Fortuitous Splenic Rupture: An Unusual Presentation of Pancreatic Cancer

Abstract

Early diagnosis of pancreatic ductal adenocarcinoma (PDAC) is difficult. Multifocal pancreatic masses are not common when it comes to PDAC. This especially holds true for cancer of the pancreatic body and tail that do not manifest with jaundice. We present a case of pancreatic cancer involving the head and tail A 52-year-old Caucasian male with past history of hypertension, gout and osteoarthritis presented to the hospital with acute left upper quadrant pain radiating to the back after sustaining a fall. Examination revealed severe tenderness to palpation of the left upper quadrant. Initial laboratory data showed hemoglobin of 10.4 g/dl, AST of 166 U/L, ALT of 352 U/L, ALP of 368 U/L and serum lipase level of 869 U/L. CT abdomen showed splenic laceration with hemoperitoneum. The patient was vigorously resuscitated, and subsequently underwent emergency laparotomy. Operative findings revealed splenic laceration with hemoperitoneum. Intraoperatively, the pancreatic tail was hard and abutted the mesocolon and omentum. Short gastric vessels were engorged suggestive of splenic vein thrombosis. Irregular masses were noticed in the head of the pancreas without involvement of superior mesenteric vasculature. Histopathology of the mass revealed PDAC. The patient underwent Whipple surgery with adjuvant FOLFIRINOX therapy. Post-operative pathology showed T3N1 disease with perineural and lymphovascular invasion. The patient is currently undergoing surveillance for recurrence. Splenic rupture is extremely rare presenting feature of pancreatic cancer. Only ten prior cases have been reported in literature. Most of those cases reported rupture of splenic artery aneurysm secondary to direct vascular invasion of PDAC. Cancer of the pancreatic tail can invade the splenic hilum causing splenic ischemia and vein occlusion which may culminate in splenic rupture. Another rare finding in our case was the multifocal nature of pancreatic cancer. Only around 50 cases have been reported so far as per our literature review. Most of the cases that have been reported in literature present as contiguous masses. Surgical removal is recommended in the absence of distant metastatic disease and local vascular invasion. Overall prognosis continues to remain grim for all stages.Figure: Splenic rupture is a rare presenting feature of pancreatic cancer. It can however present an opportunity for early stage discovery that may lead to improvement in prognosis by earlier initiation of treatment.