Fluid-fluid levels in hepatic metastases - pancreatic adenocarcinoma

Case contributed by Henry Knipe

Presentation

Abdominal pain and deranged liver function tests.

Patient Data

Age: 65 years
Gender: Male

Pancreatic head mass with small cystic foci and generally slight hypoenhancement compared to the remainder of the pancreas. Main pancreatic duct is dilated with pancreatic parenchymal atrophy.

Common bile duct is dilated and is narrowed as it passes and is contacted by the mass although is not completely obstructed. Gallbladder and intrahepatic ducts are also dilated. No enlarged upper abdominal lymph nodes.

More than a dozen hepatic masses of mixed T2 high signal with fluid-fluid levels. These are all hypoenhancing compared to the liver with peripheral enhancement due to the pseudocapsule phenomenon.

Case Discussion

The pancreatic head tumor appears locally advanced. Extensive hepatic metastases demonstrate fluid-fluid levels, which is reported to be specific for neuroendocrine tumor origin. The pancreatic mass signal and enhancement characteristics are not typical for a neuroendocrine tumor but this may be due to its larger size.

The patient underwent a DOTOTATE PET-CT, which did not demonstrate avidity. Subsequently, the patient underwent an ultrasound-guided liver biopsy of a liver metastasis, which demonstrated adenocarcinoma. 

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