What's Causing This Woman's Chest Pain?
Article Outline
- Answer to the Clinical Challenges and Images in GI Question: Image 1: Leptomeningeal and Brain Metastasis in a Patient With Pancreatic Cancer
- References
- Copyright
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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Answer to the Clinical Challenges and Images in GI Question: Image 1: Leptomeningeal and Brain Metastasis in a Patient With Pancreatic Cancer
A bone scan failed to show any evidence of metastatic disease. A magnetic resonance imaging (MRI) scan was performed of her spine and brain which revealed an abnormal, nodular dural signal intensity and enhancement extending throughout the cervical spine, most pronounced at the C3 and C5-C6 levels (Figure B and C). A lumbar puncture was performed under fluoroscopy to assess for cerebral spinal fluid (CSF) involvement. The fluid analysis revealed 8 nucleated cells. The final cytology report was negative for malignant cells. Despite the negative cytology, given the prior parenchymal metastases and the current MRI findings, we felt she had leptomeningeal disease. Of note, disruption of the meninges by surgical resection of brain metastases is felt to be a cause of leptomeningeal disease.1 Palliative radiation therapy was administered to C7–T7 vertebral bodies for a total of 1000 cGy with additional 600 cGy boost to the epidural tumor, which provided good symptom relief.
As newer targeted therapies have emerged, unusual patterns of disease are becoming apparent.1 Recently, recurrences in brain and bone are being recognized in patients with colon cancer, especially in patients with a prolonged, progression-free interval of systemic disease.2 Recurrences in the bone or central nervous system seem to be a late event, and generally seen in patients with systemic disease for >12 months3; this now seems to be true for pancreatic cancer as well. Unfortunately, the diagnosis is not immediately confirmed and up to 40% of patients with negative CSF cytopathologic analysis are found to have leptomeningeal disease at autopsy.1
References
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Conflicts of interest The authors disclose no conflicts.
PII: S0016-5085(09)00741-0
doi:10.1053/j.gastro.2009.03.063
© 2010 AGA Institute. Published by Elsevier Inc. All rights reserved.
