Diagnosis of a Rare Coexisting Adenocarcinoma and Endocrine Tumor of the Pancreas with EUS-FNA in an Elderly Patient

Abstract

Purpose: Pancreatic cancer is the fourth leading cause of cancer death in the U.S. and leads to an estimated 22 7,000 deaths per year worldwide. Majority of pancreatic cancer are adnocarcinoma which account 96% of cases with remaining 4% are indolent neuroendocrine tumors. Pancreatic neuroendocrine tumors (PNETs) are uncommon tumors which arise from endocrine cell of the pancreas. We report a case of coincidence of neuroendocrine tumor at the tail of pancreas and adenocarcinoma of the body of pancreas in an elderly patient, which we believe that a rare synchronous finding. Case: An 81 year-old man was admitted to the hospital for evaluation of three months history of weakness, upper abdominal pain, watery diarrhea and 20 lbs weight loss. Past medical and surgical history significant for diabetes, hypertension, coronary artery disease and inguinal hernia repair. He is a former smoker of 1 pack per day for approximately 20 and had no history of alcohol use. Physical examination was unremarkable. Liver function tests revealed Total Bilirubin of 0.7 mg/dl Alkaline phosphatase of 219 U/L, Alanine aminotransferase of 104 U/L and Aspartate aminotransferase of 62 U/L. Ultrasound of the abdomen showed mass in the mid body of the pancreas measured 30.1 x 30 x 40 mm in size. Computed tomography showed two masses in the pancreas. The first mass located at the mid body of the pancreas and was large, bi-lobed and the entire size of the mass measured 55.7 x 50.6 mm. The second mass was rounded and located at the distal tail of the pancreas, close to the spleen and measured 20.8 x 26.4 mm. The endosonographic examination of the pancreas was performed and revealed a large bi-lobed pancreatic body mass. The right lobe of the mass measured 29.5 x 32.8 mm and was hypoechoic, round and obstructed the pancreatic duct and invaded the splenic artery. The left lobe of the mass measured 36.4 x 43.5 mm and was hypoechoic, heterogeneous with an anechoic, necrotic center. Fineneedle aspiration with 25 gauge needle of both lobes of the mass was performed. The second pancreatic mass was seen at the tail of the pancreas measuring 20.6 x 18.9 mm. The mass was hypoechoic, round and had a well demarcated boarder. Fine needle aspiration was performed using a second 25 gauge needle. The results of fine needle aspirations of the pancreatic body and tail masses revealed moderately differentiated adenocarcinoma and neuroendocrine tumor respectively. Conclusion: Coexistence of adenocarcinoma and neuroendocrine neoplasm of the pancreas is a rare entity. The findings of more than one pancreatic mass, as in our patient, may prompt an EUS with FNA of each of the masses to make the definite diagnosis of potential coexisting neoplasms.