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 and MRI objectives

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

Fig. 1. EOB-MRI
Fig. 1. EOB-MRI
Fig. 1. EOB-MRI
Fig. 1. EOB-MRI

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
Fig. 2. 18F-FDG-PET/CT
Fig. 2. 18F-FDG-PET/CT
Fig. 2. 18F-FDG-PET/CT

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 typePhotography 
sequence
Photography 
duration
TE 
(msec)
TR 
(msec)
FA 
(deg)
Fat sat 
(type)
P-MRI 
(Reduction Factor)
T2WI CorHASTE17s118800150(-)GRAPPA 
2
T1WI Tra2D FLASH 
in-opposed phase
20s1.92/4.7620975(-)GRAPPA 
2
Contrast agent administration
Dynamic TraVIBE3D16s24.613(+)CAIPIRINHA 
PE 1 / 3D 2
MRCP COR3D SPACE PACE*Respiratory 
synchronization
5702500140(+)GRAPPA 
3
DWI TraEPI 
(b-0,800)
*Respiratory 
synchronization
72250090(+)GRAPPA 
2
T2WI TraTSE PACE*Respiratory 
synchronization
682000160(-)GRAPPA 
2
T2WI TraHASTE21s88800150(-)GRAPPA 
2
Hepatobiliary 
phase Tra 
 
VIBE3D16s24.613(+)CAIPIRINHA 
PE 1 / 3D 2
Hepatocyte 
phase COR
VIBE3D18s1.353.4312(+)CAIPIRINHA 
PE 3 / 3D 1
Imaging typeHolding breath 
(yes/no)
NEX 
(calculation 
number)
In-plane 
resolution 
(mm)
Slice 
thickness 
(mm)
FOV 
(mm)
Rectangular 
FOV(%)
Slice Gap 
(mm)
Slice 
number
T2WI CorYes1320*1928320100220
T1WI TraYes1320*192732081.31.524
Contrast agent administration
Dynamic TraYes1320*205336075064
MRCP CORNo1.7320*2881.3320100080
DWI TraNo2128*967320751.524
T2WI TraNo2384*230732081.31.524
T2WI TraYes1384*250732081.31.524
Hepatobiliary 
phase Tra
Yes1320*205336075064
Hepatocyte 
phase COR
Yes1320*2244400100052

* Photography duration varies between patients, due to respiratory synchronization.

Devices used and contrast conditions

MRI deviceSIEMENS MAGNETOM Aera 1.5T
Automatic injection deviceSonic Shot 7 (Nemoto Kyorindo Co., Ltd.)
Workstation
Contrast conditions Dose (mL)Administration rate (mL/s)Photography timing
Gadoxetate disodium(Gd-EOB-DTPA)0.1ml/kg1.5Arterial phase: 30 s  
Portal phase: 75 s  
Late phase: 160 s
Physiological saline solution for flushing501.5

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.