Illusory neoplasms of the stomach and duodenum as a manifestation of carcinoma of the pancreas.

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Carcinoma of the pancreas may simulate primary tumors arising from the stomach or duodenum. In reviewing our experience, we have been impressed with the number of cases of pancreatic cancer that presented in this fashion. Anatomic and Radiographic Changes in Carcinoma of the Pancreas The head of the pancreas fills the duodenal loop and is in contact with the pyloric region of the stomach. The body is closely associated posteriorly with the duodenojejunal flexure and anteriorly with the greater curvature and posterior wall of the stomach. The tail extends supero-laterally and makes contact with the hilus of the spleen, posterior wall of the upper third of the stomach, and the colon. The pancreas is difficult to visualize radio-graphically. Technics to demonstrate it by indirect contrast methods (10, 12) or by direct injection of the ducts at laparotomy (5) have been described. For the detection of pancreatic cancer, however, primary reliance is placed on distortion of adjacent barium-filled viscera. The classic roentgen changes of this disease have been recorded in a number of excellent studies (1–4, 7–9, 11, 13, 14, 19). Most authors report positive roentgen findings in about 50 per cent of the cases that they review. Carcinoma of the head of the pancreas may produce extrinsic pressure defects in the antrum and duodenum. In a small percentage of cases the entire head may enlarge and produce the inverted 3 deformity of the descending duodenum (6). Carcinoma located within the body may compress the body of the stomach. Lesions in the tail may make an impression high on the greater curvature and may displace the left side of the transverse colon. In addition to these pressure phenomena, more advanced tumors will invade or adhere to the wall of the stomach or duodenum. It is these latter cases that closely resemble primary gastric or duodenal neoplasms. Method of Study All cases accepted for this study were proved by exploratory laparotomy and microscopic study; one case was subsequently subjected to necropsy. Only those cases were selected in which the radiographic findings were confined to the stomach or duodenum and the other classic changes associated with pancreatic cancer were absent. Radiographic study consisted of fluoroscopic and film examination. The diagnosis of carcinoma of the pancreas was made on 180 patients seen at The New York Hospital in the years 1953–1958. In 5 of these, pathologic confirmation was inadequate, and 14 were not examined roentgenographically. Of the remaining 161 cases, 52 (32 per cent) had definite roentgenologic abnormalities detected by the Radiology Department before operation. These varied from slight extrinsic pressure on the duodenal bulb to frank invasion of the stomach. Further selection yielded 12 cases which were indistinguishable radiologically from primary neoplasms of the stomach or duodenum.