Presentation
Weight loss and mild epigastric discomfort. Referred for further evaluation after US in a different institution demonstrated multiple solid masses in the liver.
Patient Data
Scheduled outpatient abdominal CT
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The extent of the abnormalities present in this exam is dangerously overwhelming, but the critical finding necessitating immediate attention is present in the first few slices of the axial arterial phase scan:
- multiple subsegmental emboli are partially visible in right lower lobe pulmonary arteries
- in the venous phase partially occlusive bilateral CFV deep venous thromboses are visualized
Fortunately although this was an outpatient, non-emergent exam, it was read within minutes, before the patient left the clinic , who was therefore immediately brought back for a chest CT angiography to evaluate the extent of the PE (see next exam).
Other major findings:
A hypodense mass is visible in the body and tail of pancreas, with distal pancreatic duct dilation. The splenic artery passes through it, and shows marked narrowing and wall irregularity. The splenic vein is obstructed, as a consequence the umbilical vein has recanalized.
Large parts of the spleen show geographic hypoenhancement, in line with splenic infarction caused by the pancreatic mass.
Multiple hypodense solid lesions showing early washout are visible in the enlarged liver, characteristic of liver metastases.
Locoregional lymphadenomegaly. Smaller hypoenhancing masses in the left adrenal. Inhomogenous soft tissue mass in the ventral lower mediastinum.
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CT angiography revealed extensive bilateral segmental and subsegmental PEs and a saddle embolus in the left pulmonary artery.
Other: subsegmental atelectasis in the right middle lobe, soft tissue nodule in the left lower lobe, multiple micronodules.
Rewindowed venous phase image highlighting the bilateral DVTs in the CFVs.
Case Discussion
The case demonstrates PE as a consequence of bilateral DVT, which itself was likely a paraneoplastic sequela of the advanced pancreatic cancer. The patient was admitted for therapy after the exam.
Incidental, clinically unsuspected PE can be sporadically encountered in oncological patients, especially in those with late-stage cancer 1. What makes them perilous is that staging and restaging exams are mostly done in an outpatient setting, where they are rarely read immediately. Many of these incidental pulmonary embolisms can be picked by the CT technicians who then can alert the radiologist, however, even this practice offers little protection against the delay in the diagnosis of more subtle "edge of the scan field" incidental PEs detected in abdominal exams, such as this.
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