Pancreatic cancer, and the importance of searching for hepatic metastases by EOB-MRI
Yamagata University Hospital
Dr. Yoshihiro Konno, Dept. of Diagnostic Radiology
Dr. Kazuyuki Haga, Dept. of Radiology
DATE : 2021
Introduction
Patient’s background
Male; 70s; body weight: 66 kg; pancreatic body cancer with hepatic metastases
Assessment objectives
During medical treatment of this patient for diabetes mellitus by a local physician, he was found to have poor blood-sugar control. Contrast computed tomography (CT) was performed as a thorough examination, and a mass was found in the pancreatic body, followed by diagnosis as infiltrative pancreatic ductal carcinoma by EUS-FNA. CT showed no abnormalities suggesting distant metastases in the liver or elsewhere. EOB-MRI and 18F-FDG-PET/CT were then performed as more detailed searches for metastases.
Contrast agent used
Gadoxetate disodium(Gd-EOB-DTPA) injection, 0.1 mL/kg
Case explanation
Although no signs showing that resection of local lesions in the pancreatic body was inappropriate were found (Fig. 1A), a low-signal area approximately 6 mm in diameter was found in the inferior angle of liver S6 in the hepatobiliary phase (Fig. 1B). A high DWI signal and low ADC value were found (Fig. 1C, D), and hepatic metastasis was suspected. PET/CT (pre-test glucose level: 226) showed increased accumulation in the pancreatic body lesion, but increased accumulation in the hepatic S6 lesion was not detected (Fig. 2). An ultrasound biopsy of the hepatic lesion was performed, and hepatic metastasis was diagnosed. As radical resection was judged to be difficult, gemcitabine + nab-paclitaxel chemotherapy was initiated.
Imaging findings
A) Late phase: A low-contrast tumor was found in the pancreatic body (→), and the main pancreatic duct was interrupted.
B) Hepatobiliary phase: A low-signal mass approximately 6 mm in diameter was found in the liver inferior angle (→).
C, D) The lesion in liver S6 shows a high signal with DWI (C), and a decreased ADC value (D).
Fig. 1. EOB-MRI
A) Systemic MIP: Increased accumulation in the pancreatic body lesion (→)
B) CT fusion imaging: Increased accumulation in pancreatic lesions (SUVmax: 3.8)
C) CT fusion imaging: Increased accumulation in liver S6 lesion not shown
Fig. 2. ¹⁸F-FDG-PET/CT
Photography protocol
| Imaging type | Photography sequence | Photography duration | TE （msec） | TR （msec） | FA （deg） | Fat sat (type) | P-MRI (Reduction Factor) |
| T2WI Cor | HASTE | 17s | 118 | 800 | 150 | (-) | GRAPPA 2 |
| T1WI Tra | 2D FLASH in-opposed phase | 20s | 1.92/4.76 | 209 | 75 | (-) | GRAPPA 2 |
| Contrast agent administration | |||||||
| Dynamic Tra | VIBE3D | 16s | 2 | 4.6 | 13 | (+) | CAIPIRINHA PE 1 / 3D 2 |
| MRCP COR | 3D SPACE PACE | *Respiratory synchronization | 570 | 2500 | 140 | (+) | GRAPPA 3 |
| DWI Tra | EPI (b-0,800) | *Respiratory synchronization | 72 | 2500 | 90 | (+) | GRAPPA 2 |
| T2WI Tra | TSE PACE | *Respiratory synchronization | 68 | 2000 | 160 | (-) | GRAPPA 2 |
| T2WI Tra | HASTE | 21s | 88 | 800 | 150 | (-) | GRAPPA 2 |
| Hepatobiliary phase Tra | VIBE3D | 16s | 2 | 4.6 | 13 | (+) | CAIPIRINHA PE 1 / 3D 2 |
| Hepatocyte phase COR | VIBE3D | 18s | 1.35 | 3.43 | 12 | (+) | CAIPIRINHA PE 3 / 3D 1 |
| Imaging type | Holding breath (yes/no) | NEX (calculation number) | In-plane resolution (mm) | Slice thickness (mm) | FOV (mm) | Rectangular FOV(%) | Slice Gap (mm) | Slice number |
| T2WI Cor | Yes | 1 | 320*192 | 8 | 320 | 100 | 2 | 20 |
| T1WI Tra | Yes | 1 | 320*192 | 7 | 320 | 81.3 | 1.5 | 24 |
| Contrast agent administration | ||||||||
| Dynamic Tra | Yes | 1 | 320*205 | 3 | 360 | 75 | 0 | 64 |
| MRCP COR | No | 1.7 | 320*288 | 1.3 | 320 | 100 | 0 | 80 |
| DWI Tra | No | 2 | 128*96 | 7 | 320 | 75 | 1.5 | 24 |
| T2WI Tra | No | 2 | 384*230 | 7 | 320 | 81.3 | 1.5 | 24 |
| T2WI Tra | Yes | 1 | 384*250 | 7 | 320 | 81.3 | 1.5 | 24 |
| Hepatobiliary phase Tra | Yes | 1 | 320*205 | 3 | 360 | 75 | 0 | 64 |
| Hepatocyte phase COR | Yes | 1 | 320*224 | 4 | 400 | 100 | 0 | 52 |
* Photography duration varies between patients, due to respiratory synchronization.
Devices used and contrast conditions
| MRI device | SIEMENS MAGNETOM Aera 1.5T |
| Automatic injection device | Sonic Shot 7 (Nemoto Kyorindo Co., Ltd.) |
| Workstation | ー |
| Contrast conditions | Dose (mL) | Administration rate (mL/s) | Photography timing | |
| Gadoxetate disodium(Gd-EOB-DTPA) | 0.1ml/kg | 1.5 | Arterial phase: 30 s Portal phase: 75 s Late phase: 160 s | |
| Physiological saline solution for flushing | 50 | 1.5 |
Usefulness of Gadoxetate disodium(Gd-EOB-DTPA) contrast MRI with this patient
The existence or non-existence of hepatic metastases is an important factor for deciding whether or not pancreatic carcinoma should be resected.
EOB-MRI has been reported to be a useful modality for detecting hepatic metastases in patients with pancreatic cancer that has been diagnosed as resectable on the basis of MDCT and ultrasonography1). In general, FDG-PET is useful for detecting metastases, but pancreatic cancer patients may be tested in a hyperglycemic state, and it is necessary to bear in mind that, as with the present patient, accumulation in the lesions may be underestimated. At MRI photography of pancreatic cancer patients, not only local pancreatic evaluation but also evaluation of the liver using EOB and Gadoxetate disodium(Gd-EOB-DTPA) is recommended.
References
- １) Ito T, Sugiura T, Okamura Y, Yamamoto Y, Ashida R, Aramaki T, et al. The diagnostic advantage of EOB-MR imaging over CT in the detection of liver metastasis in patients with potentially resectable pancreatic cancer. Pancreatology 2017;17(3):451-6.
Precautions relating to administration
9. Precautions relating to patients with specific background factors (taken from the Package Insert)
9.8 Elderly patients
Administration must be performed with care, and with sufficient monitoring of the patient’s condition.
Elderly patients generally have depressed physiological function.
- *The case introduced is just one clinical case, so the results are not the same as for all cases.
- *Please refer to the Package Insert for the effects and indications, dosage and administration method, and warnings, contraindications, and other precautions with use.
