Case: Pancreatic Lesion & Multiple Hepatic Lesions

Clinical Presentation

Patient: 63-year-old male, referred to abdominal ultrasound. 
Anamnesis: Complaining of 10 kg weight loss over the last six months, as well as pain in the right upper quadrant (RUQ).

Main Sonographic Findings:

Liver: Diffuse-focal changes are noted in segments V and VI. Doppler evaluation of this area demonstrates intense, disorganized blood flow with neovascularization, characterized by several feeding arteries with high linear blood flow velocity.

Pancreas: Examination reveals a hypoechoic mass in the head of the pancreas with irregular contours. The mass demonstrates internal blood flow on Color Doppler Imaging (CDI).

Here are the patient’s loops: 

On the ultrasound loops you see lesions in both the liver and the head of the pancreas. Which of the following statements is most accurate?

A) The pancreatic mass and liver lesions likely represent a primary pancreatic malignancy with hepatic metastases.

B) The hepatic and pancreatic lesions show completely different vascular patterns, suggesting two unrelated findings.

C) The pancreatic lesion is anechoic and could be a simple cyst; MRI is needed to disambiguate.

Solution and Explanation of the Case

• Diffuse-focal changes in the liver, based on the sonographic appearance, are most consistent with metastases.
• The overall findings are suggestive of adenocarcinoma of the head of the pancreas.
• The patient will undergo definitive staging with a multiphase CT or MRI and a biopsy (often via EUS or a biopsy of a liver lesion) to confirm the diagnosis and plan treatment.

Metastases in Pancreas Cancer

Pancreatic cancer, particularly Pancreatic Ductal Adenocarcinoma (PDAC), is an aggressive malignancy known for its early systemic spread. The liver is the most common site for distant metastasis, which occurs via hematogenous dissemination through the portal venous system. This is precisely the pattern suggested in this case. Other common sites include the peritoneum (presenting as peritoneal carcinomatosis), the lungs, and, less frequently, bone. On ultrasound, these liver metastases often present as multiple, solid, hypoechoic lesions, similar in texture to the primary tumor. While classically "hypovascular" on contrast-enhanced CT/MRI due to a dense fibrotic stroma, on Doppler ultrasound, they can demonstrate the malignant feature of disorganized neovascularization, as seen in our patient's case, which is a key indicator of metastatic disease.

Established Risk Factors for Pancreatic Cancer (PDAC)

While the etiology of pancreatic cancer is multifactorial, several established risk factors for the more common PDAC are recognized. Smoking  is a primary modifiable risk factor. Other significant associations include obesity and long-standing type 2 diabetes mellitus. Notably, new-onset diabetes after age 50, particularly without concomitant weight gain, can be a paraneoplastic sign of an occult pancreatic malignancy. Chronic pancreatitis (especially hereditary or alcohol-induced) confers a substantially elevated risk. Finally, approximately 5-10% of cases are linked to hereditary factors, including germline mutations in genes such as BRCA1/2, PALB2, and ATM, or in the context of syndromes like Peutz-Jeghers

The Problem of Late Diagnosis in Pancreas Cancer

Pancreatic cancer has one of the poorest prognoses of all major malignancies, a fact directly linked to its tendency for late-stage diagnosis. The primary challenge is its "silent" nature. Located deep within the retroperitoneum, tumors can grow substantially before causing symptoms. When symptoms do arise, they are often vague and non-specific, such as diffuse abdominal or back pain, indigestion, or, as in this patient, significant unintentional weight loss. These symptoms are frequently attributed to more benign conditions, causing critical delays in diagnosis. More specific signs, like painless jaundice, typically only occur when a tumor in the pancreatic head obstructs the common bile duct. By the time pain becomes severe (often from nerve invasion) or cachexia is profound, the disease is almost always advanced. 

Consequently, approximately 80% of patients present with unresectable regional or distant metastatic disease, most commonly to the liver. This diagnostic delay is the primary driver of mortality; the overall 5-year relative survival rate for all stages is only 13%. For the vast majority diagnosed with distant disease, this rate drops to just 3%.

Abdominal ultrasound is often the first imaging modality used for these non-specific symptoms. However, its sensitivity for detecting the primary mass is highly variable, being operator-dependent and often limited by patient habitus and overlying bowel gas. Very proficient sonographers can achieve better sensitivity, for example, by creatively modifying the ultrasound windows or by patiently applying pressure to the subxiphoid region to displace obstructing gas.

Therefore, the potential of abdominal ultrasound can be maximized in the hands of a skilled sonographer. It remains a critical first-line tool that, when applied meticulously, can lead to earlier detection in symptomatic patients.

This is precisely why we want to raise awareness for this disease, its risk factors, and the critical importance & possibility of early diagnosis.

Learn how to diagnose abdominal pathologies, including pancreatic lesions, in our Abdominal BachelorClass featuring Ulrike Handler, MD, and Christian Aiginger, MD. Start learning with our free lectures now!