증 례
ISSN 2093-9272 일산병원학술지 2019;18(1):85-87Volume 18 Number 1 June 2019
85 INTRODUCTION
Pancreatic cancer (PC) is one of the most fatal can- cers. However, patients with small resectable tumors of 2 cm or smaller are known to have better survival rates in PC than patients with larger tumors.1 Therefore, the detection of small PC may be helpful for better patient outcome. Furthermore, a better understanding of the growth rate of PC is essential to evaluate its natural course, prognosis and to provide recommendations on the optimal screening interval for high- risk patients. The present case reports the growth rate of a small ductal adenocarcinoma of the pancreas from imaging studies in which the tumor volume doubling time (TVDT) was
62 days.
CASE
A 78-year-old man was referred to our gastroen- terology clinic for the evaluation of a pancreatic mass revealed on contrast-enhanced computed tomography (CT) scan. The patient, who was a current smoker, was also being followed-up for chronic obstructive lung dis- ease. He underwent abdominal CT 2 years prior and presented no abnormal findings in the pancreas (Fig.
1(A)).
Five months ago, when he was hospitalized with pneumonia at a general hospital, his chest CT inciden- tally showed dilatation of the pancreatic duct. Subse- quently, a pancreatobiliary CT scan was performed, and it showed pancreatic ductal dilatation with no definite mass lesion seen (Fig. 1(B)). Laboratory results for as- partate aminotransferase (AST), alanine aminotrans- ferase (ALT), total bilirubin, amylase and lipase were
췌관 선암의 성장률 증례 보고 :
연세대학교 의과대학 내과학교실 소화기병연구소, 1, 영상의학과교실2, 병리학교실3,
국민건강보험 일산병원 소화기내과4
이현정
1, 정재복
1,4, 김예은
2, 전해민
3, 박병규
4Growth Rate of Pancreatic Ductal Adenocarcinoma: A Case Report
Hyun Jung Lee1, Jae Bock Chung1,4, Yeo Eun Kim2, Hyae Min Jeon3, Byung Kyu Park4
Department of 1Internal Medicine and Institute of Gastroenterology, 2Radiology, and 3Pathology, Yonsei University College of Medicine, Seoul, Korea
4Department of Institute of Gastroenterology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
Invasive ductal adenocarcinoma of the pancreas (PC) is a disease with a poor prognosis. Therefore, a better understanding of the growth rate of PC is fundamental for providing comprehensive recommendations regarding the optimal screening interval to detect small PC in high-risk patients. This report presents a case of small PC in which the tumor volume doubling time (TVDT) was 62 days.
Key Words: Pancreas, Ductal adenocarcinoma, Computed tomography (CT), Magnetic resonance imaging (MRI), Tumor volume doubling time (TVDT)
책임저자 박병규:
경기도 고양시 일산동구 일산로
10444 100
국민건강보험 일산병원 소화기내과 전화: (031)900-0455, 팩스: 0303-3448-7107 E-mail : [email protected]
HJ Lee et al. Growth Rate of Pancreatic Adenocarcinoma
86
Korean Journal of National Health Insurance Service Ilsan Hospital normal. The serum carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA 19-9) levels were 3.8 ng/ml and 36.88 U/ml, respectively. After one month and because the initial diagnosis was uncertain, the physician decided to observe the lesion using magne- tic resonance imaging (MRI) which still showed a pan- creatic ductal dilatation with no definite tumorous le- sion (Fig. 2(A)). Even though no definite mass was no- ticed after serial imaging testing, considering the high risk of pancreatic adenocarcinoma, the physician re- commended surgery. However, the patient refused to be treated due to his general condition, and the lesion was examined 2 months later.A CT scan taken 2 months later revealed a hypo- dense mass of 13 mm in diameter located in the pan- creatic body, with distal dilatation of the pancreatic duct (Fig. 1(C)). Subsequently, the patient was admitted to our hospital for evaluation and treatment of the pancreatic mass. At the time, the serum CEA and CA 19-9 levels were 9.75 ng/ml and 21.3 U/ml, respec- tively. Because of the presence of several low attenu- ating lesions on the liver CT scan, magnetic resonance
cholangiopancreatography (MRCP) was requested. MRCP demonstrated that the mass, which had increased in size to 19 mm in diameter with multiple small nodules in the liver, suggested pancreatic metastasis (Fig. 2(B)).
Retrospectively, prior CT scan and MRI images were reviewed by an expert radiologist, who observed a hypodense mass of 9 mm in diameter on the initial CT scan (Fig. 1(B)) and 10 mm on MRI (Fig. 2(A)), that was not visualized on the CT scan from 2 years ago (Fig.
1(A)). Lastly, endoscopic ultrasonography (EUS) guided needle aspiration biopsy was performed and the cytology confirmed invasive ductal adenocarcinoma of the pancreas (Fig. 3).
We recommended diagnostic laparoscopy to verify liver metastasis or peritoneal dissemination. However, the patient refused further treatment and was dis- charged.
(A)
(B)
(C)
Fig. 1. (A) Serial CT images are shown. CT scan in 2 years ago revealed no mass lesion. (B) Baseline CT showed a hypodense mass, 9 mm in diameter, in the pancreatic body (arrow). (C) After 98 days, the diameter of the mass had increased to 13 mm (arrow)
(A)
(B)
Fig. 2. (A) Serial MRI images are shown. Baseline MRI dem- onstrated the pancreatic mass, 10 mm in diameter (arrow).
(B) After 129 days, the diameter of the mass had increas- ed to 19 mm (arrow)
(A) (B)
Fig. 3. The histologic finding of the pancreatic mass as- piration cytology showed tubular adenocarcinoma ((A), H&E stain, x40, (B), x400)
이현정 외 췌관 선암의 성장률 .
Volume 18 Number 1 June 2019
87 DISCUSSION
The growth rate of PC is important because it could lead to recommendations on the optimal screening interval for high-risk patients to detect small PC.
Since Collins et al.2 studied cancer growth rate with the assumption that cancer growth is exponentially stable and defined the time needed for the tumor vol- ume to increase two-fold as the “tumor volume doubl- ing time (TVDT),” many articles have been published on the topic such as the growth rate of hepatocellular carcinoma,3,4 breast cancer, and primary or metastatic lung cancers.5
In our case, although no definite mass was observed at the initial CT at the other general hospital, the pan- creatic ductal dilatation was present, and the patient was a current smoker. Therefore, we decided to repeat examination at short-term intervals. The TVDT was calculated using the formula developed by Schwartz.6 The tumor volume was calculated as follows, the tumor to have a spheroidal shape: V = 4/3 × π × (a/2)3 where a indicates the maximum tumor diameter. The TVDT was calculated using the following equation:
TVDT = (T2– T1) × log2/logV2– logV1 where (T2– T1) rep- resents the time interval between 2 measurements and V1 and V2 denote the TVDT at 2 points of measure- ment. The calculated TVDT of the PC on CT imaging in this case was 62 days. It was shorter than the TVDT reported by previous studies, which were 159±67 (me- dian, 144) days according to Furukawa et al.7 and 252 days as indicated by Hisa et al.8 The reason for this difference may be related to the fact that liver metas- tases have been detected on serial examinations, and advanced tumors, which may have undergone more sig- nificant genetic changes, can grow faster. In agree- ment with our results, Amikura et al.1 and Nishida et al.9 reported TVDT of liver metastasis of PC of 99.5 days and 66.5 days, respectively.
In previous studies of other type of cancers, the screening interval was estimated based on the TVDT.
For example, Kubota et al.3 reported the CT screen- ing intervals of 3 months is optimal for detecting small (< 20 mm) HCC nodules in high-risk patients for HCC and Taouli et al.4 suggested an interval follow-up of 4.5 months based on the mean TVDT (127 days). However, in our literature review, there were no studies regard- ing the optimal screening interval of PC. Because dis- tant metastases often appear in PC even when the pri- mary lesion is small as in this case, there may be dif- ficulties in clarifying a follow-up interval to detect small PC. Further analysis of more cases on this subject is needed to suggest more accurate recommendations on the ideal screening interval for high-risk patients of PC.
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