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Hospital Universitari Germans Trias i Pujol Autonomous University of Barcelona Badalona, E-08916, Spain
A 32-year-old woman presented at our institution for evaluation of jaundice, choluria, and acholia. One year earlier, she had been diagnosed with multiple myeloma and had been treated with chemotherapy cycles and autogenic transplantation of hematopoietic progenitors from peripheral blood. After this treatment, the myeloma apparently was in complete remission.
Abdominal sonography showed dilatation of the intra- and extrahepatic biliary tract up to the region of the pancreas, where several hypoechoic nodules of similar size, evenly distributed throughout the pancreas, were observed (Fig. 4A). Contrast-enhanced CT showed an enlarged polylobulated pancreas with homogeneous contrast agent uptake (Fig. 4B). Abdominal MR imaging showed a diffusely enlarged pancreas. Before contrast material administration, the parenchyma showed diffuse signal alteration with homogeneously decreased signal on T1-weighted sequences and diffusely increased signal on T2-weighted sequences (Fig. 4C). Infiltration of the pancreatic head had caused diffuse stenosis of the intrapancreatic common bile duct, resulting in dilatation of the intra- and extrahepatic biliary tract and causing a considerable mass effect in the duodenum, inferior vena cava, and left renal vein. Dynamic MR imaging after gadolinium injection revealed multiple nodules diffusely distributed along the entire gland that were hypointense compared with the normal pancreatic parenchyma and were more sharply defined in the late venous phase of the dynamic imaging study (Fig. 4D).
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A postautotransplantation extramedullary recurrence of myeloma was suspected, and laparotomy was performed. The procedure evidenced a diffusely hard pancreas and infiltration of the duodenum and the biliary tract up to the cystic duct. Perioperative biopsy of the pancreas showed infiltration by a lymphoproliferative process with plasmocellular differentiation consistent with multiple myeloma. Gastrojejunal and laterolateral choledochojejunal anastomoses were performed. Four days later, the patient died due to bilateral pneumonia.
The pancreas is seldom affected by multiple myeloma, and the diagnosis is usually made postmortem. The rare clinical symptoms that occur with this condition are typically jaundice and abdominal pain, usually resulting from a mass at the head of the pancreas. On sonography, pancreatic infiltration by myeloma has been described as a heterogeneous focal mass most often located in the head of the pancreas that is hypoechoic relative to the normal parenchyma and shows fine internal echoes [1]. The CT features of this condition have been described as a focal multilobulated mass with homogeneous IV contrast enhancement [1]. Diffuse enlargement of the pancreatic gland has been cited in only a few cases [2, 3]; the contrast enhancement has been described as homogeneous [2] or heterogeneous [3]. The presence of two plasmacytomas in the same pancreas, one in the tail and one in the body, was reported in a single case, in which sonographic and CT characteristics were similar to those described previously for single plasmacytomas [4]. MR imaging features, reported in only one patient in the literature, included pancreatic enlargement and a lobulated contour. On fat-suppressed T1-weighted MR images, the signal intensity of the pancreas was less than that of the liver, whereas on T2-weighted images, it was higher. Pancreatic contrast enhancement was heterogeneous, but dynamic MR imaging was not performed [3].
In summary, pancreatic involvement by multiple myeloma is rare and presents nonspecific radiologic features. To our knowledge, ours is the first case of myelomatous involvement of the pancreas with a multinodular appearance. It is noteworthy that this type of pancreatic infiltration was better characterized on sonography and gadolinium-enhanced MR imaging than on CT or unenhanced MR imaging.
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  M. Patlas, K. Khalili, M. J. Dill-Macky, and S. R. Wilson Spectrum of Imaging Findings in Abdominal Extraosseous Myeloma Am. J. Roentgenol., October 1, 2004; 183(4): 929 - 932. [Abstract] [Full Text] [PDF]
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