SECTION IV--Roentgenology

Carcinoma of the Body of the Pancreas: A Clinico-Roentgenologic Diagnosis*

By

MARTIN G. VORHAUS, M.D. N E W YORK CITY, N E W YORK

T HERE are many obscure clinical syndromes still awai t ing recognition. Too many of these require

post mortem study for the i r identification. However, not Uncommonly, the clinician can a r r ive at an accur- ate concept of many of them by a close correlat ion of the clinical findings and t h e abnormali t ies revealed radiographical ly. This repor t is an i l lustrat ion of the dove-tail ing of such data.

Carcinoma of the pancreas is relatively uncommon. The incidence is given as 1.5% of all carcinomata (1). I ts clinical recognit ion long has been delayed. Path- ological studies show tha t the pancreas is the site of secondary invasion of carcinoma more frequently than it is the or igin of a p r i m a r y growth (2).

In the past few decades, many reports have appeared of the recognition of carcinoma of the head of the pancreas. This is the most likely location for a pri- mary pancreat ic carcinoma and occurs in 66-2/3% of all such pancreat ic neoplasms found surgical ly (3). Autopsy s ta t is t ics place its occurence at the higher figure of 80% (4). I t is not the grea te r frequency alone which has made carcinoma of the head of the pancreas a disease which is diagnosed often. The close re la t ionship of the second portion of the duo- denum and the common bile duct to the head has afforded tell-tale information.

I t is accepted now tha t this disease should be sus- pected in a case of painless, deepening jaundice, usu- ally in association with a small, firm liver and often, but not always, accompanied by an enlarged gall blad- def. To these clinical facts is added the roentgen demonstrat ion of an increased convexity of the second portion of the duodenum, to the r ight , producing a capital "C" configuration, and usually revealing a de- lay in the bar ium t r ans i t through this region. The dove-tail ing of these clinical and roentgen findings have led m a n y - - a n d should lead m o r e - - t o the early recognit ion of p r ima ry carcinoma of the head of the pancreas.

The pancreas apar t f rom its head, is more rare ly involved. Occasionally, the tai l alone is the si te of p r ima ry carcinoma; i ts recognition is extremely diffi- cult. One observer (1, 5), reported only three such cases, seen in twenty-five years of search. Each of these gave the confusing roentgen findings of a large,

~From the Medical Service of Dr. Albert A. Epstein, Hospi ta l for Jo in t Diseases.

Submit ted Feb rua ry 9, 1935.

248

i r regular , " infi l t rat ing-l ike" lesion on the g rea te r curvature of the stomach in the medio-gastr ic region, the shadow of which most closely resembled a gas t r ic carcinoma. Operation and autopsy disclosed a pr i - mary carcinoma of the tai l of the pancreas. The roent- gen defect in the stomach was due to a t tachment or extension to this organ from the p r i m a r y lesion.

The sole remaining site for carcinoma of the pan- creas is its body, or mid-portion. A complete review of the l i te ra ture reveals some reports (6, 7, 8, 9, 10, 11) upon the pathologic findings and suggestive clin- ical data. Several roentgen art icles (12, 13, 14), in discussing the findings in carcinoma of the head of the pancreas and in pancreat ic cyst, s tate tha t carcin- oma of the body of the pancreas should show roentgen changes in the duodenum. However, this Author could not find a single repor t of the clinical and roentgen findings which would enable such diagnosis to be es- tablished. F o r tha t reason, this case is reported.

CASE REPORT S. H., 59 year old male, admitted to the Medical Service

on October 25, 1934, complaining of pain in the back, in the region of the lower thoracic vertebrae.

On August 11, 1934, he had been hospitalized in Brook- lyn for the same complaint. He stated that he had had this pain for from four to five months. It was relieved by aspirin, associated disturbances were epigastric pain, con- stipation and a weight loss of twenty-five pounds during the preceding five months. The examination at the previ- ous hospital (which included, in addition to the usual clinical and laboratory studies, roentgen films of the spine, the gastro-intestinal tract and the gall gladder), failed to reveal any positive anomolies; he was discharged on Sep- tember 18, 1934, "with no positive findings and, in all probability was suffering with a myositis."

On admission here, the patient complained of a dull, nagging pain in the back, located in the region of the lower thoracic and upper lumbar vertebrae. The pain practically always was present; at times was severe, radi- ated up and down along the spine for short distances, but did not radiate anteriorly. Several months after the onset of the back pain, the patient stated that he experienced the same type of pain in the epigastrium and that this radiated straight through to the back pain; it was more severe when the back pain was increased. Both pains were greatly aggravated by walking but bore no relation to coughing, breathing, defecation or urination and little, if any, relation to food. Since discharge from the other hos- pital, he had lost more weight, the total loss being fifty

VORHAUS--CARCINOMA OF THE BODY OF THE PANCREAS 249

Fig. 1. Immediate Film.

The blood counts ranged f rom 75 to 90% hemoglobin, 4.6 to 5.3 million r. b. c., 10 to 16 thousand w. b. c., wi th a re la t ively normal differential count. Serological tests were negat ive, as was the blood chemistry.

X-ray of the chest showed only a thickened pleura a t the lef t apex and some increased sclerosis of the aort ic arch. X- ray of the lumbosacral spine and pelvis disclosed no definite evidence of a metas ta t ic neoplastic process. There was a sacral izat ion of the fifth lumbar ver tebrae on the lef t side with modera te a r th r i t i c changes in the ver tebra l segments. (Dr. Pomeranz ) .

X-ray of.the gastro-intestinal tract gave the first real clue to the diagnosis. There was no appa ren t in t r ins ic disease of the stomach (Fig . 1). There was increased per- istalsis with a tendency towards segmentat ion. A dotted line has been drawn on the film to show the probable out- l ine of the g r ea t e r cu rva tu re of the ant rum. The duodenal cap is moderate ly dilated and shows no defects. The de- scending port ion and the beginning of the t ransverse por- t ion of the duodenum are markedly dilated. To the lef t of the th i rd lumbar ver tebrae can be seen a well filled duodenal- j e juna l junct ion which appears normal. F i g u r e 2 is a three hour observat ion and shows tha t the s tomach is al- most completely empty. There is a mass of bar ium located at the level of the th i rd and four th lumbar ver tebrae , s l ight ly to the r igh t of the mid-line, which seems to be in the duodenum. This is more apparen t in the six hour film (Fig . 3), at which t ime the descending port ion and begin- ning of the t r ansverse port ion of the duodenum are seen clearly, filled with bar ium and s l ight ly dilated. The de- scending port ion of the duodenum shows no loss of its normal markings , and its configurat ion and posit ion are

Fig. 1

pounds since the beginning of his illness. His weight , on admission, was 1001~ pounds. Marked const ipat ion was present. In addition, he complained of anorexia , increas- ing weakness and insomnia due to pain. There was noth- ing of significance in his past or in his fami ly history. Syphil is was denied by name and signs.

The physical examination revealed a markedly emaci- ated, elderly, white male who, a l though weak, was or iented and cooperat ive. The head and neck revealed no signifi- cant findings except for a thickly coated tongue and dry lips. The fundi showed modera te ar ter io-sclerot ic changes. The cardiovascular system showed modera te ar ter ioscler- otic changes a l though the hear t was enlarged only slightly, and the blood pressure was 126/90. The lungs were nega- t ive except for some dullness at the lef t apex and some harsh brea th ing at this point.

The abdomen was scaphoid and tense. There was some tenderness, on deep palpat ion in the ep igas t r ium but no mass was palpable. The l iver was enlarged f rom one to two f ingers ' breadth below the costal marg in and the edge was smooth and firm. No other abnormal i t ies were present in the abdomen. There was s l ight tenderness, poster iorly, over the eighth, n in th and tenth dorsal ve r t eb rae and at the costo-vertebral angles. The remainder of the exami- nat ion revealed nothing of significance.

The clinical impression was tha t of unidentified mal ig- nancy and a diagnost ic survey was inst i tuted. The neur- ologist (Dr. Rosenheck) , expressed the opinion tha t there was no p r i m a r y neurological condition to account for the pain. The ur ine revealed nothing of significance. F rac - t ional gas t r ic analysis gave figures wi thin normal l imits.

Fig. 2. Three Hour Film. Fig. 2

250 AMERICAN JOURNAL OF DIGESTIVE DISEASES AND NUTRITION

Fig. 3

relatively within normal limits. The remainder of the gastro-intestinal series revealed no abnormalities and a detailed description of the other films is unnecessary.

D I S C U S S I O N

The roentgenologic s igns indicated a par t ia l ly ob- s t ruc t i ng lesion a t the b e g i n n i n g of the t r ansverse por t ion of the duodenum. The d i la ta t ion of the sec- ond por t ion of the duodenum and the par t ia l d i la ta t ion of the cap, and the vigorous gas t r ic peristalsis , all indicated a slowly developing obstruct ion. This sug- gested a slowly developing t umor and since the only organ of impor tance a t tha t exact site is the pancreas, suspicion was directed to a neoplasm in this organ. The next quest ion was the exact location of the tumor. The site of the obs t ruc t ion indicated very clearly tha t it was in the mid-por t ion. The films, as indicated in the figures above, all showed a normal conf igurat ion of the descending or second por t ion of the duodenum, tha t is, there was not an increased convexity of the second port ion producing the capital "C" configurat ion which is typical of carc inoma of the head.

The next step was the correlat ion of the clinical data. The absence of j aundice and of a palpable gall b ladder mi l i ta ted aga ins t the diagnosis of involvement of the head of the pancreas. For these reasons, it was held just i f iable to postulate a p r i m a r y carcinoma, s t a r t i n g in the body of the pancreas and not involving the head.

Fig. 3. Six Hour Film.

The clinical course was rapid ly downhil l wi th in- c reas ing loss of weight, weakness, inab i l i ty to eat and diar rhea . There was a t e mpor a r y improvement fol- lowing the admin i s t r a t i on of i n t r avenous glucose solu- t ions but, wi th in a few days thereaf te r , the pa t i en t became mor ibund and exitus occurred wi thout eleva- t ion of t empera tu re or pulse rate. Death occurred on December 5, 1934, six weeks a f t e r admission.

An autopsy was per formed four hours a f t e r death (Dr. S. A. Jacobson) . Excerpts f rom the protocol which are pe r t i ne n t only are given.

Heart. The epicardium is everywhere smooth and glistening. A large area over the right ventricle is white and thickened. The small quanti ty of pericardial fat which is present has been converted into an edematous mass (serous degeneration). Coronary vessels are tor- tuous and very thick and sclerotic to palpation. On sec- tion, myocardium is dark brown and firm. Walls are of normal thickness, but all cavities are diminished in size. The mural endocardium is everywhere transparent. All valves are thin and delicate with the exception of the aortic. One of the commissures of this valve shows a moderate degree of fusion with thickening and hardening of adjacent portions of the cusps. Otherwise, there is no thickening o1' calcification, even in the mitral ring. All branches of both coronaries show very marked thickening and hardening of their walls, although complete occlusion of the lumen is nowhere demonstrable.

Lungs. Both are rather large; except for some consoli- dated areas in the right, they are crepitant, albeit slightly edematous, to palpation. Apices shows some thickening of the pleura. F i rm pleural nodules can be felt in the upper portions of the organs, and, in diminishing num- bers for a considerable distance downward. On section, the parenchyma is for the most part bright pink and wet. The parenchyma of the apices, however, is dark gray and more or less solid in appearance. Irregular areas of the middle and lower lobes of the right lung reveal upon close inspection areas which are firmer and slightly raised and granular. Bronchial mucosae are smooth; in the lumina is found some thin whitish matter. Pulmonary vessels show nothing noteworthy.

Liver. The organ is decidedly reduced in size. On the surface and in the interior are numerous large, sharply demarcated, white tumor nodules which stand out from the cut surface. The parenchyma is dark reddish brown; lobules are clearly demarcated. The gall bladder is con- siderably distended, as also is the common bile duct. Their walls show no abnormality; they contain thin green bile.

Fig. 4. Photomicrograph of the primary Carcinoma in the body of the Pancreas removed at autopsy. Fig. 4

V O R H A U S - - C A R C I N O M A OF T H E B O D Y OF T H E P A N C R E A S 251

Suprarenals. That on the right is normal in size and shape. The cortex is rich in brown matter. That on the left is infiltrated by direct extension with the tumor mass of the adjacent pancreas.

G. I. Tract. The esophagus shows nothing noteworthy; stomach contains some greenish fluid ; its mucosa is slightly congested; duodenum shows nothing unusual, its mucosa is pale and smooth. The je junum and ileum are similarly negative, except for the presence of a diverticulum meas- uring approximately 4 cm. in length, situated approxi- mately i meter cephalad of the ileocecal valve. The colon shows nothing noteworthy.

Pancreas. The head of the organ is soft, lobules pull- ing apart readily. The body and tail, however, have been destroyed and replaced by an irregular mass of very hard, white tissue in which yellow areas are visible. This mass does not extend into adjacent structures, with the excep- tion (left suprarenal) noted above.

Blood Vessels. The aorta, throughout its length (with the exception of the ascending portion) bears numerous, yellowish and, particularly about the mouths of the in- tercostal arteries, whitish placques. A few of these in the lowermost portion are ulcerated. Hardly any of them are brittle. Vena cava and portal vein are smooth; the latter is slightly distended.

Lymph Nodes. Those of the hilum of the lungs are large, gray and firm. Those in the vicinity of the pan- creas, particularly about (and pressing on) the bile ducts, are infiltrated with white tumor tissue, as are some of the more distant mesenteric nodes.

ANATOMICAL DIAGNOSIS 1. Carcinoma of the body and tail of pancreas, with

direct extension into left suprarenal gland and metastases to liver and regional lymph nodes.

2. Coronary arteriosclerosis. 3. Brown degeneration of heart and liver. 4. Chronic passive congestion of viscera. 5. Chronic (inactive) puhnonary tuberculosis of both

apices. Microscopical. Section of the pancreas (Fig. 4), shows

part of it to be in a good state of preservation, except for

a slight degree of fibrosis. There is, however, a large amount of tumor tissue, as indicated in the gross study. This is in part divided from the surviving pancreatic tis- sue by a thick fibrous septum; in part, however, it has crossed this boundary and infiltrates the parenchyma freely. The tumor consists of glandular elements made up of moderate-sized, somewhat hyperchromatic and ple- omorphic, polyhedral cells. Giant cells are very numerous. The architecture is extremely irregular. The amount of fibrous tissue is very variable. Large areas of tumor are completely necrotic.

SUMMARY

The ou t s t and ing clinical facts were a marked loss of weight, appeti te and s t rength , increas ing cachexia and the development of an unexpla ined pe rs i s t en t and in- creas ing pain located at the level of the lower dorsal ver tebrae and r a d i a t i ng up and down the spine for shor t distances. Later, an ident ical type of pain, lo- cated in the ep igas t r ium, developed which radia ted th rough to the region of the back pain. Both of these pains were aggrava ted by walking. The roentgen findings demonst ra ted no osseous change in the dorso- l umbar spine. The gas t ro - in tes t ina l roentgen exami- na t ion revealed a par t ia l obs t ruct ion at the b e g i n n i n g of the t r ansverse ( th i rd) por t ion of the duodenum with d i la ta t ion of the descending port ion of the duo- denum and of the cap, and increased gas t r ic per is- talsis, ind ica t ing gradual ly developing obstruct ion. Based upon these clinical and roentgen findings, a diagnosis of carc inoma of the body of the pancreas was made. This diagnosis subsequent ly was verified at autopsy.

CONCLUSIONS

1. A case of carc inoma of the body of the pancreas is reported.

2. The diagnosis was made on the basis of the clinical and roentgen findings, and verified at autopsy.

3. I t is believed tha t this is the first case of its kind to be reported.

REFERENCES

1. Seholz, T. : Zur Rontgenologischen und Klinischen Diagnose des Karzinoms des Schwanzteiles des Pankreas . Berieht eines weiteren Falles. Rontgenpraxis (Hf t . 24), 4:1043-1046. December, 1992.

2. Har ing , W . : Die Erk rankungen der Bauchspeicheldruse in Rontgenbilde. Ergebnisse der Medizinische Strahlenforschunge, 6:407-457. 3. Riese, H . : Die Chirurgie des Pankreas . Kirschner-Nordmann, Die Chirurgie (Urban & Schwarzenberg, Berl in) , 1927, idem. 4. Gruber, G. B. : Handbuch d. Spez. Path., Anat. u Hist. (Henke & Lubarsch) , 1929, idem. 5. Scholz, T., and Pfeiffer, F . : Roentgenologic Diagnosis of Carcinoma of the Tail of the Pancreas. J . A. M. A., 81:275-277, 1923. 6. Hebb, R. G. : Cancer of Body and Tail of Pancreas. Westminster Hosp. Repts., London, 16:44-66, 1909. 7. Malbot, H . : Contribution ~ l'~tude des cancers doulourcux du corps du pancreas. Bull. et mere. Soc. todd. d. Hop. de Paris, 27:305-318, 1909. 8. Mollard, J. , and Rimaud, L . : Cancer du corps du Pancreas. Lyon Mgdieal, 64:602-604, 1910. 9. Leriche, R . : Etude Clinique sur le cancer du corps du Pancreas. Mddicine Moderne, 21:289-294. 1910.

10. Leriche, R . : Studie fiber das Carcinom des Corpus pancreatis. Arch. f. Klin. Chir., 42:1048-1071, 1910. 11. Labbe, )/i., and Gendron, A. : Cancer du Corps du Pancreas avec Sacrodynie et Crises Apoplectiformes. Bull. et. mvm. Soc. todd. de Hop. de

Paris, 34:596-601, 1912. 12. Ludin, M. : Die Roentgenuntersuchung bei Pankreaserkrankungen . Schweiz. Med. Woehenschr., 64:692-695, 1934. 13. TiUier, M.: Du Diagnostic radiologique des tumeurs du Pancreas. Bull. et Mem. de la Soe. de Radiologie Mddicale de France, 21:023-626, 1933. 14. Ernst , G.: Zweckmassige Rontgentechnik zur Diagnose dcr Pankrea t i t i s und der Pankreas tumoren. Med. Welt., 8:794, 1934.

ABSTRACTS

S A P O Z N I K , H . J.; ARENS, R . A.; MEYER, JACOB, AND N E C H -

ELES, H E I N R I C H

The Effect of Oil of Peppermint on the Empty ing Time of the Stomach. J. A. M. A., 104:1792, May 18, 1935.

The authors have previously reported that oil of pepper- mint diminished gastric acidity. In this study they report the effect of oil of peppermint on the emptying time of the stomach. In the empty stomach small doses of oil of pep- permint had no effect on the hunger contractions of dog or man. Large quantities of oil of peppermint decreased the motility in six tests and produced no change in two.

In experiments with a meat meal and oil of peppermint, shortening of the emptying time was observed.

In six normal young females the addition of two cc. of oil of peppermint to a barium-milk shortened the emptying time of the stomach as observed fluoroscopically.

These studies seem to explain the popular use of oil of peppermint in many stomach remedies. The use of pepper- mint candy and peppermint alcohol after a heavy meal appears useful because by increasing motility distension and fullness are relieved more promptly.

Francis D. Murphy, Milwaukee.