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Primary or metastatic tumor? - A case report of mucinous adenocarcinoma of pancreas
Authors:Rui Cheng [1], Ying Wang [1], Li Wei [1], Jung Ernst Michael [2], Yi Dong [1]
[1] Department of Ultrasound, Xin Hua Hospital Affiliated to Shang Hai Jiaotong University School of Medicine, Shanghai, China
[2] Institute for Diagnostic Radiology and Interdisciplinary Ultrasound, University Hospital Regensburg, Regensburg, Germany
Figure 4a: The masses in the liver showed annular enhancement in the arterial phase of CEUS, with faster washout compared to the surrounding parenchyma. It appeared hypoechoic in the portal venous and delayed phases (a). The vascular structure and morphology of liver metastases were clearly displayed on SR CEUS (b).
Figure 4b: The masses in the liver showed annular enhancement in the arterial phase of CEUS, with faster washout compared to the surrounding parenchyma. It appeared hypoechoic in the portal venous and delayed phases (a). The vascular structure and morphology of liver metastases were clearly displayed on SR CEUS (b).
1Clinical History
A 47-year-old woman presented to the hospital due to pancreatic mass discovered for a week. The symptoms, such as abdominal distension and backache lasted for more than one month. Some of the tumor makers were out of normal range, with CA125, CA19 - 9, AFP, CEA, CA15 - 3 increased.
2Image Findings
Transcutaneous ultrasound was performed with a high-end ultrasound machine (Mindray/Resona A20; SC7-1M convex array probe). Examination of the pancreas revealed a hypoechoic mass of about 26 × 21 mm in the pancreatic neck with irregular shape and unclear margins (Figure 1). Real time ultrasound scanning around the pancreas found multiple hypoechoic lesions in the liver, the maximum diameter reached 29mm. HD Scope modality was performed to observe more details without decreasing the spatial resolution, offering a better way to evaluate the relationship between the mass and the liver parenchyma (Figure 2). Then, contrast enhanced ultrasound (CEUS) was performed. CEUS via intravenous injection of SonoVue 1.5 mL (Bracco SpA, Milan, Italy) as contrast agent. The degree of the enhancement in tumor of pancreas was faster than the parenchyma (Figure 3). The metastatic lesions in the liver showed fast wash out in the delayed phase (Figure 4). Contrast enhanced computed tomography (CECT) of the abdomen was also performed, which revealed an enhanced lesion of size 28 x 24 mm in the neck of the pancreas, with dilation of the pancreatic duct. In addition, the lesions in the liver showed annular enhancement in the arterial phase (Figure 5).
3Diagnosis
Pancreatic metastasis of lung adenocarcinoma.
4Discussion
BACKGROUND:
Pancreatic metastasis of lung adenocarcinoma is rare[1]. A retrospective study of 2872 patients with lung adenocarcinoma showed pancreatic metastases in only 17 patients (0.59%) [2]. Primary pulmonary mucinous adenocarcinoma is a special subtype of lung adenocarcinoma [3], accounting for about 0.24% of lung cancer [4]. Thus, this case is extremely unusual. We report a 47-year-old woman who was admitted to our hospital for the pancreatic and hepatic masses. Symptoms, such as abdominal distension and backache, were non-specific. Diagnostic imaging, especially CEUS, with intravenous microbubbles, plays a vital role in differentiating the masses.
CLINICAL PERSPECTIVE:
Based on the clinical symptoms and the former three cross-sectional imaging methods, the clinical diagnosis was primary pancreatic cancer together hepatic metastasis, with tumor cells originating from ductal epithelium. Histopathological results of masses from both pancreas and liver were mucinous adenocarcinomas. These findings were consistent with the ultrasound diagnosis —— pancreatic tumor originating from epithelial cells. However, immunohistochemistry showed that ALK (+), a specific manifestation of lung adenocarcinoma. Thus, we back to Positron Emission Tomography/Computed Tomography (PET/CT) reports, and found an abnormal FDG concentrations in the lung (Figure 6). Finally, after the discussion of multi-disciplinary team (MDT), pancreatic lesion was diagnosed as metastatic mucinous adenocarcinoma, originating from primary lung mucinous adenocarcinoma.
THERAPY PLANNING:
Surgical resection was excluded because of the multiple metastases. Since immunohistochemistry results showed ALK (+), the patient received targeted therapy, which has potential efficacy.
OUTCOME & PROGNOSIS:
Our final diagnosis was pancreatic metastasis of lung adenocarcinoma. Primary pulmonary mucinous adenocarcinoma is a special subtype of lung adenocarcinoma, with poor prognosis [3]. In this case, the patient presented with multi-organ metastases and progressed rapidly , therefore could not undergo surgery.
Pancreatic metastasis of lung adenocarcinoma is rare[1]. A retrospective study of 2872 patients with lung adenocarcinoma showed pancreatic metastases in only 17 patients (0.59%) [2]. Primary pulmonary mucinous adenocarcinoma is a special subtype of lung adenocarcinoma [3], accounting for about 0.24% of lung cancer [4]. Thus, this case is extremely unusual. We report a 47-year-old woman who was admitted to our hospital for the pancreatic and hepatic masses. Symptoms, such as abdominal distension and backache, were non-specific. Diagnostic imaging, especially CEUS, with intravenous microbubbles, plays a vital role in differentiating the masses.
CLINICAL PERSPECTIVE:
Based on the clinical symptoms and the former three cross-sectional imaging methods, the clinical diagnosis was primary pancreatic cancer together hepatic metastasis, with tumor cells originating from ductal epithelium. Histopathological results of masses from both pancreas and liver were mucinous adenocarcinomas. These findings were consistent with the ultrasound diagnosis —— pancreatic tumor originating from epithelial cells. However, immunohistochemistry showed that ALK (+), a specific manifestation of lung adenocarcinoma. Thus, we back to Positron Emission Tomography/Computed Tomography (PET/CT) reports, and found an abnormal FDG concentrations in the lung (Figure 6). Finally, after the discussion of multi-disciplinary team (MDT), pancreatic lesion was diagnosed as metastatic mucinous adenocarcinoma, originating from primary lung mucinous adenocarcinoma.
THERAPY PLANNING:
Surgical resection was excluded because of the multiple metastases. Since immunohistochemistry results showed ALK (+), the patient received targeted therapy, which has potential efficacy.
OUTCOME & PROGNOSIS:
Our final diagnosis was pancreatic metastasis of lung adenocarcinoma. Primary pulmonary mucinous adenocarcinoma is a special subtype of lung adenocarcinoma, with poor prognosis [3]. In this case, the patient presented with multi-organ metastases and progressed rapidly , therefore could not undergo surgery.
5Teaching Points
We need to combine all the imaging findings to analyze the lesions. HD Scope, Super resolution CEUS (SR CEUS) and CEUS as real-time, cost-efficient, radiation-free and noninvasive imaging method, could provide crucial imaging details for diagnosis.
6References
1. Saltman D L, NielsenT J, Salina D, et al. Characterization of the tumor immune-microenvironment of adenocarcinoma of lung with a metastatic lesion in the pancreas treated successfully with first-line, single-agent pembrolizumab. Ther Adv Med Oncol, 2021, 13: 17588359211010156.
2. Niu FY, Zhou Q, Yang JJ, et al. Distribution and prognosis of uncommon metastases from non-small cell lung cancer. BMC Cancer, 2016, 16: 149.
3. Li W, Yang Y, Yang M, et al. Clinicopathologic Features and survival outcomes of primary lung mucinous adenocarcinoma based on different Rrdiologic Subtypes. Ann Surg Oncol, 2024, 31(1): 167-77.
4. Xue H, Zhou W, Zkang Z, et al. Femoral head metastases from primary mucinous lung adenocarcinoma with left hip pain: A case report and literature review. Front Surg, 2022, 9: 987627.
2. Niu FY, Zhou Q, Yang JJ, et al. Distribution and prognosis of uncommon metastases from non-small cell lung cancer. BMC Cancer, 2016, 16: 149.
3. Li W, Yang Y, Yang M, et al. Clinicopathologic Features and survival outcomes of primary lung mucinous adenocarcinoma based on different Rrdiologic Subtypes. Ann Surg Oncol, 2024, 31(1): 167-77.
4. Xue H, Zhou W, Zkang Z, et al. Femoral head metastases from primary mucinous lung adenocarcinoma with left hip pain: A case report and literature review. Front Surg, 2022, 9: 987627.
