AJR 2003; 181:1627-1628
© American Roentgen Ray Society
Radiation Therapy for a Massive Arteriovenous Malformation of the Pancreas
Morio Sato1,
Kazushi Kishi1,
Shintaro Shirai1,
Kazuhiro Suwa1,
Masashi Kimura1,
Nobuyuki Kawai1,
Hirohiko Tanihata1,
Katsuyuki Yamada1,
Masaki Terada1 and
Hiroki Yamaue2
1 Department of Radiology, Wakayama Medical University, 811-1 Kimiidera,
Wakayama Shi, Wakayama 641-8510, Japan.
2 Department of 2nd Surgery, Wakayama Medical University, Wakayama Shi, Wakayama
641-8510, Japan.
Received February 28, 2003;
accepted after revision June 23, 2003.
Address correspondence to M. Sato
(morisato{at}mail.wakayama-med.ac.jp).
Introduction
Although pancreatic arteriovenous malformation (AVM) is a rare condition,
patients with this malformation can have progressive portal hypertension,
causing esophageal and gastric varices and hemorrhagic gastritis, leading to
intractable hematemesis and melena
[1–3].
Surgical pancreatectomy is a radical treatment for pancreatic AVM. However, as
the malformation grows, various vessels including feeding arteries and
draining veins contribute to it and increase the difficulty of surgical
hemostatic treatment.
One of our patients had a massive pancreatic AVM that had been treated by
transcatheter arterial embolization that resulted in a short-term recurrence.
He underwent intraoperative irradiation with additional external irradiation.
We report the long-term outcome of safety and effect of radiation treatment
for massive pancreatic AVM.
Subject and Methods
A 60-year-old man came to our hospital with melena. Hemoglobin level had
decreased from 12.2 to 8.5 g/dL. He had undergone esophageal variceal
sclerotherapy five times for repeated hematemesis caused by esophageal
varices. The varices were initially attributed to liver cirrhosis, because his
laboratory data revealed a hepatitis C infection. His past history indicated
no evidence of pancreatitis, trauma, or abdominal surgery. Contrast-enhanced
CT showed not only liver cirrhosis but also a pancreatic AVM. Celiac
arteriography revealed that the feeding arteries for the pancreatic AVM
included the dorsal pancreatic artery, the anterior and posterior superior
pancreaticoduodenal arteries, the right and left gastric arteries, and the
left hepatic artery. Superior mesenteric arteriography also revealed the
contribution of the inferior pancreaticoduodenal artery and the middle colic
artery. We were reluctant to perform surgical pancreatectomy because of the
liver cirrhosis and the danger of intraoperative bleeding. Arterial
embolization was performed using gelatin sponge particles and microcoils after
inserting catheters selectively into these arteries. However, hematemesis and
melena recurred at intervals of 1 to 4 months, and arterial embolization was
performed on seven different occasions. Each follow-up celiac arteriogram
before embolization showed feeding artery recanalization and a massive
pancreatic AVM (Fig. 1A). After
informed consent was obtained from the patient, the pancreatic head and body
were irradiated during surgical laparotomy to a radiation range 7 cm in
diameter with a dose of 30 Gy using a 12-MeV electron beam. External X-ray
irradiation from a 10-mV linear accelerator was also administered to the
pancreatic AVM for a total radiation dose of 20 Gy (200 cGy/day for 10
days).
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Fig. 1A. —60-year-old man with massive pancreatic arteriovenous
malformation (AVM). Celiac arteriogram obtained before intraoperative
irradiation shows massive blood flow in AVM. Note that portal vein is enlarged
and tortuous despite previous repeated embolization with gelatin sponge
particles and microcoils.
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Results
Results of celiac arteriography 8 months later showed a reduced AVM and a
decreased number of shunts (Fig.
1B). Five years 2 months later, the pancreatic AVM had disappeared
(Fig. 1C). The latest blood
test of the patient showed no pancreatic insufficiency, and the diabetes
mellitus, which had been diagnosed before radiation treatment, had improved.
No hematemesis, melena, or adverse events caused by irradiation have recurred
for more than 6 years since the radiation treatments.
Discussion
A patient with massive pancreatic AVM causing intractable hematemesis and
melena underwent radiation treatments resulting in marked reduction of the
pancreatic AVM and nonrecurrence of hematemesis and melena, with no adverse
effects from the radiation treatments noted more than 6 years later. The
radiation treatments were safe and useful for massive pancreatic AVM in our
patient, for whom surgical pancreatectomy was contraindicated.
The treatments for esophageal or gastric varices caused by pancreatic AVM
are endoscopic sclerotherapy, balloon-occluded retrograde sclerotherapy, and
transjugular intrahepatic portosystemic shunts
[2,
4,
5]. Transient satisfactory
results from these treatments have been reported; however, the long-term
effects are uncertain because these are not radical treatments. Although
arterial embolization is indicated for pancreatic AVM
[5–8],
hematemesis and melena recur as collaterals develop. Surgical pancreatectomy
is the sole radical treatment for pancreatic AVM. One report
[3] reviewing outcomes for 24
patients with pancreatic AVM indicated that eight patients died within 4.5
years, including one patient who died within 3 weeks of surgical
pancreatectomy. Surgery was not attempted in our patient with massive
pancreatic AVM because of the risk of bleeding caused by liver dysfunction and
the difficulty of hemostatic treatment of such a large number of blood
vessels. To our knowledge, no previous report describes radiation treatment
for pancreatic AVM. External irradiation for pancreatic AVM does not treat it
fully because the pancreas is surrounded by organs with low tolerance for
irradiation, such as the stomach, duodenum, kidneys, and spinal cord. Also,
exact irradiation to the pancreatic AVM is difficult to achieve because of
migration associated with respiration. For these reasons, we performed
intraoperative high-dose irradiation directly to the pancreatic AVM using an
electron beam and an additional external irradiation of 20 Gy of 10-mV X rays,
which is within the acceptable dose range for low-tolerance organs. The
massive pancreatic AVM was markedly reduced, and no recurrent hematemesis and
melena have occurred for more than 6 years. However, longer term observation
is needed to evaluate the adverse effect of radiation treatment for pancreatic
AVM.
In conclusion, radiation treatment can be a useful alternative treatment
for massive pancreatic AVM for patients in whom the risk of surgical
pancreatectomy is deemed too high.
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Introduction
Subject and Methods
