The Evil May Appear in Multiple Copies: A Rare Case of Multi-Focal Pancreatic Adenocarcinoma

Abstract

Introduction Pancreatic cancer is the 3rd leading cause of cancer-related death in the United States. Five year survival rate is a dismal 9%. It usually presents as a single tumor in the head of the pancreas (60% of cases) or in the body, tail or unknown (40%). Literature data is limited for multi-focal pancreatic cancer. This case report describes a rare presentation of pancreatic cancer simultaneously involving the head, body and tail. Case description A 67-year-old man with history of alcohol abuse, uncontrolled DM and a surgically resected prostate cancer presented with complaints of yellowish discoloration of the eye and clay colored stool of only 3 weeks duration. Upon admission to the hospital, his total bilirubin was 20.2 mg/dl, AST of 178 U/L, ALT of 428 U/L, alkaline phosphatase of 734 U/L and Lipase of 464 U/L. He had leukocytosis of 13.5 K/CMM. CT abdomen with IV contrast showed three masses within the pancreas (2.5 cm in the pancreatic body, 2 cm in the head and 1 cm in the tail). Also there were multiple hepatic masses scattered throughout the liver consistent with metastases causing severe intrahepatic biliary dilatation. ERCP showed a stricture of the Common Hepatic duct at the hilum. Biliary sphincterotomy followed by a brush cytology and plastic biliary stent placement to relieve biliary obstruction. Bili levels subsequently decreased to 6.7 mg/dl. Endoscopic ultrasound demonstrated the same 3 hypoechoic lesions in the pancreas with invasion of the splenic vein and multiple peri-pancreatic lymphadenopathy. Fine needle aspiration (FNA) samples collected from the three pancreatic masses were positive for adenocarcinoma. Six weeks after the initiation of chemotherapy with Gemcitabine and paclitaxel the patient developed portal hypertension with gastric variceal bleeding and lung metastases. Subsequently patient elected hospice care. Discussion Our case describes a rare case of multifocal pancreatic adenocarcinoma. Cancer affecting the head of the pancreas usually present earlier, is more common and has better survival outcomes when compared to those of the body or tail. In this case, the patient denied any prior obstructive symptoms related to a cancer in the head of the pancreas before this presentation suggesting the simultaneous de novo occurrence of the three masses. This case suggests the need for meticulous evaluation of all parts of the pancreatic organ when malignancy is detected which may have an impact on management and survival.2918_A Figure 1. First and Second Pancreatic masses in Body and Tail2918_B Figure 2. Third Pancreatic mass in the Head2918_C Figure 3. Metastases in the liver