Metastatic Small Cell Lung Carcinoma Masquerading as Recurrent Acute Pancreatitis

Abstract

Purpose: A 57-year-old Caucasian female was referred to the gastroenterology service at our institution for evaluation of chronic abdominal pain and multiple admissions for recurrent attacks of acute pancreatitis. Clinically, the patient suffered from severe mid-epigastric pain with nausea, emesis, lumbago, and stools consistent with steatorrhea. Her constellation of symptoms also included unintentional weight loss of 35 pounds in 6 months and anorexia. She denied any history of diabetes mellitus, hyperlipidemia, or alcohol use, or a family history of gastrointestinal or other malignancy. She was, however, an avid tobacco user and was status-post cholecystectomy. On physical exam, the patient was afebrile with a benign, non-surgical abdomen with mild epigastric tenderness to palpation without obvious masses, hepatosplenomegaly, ecchymosis, icterus, jaundice, or nodules. Labs were consistent with transaminasemia (elevated AST and ALT >3 times upper limit of normal), cholestasis (alkaline phosphatase over 400), mild hyperbilirubinemia, and hyperlipasemia (over 400). Previous computed tomography of the abdomen with intravenous contrast was negative for pancreatic parenchymal changes, biliary dilation, or mass; on this admission, a repeat study revealed mild pancreatic ductal dilation and a questionable 1.3-cm focal hypodensity within the pancreatic body. Subsequent magnetic resonance cholangiopancreatography showed multifocal hypodense lesions throughout the pancreas suspicious for neoplasm, and the patient underwent esophagogastroduodenoscopy with endoscopic ultrasound and fine needle aspiration to rule out lymphoma versus neuroendocrine tumor of the pancreas. Final pathology indicated the lesions to be small cell lung cancer with neuroendocrine features. Although previous chest radiography was negative, a subsequent computed tomography of the chest revealed a right hilar prominence/mass and mediastinal lymphadenopathy. Hematology-oncology facilitated the insertion of a port for chemotherapy, and the patient received and tolerated her first course without incident prior to discharge. Metastatic disease to the pancreas is seldom included in the differential diagnosis of the etiology of pancreatitis due to its rare occurrence. This case represents a rare occurrence of small cell lung neoplasm with metastasis to the pancreas, and illustrates the need for a higher index of suspicion for possible neoplastic process in patients with pancreatitis, especially in the instance of recurrent attacks, chronic pancreatitis, and attacks recalcitrant to standard therapy.