Gastrointestinal: A wandering pancreatic adenocarcinoma.

Abstract

A 79-year-old woman was referred to our hospital complaining of upper abdominal pain. She had no history of diabetes mellitus or other malignant diseases. Blood analysis showed no atypical findings other than elevated levels of CEA and Dupan-2. Contrast-enhanced computed tomography (CT) showed a 50 × 40-mm mass with poor contrast and irregular margins in the head of the pancreas (Fig. 1). Invasion into the superior mesenteric artery and portal vein was also evident. Histopathological examination of a specimen from endoscopic ultrasound-guided fine needle aspiration revealed adenocarcinoma. We diagnosed the mass as locally advanced unresectable pancreatic adenocarcinoma, and decided to perform chemoradiotherapy in order to help control the cancer and slow down its growth. To design radiotherapy, we performed CT on inhalation and free-breathing. The pancreatic mass was on the right side of the spine on inhalation, but surprisingly appeared on the left side of the spine on free-breathing (Fig. 2). We administered radiation at 1.8 Gy/day with fixation of the mass using a body shell and also administered gemcitabine. On day 8 after therapy, the patient developed multiple cerebral infarctions associated with Trousseau syndrome. She subsequently received best supportive care. In general, pancreatic masses have been considered immovable, because the pancreas is fixed to the retroperitoneum with the duodenum. The anterior surface of the pancreas is covered by parietal peritoneum and the inferior border abuts the root of the transverse mesocolon. A loose connective tissue layer, known as the fusion fascia of Treitz in the region of the head of the pancreas and as the fusion fascia of Told in the region of the body and tail, is coherent with the posterior of the pancreas. Some reports have pointed out that the pancreas can change position in some patients, particularly women. However, few reports in the English literature have described a wandering pancreatic mass. A case of wandering neuroendocrine tumor of the head of the pancreas has been reported, involving an encapsulated mass. In that case, CT showed a shift of the large mass in the pancreas from the right to the left side of the aorta. However, wandering pancreatic adenocarcinoma has not previously been reported. Malrotated pancreas or pancreatic volvulus has been reported with wandering spleen as a very rare clinical entity, but the present case demonstrated no clinical complications, such as mobile spleen or other abdominal organs. In our case, acquired pancreatic mobilization due to tissue weakening was speculated as the cause of motility. Pancreatic carcinoma should also be considered among the differential diagnoses for mobile abdominal mass.