancreas. Br J Radio1 1980; 53: 760-764.
Elsevier
EJR 0011 I
Ultrasound and computed tomographic findings in pancreatic metastases J.M. Biset, F. Laurent, G. de Verbizier, B. Houang, Department of Radiology, H6pital Haut Leveque,
(Received
Key words: Pancreas,
ultrasound
and J. Drouillard
Centre Hospitalier Universitaire de Bordeaux.
12 March 1990; accepted
CT; Pancreas,
G. Constantes
France
after revision 1 August 1990)
study; Pancreas,
metastases;
Computed
tomography,
pancreas
Abstract
This is a retrospective study of a series of seven patients with pancreatic metastases studied by ultrasonography and computed tomography. They were detected during tumor staging, or in the follow-up period of over 10 years of patients with advanced known malignancy. Lesions were multiple in two patients and solitary in five; solid in six cases and cystic in one. Clinically, four cases were asymptomatic and three cases presented with jaundice or epigastric pain. Ultrasonography and computed tomography findings were non-specific. Consequently it was not possible to differentiate solitary metastases from primary solid adenocarcinoma and cystadenocarcinoma of the pancreas. In these cases, computed tomography- or ultrasonography-guided biopsies had to be performed to obtain histological proof. However, multiple lesions discovered in a patient with a known malignancy can be assumed to be due to metastases.
Introduction
patients from US and CT guided biopsies, in two from surgical resection and in one from necropsy.
Metastases localized in the pancreas are seldom reported [ l-51. However, the frequency of these lesions at autopsy is approximately estimated at 3 y0 [6]. Improvement in the treatment of patients with diffuse metastases and their follow-up with new imaging techniques lead to more frequent detection of pancreatic metastases. Our purpose is to describe ultrasonography (US) and computed tomography (CT) findings of pancreatic metastases in seven patients. Patients and Methods Between 1984 and 1989, we found in the charts of our institution seven patients with pancreatic metastases discovered by US or CT during follow up in a population of approximately 4000 cases with a known malignancy. All these patients underwent a CT examination and four of them had US as well. Patients with pancreatic lymphoma were excluded. Clinical data are reported in Table 1. Histological proof was obtained in four Address for reprints: J.M. Biset, M.D. Department of Radiology H8pital Haut-Leveque, Avenue de Magellan 33604 Pessac France. 0720-048X/91/$03.50
0 1991 Elsevier Science Publishers
Results US and CT findings are reported in Table 1. Pancreatic metastases were solitary in five patients and multiple in two. The size of the lesions ranged from 1.5 to 8 cm. Among the solitary metastases, three were located in the head of the gland (Fig. l), and two in body or tail. US findings in two cases were hypoechoic, well delineated, round or lobulated masses. In two other cases the lesions were hyperechoic (Fig. 2a). On CT, they appeared as solid masses (Fig. 2b) in six patients, well defined in four and ill defined in two. Dynamic CT showed enhancement of the lesion during the arterial phase in two cases (Fig. 3). In one of those (case l), a duplex examination confirmed the hypervascularity of the lesions. In one patient, the pancreatic lesion was a cystic mass with a thin wall which enhanced after i.v. contrast. This resembled a primary cystic tumor of the pancreas (Fig. 4). In two cases (2 and 7), US and CT derponstrated retropancreatic and porta hepatis adenopathy (Fig. 4).
B.V. (Biomedical
Division)
Liver, bones, lung, muscles. Retroperitoneal and mediastinal nodes Lung
Liver and lung
Lung
Squamous bronchogenic carcinoma Small cell carcinoma of the lung
Renal cell carcinoma
Renal cell carcinoma
Squamous cell carcinoma of pharyngeal tonsils
Abdominal pain jaundice 6 months
During the staging
Staging of a pulmonary metastase 9 years
Abdominal pain and mass 6 years
M/55
M/38
M/65
M/85
M/62
3
4
5
6
7
Jaundice 6 years
Lung and brain
Squamous cell oesophageal carcinoma
Retro-pancreatic adenopathies
im-
During the staging
2
Peritoneal plants
M/58
F/63
1
Renal cell carcinema
organ
Incidental discovery 10 years
Additional metastases
Primary malignancy
Sex/age
Case
Circumstances of discovery, delay of diagnosis
Clinical and imaging findings of the seven patients
TABLE 1
’
Single hypoechoic mass on head (3.5 cm). Biliary duct obstruction. Porta hepatitis nodes
Two echoic lobulated masses on head and body (3-6.5 cm)
Single hypoechoic mass (1 cm) on head. Biliary and pancreatic duct obstruction
Multiple echoic lobulated masses disseminated on the pancreas (1.5 cm to 6 cm) High velocity biphasic signal on Duplex US
US findings
Soft tissue mass hypodense on head. Biliary duct obstruction, Porta hepatitis nodes
Hypervascular bulging mass (8 cm) on tail with retroperitoneal involvement
Two hypervascular soft tissue masses during dynamic CT on head and body
Low density infiltrative mass on the head (2.5 cm)
biopsy
biopsy
Percutaneous
biopsy
biopsy
Percutaneous
Percutaneous
Necropsy
Percutaneous
Surgical biopsy
Cystic like mass (2.5 cm) on the isthmus with retropancreatic duct obstruction Single low density mass on head with biliary and pancreatic duct obstruction
Pancreatectomy
Verification of pancreatic metastases
Lobulated solid masses spontaneously hypodense disseminated on the pancreas
CT findings
R
43
Fig. 1. (case 3) Solitary metastasis of epidermoid bronchial carcino maL.Initial CT (a) shows a 1.5 cm sized hypodense pancreatic head with considerable increa se in size 3 months later (control scan (b)).
nodule (arrow) on
Fig. 2 (case 1) Multiple pancreatic metastases of renal cell carcinon ia. US (a) and plain (b) CT. US sagittal section (a) showing a lobulated hyperechoic mass (star) anterior to the superior mesenteric vein (a rrow). Multiple hypodense nodules (stars) within the pancreas on #L T( ,b).
Fig. 3 (case 5) Metastases of a renal cell carcinoma. Dynamic CT shows hyperdense masses compressing the uncinate process (u) and the mesenteric W:ssels. Another localisation
(arrowhead) in the head of pancreas in the body of the pancreas (b).
(a)
Fig. 4 (case 2) Pancreatic metastasis of epidermoid oesophageal carcinoma. Enhanced CT shows a well-defined cystic-like mass with a peripheral rim enhancement (arrowhead) bulging on the pancreatic isthmus. Necrotic retropancreatic nodes (arrow).
Discussion Pancreatic metastases are rarely reported in imaging studies though their reported incidence in autopsies is 3% [6] and even higher in bronchogenic carcinoma (8.4%) and melanoma (37.5%) [4,7]. Less often, carcinomas of ovary, breast, prostate and kidney can metastasize to pancreas. Pancreatic metastases may be discovered as the first manifestation of a malignancy, incidentally during tumor staging or during follow-up of a known primary malignancy. The latter is the most frequent and can occur very late particularly for renal cell carcinoma [l-3,8,9], (up to 10 years for one of our patients). Quite often, pancreatic metastases are simultaneously detected with secondaries elsewhere (six cases in our series). Pancreatic metastases are often asymptomatic lesions [4,7]. However, clinical findings like jaundice or pancreatitis due to main pancreatic and/or bile duct obstruction can occur [ 10,111. Gastrointestinal hemorrhage can be due to secondary duodenal extension or portal hypertension [ 31. US and CT findings are pleiomorphic, non-specific and cannot differentiate a primary pancreatic neoplasm from a secondary tumor [ 1,4,5,7]. Moreover, metastases may compress the main bile and pancreatic ducts [4]. Wemecke et al. report US to be the most sensitive technique for the detection of small lesions [4], but dynamic CT is very sensitive in detecting a pancreatic lesion particularly in the tail, not always visible with US. Pancreatic tumors with retropancreatic nodes are usually considered to be primary lesions. However, this is non-specific, since these findings were present in two of our cases of pancreatic metastases. In these latter cases, the explanation could be the local spread of metastatic retroperitoneal nodes in the pancreas. A cystic appearance of pancreatic metastases seems to be relatively rare. One of the cases showed this
appearance (case 2), and another has also been reported by Freeny et al. [7]. Metastases from a renal cell carcinoma are often hypervascular [2,3]. In our experience, they appear hyperechoic on US and are enhanced during the arterial phase of dynamic CT (Fig. 3). Other imaging techniques than US and CT do not add any additional information to differentiate primary from secondary tumor. Angiograms can demonstrate hypervascularity which is mostly observed in metastases from renal adenocarcinomas. Endoscopic retrograde cholangiopancreatography (ERCP) is very sensitive (but not specific) and can show displacement, stenosis, or involvement of bile and pancreatic ducts [ 7,111. When a solitary pancreatic mass is discovered in a patient with a known primary malignancy, guided biopsy has to be done to exclude synchronous primary malignant tumors. However, in patients with known malignant disease and multiple pancreatic masses on US or CT associated with metastases to other organs, pancreatic metastases must be considered to be the diagnosis [4]. Conclusion US and CT findings of pancreatic metastases are pleiomorphic and non-specific. In a patient with an advanced primary cancer and multiple pancreatic masses, pancreatic metastases should be considered as the most likely cause for this. References 1 Rumancik WM, Megibow AJ, Bosniak MA, Hilton S. Metastatic disease to the pancreas: evaluation by computed tomography. J Comput Assist Tomogr 1984; 8: 829-834. 2 Strijk SP. Pancreatic metastases of renal cell carcinoma. Report of two cases. Gastrointest Radio1 1989; 14: 123-126. 3 Tongio J, Peruta 0, Wenger JJ, Warter P. Metastases duodenalis et pancreatiques du nephroepitheliome. A propos de quatre observations. Ann Radio1 1977; 20: 641-647. 4 Wernecke K, Peters PE, Galanski M. Pancreatic metastases: US evaluation. Radiology 1986; 160: 399-402. 5 Whittington R, Moylan DL, Dobelbower RR, Kramer S. Pancreatic tumours in patients with previous malignancy. Clin Radio1 1982; 33: 297-299. 6 Willis RA. The spread of tumors in the human body. London: Butterworths, 1952; 217- 218. 7 Freeny PC, Lawson TL. Radiology of the pancreas. New York: Springer-Verlag, 1982; 580-582. 8 Ritchie AWS, Chisholm GD. The natural history of renal carcinoma. Semin Oncol 1983; 10: 390-400. 9 Marquand J, Giraud B, Maliakas S. Metastase pancreatique rtvelatrice d’un cancer du rein. Chirurgie 1971; 97: 52-56. 10 Niccolini DG, Graham JH, Banks PA. Tumor-induced acute pancreatitis. Gastroenterology 1976; 71: 142-145. 11 Swensen T, Osnes M, Serck-Hanssen A. Endoscopic retrograde cholangio-pancreatography in primary and secondary tumours of the pancreas. Br J Radio1 1980; 53: 760-764.