An Unusual Case of Pancreatic Cancer with Leptomeningeal Infiltration

Abstract

Pancreatic cancer is a common malignancy and often presents at an advanced stage. Metastases are common but neurological involvement is rare. We aim to describe an unusual case of leptomeningeal involvement from pancreatic cancer. A 59-year-old man presented with a several-year history of abdominal pain, weight loss and anaemia, which had been extensively investigated. Four years after initial presentation, he presented with left leg weakness and sensory disturbance. He was observed to suffer intermittent complex seizures. CT scan of the abdomen showed subtle narrowing of the common bile duct and pancreatic ducts. Endoscopic ultrasound showed a 5-cm lesion in the head of the pancreas with adenocarcinoma cells on fine needle aspiration. Serum CA19.9 was 2,293 U/ml. MRI study of the brain and spinal cord showed widespread leptomeningeal enhancement. Cytological examination of cerebrospinal fluid revealed epithelial cells staining positive for MNF116 and EMA. He started on a weekly regimen of intrathecal combination chemotherapy of hydrocortisone 50 mg, methotrexate 12.5 mg and cytarabine 50 mg. He was also treated synchronously with palliative systemic gemcitabine. His clinical condition continued to deteriorate, cytotoxic therapy was withdrawn after 2 weeks and he died the following month. This case represents the unusual presentation of advanced leptomeningeal carcinomatosis in a locally early stage pancreatic adenocarcinoma. Other reported cases have been in patients with advanced metastatic disease. In the case of significant neurological symptoms and signs, clinicians should have a low threshold for performing investigations to exclude neurological involvement.