S3463 Obvious or Elusive? Pancreatic Adenocarcinoma

Abstract

Introduction: Pancreatic cancer is the fourth leading cause of cancer-related deaths in the United States over the pastthree decades. Many experts postulate that the poor prognosis of pancreatic cancer is related to its delayed diagnosis and lack of symptoms early in disease course. Here, we present a case of pancreatic adenocarcinoma with an aim of focusing on early diagnostic challenges. Case Description/Methods: A 43-year-old male presented to gastroenterology clinic with complaints of fifteen-pound unintentionalweight loss and yellowing of the skin for one month duration. He denied current alcohol, tobacco or illicit drug use. Physical examination was pertinent for scleral icterus and jaundiced skin. Labs were significant for elevated transaminases, elevated CA 19-9 and carcinoembryonic antigen. CT abdomen/pelvis revealed proximal dilatation of the common bile duct (CBD) up to 1cm with a questionable incomplete annular pancreas and a tubular density noted in the 3 rd portion of the duodenum. ERCP revealed an abrupt cut-off above the pancreaticobilliary junction; stent placement was attempted unsuccessful. Consequently, interventional radiology inserted a cholecystectomy tube for decompression. A week later, a repeat ERCP was performed with successful placement of a plastic stent (IMAGE). Biliary brushings were unremarkable; however, clinical suspicion remained high for malignancy. A multidisciplinary team meeting was held and the decision was made to pursue a Whipple procedure. The findings were consistent with a distal CBD tumor with portal vein invasion but no gross evidence of metastasis. Histopathology reported invasive adenocarcinoma well-to-moderately differentiated with negative surgical margins. Currently, the patient is receiving adjuvant chemotherapy with FOLFIRINOX and following in GI clinic. Discussion: Pancreatic cancer is associated with very poor prognosis and resection is the only curative option. Earlydiagnosis can improve prognosis. This case highlights the notion that timely diagnosis for appropriate surgical candidates leads to survival benefit. Endoscopic ultrasound has evolved to play an integral role in determining whether a tumor meets resectability criteria. To date, despite advances in technology, mortality for pancreatic cancer has only marginally improved. This case highlights the need for further research on enhancing imaging techniques and developing sensitive bio-markers for earlier detection ofpancreatic malignancy.Figure 1.: Fluoroscopic image showing guidewire passing beyond distal CBD stricture. Cholecystectomy tube appropriately positioned within gallbladder for decompression.