S1555 Stage IV Tail of the Pancreas Tumor Presenting With Obstructive Jaundice Secondary to Liver Metastasis

Abstract

Introduction: Pancreatic cancer is an aggressive disease with a poor prognosis. It is most commonly found in the head of the pancreas and 20-25% in the body and tail. The clinical manifestations vary based on the location and spread of the tumor. Case Description/Methods: Our patient is a 55-year-old male with a past medical history of hypertension and nicotine use disorder who presented with dull epigastric abdominal pain of 3-month duration. The review of systems was significant for anorexia, unintentional weight loss of 40 pounds, tea-colored urine, and acholic stool. He was vitally stable. Physical examination showed scleral icterus and a diffusely tender abdomen without peritoneal signs. Laboratory work showed elevated AST, ALT, alkaline phosphatase, total bilirubin, direct bilirubin, and lipase. A computerized tomography (CT) scan of the abdomen revealed a mass in the pancreatic tail, multiple heterogeneous hypodense hepatic masses, and basilar lung nodular opacities. An abdominal ultrasound (US) showed ascites, multiple hepatic masses, intrahepatic biliary dilatation, and a common bile duct of 7 mm. US-guided liver and pancreas biopsies were performed. Magnetic resonance cholangiopancreatography (MRCP) revealed a 3.5 cm mass in the tail of the pancreas, multiple hepatic masses that were compressing the common hepatic duct, and retroperitoneal lymphadenopathy (Figure 1). Histopathology studies confirmed stage IV pancreatic adenocarcinoma with metastasis to the liver, lung, and peritoneum. Given the patient's extensive metastatic disease, he was not a candidate for chemotherapy or surgical intervention. Hospice and palliative care were pursued. Discussion: Tumors of the body and tail of the pancreas have been associated with poor outcomes with a 0-25% 5-year survival rate even after surgical resection. Its late presentation prompts an increased risk of distant lymphatic and hematogenous dissemination when compared with pancreatic head neoplasms. Consequently, patients with tumors originating in the head of the pancreas often present early with symptomatic obstructive jaundice. Interestingly, our patient presented with obstructive jaundice, but it was caused by intrahepatic cholestasis secondary to liver metastasis compressing the common hepatic duct. This case highlights that even as obstructive jaundice is most frequently related to pancreatic head malignancies, pancreatic body/tail neoplasms may have this clinical presentation in the presence of liver metastasis.Figure 1.: MRCP of abdomen showing a mass in the tail of the pancreas (Black arrow) and multiple hepatic masses (White arrow).