Pulmonary and Critical Care Pearls |

A 52-Year-Old Man With a Lung Mass and Acute Abdominal Pain* FREE TO VIEW

Anthony Papagiannis, MD, FCCP; Kostas Zarogoulidis, MD, PhD; Dimitrios Delis, MD; Dimitrios Patakas, MD, PhD
Author and Funding Information

*From the Academic Pulmonary Department, George Papanikolaou Hospital, Thessaloniki, Greece.

Correspondence to: Anthony Papagiannis, MD, FCCP, Gregoriou E’ 42, GR 542 49, Thessaloniki, Greece; e-mail: antpap@the.forthnet.gr

Chest. 2000;117(3):894-896. doi:10.1378/chest.117.3.894
Text Size: A A A
Published online

A 52 -year-old man who was a heavy smoker was referred for investigation of voice hoarseness. Physical examination disclosed a left-sided hard supraclavicular lymph node. The initial chest radiograph is shown in Figure 1 . Fiberoptic bronchoscopy showed a paralyzed left vocal cord and stenosis of the left upper lobar bronchus; endobronchial biopsies were obtained. The lymph node was separately excised under local anesthesia.

Some days later, when the patient attended the hospital to get the biopsy results, he reported severe abdominal pain that he had had for> 24 h, and that was not relieved by simple analgesics. The pain had been acute in onset, without associated nausea, vomiting, or fever.

The patient was in pain, but not in shock, with a pulse rate of 100 beats/min; BP, 200/100 mm Hg; and temperature, 36.8°C. There was no clubbing. The lungs were clear. Cardiac examination was normal. Examination of the abdomen showed absent bowel sounds, moderate distension, and diffuse tenderness in the periumbilical area with minimal guarding. The liver and spleen were not palpable.

Laboratory findings were as follows: WBC count, 18.4 × 103/μL (86.3% neutrophils, 4% lymphocytes, and 8.3% monocytes); hematocrit, 48.2%; platelets, 480 × 103/μL; glucose, 118 mg/dL; BUN, 20 mg/dL; creatinine, 0.9 mg/dL; sodium, 149 mmol/L; potassium, 5.0 mmol/L; and calcium, 10.6 mmol/dL. Serum aspartate aminotransferase was 55 IU/L (normal, 10 to 40 IU/L); serum alanine aminotransferase, 67 IU/L (normal, 10 to 40 IU/L); serum gamma-glutamyl transpeptidase, 92 IU/L (normal, 20 to 75 IU/L); and serum alkaline phosphatase, 99 IU/L. A plain radiograph of the abdomen revealed multiple air/fluid levels in both the small and the large bowel.

Answer: Metastasis-induced acute pancreatitis

In pathologic studies, the prevalence of pancreatic metastases from small cell lung cancer (SCLC) has been estimated to be from 20 to 40%. However, clinically evident acute pancreatitis has been reported only in a handful of cases of lung cancer; most of them are SCLC (estimated prevalence, 3.3 to 7.5%). In most of these patients, the pancreatitis occurred in the setting of known carcinoma (usually with clinical and radiologic appearances of widespread metastasis); occasionally, it was the presenting manifestation of a hitherto occult tumor or the site of first relapse after the initial response to treatment. It has been suggested that the diagnosis should be considered in any patient with known SCLC who develops an acute abdomen. The postulated mechanisms include mechanical ductal obstruction and rupture, and vascular compromise from tumor invasion or compression from enlarged lymph nodes.

Given the difficulty of obtaining pancreatic biopsies for confirmation and the usually grave condition of the patient, the diagnosis should be based on the clinical, biochemical, and radiologic features of pancreatitis, as well as evidence of disease progression elsewhere and failure to respond to conservative management. The clinical features are virtually indistinguishable from those of pancreatitis of any other cause (to which lung cancer patients are not immune); the more common risk factors, such as alcohol, gallstones, and hypertriglyceridemia, should be considered. In some cases, ultrasonography or CT may reveal masses or nodules in the pancreas and thus point to the cause of the pancreatitis. A useful algorithm has been produced for the management of patients with acute pancreatitis and a suspicious chest radiograph.

The prognosis of metastatic pancreatitis is grim: without specific treatment, most of the patients described in the literature survived only 10 to 14 days. The known chemosensitivity of SCLC prompted some clinicians to attempt aggressive combination chemotherapy. Four patients responded despite extensive metastases to liver, brain, skin, and adrenals, with survival of 4 to 6 months. On the other hand, two patients received chemotherapy without response and died in < 2 weeks. Obviously, the decision about chemotherapy should take into account the degree of certainty of the diagnosis, the exclusion of other likely causes for the pancreatitis, and the general condition of each specific patient. The Ranson score for the severity of the pancreatitis has been used to predict outcome: patients with more than three poor prognostic signs did not survive for > 2 weeks and thus should be given supportive care only. Patients with a lower Ranson score may receive chemotherapy; however, attention should be paid to the choice of antineoplastic agents, as there have been reports of pancreatitis associated with ifosfamide, vinorelbine, and cisplatin.

In our patient, the diagnoses of pancreatitis (possibly related to his high alcohol consumption), obstruction due to primary tumor or metastatic disease, and GI perforation due to his intake of nonsteroidal anti-inflammatory agents for pain relief were initially considered. The serum amylase measurement on admission was 934 IU/L (normal, up to 210 IU/L). He was managed conservatively with dietary restriction, parenteral fluids and alimentation, and prokinetic agents, and his paralytic ileus resolved. He required opiates for pain relief. A CT scan of the abdomen (Fig 2 ) showed an enlarged inhomogeneous pancreas with “soiling” of the peripancreatic fat and thickened perirenal fascia. No distinct pancreatic masses were described, but there was enlargement of both adre-nal glands and multiple hypoechoic areas in the liver indicating metastatic disease; there were no gall-stones. Both the endobronchial and lymph node biopsies revealed a poorly differentiated tumor with features suggestive of small cell carcinoma. He had persistently raised serum amylase levels (around 1,000 IU/L) and continued to experience severe periumbilical pain for the next 2 weeks. The use of chemotherapy was considered, but, as the causative relation of the pancreatitis to the neoplasm was not certain, this was postponed until there was some symptomatic improvement. Unfortunately, the patient’s symptoms did not abate, and he died 3 weeks after the onset of the pancreatitis. An autopsy was not performed. In the setting of widespread metastatic disease and in view of the lack of response to conservative management (even after the administration of somatostatin), we speculate that the pancreatitis may have been due to involvement of the pancreas by the small cell lung tumor.

  1. Acute pancreatitis is a rare manifestation of small cell lung carcinoma, usually in the setting of extensive disease.

  2. Acute pancreatitis may occasionally be the presenting manifestation of an occult tumor or the site of relapse following initial response to treatment.

  3. Differentiating metastasis-induced acute pancreatitis from the usual forms of acute pancreatitis is virtually impossible by noninvasive means; the lack of response to conservative management may provide a clue.

  4. Chemotherapy may provide a survival benefit in some patients and should be considered on an individual basis. It probably should not be offered to patients with more than three poor prognostic factors using the Ranson score.

Allan SG, Bundred N, Eremin O, et al. Acute pancreatitis in association with small cell lung carcinoma: potential pitfalls in diagnosis and management. Postgrad Med J 1985; 61:643–644

Chowhan NM, Madajewicz S. Management of metastases-induced acute pancreatitis in small cell carcinoma of the lung. Cancer 1990; 65:1445–1448

Hall M, Bundred NJ, Hall AW. Oat cell carcinoma of the bronchus and acute pancreatitis. Eur J Surg Oncol 1987; 13:371–372

Levine M, Danovitch SH. Metastatic carcinoma to the pancreas: another cause for acute pancreatitis. Am J Gastroenterol 1973; 60:290–294

Niccolini DG, Graham JH, Banks PA. Tumor-induced acute pancreatitis. Gastroenterology 1976; 71:142–145

Ranson JHC, Rifkind KM, Roses DF, et al. Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet 1974; 139:69–81

Stewart KC, Dickout WJ, Urschel JD. Metastasis-induced acute pancreatitis as the initial manifestation of bronchogenic carcinoma. Chest 1993; 104:98–100

Yeung KY, Haidak DJ, Brown JA, et al. Metastasis-induced acute pancreatitis in small cell bronchogenic carcinoma. Arch Intern Med 1979; 139:552–554

Figure Jump LinkFigure 1. Chest radiograph showing left hilar enlargement.Grahic Jump Location
Figure Jump LinkFigure 2. CT scan of the abdomen showing diffuse, inhomogeneous enlargement of the pancreas (arrows).Grahic Jump Location


Figure Jump LinkFigure 1. Chest radiograph showing left hilar enlargement.Grahic Jump Location
Figure Jump LinkFigure 2. CT scan of the abdomen showing diffuse, inhomogeneous enlargement of the pancreas (arrows).Grahic Jump Location



Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543