Shinshu Med J, 66⑵：151～155, 2018

A Case of Pancreatic Carcinoma with Bilateral Hilar
18
F-FDG and 67Ga Hyperaccumulation
Satoshi Kawakami1）＊, Yasunari Fujinaga1）, Shin Yanagisawa1）
Masumi Kadoya1）, Akira Kobayashi2） and Kazuhiro Oguchi3）1） Department of Radiology, Shinshu University School of Medicine
2） First Department of Surgery, Shinshu University School of Medicine
3） Positron Imaging Center, Aizawa Hospital

A pancreatic mass was found in a 47-year-old female by abdominal CT. 18F-fluorodeoxyglucose positronemission tomography (FDG PET) showed abnormal uptake in the pancreatic mass as well as in the bilateralhilar region of the chest. Chest CT revealed the presence of bilateral hilar lymphadenopathy (BHL). Thesefindings suggested not only pancreatic carcinoma but also autoimmune pancreatitis (AIP). A pancreatoduo­
denectomy was performed and the pancreatic lesion was diagnosed as pancreatic carcinoma. Non-caseous gran­ulomas were observed in the peri-pancreatic tissue and regional lymph nodes of the pancreas, and they werethought to be sarcoid-like reactions. Hilar 18F-FDG uptake had vanished on the follow-up PET study ; therefore
the result suggested that BHL was also a sarcoid-like reaction. Lymphadenopathy due to sarcoid-like reaction
associated with malignancy should be considered in the differentiation between a pancreatic carcinoma andAIP. Shinshu Med J 66 : 151―155, 2018
(Received for publication October 2, 2017 ; accepted in revised form November 29, 2017)
Key words : pancreatic carcinoma, autoimmune pancreatitis (AIP), sarcoid-like reaction, bilateral hilar
lymphadenopathy (BHL)

ⅡⅠ Introduction

Case Report

It is often difficult to differentiate pancreatic car­A 47-year-old female was hospitalized for an ex­

cinoma from autoimmune pancreatitis (AIP) in com­amination of upper abdominal pain. CT and MRI

puted tomography (CT) as well as in MR imaging

showed a mass about 3 cm in diameter in the pan­

(MRI).

67

Ga scintigraphy and FDG PET are useful67

creatic head. The pancreatic body and tail wereGa andswollen and the main pancreatic duct was slightly

F-FDG uptake in the bilateral hilar lymph nodes

dilated (Fig. 1). These findings were suggestive ofare observed more frequently in AIP than in pancre­

either pancreatic carcinoma or AIP. FDG PET

to distinguish between the two conditions.
181）
2）. If a pancreatic mass with bilateral

showed intense uptake in the pancreatic lesion and18

hilar Ga or F-FDG uptake is shown, the possibility

bilateral hilar regions (Fig. 2), and chest CT showedof AIP must be considered.

bilateral hilar lymphadenopathy (BHL) (Fig. 3).

atic carcinoma
67

These image patterns were more likely to reflect
AIP than pancreatic carcinoma. However, her serumIgG4 level was normal. 67Ga scintigraphy showed hy­＊Corresponding author : Satoshi Kawakami
Department of Radiology Shinshu University School ofMedicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621,
Japan
E-mail : kawasato@shinshu-u.ac.jp

No. 2, 2018peraccumulation in the bilateral hilar region, but noaccumulation in the pancreatic lesion (Fig. 4). Theabsence of 67Ga accumulation in the pancreatic massstrongly indicated a pancreatic carcinoma. Another151

Kawakami・Fujinaga・Yanagisawa et al.

Fig. 1 Abdominal CT(a) Contrast-enhanced abdominal CT shows a mass lesion at pancreatic head (arrowheads).
(b) The pancreatic body and tail are slightly swollen and main pancreatic duct is dilated (arrow).

Fig. 2 FDG PET
A FDG PET image shows hyperaccumulation at thepancreatic lesion (arrow) and bilateral hilar region.

Fig. 3 Chest CT
Contrast-enhanced chest CT shows bilateralhilar lymphadenopathy (BHL).

possibility was a pancreatic carcinoma complicatedpancreatic mass and non-caseous granulomas in thewith sarcoidosis. However, there was no clinicalpancreatic tissue near the tumor and in the regionalevidence of systemic sarcoidosis and her serum ACE

lymph nodes (Fig. 5). These granulomas were thoughtlevel was normal. The cause of BHL was not diag­

to be sarcoid-like reactions. Eight months after thenosed. Because pancreatic carcinoma could not beoperation, FDG PET showed no accumulation in theruled out, a pancreatoduodenectomy was performed.

hilar region (Fig. 6). Therefore, the BHL was also

Pathological examination showed a carcinoma in thethought to have been a sarcoid-like reaction.

152Shinshu Med Jol. 66

Pancreatic Ca. with hilar 18F-FDG and 67Ga hyperaccumulation

ⅢDiscussion

Patients with malignant tumors rarely have noncaseous granulomas, which are called sarcoid-likereactions, in the tissue near a primary tumor, region­
al lymph node and hilar lymph node. A case of pan­creatic carcinoma with sarcoid-like reactions in thepancreatic tissue near the tumor and regional lymph
nodes was reported3）.
Up to now only a few cases of BHL with a sar­coid-like reaction in an extra-thoracic malignancy,such as a testicular tumor and hemangiopericytoma
of the upper leg, have been reported4）5）. The etiologyof BHL with sarcoid-like reaction has remained
unclear. Sarcoid-like reactions were more commonly
observed in lymph nodes without metastases than inthose with metastases6）. Therefore, sarcoid-like reac­
Fig. 4 67Ga scintigraphy
A 67Ga scintigram shows hyperaccumulation at
the bilateral hilar region, and unclear accumulation
at the pancreatic region.

tions at distant sites might be regarded as a reaction
caused by macrophages activated by T-lymphocytes
against metabolic or disintegration products fromthe tumor6）7）. No cases of BHL with a sarcoid-likeFig. 5 Histopathological images(a) HE staining. Poorly-differentiated adenocarcinoma is observed in thepancreatic mass. (b)(c) HE staining. Non-caseous granulomas are observed in
the pancreatic regional lymph node. Langhans giant cell (arrow) and giant cellwith asteroid body (arrowhead) are shown in the granuloma.
No. 2, 2018153

Kawakami・Fujinaga・Yanagisawa et al.

in the pancreatic tissue near the tumor and in theregional lymph nodes. Therefore, this BHL was sus­
pected to be a sarcoid-like reaction associated withpancreatic carcinoma.
Bilateral hilar lymph node lesions are seen fre­quently in patients with AIP and sarcoidosis. Michelet al.8） reported a case with both AIP and sarcoid­osis. This report suggests a possible association be­
tween them. 67Ga and 18F-FDG hyperaccumulation in
the bilateral hilar regions are one of the characteris­tic findings of AIP and sarcoidosis. Ozaki et al. re­ported the clinical utility of FDG PET for differentia­
tion between AIP from pancreatic carcinoma2）. 18FFDG uptake is significantly more frequent in AIP
than in pancreatic carcinoma and 18F-FDG uptake toextrapancreatic organs may assist in differentiating
AIP from pancreatic carcinoma. The bilateral hilarFig. 6 FDG PET (post operation)
A FDG PET image obtained 8 months after
operation shows decreased accumulation at thebilateral hilar region.

lymph nodes are one of the extrapancreatic organs
where 18F-FDG uptake is frequently seen in AIP.
Therefore, in our case, the possibility of AIP could
not be excluded by the FDG PET findings.

reaction in a pancreatic carcinoma have been report­

A sarcoid-like reaction may be one of the pitfall

ed previously. However, the previous reports sug­conditions in the differentiation between pancreatic

gest the possibility that sarcoid-like reactions at

carcinoma and AIP by FGD PET and 67Ga scintigra­

hilar regions may occur in patients with pancreaticphy.

carcinoma.

In conclusion, we presented a case of pancreatic

In our case, there was no pathological proof thatcarcinoma with BHL that was suspected to be a sar­the BHL was a sarcoid-like reaction. The most im­

coid-like reaction. FDG PET and 67Ga scintigraphy

portant differential diagnosis was metastasis. Howev­

showed hyperaccumulation in the bilateral hilar re­67

er, Ga scintigraphy showed no accumulation at thegion. These findings made it difficult to distinguishpancreatic lesion and hyperaccumulation at the hilar

pancreatic carcinoma from AIP. It is important toregion. These findings suggested the hilar lesion wasconsider the possibility of sarcoid-like reactions as­

not of the same pathology as the pancreatic lesion.

sociated with malignancy, especially in the differenti­

In this case, non-caseous granulomas were observed

ation of pancreatic mass lesions.

References
1） Saegusa H, Momose M, Kawa S, Hamano H, Ochi Y, Takayama M, Kiyosawa K, Kadoya M : Hilar and pancreaticgallium-67 accumulation is characteristic feature of autoimmune pancreatitis. Pancreas 27 : 20-25, 2003
2） Ozaki Y, Oguchi K, Hamano H, Arakura N, Muraki T, Kiyosawa K, Momose M, Kadoya M, Miyata K, Aizawa T,Kawa S : Differentiation of autoimmune pancreatitis from suspected pancreatic cancer by fluorine-18 fluorodeoxy­
glucose positron emission tomography. J Gastroenterol 43 : 144-151, 2008
3） Ozeki Y, Tateyama K, Iizuka A : A case of small pancreatic cancer with sarcoid reaction. Nippon Shokakibyo GakkaiZasshi 96 : 310-313, 1999
4） Urbanski SJ, Alison RE, Jewett MA, Gospodarowicz MK, Sturgeon JF : Association of germ cell tumors of the testis154

Shinshu Med Jol. 66

Pancreatic Ca. with hilar 18F-FDG and 67Ga hyperaccumulationand intrathoracic sarcoid-like lesions. CMAJ 137 : 416-417, 19875） van Hoesal AQ, Hoekstra HJ, de Boer NK, Jager PL, van der Graaf WT : A sarcoid-like reaction in a patient withhemangiopericytoma. Acta Oncol 42 : 790-791, 2003
6） Brincker H : Sarcoid reactions in malignant tumours. Cancer Treat Rev 13 : 147-156, 1986
7） Bassler R, Birke F : Histopathology of tumour associated sarcoid-like stromal reaction in breast cancer. An analysisof 5 cases with immunohistochemical investigations. Virchows Arch A Pathol Anat Histopathol 412 : 231-239, 1988
8） Michel L, Clairand R, Neel A, Masseau A, Frampas E, Hamidou M : Association of IgG4-related disease and sarcoid­osis. Thorax 66 : 920-921, 2011（2017. 10. 2 received；2017. 11. 29 accepted）

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