Pancreatic metastases are rare, with a reported incidence varying

Transcription

1 Diagn Interv Radiol DOI / DIR Turkish Soiety of Radiology 2009 ABDOMINAL IMAGING ORIGINAL ARTICLE Panreati metastases: CT and MRI findings Ioannis Tsitouridis, Aglaia Diamantopoulou, Mihael Mihaelides, Mary Arvanity, Sofia Papaioannou PURPOSE The panreas is an unusual ut oasionally favored site for metastases in patients with advaned malignany. The pivotal role of omputed tomography (CT) and magneti resonane imaging (MRI) examination in deteting the panreati mass and providing guidane to otain a definitive tissue is emphasized in this study. MATERIALS AND METHODS Eleven patients with panreati metastases, 4 women and 7 men with a mean age of years, were examined in a period of 5 years. All patients underwent CT examination and 3 patients were further evaluated y MRI. RESULTS The primary malignany was lung arinoma in 7 patients, reast arinoma in 3 patients and renal ell arinoma in 1 patient. The panreati metastases were deteted during initial staging in 4 ases and during followup in 7 ases. The type of metastases was solitary in 7 patients, multiple in 3 patients and diffuse in 1 patient, with rim or homogeneous enhanement. Seven patients had metastases to other organs. CTguided iopsy was performed in 5 patients. CONCLUSION Disparity in prognosis and management of patients with seondary panreati tumors makes detetion and haraterization of metastases to the panreas an important goal of CT and MRI evaluation. Key words: neoplasm metastasis panreati neoplasms omputed tomography magneti resonane imaging From the Department of Diagnosti and Interventional Radiology (M.M. mihaelidesm@yahoo.om), Papageorgiou General Hospital, Thessaloniki, Greee. Reeived 16 June 2008; revision requested 28 Deemer 2008; revision reeived 17 Feruary 2009; aepted 23 Marh Pulished online 18 Deemer 2009 DOI / DIR Panreati metastases are rare, with a reported inidene varying from 1.6% to 11% in autopsy studies of patients with advaned malignany. In linial series, the frequeny of panreati metastases ranged from 2% to 5% of all panreati malignant tumors (1 5). The most ommon primary tumors to give rise to panreati metastases are renal ell arinoma, lung aner, reast aner and oloretal arinoma followed y malignant melanoma and leiomyosaroma (1, 6). The disparity in prognosis and management of patients with primary and seondary panreati tumors, as well as the fat that in very seleted ases a radial surgial resetion an e onsidered as treatment of panreati metastases and ahieve prolonged survival, underlines the importane of detetion and haraterization of these lesions on omputed tomography (CT) and magneti resonane imaging (MRI) (1, 6, 7). CT an also e onsidered as an important tool in providing guidane in order to otain a definitive tissue in ontroversial ases (1, 2, 7). Material and methods In a period of 5 years, etween January 2002 and January 2007, 11 patients with panreati metastases, 4 women and 7 men, were examined. Patients ages ranged from 27 to 78 years with a mean age of years. All patients underwent CT examination and 3 patients were further evaluated y MRI. CTguided iopsy was performed in 5 ases. Patients with neoplasti involvement of the panreas y diret extension from adjaent visera, as well as patients with metastati involvement of peripanreati lymph nodes ut not of the panreas itself, were exluded from the study. CT sans were otained with a Piker PQ 5000 CT sanner devie with slie thikness, 5 mm; pith, 2; reonstrution interval, 5 mm; FOV, ranging from mm depending on the patient s size. Images were otained after ontrast agent administration during portal phase (60 70 s after injetion). A olus injetion of ml (3 4 ml/s) of nonioni ontrast medium was given. MRI sans were otained with a Siemens 1 T sanner (Siemens Expert Plus, Erlangen, Germany). Before ontrast administration, axial and oronal HASTE T2weighted images (TR, 6 ms; TE, 60 ms) were otained with a slie thikness of 8 mm; FOV, mm depending on patient s size; and matrix, 256 x 192. After administration of 10 ml of ontrast agent axial FLASH T1weighted images (TR, 11 ms; TE, 4.2 ms) were otained with a slie thikness of 8 mm; FOV, mm, matrix, 256 x 192. CT guided panreati iopsies were performed using 18 G utting needles with the oaxial tehnique (Temno Evolution, Cardinal Health, Orlando, Florida, USA). All patients were informed and gave their written onsent efore iopsy.

2 Results The primary malignany was lung arinoma in 7 patients, reast arinoma in 3 patients, and renal ell arinoma in 1 patient. Of the 7 patients with lung arinoma, 2 patients had small ell arinoma and 5 patients nonsmall ell arinoma; 3 patients had adenoarinoma and 2 patients squamous ell arinoma (Figs. 1 and 2). All 3 patients with reast aner had infiltrative loular arinoma. Panreati metastases were deteted during initial staging (within 2 weeks from of primary arinoma) in 4 patients and during followup in 7 patients. In the latter ase, the time interval etween of the primary tumor and detetion of panreati metastases ranged from 13 to 50 months (mean, 29.4 months). At the time of detetion of panreati metastasis 6 patients were asymptomati and in 2 of these patients the was set during the initial staging of the primary tumor. Clini al symptoms in the 5 symptomati patients inluded adominal pain in 3 patients, vomiting in 2 patients and jaundie in 3 patients (Tale). Panreati metastases were solitary in 7 patients (63.6%), multiple in 3 patients (27.3%) and diffuse in 1 patient (9%) ausing generalized enlargement of the organ (Fig. 3). In 10 patients with solitary and multiple metastases 18 tumors were deteted; 5 tumors were loated in the head of the panreas (27.8%), 2 in the nek (11.1%), 6 in the ody (33.3%) and 5 in the tail (27.8%). Tumors showed no prediletion for a partiular part of the organ with the nek eing less ommonly involved. Size of the tumors ranged from 1.2 m to 5.2 m (mean, 2.75 m). Lesions were solid in 10 patients and ysti with multifoal distriution in 1 patient with small ell lung arinoma (Fig. 4). Margins of the tumors were welldefined in 9 patients; smooth in 6 patients and loulated in 3 patients. In 2 ases the margins of the lesions were illdefined; 1 with multiple and 1 with diffuse distriution (Tale). Enhanement pattern of panreati metastases on CT and MRI was homogeneous in 3 patients; 2 with solitary metastases from lung adenoarinoma and squamous ell arinoma and 1 with multiple metastases from renal ell arinoma (Fig. 5). In the remaining 8 patients, panreati metastases demonstrated rim enhanement pattern. Of the 3 patients who underwent further MRI evaluation, panreati metastases had intermediate signal intensity on T2weighted images in all ases. At the time of detetion of the panreati metastases, 7 patients had metastases to other organs; 3 patients had adrenal metastases, 2 patients metastases to the pararenal spae, 2 patients metastases to the lumar spine, 2 patients metastases to mediastinal lymph nodes, 1 patient had rain metastases and metastases to panreatioduode Tale. Clinial data and imaging findings in 11 patients with panreati metastases Primary tumor Gender Age CTMRI Diagnosis Symptoms Loation of Types of metastases panreati metastases Size (m) Solid/ysti Margins Pattern of enhanement Extrapanreati metastases CT guided iopsy Breast F 51 CT Followup (38 months) Asymptomati Solitary Body 2.9 Solid Smooth Rim Liver, R kidney, R adrenal LN (retroperitoneall gastri artery) (AdCa) M 72 CT MRI Initial Asymptomati Solitary Nek 2 Solid Smooth Rim + (AdCa) M 78 CT Initial Pain Vomiting Solitary Head 2.4 Solid Smooth Rim + (AdCa) M 68 CT MRI Initial Pain Jaundie Solitary Head 4 Solid Smooth Homogeneous + Kidney F 77 CT MRI Followup (50 months) Asymptomati Multiple (4) Body (3) Tail (1) Solid Smooth Homogeneous Mediastinal LN, loal reurrene (SqCC) M 52 CT Followup (35 months) Asymptomati Solitary Head 3.5 Solid Loulated Homogeneous Adrenals (SmCC) M 69 CT Followup (20 months) Pain Vomiting Multiple (5) Head (1) Body (2) Tail (2) Cysti Smooth Rim Mediastinal LN, lumar spine, ilateral pararenal spae Breast F 27 CT Initial Asymptomati Diffuse Solid Illdefined Rim + (SqCC) M 57 CT Followup (26 months) Asymptomati Solitary Tail 3 Solid Loulated Rim L adrenal, L pararenal spae Breast F 77 CT Followup (24 months) Jaundie Solitary Head 3.5 Solid Loulated Rim Lumar spine + (SmCC) M 59 CT Followup (13 months) Jaundie Multiple (2) Head (1) Tail (1) Solid Illdefined Rim Brain, panreatoduodenal LN AdCa, adenoarinoma; SmCC, small ell arinoma; SqCC, squamous ell arinoma; M, male; F, female; R, right; L, left; LN, lymph nodes. ii Diagnosti and Interventional Radiology Tsitouridis et al.

3 a Figure 1. a. Contrast enhaned CT (a), HASTE T2weighted MR (), and ontrast enhaned FLASH T1weighted MR () images of a solitary metastasis in the nek of the panreas, with rim enhanement and intermediate signal intensity on the HASTE T2weighted MR image (), in a 72yearold patient with lung adenoaninoma. Figure 2. A homogeneously enhaning solitary metastasis in the head of the panreas is visile on CT of a 52yearold patient with squamous ell lung arinoma and ilateral adrenal metastases. initial staging. In these ases, the iopsy was performed in order to exlude a synhronous primary panreati tumor. The primary malignany of the remaining 2 patients was loular reast arinoma. In 1 patient with diffuse panreati metastases and generalized enlargement of the gland, iopsy was performed in order to otain a definitive tissue and evaluate the possiility and type of hemotherapy. CTguided iopsy was also performed in 1 patient with reast aner and metastases to the lumar spine. In this ase, the panreati lesion was solitary and it was deteted 24 months after initial staging. Biopsy was performed to exlude a synhronous primary panreati tumor and evaluate the possiility and type of hemotherapy. In this ase, we had a small peripanreati hematoma as a ompliation. A histologial was otained in all ases. None of the remaining 6 patients underwent surgial treatment. As a result histologial onfirmation was not otained in these ases and the was ased on patients history, followup and radiologial findings. nal lymph nodes, and 1 patient had onurrent adrenal, renal, hepati metastases and metastases to retroperitoneal lymph nodes and lymph nodes of the left gastri artery. None of the patients had demonstrale involvement of extrapanreati arteries and veins. Califiation was not present in the panreati tumors. Moderate dilatation of the main panreati dut upstream from the lesion was apparent in 1 patient with lung adenoarinoma and solitary metastases in the head of the panreas. CTguided iopsy was performed in 5 patients. Out of these 5 patients, 3 had lung adenoarinoma with solitary panreati metastases deteted during Disussion Panreati metastati lesions are unommon and aount for 2 5% of panreati malignanies (2, 3, 5). On the asis of studies involving large numers of autopsies performed in patients with malignant neoplasms, the prevalene of panreati metastases has een reported to range from 1.6% CT and MRI of panreati metastases iii

4 a d e Figure 3. a e. CT showing diffuse infiltration of the panreas (a ) in a 27yearold patient with reast arinoma deteted during initial staging. Followup CT of the same patient 11 months later (d, e) demonstrates further enlargement of panreati lesions, nerosis, and a newly disovered lesion in the left kidney onsistent with renal metastasis. iv Diagnosti and Interventional Radiology to 11% (1, 4). The tumors that metastasize most ommonly to the panreas are renal ell arinoma, lung aner, reast aner and oloretal arinoma followed y malignant melanoma and leiomyosaroma (1, 6). In most studies lung arinomas or renal ell arinomas are reported to e the most ommon (4, 8 10), although one study from Japan indiated stomah aner as the main soure suggesting population ased differenes (11). In our study, the most ommon primary malignany was lung arinoma (63.6%) followed y reast arinoma (27.3%), ut renal ell arinoma did not omprise a signifiant perentage (9%). Other primary malignanies that have een reported to give rise to panreati metastases are thyroid, prostate, ovarian, hepatoellular arinomas and various types of saromas (4, 12, 13). Panreati metastases may diretly invade panreati dutal epithelium and thus linially mimi primary panreati adenoarinoma, or less ommonly, indue aute panreatitis. As a result, linial symptoms produed y seondary panreati tumors are variale and nonspeifi, inluding adominal pain, ak pain, nausea, weight loss, jaundie, melena and upper gastrointestinal leeding (12, 13). However, most patients (50 83%) with panreati metastases are ompletely asymptomati (8, 10, 12, 13). In our study, 54.5% of patients were asymptomati, 27.3% reported adominal pain, 18.2% vomiting and 27.3% had jaundie. Out of the 3 patients with jaundie, 2 patients had a solitary metastasis in the head of the panreas (3.5 m and 4 m in diameter, respetively) and 1 patient had metastases to panreatioduodenal lymph nodes. A moderate dilatation of the main panreati dut on CT, upstream from the solitary metastasis in the head of the panreas, was present in 1 patient with adominal pain and vomiting. Tsitouridis et al.

5 a Figure 4. a. CT images showing multiple ysti, rimenhaning panreati metastases in a 69yearold patient with small ell lung arinoma deteted 20 months after initial of the primary malignany. a Figure 5. a d. Multiple homogeneously enhaning metastases in the ody and tail of the panreas (CT images, a, ) with intermediate signal intensity on HASTE T2 weighted MR images (, d) in a 77yearold patient with rightsided renal ell arinoma. Panreati metastases were deteted 50 months after nephretomy. d CT and MRI of panreati metastases v

6 Panreati metastases do not appear to show a prediletion for a partiular part of the organ (9, 14). Three types of metastati involvement of the panreas have een desried. The most ommon, reported in 50 73% of ases, is that of a solitary, loalized, wellmarginated mass. A seond pattern of multiple panreati lesions has een reported in 5 10% of ases, and a third pattern of diffuse metastati infiltration ausing generalized enlargement of the organ in 15 44% of ases (2, 12, 15 17). In this study, the most ommon type was that of the solitary metastasis, present in 63.6% of patients, followed y the multiple metastases type in 27.3% of patients and the diffuse type in 9% of ases. Our results were more in aordane with those reported y Klein et al. (9) with the diffuse pattern eing the most infrequent (4.5% of ases), the solitary type representing 78.8%, and the multifoal type 16.7% of ases. Metastati panreati tumors may also have ertain features on ontrastenhaned CT and MRI that are more harateristi of their extrapanreati soure than of primary panreati arinoma. Whereas dutal adenoarinoma of the panreas typially appears as a non or poorlyenhaning mass, panreati metastases deteted in our study showed peripheral (72.7%) or less ommonly homogeneous (27.3%) enhanement. Therefore, the enhanement pattern of tumor tissue oserved in all of our ases reflets a degree of vasular perfusion that is not typial of primary panreati adenoarinoma. Several authors have also reported that rim enhanement is espeially ommon in metastati lesions larger than 1.5 m in size, whereas smaller lesions tend to demonstrate homogeneous enhanement (9, 12, 13). In our study we did not oserve a orrelation etween tumor size and pattern of enhanement. When hypervasular panreati lesions are depited on ontrastenhaned CT and MRI, differential inludes primary neuroendorine tumors, metastases, intrapanreati aessory spleen and vasular lesions suh as arteriovenous fistulas or aneurysms of the spleni artery (1, 18 20, 21). In most ases the onologi akground and existene of previous followup of the neoplasti disease allows a orret, and in ontroversial ases a CTguided iopsy an e performed. vi Diagnosti and Interventional Radiology As far as the origin of panreati metastases is onerned, metastases from renal ell arinomas are often desried as hyperattenuating masses, a pattern that reflets hypervasularity of viale tumor tissue, typial of the primary malignany (9, 12, 13). Although the solitary type is the most ommon in panreati metastases from renal ell arinoma, multifoality of the lesions is not unusual, ranging from 20% to 45% in different reports (6, 20 24). Another speifi harateristi of metastati renal ell arinoma is that panreati loalization typially ours a long period after initial nephretomy, with a median interval ranging from 6.5 to 12 years, with the longest interval reported eing 32.7 years (5, 6, 19 21, 23, 25, 26). In our ase, multiple homogeneously enhaning panreati metastases were deteted in a patient with renal ell arinoma 50 months after initial and nephretomy, and a loal reurrene of the primary tumor was deteted at the same time. The most ommon primary malignany in this study was lung aner with nonsmall ell arinoma outnumering small ell arinoma. All patients with adenoarinoma had a solitary solid panreati metastasis with smooth margins deteted during initial and no extrapanreati metastases. In all ases of small and squamous ell arinomas extrapanreati metastases were present. Both patients with small ell arinomas presented multiple panreati metastases with rim enhanement whereas in all other ases of lung arinomas panreati metastases were solitary. Nevertheless, there is not suffiient data from the literature indiating a orrelation etween speifi histologial types of lung arinoma and radiologial findings, with the exeption of reports stating that panreati metastases are more ommonly enountered in patients with small ell arinoma and that the solitary type is the most usual pattern (9, 16). The importane of detetion and haraterization of panreati metastases on CT and MRI is underlined y the disparity in prognosis and management of patients with primary and seondary panreati tumors. In seleted patients with panreati metastases, surgial resetion an e onsidered as treatment and prolong survival. Data from the literature indiate that an improved survival an e ahieved in patients with renal, reast, and oloni arinomas and saromas as primary malignany, while patients with melanoma and lung aner are related with a poor outome and should e treated nonoperatively (5, 8, 19, 27, 28). Even in patients not amenale to surgery, a definitive tissue an e helpful in evaluating the possiility and type of hemotherapy. In these ases and in ontroversial diagnosti ases, CT an e onsidered as an important tool in providing guidane in order to otain a definitive tissue (1, 2, 7, 9). The limitation of this study is the fat that a histologial was not otained in patients who did not undergo CTguided iopsy eause none of these patients had surgial treatment. In these ases was ased on patients history, followup and radiologial findings. Another limitation is the fat that during adominal CT examination, arterial phase is not routinely inluded in our protool for staging and followup of onology patients. Therefore, hypervasular panreati metastases might have een underestimated, although aording to Meho et al. (21), all ases of hypervasular metastases from renal ell arinoma were hyperdense (ompared to normal panreati tissue) in oth arterial and venous phases. In onlusion, although panreati metastases are rare, the widespread use of CT and MRI in ontemporary medial pratie has led to inreased detetion of suh lesions. In onology patients, aurate requires knowledge of patients history and primary neoplasm, and familiarity with the spetrum of radiologi appearanes of seondary panreati tumors. Definitive tissue is neessary in ontroversial ases, when preise knowledge of histology will determine or modify appropriate treatment. Referenes 1. Crippa S, Angelini C, Mussi C, et al. Surgial treatment of metastati tumors to the panreas: a single enter experiene and review of the literature. World J Surg 2006; 30: Asenti G, Visalli C, Genitori A, Certo A, Pitrone A, Mazziotti S. Multiple hypervasular panreati metastases from renal ell arinoma: dynami MR and spiral CT in three ases. Clin Imaging 2004; 28: Tsitouridis et al.

7 3. Kassian A, Stein J, Jaour N, et al. Renal ell arinoma metastati to the panreas: a singleinstitution series and review of the literature. Urology 2000; 56: Adsay NV, Andea A, Basturk O, Kilin N, Nassar H, Cheng JD. Seondary tumors of the panreas: an analysis of a surgial and autopsy dataase and review of the literature. Virhows Arh 2004; 444: Zeri A, Ortolano E, Balzano G, Borri A, Benedue AA, Di Carlo V. Panreati metastasis from renal ell arinoma: whih patients enefit from surgial resetion? Ann Surg Onol 2008; 15: Sohn TA, Yeo CJ, Cameron JL, Nakee A, Lillemoe KD. Renal ell arinoma metastati to the panreas: results of surgial management. J Gastrointest Surg 2001; 5: FritsherRavens A, Sriram PV, Krause C, et al. Detetion of panreati metastases y EUSguided fineneedle aspiration. Gastrointest Endos 2001; 53: Hiotis SP, Klimstra DS, Conlon KC, Brennan MF. Results after panreati resetion for metastati lesions. Ann Surg Onol 2002; 9: Klein KA, Stephens DH, Welh TJ. CT harateristis of metastati disease of the panreas. Radiographis 1998; 18: Le Borgne J, Partensky C, Glemain P, Dupas B, de Kerviller B. Panreatioduodenetomy for metastati ampullary and panreati tumors. Hepatogastroenterology 2000; 47: Nakamura E, Shimizu M, Itoh T, Manae T. Seondary tumors of the panreas: liniopathologial study of 103 autopsy ases of Japanese patients. Pathol Int 2001; 51: Satarige JC, Horton KM, Sheth S, Fishman EK. Panreati parenhymal metastases: oservations on helial CT. Am J Roentgenol 2001; 176: Merkle EM, Boaz T, Kolokythas O, Haaga JR, Lewin JS, Brams HJ. Metastases to the panreas. Br J Radiol 1998; 71: Ng CS, Loyer EM, Iyer RB, David CL, DuBrow RA, Charnsangavej C. Metastases to the panreas from renal ell arinoma: findings on threephase ontrastenhaned helial CT. Am J Roentgenol 1999; 172: Ferrozzi F, Bova D, Campodonio F, Chiara FD, Passari A, Bassi P. Panreati metastases: CT assessment. Eur Radiol 1997; 7: Maeno T, Satoh H, Ishikawa H, et al. Patterns of panreati metastasis from lung aner. Antianer Res 1998; 18: Muranaka T, Teshima K, Honda H, Nanjo T, Hanada K, Oshiumi Y. Computed tomography and histologi appearane of panreati metastases from distant soures. Ata Radiol 1989; 30: Ninan S, Jain PK, Paul A, Menon KV. Synhronous panreati metastases from asymptomati renal ell arinoma. J Panreas 2005; 6: Sperti C, Pasquali C, Liessi G, Piniroli L, Deet G, Pedrazzoli S. Panreati resetion for metastati tumors to the panreas. J Surg Onol. 2003; 83: Law CH, Wei AC, Hanna SS, et al. Panreati resetion for metastati renal ell arinoma: presentation, treatment, and outome. Ann Surg Onol 2003; 10: Meho S, Quiroga S, Cuellar H, Seastia C. Panreati metastasis of renal ell arinoma: multidetetor CT findings. Adom Imaging 2009; 34: Bassi C, Butturini G, Faloni M, Sargenti M, Mantovani W, Pederzoli P. High reurrene rate after atypial resetion for panreati metastases from renal ell arinoma. Br J Surg 2003; 90: Thompson L, Heffess C. Renal ell arinoma to the panreas in surgial pathology material. A liniopathologial study with 21 ases with a review of the literature. Caner 2000; 89: Wente MN, Kleeff J, Esposito I, et al. Renal aner ell metastasis into the panreas: a singleenter experiene and overview of the literature. Panreas 2005; 30: Faure JP, Tueh JJ, Riher JP, Pessaux P, Arnaud JP, Carretier M. Panreati metastasis of renal ell arinoma: presentation, treatment and survival. J Urol 2001; 165: Sellner F, Tykalsky N, De Santis M, Pont J, Klimpfinger M. Solitary and multiple isolated metastases of lear ell arinoma to the panreas: an indiation for panreati surgery. Ann Surg Onol 2006; 13: Minni F, Casadei R, Perenze B, et al. Panreati metastases: oservations of three ases and review of the literature. Panreatology 2004; 4: Yamamoto H, Watanae K, Nagata M, et al. Surgial treatment for panreati metastasis from softtissue saroma: report of two ases. Am J Clin Onol 2001; 24: CT and MRI of panreati metastases vii