Case Of Pancreatic Adenocarcinoma Research Articles

A case of pancreatic adenocarcinoma diagnosed with scrotal enlargement due to left varicocele testis following infiltration of the left renal vein

A case of pancreatic adenocarcinoma diagnosed with scrotal enlargement due to left varicocele testis following infiltration of the left renal vein

Sister Mary Joseph Nodule: A Dermatological Insight into Metastatic Pancreatic Cancer

The Sister Mary Joseph (SMJ) nodule is a metastatic umbilical growth observed in primary tumors originating from the gastrointestinal or genitourinary tract. Commonly, SMJ nodules are associated with gastrointestinal cancers, particularly those affecting the stomach and colon. While the pancreas is an uncommon primary site for umbilical metastasis, pancreatic adenocarcinoma that spreads to the umbilicus typically originates from the body or tail of the pancreas. The presence of an SMJ nodule often indicates a poor prognosis, serving as a straightforward physical indicator of advanced intra-abdominal malignancy. Although pancreatic cancer is a rare cause, it should be considered among the primary sites in such cases. This report details a case of an SMJ nodule unveiling pancreatic adenocarcinoma in a 61-year-old patient. The case underscores the significance of examining the umbilicus, an area frequently overlooked but crucial for diagnosis. Vigilant clinical follow-up and histological evaluation are imperative in such cases, highlighting the importance of not underestimating this infrequently assessed region.

A rare case of concurrent intrahepatic splenosis and pancreatic adenocarcinoma following splenectomy.

We present an extremely rare case of intrahepatic splenosis (IHS). On admission and examination, the patient was diagnosed with hepatocellular carcinoma and postoperative injury or inflammatory lesions of the pancreas, based on image analysis. Postoperative histopathology showed that the lesions of the liver and diaphragm were of splenic origin, and the pancreatic lesion was identified as a moderately differentiated adenocarcinoma. The lesson of this case is that if there is a history of splenic rupture or splenectomy, even in the presence of hepatitis or cirrhosis, doctors should be alert to the possibility of IHS. Furthermore, splenectomy may affect the blood supply to the tail of the pancreas, so patients with a pancreatic tail mass following splenectomy need follow-up and biopsy, if necessary.

S1741 Gelatinous Ascites and a Double Duct Sign: A Case of Pancreatic Adenocarcinoma

Introduction: Pseudomyxoma peritonei (PMP) is a rare disorder characterized by the accumulation of gelatinous material within the abdomen and pelvis. While usually appendiceal in origin, it can be seen with mucinous tumors arising from the ovary, GI tract, urachus, and pancreas. We describe a case of pancreatic adenocarcinoma diagnosed due to the clinical syndrome precipitated by pseudomyxoma peritonei. Case Description/Methods: A 59-year-old Hispanic male presented to the hospital for evaluation due to a 2 month history of poor oral intake and worsening abdominal fullness, distension, discomfort, and intermittent pain. The patient reported one prior hospitalization for pancreatitis of unclear etiology, 3 years ago. A CT abdomen & pelvis was obtained; findings reported include multiple hepatic subcapsular cystic liver lesions, abdominal omental caking, ascites, and extrahepatic biliary and pancreatic ductal dilatation without definitive evidence of a mass. CEA and CA 19-9 were found to be elevated at 49.4 and 416 respectively. CT chest revealed a left-sided pleural effusion. Upper endoscopy and colonoscopy were negative. Paracentesis yielded gelatinous ascites. Clinical suspicion for appendiceal malignancy was raised which required surgical exploration and biopsy to confirm. An MRI of the abdomen was obtained to assess for pancreatic mass given presence of double duct sign. MRI revealed 2.2 x 2.7 x 5 cm lesion in the body of the pancreas, pseudomyxoma peritonei with scalloping of the liver and extension into the right posterior mediastinum via the esophageal hiatus, metastatic deposits in the porta hepatis and peritoneal carcinomatosis. No apparent abnormality in the appendix was observed. EUS FNA was performed; splenic vessel invasion by the mass was noted. Cytopathology supported a diagnosis of pancreatic adenocarcinoma. The patient was initiated on palliative chemotherapy with gemcitabine and nab-paclitaxel which led to a significant reduction in ascites and pleural effusion and improvement in symptoms. Discussion: This case highlights the potential of malignancies such as pancreatic adenocarcinoma to cause pseudomyxoma peritonei despite it more commonly being associated with appendiceal origin. Knowledge of this can help guide diagnostic and therapeutic plans.

S1676 Things Are Not Always What They Seem: A Rare Case of Pancreatic Carcinoma Manifesting Through Cutaneous Metastasis

Introduction: Pancreatic cancer is an aggressive disease that commonly metastasizes to the liver, lung, and peritoneum. Cutaneous metastasis is a rare occurrence with an incidence of only 2.0%. We present a case of metastatic pancreatic adenocarcinoma primarily presenting as a cutaneous nodule. Case Description/Methods: A 50-year-old male was undergoing outpatient evaluation for a raised, left scalp lesion along with neck nodules. Associated symptoms included an unintentional 30lb weight loss. Outpatient CT soft tissue neck revealed numerous necrotic lateral neck lymph nodes, lytic lesion with epidural soft tissue extension at C2-4, and occlusion/thrombosis of the left subclavian, brachiocephalic, and left internal jugular veins (Figure). Given these findings, the patient was referred to the Emergency Department (ED). At time of ED arrival, vital signs were stable along with initial laboratory values. CTA PE study showed no pulmonary embolism but revealed numerous pulmonary and bilateral adrenal nodules, multifocal liver and osseous lesions, and widespread lymphadenopathy. Additionally, CT head demonstrated a left scalp soft tissue lesion. Follow up CT abdomen/pelvis revealed a 2.8 x 2.2 x 1.8 cm ill-defined pancreatic lesion and confirmed widespread metastasis including to the muscles. Additional testing revealed elevated cancer markers with Cancer antigen 19-9 (CA 19-9) of 5418 U/mL and carcinoembryonic antigen (CEA) of 63.8 ng/mL. Pathology from initial scalp lesion biopsy showed fragments of necrotic dermis with small foci of poorly differentiated carcinoma. Biopsies of the right and left neck masses revealed poorly differentiated adenocarcinoma of uncertain primary. Therefore, liver biopsy was performed and confirmed non-small cell carcinoma of pancreatobiliary origin. Further imaging to determine treatment course discovered intracranial metastasis and cervical spine disease resulting in cord compression. Ultimately, the patient underwent 4 out of 10 fractions of palliative radiation to the cervical spine but passed away after transitioning to comfort care one month after diagnosis. Discussion: There are less than 25 documented cases of pancreatic cancer with cutaneous involvement; however, it is even more rare that cutaneous involvement prompts initial diagnosis. The umbilicus is the most common site of cutaneous involvement and is referred to as the Sister Mary Joseph Nodule. Involvement of the soft tissue of the scalp and neck is much less common and poorly documented making this case extremely unique.Figure 1.: Axial contrast enhanced CT of the abdomen shows a 2.8 cm ill-defined hypoattenuating mass in the pancreatic tail (A) with multifocal metastatic liver lesions and bilateral adrenal metastasis (B). Axial CT image of the pelvis shows a metastatic lesion in the right rectus femoris muscle (C). On liver biopsy, H&E, 40X,(S21-41666) revealed high grade carcinoma with vesiculated nuclei, prominent nucleoli (D), CA 19-9 IHC 20X diffuse positivity in tumor cells (E) and CK AE1/3 IHC, 20X, diffusely positivee for pancytokeratin in tumor cells confirming carcinoma (F). Axial CT of the head shows a 2.4 cm nodular left parietal scalp soft tissue lesion (G) which was also seen on clinical examination (H). Biopsy of the scalp lesion (H&E, 40X) demonstrated high grade carcinoma with vesiculated nuclei, prominent nucleoli and mitoses (I), histologically similar to liver biopsy findings.

Is It a Bird? Is It a Plane? It's a Tumour – Operative Transcystic Choledochoscopy for Differentiation of Biliary Duct Filling Defect and New Early Diagnosis of Insidious Pancreatic Adenocarcinoma

Background: Operative Transcystic Choledochoscopy (OTC) during Laparoscopic Cholecystectomy (LC) is a one-procedure solution for clearance of Common Bile Duct (CBD) calculi under vision and allows identification and biopsy of biliary neoplasms. Success and complication rates in high-volume centres are similar or superior to Endoscopic Retrograde Cholangiopancreatography (ERCP). Preference for ‘minimally-invasive’ techniques like ERCP has led to infrequent use and resultant deskilling. Its ongoing role is therefore currently unclear. Case: A well 65-year-old male with epigastric pain and raised lipase, and Computed Tomography (CT) showing cholelithiasis and ‘focal pancreatitis involving the uncinate process’, underwent LC for gallstone-induced pancreatitis 6 days after presentation. Pre-operative bilirubin was normal and ALKP (133 U/L) and GGT (270 U/L) newly raised. An oedematous stone-containing gallbladder and a distal CBD filling defect on Intraoperative Cholangiogram were found. OTC demonstrated a CBD wall growth but biopsy equipment was unavailable. No peritoneal or liver metastases were seen. Ca19.9 (588 kU/L) was elevated. Pancreas-protocol CT/MRI showed a 14x14mm ‘indeterminate abnormality’ in the head/uncinate process without vascular involvement, and staging CT was negative for metastases. Endoscopic Ultrasound-guided biopsy diagnosed pancreatic adenocarcinoma following non-diagnostic ERCP. A Whipple’s procedure was planned but later abandoned as liver metastases were confirmed on frozen section at staging laparoscopy. Discussion: Despite recent movement away from OT during LC, this study highlights its utility in early identification of insidious biliary neoplasmswith the first case of preliminary pancreatic adenocarcinoma diagnosed with OTC during LC in a non-obstructed patient.

S3463 Obvious or Elusive? Pancreatic Adenocarcinoma

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.

Pancreatic Origin Hepatoid Adenocarcinoma with Liver Metastasis

Hepatoid Adenocarcinoma (HAC) is a rare form of aggressive extrahepatic neoplasm with similar morphologic features to Hepatocellular Carcinoma (HCC). HAC with pancreatic origin is rare and the exact incidence is unknown. Given shared morphological and Immunohistochemical (IHC) characteristics, it may be difficult to distinguish metastatic HAC with liver involvement from primary HCC. We present a rare case of ductal type pancreatic hepatoid adenocarcinoma involving the pancreatic head, ampulla of Vater, and liver, and illustrate strategies for diagnosis and treatment. A 65-year-old woman presented with epigastric pain, vomiting, melena, and weight loss. There was direct hyperbilirubinemia with elevated hepatic markers. Imaging displayed a pancreatic head mass with moderate biliary obstruction and a hepatic lobe lesion. Fine needle biopsy of the liver mass initially was consistent with HCC, and biopsies of the pancreatic mass and ampulla walls showed pancreatic adenocarcinoma. Due to the unusual finding of co-existing HCC and pancreatic adenocarcinoma, the hepatic mass biopsy was sent for external evaluation, which revealed poorly differentiated adenocarcinoma, consistent with HAC of pancreatic origin. The tumor was positive for mucicarmine stain, HepPar1, CEA, and CK7. It was negative for MOC-31, Arginase, ALBISH, MGB, ER, TTF-1, GCDFP15, CK-20 and CDX2, thus confirming HAC. The patient was referred to outpatient chemotherapy with gemcitabine and paclitaxel however demonstrated progression and expired following recurrent bilateral pulmonary emboli. HAC may present with non-specific symptoms, is highly aggressive, and may be difficult to distinguish from primary HCC from histopathologic characteristics alone. Accurate diagnosis requires clinicohistopathologic and IHC analysis.

High Insulin Resistance in Pancreatic Adenocarcinoma

Abstract Introduction: Diabetes mellitus and obesity is associated with increased risk of pancreatic cancer which has been postulated to be due to pancreatic beta cell dysfunction and increased insulin resistance. Pancreatic cancer also exerts its effect on pancreatic beta cells, reducing insulin secretion, affecting glucose uptake and increasing insulin resistance. We present a case of pancreatic adenocarcinoma with severe insulin resistance and uncontrolled diabetes which reversed after tumor removal. Clinical Description: 79 year old male patient with no prior diagnosis of diabetes, history of hypertension, atrial fibrillation, cerebrovascular accident got admitted to the hospital with painless jaundice, dark colored urine and pruritus for a month. He also endorsed polyuria, polydipsia and weight loss for 2 months. He underwent Magnetic Resonance Cholangiopancreatography and was diagnosed with a 2.8 cm pancreatic head mass, consistent with adenocarcinoma along with intraductal papillary mucinous neoplasm. He was diagnosed with new onset of diabetes, A1c 12.6% during that hospitalization. He weighed about 75 kg and height 170cm (BMI 26.6). Labs showed normal renal function, deranged liver enzymes with direct hyperbilirubinemia, elevated transaminases and alkaline phosphatase. C-peptide level was 1.2 ng/ml for a blood glucose of 197 mg/dl. He was discharged on once daily insulin Glargine 25 units and mealtime insulin Lispro 10 units three times a day (TID) requiring 0.7 units/kg. During follow-up, his insulin requirement started to increase despite proper insulin injection technique and medication compliance. He required glargine 150 units/day and U500 insulin 50 units TID requiring about 4 units/kg. He underwent Whipple’s procedure, partial pancreas resection after a month of his diagnosis. Patient was started on clear liquid diet and his blood glucose started to get better on post-op day 1 with just correctional insulin. He was discharged on Repaglinide 0.5mg TID with each meal and all his insulin was discontinued. His blood glucose was in range of 80 to 160 mg/dl with Repaglinide during clinical follow-up with regular diabetic diet. His severe insulin resistance got reversed after the resection of pancreatic neoplasm. Conclusion: The pathogenesis of pancreatic cancer associated diabetes has not been studied well. Basic science research found that adrenomedullin, an amionopeptide, is up-regulated in patients with pancreatic cancer and causes insulin resistance in β Cells. Cancer theories also found about metabolic reprogramming and metabolic cross talk happens between pancreatic cancer and peripheral tissue, inhibiting cellular glucose intake and inducing insulin resistance. More research is required to understand these paraneoplastic phenomenon caused by diabetogenic tumor-secreted product in pancreatic cancer associated diabetes.

Metastatic Pancreatic Adenocarcinoma Primarily Presenting with Multiple Cutaneous Nodules—a Rare Entity

Cutaneous metastasis (CM) from pancreatic adenocarcinoma is very rare. They often present as an umbilical nodule and are associated with other evidence of distant metastasis. We present the case of a 60-year-old male who presented with multiple non-umbilical cutaneous nodules, in an undiagnosed case of pancreatic adenocarcinoma, with no other evidence of distant metastasis.

Coexistence of pancreatic adenocarcinoma and a pseudocyst in cat

Abstract Exocrine pancreatic tumors in cats and dogs are very uncommon, with exocrine pancreatic adenocarcinoma described as a particularly rare, malignant tumor in a small animals. It is usually derived from pancreatic ducts, as well as glandular tissue. Very often the disease has a subclinical course and is diagnosed only during post – mortem examination. Adenocarcinoma metastasize to both the surrounding and distant organs. The etiology of the cancer progress in the pancreas remains unknown. Pancreatic pseudocyst (pseudocystis pancreatis) is a very rare disease in domestic animals. Only a few cases of pancreatic pseudocyst in dogs and cats are described in the available literature. On the other hand, in humans it is a common complication of pancreatitis. The pancreatic pseudocyst can be a result of pancreatitis, as well as be a secondary condition to acute pancreatitis, trauma or chronic inflammation. It is a capsule made of fibrous or granulation tissue, containing sterile pancreatic juice. The pathogenesis of pancreatic pseudocyst is still unknown. Clinical signs are not specific and may resemble symptoms of pancreatitis. The ultrasound examination shows a cyst in the pancreas. This paper describes the case of pancreatic adenocarcinoma in a cat that occurred simultaneously with the pancreatic pseudocyst. Currently, literature indicates the necessity to differentiate the above cancer from cystic lesion. Due to the simultaneous occurrence of both pathologies, extremely rare diagnosis and spectacular picture of changes, it was decided to present this case.

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

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

A Rare Case of Zollinger-Ellison Syndrome and Pancreatic Adenocarcinoma in a Patient with Multiple Endocrine Neoplasia Type 1

A 50 year-old male presented to the hospital with a 2-week history of abdominal pain. He also referred chronic diarrhea described as alternating between watery and pasty. Medical history was remarkable for MEN1 diagnosed at 14 years of age after he was found with hyperplasia of the parathyroid glands with elevated calcium levels for which he underwent a partial parathyroidectomy. History is also significant for a pituitary adenoma treated with bromocriptine for 1 year. Family history is pertinent for MEN1 in his mother and maternal grandfather. During hospitalization, a CT scan showed a cystic lesion at the pancreatic tail. An MRI showed a lesion at the head of the pancreas and a cystic, non-enhancing pancreatic tail lesion. Upper endoscopy was remarkable for multiple ulcerated lesions in the duodenum (fig 1). Gastrin levels were elevated. A somatostatin receptor imaging study disclosed no uptake. The patient was referred to an interventional gastroenterologist after discharge. By this time, he was presenting with jaundice and pruritus and chemistry was remarkable for a cholestatic pattern. An endoscopic ultrasound disclosed a pancreatic tail cyst, a pancreatic tail mass (fig 2), and a pancreatic head mass causing obstruction and dilation of the common bile duct (CBD). Pathologic diagnosis for the pancreatic tail cyst and mass showed hyperchromatic cells with chromogranin and synaptophysin (fig 3) and adenocarcinoma of the pancreatic head mass. An ERCP was done with stent placement at the CBD. The patient underwent a Whipple procedure with distal pancreatectomy and duodenectomy and was started on adjuvant chemotherapy with gemcitabine for an expected total duration of 6 months. MEN1 is characterized by pituitary tumors, parathyroid adenomas, and pancreatic neuroendocrine tumors (pNETs). This is the rare case of a patient with both a pNET causing Zollinger-Ellison syndrome (ZES) and a pancreatic adenocarcinoma in the setting of MEN1. A literature review disclosed one similar case in a 46 year-old patient with MEN1, ZES and a pancreatic adenocarcinoma. In our patient, pathology disclosed markers characteristic of a pNET. However, somatostatin receptor imaging did not show uptake in the pancreas. It is important to always consider the presence of a neuroendocrine tumor in patients with MEN1 in spite of negative imaging since earlier intervention with resection will have a greater impact in the patient's clinical outcome and reduce morbidity and mortality.1446_A.tif Figure 1: Erosive mucosa and multiple ulcers in the second and third portion of the duodenum.1446_B.tif Figure 2: Pancreatic tail mass distal to pancreatic cyst.1446_C.tif Figure 3: Pancreatic tail mass pathology positive for chromogranin and synaptophysin.

A Rare Case of Acute Cholangitis in a Young Male with Tropical Chronic Pancreatitis-Induced Pancreatic Adenocarcinoma with Metastasis to the Liver

Tropical chronic pancreatitis (TCP) is a rare and poorly understood variant of chronic pancreatitis. It is typically diagnosed in young, nonalcoholic patients in tropical regions such as southern Asia, often presenting with abdominal pain, and leading to several complications, including diabetes, malnutrition, and pancreatic adenocarcinoma. Though the link between chronic pancreatitis and cancer is established, the risk for malignancy is highest in those with rare causes of chronic pancreatitis. We present a case of TCP-induced pancreatic adenocarcinoma complicated by acute cholangitis. A 34 year-old Bangladeshi male with TCP complicated by diabetes and stage IV pancreatic adenocarcinoma with liver metastasis, s/p whipple procedure, and 3 cycles of adjuvant Gemcitabine and Abraxane presented with acute worsening of chronic abdominal pain. Labs were remarkable for elevated liver enzymes and a marked increase in CA 19-9. CT Abdomen/Pelvis revealed progression of metastatic disease in the liver and upper abdomen, including the peritoneum and anterior abdominal wall. His pain persisted despite EUS-guided celiac plexus block, but became acutely worse on hospital day 15 when he became febrile, jaundiced, and with blood cultures growing E. Coli, Klebsiella, and Aeromonas. Due to concern for acute cholangitis secondary to stenosis of hepaticojejunostomy, he was taken for ERCP. The biliary system was not successfully identified, so he then underwent IR-guided placement of a biliary drain via percutaneous transhepatic cholangiography, which showed central biliary stenosis and severe bilateral ductal dilation. He was subsequently placed in hospice due to his poor prognosis. The etiology of TCP is multifactorial, but also associated with a mutation of the SPINK1 gene, which causes parenchymal damage by lowering the threshold for trypsin activation. Characteristic radiographic findings include a dilated pancreatic duct with large intra-ductal calculi, pancreatic calcifications, and pancreatic atrophy. Data suggests that only 5% of patients with a 20-year history of chronic pancreatitis develop cancer, but 17% of patients with TCP develop malignancy, which is significantly higher than the near 0% risk of malignancy in those with chronic alcoholic pancreatitis. TCP is a rare disease that potentiates many long-term complications that can significantly increase mortality in an otherwise young and healthy population.1273_A.tif Figure 1: Marked dilation of pancreatic duct measuring up to 18 mm (blue arrow) that terminates at the pancreatic head due to a large calcification (red arrow).1273_B.tif Figure 2: Fine needle aspiration of mass at pancreatic head (blue arrow) and dilated CBD measuring up to 13mm (red arrow).1273_C.tif Figure 3: Multiple hepatic metastatic lesions (blue arrows) and invasion of the pancreatic head mass into the anterior abdominal wall (red arrow).

Save by the DILI

Case of a 67-year-old Hispanic male with past medical history of Diabetes, coronary artery disease and dyslipidemia who arrived to the emergency department (ED) after noticing cola like urine, acholic stools and jaundice. Laboratories were remarkable for elevated liver enzymes; ALT 1,395 U/L, AST 793 U/L, total bilirubin 3.2 mg/dL and alkaline phosphatase of 837 U/L. CBC was within normal limits. Abdominal echo performed at ED showed normal caliber of common bile duct (CBD) and no cholelithiasis. Physical examination was only remarkable for jaundice without chronic liver disease stigmata. During interview, patient reported that symptoms started 2 weeks after completing antibiotic treatment with Augmentin-Clavulanate due to an upper respiratory tract infection. Viral hepatitis profile and serum drug toxicology were unremarkable. Patient was discharged 48 hours later with diagnostic impression of drug-induced liver injury (DILI). One week upon discharge, patient was noticed with worsening jaundice and liver enzymes significative for improving trend in transaminase: ALT 178 U/L, AST 76 U/L, but elevation of total bilirubin at 7.9 mg/dL. CT with liver protocol requested was remarkable for a pancreatic head mass of 2.3 cm x 2.3 cm with secondary dilatation of the CBD, intrahepatic and extra hepatic bile ducts. ERCP was performed due to obstructive jaundice, revealed a distal CBD stricture in favor of a pancreatic head neoplasm. Brushings from the stricture were inconclusive. Surgery service was consulted and patient underwent Whipple's procedure. Pathology report showed evidence of adenocarcinoma of pancreas with T2N1 staging and negative margins. PET scan performed after study, which showed no avid lesions. Patient had an uneventful recovery. Augmentin-Clavulanate is a widely used antibiotic and a frequent cause of idiosyncratic DILI. The onset of presentation is typically on average 3 weeks after antibiotic exposure and commonly presents as cholestatic liver injury. However, DILI is a diagnosis of exclusion for which other causes of hepatic injury should be sought. Hepatobiliary malignancy should be maintained high in differential, especially in an elderly patient. We present an interesting case of pancreatic adenocarcinoma which was found unexpectedly after an initial normal hepatobiliary imaging and negative workup evaluation for acute he patitis secondary to DILI.2266 Figure 1. Pancreatic Mass

Pancreatic Cancer Masked by Acute Pancreatitis as well as an Unusual Iatrogenic Complication

ABSTRACT A 62‑year‑old female presented with abdominal pain and was diagnosed as acute on chronic pancreatitis based on elevated serum amylase and imaging findings. The pancreatic duct was dilated with abrupt cutoff at neck of pancreas, but no mass was visualized. Positron emission tomography‑computed tomography (PET‑CT) revealed a fluorodeoxyglucose (FDG) avid lesion in the neck of the pancreas but ultrasound (USG)‑guided fine‑needle aspiration (FNA) from the lesion revealed only inflammatory cells. Endoscopic ultrasound, done 2 days after USG‑guided FNA, revealed pseudoaneurysm (PA) in the neck of pancreas that was confirmed on CT angiography. The PA was occluded by USG‑guided percutaneous cyanoacrylate injection. As pain persisted, repeat PET CT was done which revealed FDG avidity around the cyanoacrylate cast as well in multiple small hypodense lesions in the right lobe of the liver. USG‑guided FNA from both the liver lesion as well as the periphery of the glue cast revealed features of adenocarcinoma. We herein report a case of pancreatic adenocarcinoma that presented as acute pancreatitis and got masked because of formation of PA consequent to USG‑guided FNA.

Gata3 Immunohistochemical Staining is A Useful Marker for Metastatic Breast Carcinoma in Fine Needle Aspiration Specimens.

Aims:The utility of GATA3 immunohistochemistry (IHC) as an aid to the cytological diagnosis of metastatic breast carcinoma in fine needle aspiration (FNA) specimens was investigated.Materials and Methods:Cell block sections from 111 FNA cases of metastatic malignancy were stained for GATA3, including metastases from 43 breast and 44 nonmammary adenocarcinomas, 19 melanomas, 4 urothelial carcinomas, and 1 thyroid medullary carcinoma. Sites sampled included lymph nodes (87), bone (8), liver (5), lung (6), superficial masses (4), and pelvic mass (1).Results:Ninety-one percent (39/43) of metastatic breast carcinoma cases were positive for GATA3. All estrogen receptor (ER)-positive were also GATA3 positive cases. The majority (9/14; 64%) of ER-negative and 37% (3/8) of triple-negative cases were positive for GATA3. All nonmammary adenocarcinoma cases were negative with the exception of one case of metastatic pancreatic adenocarcinoma. Metastatic melanoma cases were all negative but 75% (3/4) urothelial carcinomas expressed GATA3.Conclusions:GATA3 IHC staining is a useful addition to IHC panels for FNA samples in specific settings such as distinguishing metastatic breast from lung carcinoma or melanoma.

An Uncommon Cause of Colonic Obstruction

Introduction: Pancreatic adenocarcinoma has a poor prognosis and is a leading cause of cancer mortality in the United States. The symptoms are often unnoticed until late stage or metastatic changes induce alarm symptoms. When diagnosed, pancreatic adenocarcinoma has often metastasized with common sites of metastasis involving liver, lungs, abdomen, regional lymph nodes, or peritoneum. Colonic metastasis is rare with four reported cases in the literature to our knowledge. We report a case of pancreatic adenocarcinoma with colonic metastasis presenting as colonic obstruction. Case Description: A 91-year-old woman with history of recently diagnosed diabetes mellitus and chronic constipation presented with early satiety, unintentional weight loss, and nausea with emesis. Initial labs showed Alk Phos 24 unit/L, AST 24 unit/L, ALT 11 unit/L, and Total Bili 0.3mg/dL. Initial Abdominal XR and subsequent barium swallow were normal. Following admission, she developed progressively worsening distention and repeat Abdominal XR showed 14cm right sided colonic distention with concern for obstruction. CT scan was not performed at that time due to retained barium. Colonoscopy was performed to attempt decompression however a severe sigmoid stricture was unable to be traversed. She then underwent sigmoid colectomy with end colostomy. Pathology of sigmoid colonic mass confirmed well-differentiated pancreatic adenocarcinoma metastasis. CT findings indicated mass in the pancreatic head measuring 4x3.3cm with encasement of proximal vasculature. Tumor markers were significant for CA 19-9 7480 unit/mL and CEA 3.6 ng/mL. Discussion: Our patient's risk factors for pancreatic adenocarcinoma included tobacco exposure and recently diagnosed diabetes mellitus. Her presentation with unintentional weight loss, early satiety, and colonic obstruction is not a typical presentation of pancreatic adenocarcinoma. Colonic metastasis of pancreatic cancer is extremely rare, with four previously described cases in the literature to our knowledge. One previous case had an initial presentation with weight loss and imaging suspicious for primary ascending colon malignancy with later identification showing pancreatic cancer metastasis. Our case is the first case, to our knowledge, of pancreatic adenocarcinoma presenting with sigmoid colon metastasis. Therefore, the differential for patients presenting with colonic obstruction and concern for colonic mass should include pancreatic adenocarcinoma.

A Case of Pancreatic Adenocarcinoma with Unique Clinical and Unusual Pathological Features

Pancreatic adenocarcinoma is a form of cancer with ominous prognosis which occurs particularly among men above 50 years old with genetic predisposition and environmental and lifestyle risk factors. The incidence is low in patients less than 50 years old. We report a case of a 35 year old male, who was admitted to our hospital complaining of difficulty in breathing, and was found to have a mediastinal mass, a right subscapular mass, a duodenal polyp, a thickening of the roof of the right orbit. Immunostains of the right subscapular mass showed positivity for CK19, CK7 and focal positivity for B-HCG and alpha fetoprotein

AN UNUSUALLY PROLONGED SURVIVAL IN METASTATIC PERIAMPULLARY PANCREATIC ADENOCARCINOMA

Periampullary cancer is the term used for neoplasms arising from the head of pancreas, ampulla of Vater, distal bile duct and periampullary region of duodenum. Of these, the pancreatic adenocarcinoma carries the worst prognosis with majority of mortalities within the 1st year. The overall 5-year survival is <3%. Studies have shown that pancreatic carcinoma has the shortest median survival of 17.1 months of all periampullary carcinomas. With the development of metastasis, the median survival tends to reduce to 3–6 months. We are reporting a case of metastatic periampullary pancreatic adenocarcinoma that received minimal and interrupted chemotherapy due to poor tolerance and yet managed to survive far beyond the reported median survival. Key words: Adenocarcinoma, pancreas, periampullary, prognosis