What's Causing This Woman's Chest Pain?

Question: A 64-year-old woman was initially diagnosed with a potentially resectable pancreatic adenocarcinoma after workup for deep venous thrombosis and pulmonary emboli in November 2005. A Whipple procedure was performed and pathologic staging was T1N1 with 15/27 regional nodes involved (stage IIB). Adjuvant chemotherapy was administered using erlotinib and gemcitabine for 6 months ending in April 2006. Her first recurrence occurred in May 2006 in a retrocrural node. The patient underwent radiation therapy with concurrent capecitabine. The patient had a good radiologic response to therapy, and remained free of progression or recurrence until June 2007, when she presented with an enlarged node in the left supraclavicular area. A biopsy of the node confirmed metastatic adenocarcinoma; the patient received irradiation to her neck and mediastinum with capecitabine, ending in June 2007. After the radiation therapy, she was continued on capecitabine alone for 3 cycles ending in August 2007. Follow-up serial computed tomography and positron emission tomography scans revealed no evidence of systemic disease and the CA19-9 level remained in the normal range. In March 2008, the patient presented with headache and was found to have a solitary brain metastasis (Figure A) and underwent a right frontal craniotomy; this was followed by cyberknife therapy. Shortly thereafter, she developed a second lesion in the right posterior temporal region which was resected in August 2008, followed by whole brain RT. In December 2008, the patient developed new-onset pain over her chest, arms, and neck that were only partially responsive to narcotics. What did her scans show?

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