UNUSUAL PANCREATIC MALIGNANCY J. Coe MD, A. Mahmood MD, F. Shaikh MD, R. Lee DO, R. Randive DO, S. Aggarwal MD, N. Salagundla MD Department of Medicine, University Hospital and Clinics, LSU Health, Lafayette, LA
INTRODUCTION: Typically, pancreatic malignancies arise from the exocrine portion of the pancreas. However, a subset of pancreatic cancers are derived from neuroendocrine cells, leading to the development of small cell cancers. These cells are present mainly in the gastrointestinal tract and lung.
CASE: A 58 year old man with hypertension and alcohol abuse presented endorsing severe lower back pain for 3 weeks. This pain radiated towards the abdomen and was described as a sharp that worsened with ambulation. CT abdomen and pelvis 1 week prior to presentation had shown a mass at the junction of the head and body of the pancreas. This CT also showed hepatic and pulmonary lesions concerning for possible metastases. A EUS was performed with biopsy of the pancreatic and a liver lesion CT thorax demonstrated multiple nodules consistent with metastases and necrotic hilar and mediastinal lymph nodes. MRI brain revealed supratentorial and intratentorial enhancing foci. The pathology results from both masses revealed poorly differentiated neuroendocrine carcinoma, small cell variant. He was discharged with pain control and urgent follow up in oncology clinic. DISCUSSION: While pancreatic neuroendocrine neoplasms are very rare (1-2% of pancreatic malignancies), their incidence in the U.S. has been increasing. These malignancies can present similar to small cell carcinoma of the lung. These cancers are graded based on mitotic count and Ki-67 index with higher levels indicating a higher grade and the more poorly differentiated the tumor. The mainstay of treatment is systemic chemotherapy. The prognosis for these patients tends to be poor with median survival time from diagnosis at less than 1 year. Malignant cells which are hormonally active (producing glucagon, insulin, or gastrin) tend to be discovered earlier, improving survival rates. Pancreatic small cell cancer tends to metastasize in a pattern similar to small cell lung cancer. As a result, patients with pancreatic small cell should have brain imaging as well as lung imaging to screen for metastatic lesions.
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