Case reportsFIG. 4. Osteosclerotic metastasis in vertebral body. Adenocarcinoma is present in the cavities between new bone trabeculae. (H. & E. X 250)
HistologyThe body of the pancreas contained diffusely infiltrating, moderately well-differentiated adenocarcinoma (Fig. 3). Metastatic tumour was present in the liver, on the serosal surface of the large bowel and in the omentum. The metastatic tumour in the thoracic vertebrae was associated with the formation of new bone trabeculae (Fig. 4).
DISCUSSIONOsteoblastic metastases are a valuable radiological sign for they usually derive from a primary carcinoma of prostate or breast: much less commonly the primary tumour may be in the gastro-intestinal tract or bladder. Even less frequently, a primary carcinoma of bronchus may be responsible and a few patients with a bronchial carcinoid have developed densely sclerotic osseous metastases. Radiological appearances similar to osteoblastic metastases may occur in lymphadenoma or Paget's disease.In the present case the bone lesions were very unusual by virtue of the extreme sclerosis and the sharp demarcation between normal and abnormal bone. They closely resembled the metastatic lesions seen previously in a patient with metastatising bronchial carcinoid (Pollard et al., 1962).The radiological suggestion that the patient had an intestinal carcinoid with osteoblastic metastases was supported by the clinical and radiological evidence of intestinal obstruction, and by the subsequent finding of bright yellow intestinal nodules at laparotomy. Histological examination and subsequent autopsy demonstrated, however, that the primary tumour was pancreatic and that the yellow nodules and the bone lesions were pancreatic metastases.A very interesting feature is the disposition of the two most severely affected vertebrae (the whole of the body of LI and the left half of the body of D12) in relation to the pancreas. As can be seen on Fig. 1B, these two vertebrae form the posterior bed of the head, neck and right portion of the body of the pancreas, which was the site of the primary carcinoma. This coincidence of position is almost certainly due to the direct invasion by the tumour (perhaps via lymphatics or veins) of its posterior bed.The involvement of D9 vertebra and of the 7th right rib with the same pathological (and radiological) process suggests that these two lesions were due to haematogenous spread. The extensive peritoneal metastatic lesions might also be caused by haematogenous dissemination or by intra-peritoneal spread.We have been unable to find any previous authenticated reports of a pancreatic carcinoma having produced densely sclerotic osseous metastases.Pancreatic carcinoma should therefore be considered in the search for a primary tumour when osteoblastic metastases are evident on the radiographs but no primary tumour is apparent. Pancreatic carcinoma should be very carefully considered if the sclerotic process involves the bones which form the bed of the pancreas.
