1992, The British Journal of Radiology, 65, 547-548 Case reports
construction of the graft. These pores may pass indirectly from the luminal aspect to the exterior, but in the normal situation may be occluded by thrombus. With the application of a thrombolytic agent such as rtPA, the blood in the pores may well be thrombolysed permitting extravasation. We are unsure of the clinical significance of this phenomenon and we do not know if it would occur in a well established graft, but recommend caution in the use of thrombolytic agents in the Pulse-Tec graft.
thrombolytic therapy. American Journal of Roentgenology, 142, 573-574. PERLER,
B. A.,
KINNISON,
M.
&
HALDEN,
W. J.,
1986.
Trans-graft haemorrhage: a serious complication of low-dose thrombolytic therapy. Journal of Vascular Surgery, 3, 936-938. RABE, F. E., BECKER, G. J., RICHMOND, B. D., YUNE, H. Y., HOLDEN, R. W., DILLEY, R. S. & KLATTE, E. C , 1982.
Contrast extravasation through Dacron grafts: a sequela of low-dose streptokinase therapy. American Journal of Roentgenology, 138, 917-920. ROSNER, N. H. & DORIS, P. E., 1984. Contrast extravasation
References BECKER, G. J., HOLDEN, R. W., & RABE, F. E., 1984. Contrast
extravasation from a Gore-Tex graft: a complication of
through a Gore-Tex graft: a complication of low dose streptokinase therapy. American Journal of Roentgenology, 143, 633-634.
Pancreatic metastasis from renal cell carcinoma By F. Rypens, MD, D. Van Gansbeke, MD, *J. P. Lambilliotte, MD, tG. Van Regemorter, MD, tA. Verhest, MD and J. Struyven, MD Departments of Radiodiagnosis, *Surgery, tUrology and tPathology, Hopital Erasme, Cliniques Universitaires de Bruxelles, B-1070 Brussels, Belgium {Received 15 July 1991 and accepted 20 September 1991) Keywords: Pancreas, Neoplasms, Renal cell carcinoma
Pancreatic metastasis from renal cell carcinoma is exceptional, but may appear many years after initial diagnosis and radical nephrectomy of an apparently limited tumour. We report one case of an asymptomatic isolated pancreatic metastasis discovered fortuitously, 21 years after right radical nephrectomy for a low-grade renal cancer.
antigen (Fig. 3). Comparison with the histology slides from the previous right renal tumour confirmed similarity of the two tumours. Final diagnosis was therefore of a solitary asymptomatic pancreatic metastasis from renal cell carcinoma 21 years after radical nephrectomy.
Case report In 1969, a 47-year-old man underwent right nephrectomy for renal cell carcinoma of "low-grade malignancy". At this time, no metastases were evident and he remained well on follow-up. In June 1990, he complained of prostatism and a fine-needle biopsy disclosed a well differentiated prostatic carcinoma. Abdominal sonography demonstrated a hyperechoic heterogeneous mass measuring 5 cm x 4 cm x 3 cm in the pancreatic tail (Fig. 1). On computed tomography (CT), the pancreatic tail appeared enlarged by a hypodense mass. The lesion was limited to the pancreatic parenchyma, and remained hypodense and heterogeneous after intravenous contrast medium enhancement. No other abnormality was identified (Fig. 2). Endoscopic retrograde cholangiopancreatography revealed a pancreatic duct stenosis with overhanging of secondary pancreatic canaliculi. Fine-needle aspiration was haemorrhagic and inconclusive, hence partial pancreatectomy was performed. Histological examination of the mass showed neoplastic clear cells containing glycogen and fat but no prostatic specific Address correspondence to Dr F. Rypens, MD, Department of Radiodiagnosis, Hopital Erasme, Cliniques Universitaires de Bruxelles, route de Lennik 808, B-1070 Brussels, Belgium.
Vol. 65, No. 774
Figure 1. Sonography shows a hyperechoic heterogeneous mass (between crosses) in the pancreatic tail (P: pancreas, V: splenic vein).
547
Case reports
Figure 2. CT scan after intravenous contrast medium enhancement demonstrates a hypodense mass limited to the pancreatic tail, without adenopathy (P: pancreas, T: tumour).
Discussion
Metastatic disease to the pancreas is rare, being described at autopsy in only 3% of patients with generalized malignancies. Generally, the primary tumour is melanoma, breast carcinoma or bronchogenic carcinoma but rare cases have been reported in association with oesophageal, gastric, hepatocellular, biliary, colonic, renal, prostatic and ovarian carcinomas and also in various sarcomas (leiomyosarcoma, Merkel spindle cell sarcoma) (Friedman & Edmonds, 1989;
Rumancik et al, 1984). In most cases the pancreatic metastasis is part of widespread nodal and visceral involvement (Malek & Madsen, 1969; Strijk, 1989). About half the patients have pancreatic symptoms or signs including pancreatitis, endocrine or exocrine dysfunction, pain, biliary obstruction or gastrointestinal bleeding. In the other patients, symptoms are absent or masked by the presence of other symptomatic metastasis and pancreatic involvement is only discovered during a staging procedure in advanced tumour. Two sonographic patterns are described: multiple small lesions disseminated throughout the pancreas or large solitary pancreatic lesions. Sonographically, these metastases appear generally more hypoechoic than the pancreatic parenchyma (Strijk, 1989). In our case, the fatty tumoral content may be responsible for the hyperechoic heterogeneous aspect. The CT scan usually shows a hypodense mass sometimes associated with pancreatic or bile duct dilatation. Differentiation from a primary pancreatic tumour will be impossible without tissue sampling; however, the prognosis of these metastases is better than that for primary pancreatic cancer. Here diagnosis was made more difficult because the lesion was solitary and because the renal cell cancer was treated so many years earlier. Cytological examination initially was non-contributory because the sample was heavily blood-stained, but on review neoplastic clear cells similar to those of the pathological specimen were identified. To our knowledge, only one case of pancreatic metastasis from renal cell carcinoma has been reported, discovered 17 years after the initial diagnosis but in that case it was associated with retroperitoneal lymph node enlargement and melaena (Werneke et al, 1986). Our case illustrates the difficulties in the diagnosis in such a late solitary lesion. References FRIEDMAN, A. C. & EDMONDS, P. R., 1989. Rare pancreatic
malignancies. Radiologic Clinics of North America, 177-190.
27(1),
MALEK, G. H. & MADSEN, P. O., 1969. Carcinoma of the
prostate with unusual metastases. Cancer, 24, 194-197. RUMANCIK,
W. M.,
MEGIBOW,
A. J.,
BOSNIAK,
M. A.
&
HILTON, S., 1984. Metastatic disease to the pancreas: evaluation by computed tomography. Journal of Computer Assisted Tomography, 8(5), 829-834. STRIJK, S., 1989. Pancreatic metastases of renal cell carcinoma: report of two cases. Gastrointestinal Radiology, 14, 123-126. Figure 3. Histological examination shows a tubular clear-cell pattern, typical of renal cell carcinoma.
548
WERNEKE, K., PETERS, P. E. & GALANSKI, M., 1986. Pancreatic
metastases: US evaluation. Radiology, 160, 399-402.
The British Journal of Radiology, June 1992
construction of the graft. These pores may pass indirectly from the luminal aspect to the exterior, but in the normal situation may be occluded by thrombus. With the application of a thrombolytic agent such as rtPA, the blood in the pores may well be thrombolysed permitting extravasation. We are unsure of the clinical significance of this phenomenon and we do not know if it would occur in a well established graft, but recommend caution in the use of thrombolytic agents in the Pulse-Tec graft.
thrombolytic therapy. American Journal of Roentgenology, 142, 573-574. PERLER,
B. A.,
KINNISON,
M.
&
HALDEN,
W. J.,
1986.
Trans-graft haemorrhage: a serious complication of low-dose thrombolytic therapy. Journal of Vascular Surgery, 3, 936-938. RABE, F. E., BECKER, G. J., RICHMOND, B. D., YUNE, H. Y., HOLDEN, R. W., DILLEY, R. S. & KLATTE, E. C , 1982.
Contrast extravasation through Dacron grafts: a sequela of low-dose streptokinase therapy. American Journal of Roentgenology, 138, 917-920. ROSNER, N. H. & DORIS, P. E., 1984. Contrast extravasation
References BECKER, G. J., HOLDEN, R. W., & RABE, F. E., 1984. Contrast
extravasation from a Gore-Tex graft: a complication of
through a Gore-Tex graft: a complication of low dose streptokinase therapy. American Journal of Roentgenology, 143, 633-634.
Pancreatic metastasis from renal cell carcinoma By F. Rypens, MD, D. Van Gansbeke, MD, *J. P. Lambilliotte, MD, tG. Van Regemorter, MD, tA. Verhest, MD and J. Struyven, MD Departments of Radiodiagnosis, *Surgery, tUrology and tPathology, Hopital Erasme, Cliniques Universitaires de Bruxelles, B-1070 Brussels, Belgium {Received 15 July 1991 and accepted 20 September 1991) Keywords: Pancreas, Neoplasms, Renal cell carcinoma
Pancreatic metastasis from renal cell carcinoma is exceptional, but may appear many years after initial diagnosis and radical nephrectomy of an apparently limited tumour. We report one case of an asymptomatic isolated pancreatic metastasis discovered fortuitously, 21 years after right radical nephrectomy for a low-grade renal cancer.
antigen (Fig. 3). Comparison with the histology slides from the previous right renal tumour confirmed similarity of the two tumours. Final diagnosis was therefore of a solitary asymptomatic pancreatic metastasis from renal cell carcinoma 21 years after radical nephrectomy.
Case report In 1969, a 47-year-old man underwent right nephrectomy for renal cell carcinoma of "low-grade malignancy". At this time, no metastases were evident and he remained well on follow-up. In June 1990, he complained of prostatism and a fine-needle biopsy disclosed a well differentiated prostatic carcinoma. Abdominal sonography demonstrated a hyperechoic heterogeneous mass measuring 5 cm x 4 cm x 3 cm in the pancreatic tail (Fig. 1). On computed tomography (CT), the pancreatic tail appeared enlarged by a hypodense mass. The lesion was limited to the pancreatic parenchyma, and remained hypodense and heterogeneous after intravenous contrast medium enhancement. No other abnormality was identified (Fig. 2). Endoscopic retrograde cholangiopancreatography revealed a pancreatic duct stenosis with overhanging of secondary pancreatic canaliculi. Fine-needle aspiration was haemorrhagic and inconclusive, hence partial pancreatectomy was performed. Histological examination of the mass showed neoplastic clear cells containing glycogen and fat but no prostatic specific Address correspondence to Dr F. Rypens, MD, Department of Radiodiagnosis, Hopital Erasme, Cliniques Universitaires de Bruxelles, route de Lennik 808, B-1070 Brussels, Belgium.
Vol. 65, No. 774
Figure 1. Sonography shows a hyperechoic heterogeneous mass (between crosses) in the pancreatic tail (P: pancreas, V: splenic vein).
547
Case reports
Figure 2. CT scan after intravenous contrast medium enhancement demonstrates a hypodense mass limited to the pancreatic tail, without adenopathy (P: pancreas, T: tumour).
Discussion
Metastatic disease to the pancreas is rare, being described at autopsy in only 3% of patients with generalized malignancies. Generally, the primary tumour is melanoma, breast carcinoma or bronchogenic carcinoma but rare cases have been reported in association with oesophageal, gastric, hepatocellular, biliary, colonic, renal, prostatic and ovarian carcinomas and also in various sarcomas (leiomyosarcoma, Merkel spindle cell sarcoma) (Friedman & Edmonds, 1989;
Rumancik et al, 1984). In most cases the pancreatic metastasis is part of widespread nodal and visceral involvement (Malek & Madsen, 1969; Strijk, 1989). About half the patients have pancreatic symptoms or signs including pancreatitis, endocrine or exocrine dysfunction, pain, biliary obstruction or gastrointestinal bleeding. In the other patients, symptoms are absent or masked by the presence of other symptomatic metastasis and pancreatic involvement is only discovered during a staging procedure in advanced tumour. Two sonographic patterns are described: multiple small lesions disseminated throughout the pancreas or large solitary pancreatic lesions. Sonographically, these metastases appear generally more hypoechoic than the pancreatic parenchyma (Strijk, 1989). In our case, the fatty tumoral content may be responsible for the hyperechoic heterogeneous aspect. The CT scan usually shows a hypodense mass sometimes associated with pancreatic or bile duct dilatation. Differentiation from a primary pancreatic tumour will be impossible without tissue sampling; however, the prognosis of these metastases is better than that for primary pancreatic cancer. Here diagnosis was made more difficult because the lesion was solitary and because the renal cell cancer was treated so many years earlier. Cytological examination initially was non-contributory because the sample was heavily blood-stained, but on review neoplastic clear cells similar to those of the pathological specimen were identified. To our knowledge, only one case of pancreatic metastasis from renal cell carcinoma has been reported, discovered 17 years after the initial diagnosis but in that case it was associated with retroperitoneal lymph node enlargement and melaena (Werneke et al, 1986). Our case illustrates the difficulties in the diagnosis in such a late solitary lesion. References FRIEDMAN, A. C. & EDMONDS, P. R., 1989. Rare pancreatic
malignancies. Radiologic Clinics of North America, 177-190.
27(1),
MALEK, G. H. & MADSEN, P. O., 1969. Carcinoma of the
prostate with unusual metastases. Cancer, 24, 194-197. RUMANCIK,
W. M.,
MEGIBOW,
A. J.,
BOSNIAK,
M. A.
&
HILTON, S., 1984. Metastatic disease to the pancreas: evaluation by computed tomography. Journal of Computer Assisted Tomography, 8(5), 829-834. STRIJK, S., 1989. Pancreatic metastases of renal cell carcinoma: report of two cases. Gastrointestinal Radiology, 14, 123-126. Figure 3. Histological examination shows a tubular clear-cell pattern, typical of renal cell carcinoma.
548
WERNEKE, K., PETERS, P. E. & GALANSKI, M., 1986. Pancreatic
metastases: US evaluation. Radiology, 160, 399-402.
The British Journal of Radiology, June 1992
