Markedly Elevated CA 19–9 Levels in a Patient with Jaundice

Abstract

Carbohydrate antigen 19–9 (CA 19–9) can be elevated in pancreatic adenocarcinoma, other GI malignancies, and a host of benign conditions. Few cases however have been reported with values markedly elevated in a benign condition. We report a case of a patient with a markedly elevated CA 19–9 that led to an exhaustive workup to find a non-existent pancreatic “mass”. Case: A 43 year-old male was admitted for evaulation of abdominal pain, nausea, and vomiting. He also noted progressive jaundice and a 50 lb weight loss over 6 months. Prior to admission, he was on a 6 month alcholic binge. Exam revealed jaundice, scleral icterus, and hepatomegaly. Initial labs: Total bilirubin 27.2 mg/dl, direct bilirubin of 17.5 mg/dl, AST 136 IU/L, ALT 126 IU/L, and alkaline phosphatase 359 IU/L. CT of the abdomen showed a 7 cm pancreatic pseudocyst with suspicion of mass. Because of the “suspicion of mass”, and profound jaundice, a CA 19–9 was obtained (5275 U/ML). Because the CA 19–9 was elevated, an extensive workup was undertaken to evaluate the “mass”. MRCP showed fatty infiltration of liver, pancreatic pseudocyst, and chronic pancreatitis, but no dilatation of the common bile duct. A viral hepatitis panel, EBV, CMV, and HIV were negative. The patients bilirubin increased to 38 mg/dl by one week after admission. Because of continued concern for malignancy, an ERCP was performed which showed no abnormalities. Ductal brushings were negative for malignant cells. A Fine needle aspiration of the pseudocyst showed no malignant cells. After one week, the bilirubin started to fall and by 1 month, it was 1.1 mg/dl. A repeat CA 19–9 at 1 month was 8584 U/ml. An endoscopic ultrasound again revealed no mass. CA 19–9 levels decreased to 171 U/ml at 2 month follow up. A repeat CT scan 6 months after presentation showed a decrease in the size of the pseudocyst and no “mass”. At 6 months, the patient has stopped drinking and is asymptomatic. Conclusions: Markedly elevated serum levels of CA 19–9 are associated with pancreatic cancer, however, it can also occur in some non-malignant conditions. Ordering a CA 19–9 test in a situation where there is limited suspicion of pancreatic carcinoma (questionable mass) may lead to an unnecessary, risky, and expensive work-up.