SESSION TITLE: Cancer Student/Resident Cases
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 04:30 PM - 05:30 PM
INTRODUCTION: Small cell carcinoma of the lung (SCLC) is an aggressive disease that tends to metastasize early in its course and has a poor prognosis. Pancreatic metastasis generally constitutes a late manifestation of this disease and most patients do not have organ specific symptoms i.e. jaundice, abdominal pain and weight loss. We hereby, present an interesting case of small cell carcinoma of lung, which had acute pancreatitis as the initial manifestation of the disease.
CASE PRESENTATION: A 71 year old female with significant history of tobacco abuse presented with complaints of epigastric abdominal pain radiating to the back for 2 days. She also reported weight loss of 40 lbs during the past 4 months. There was no history of alcohol abuse or gall stones. Physical examination was unremarkable except for epigastric tenderness and scleral icterus. Laboratory investigation revealed Amylase 1469 U/L, Lipase 1632 U/L, total bilirubin 3.9 mg/dl, Alkaline Phosphatase 332 IU/L, ALT 79 IU/L and AST 88 IU/L. Diagnosed with acute pancreatitis, she had MRCP which showed hyper intense hepatic nodules on background of iron deposition and mild dilation of biliary system. ERCP revealed displaced major papilla, distal common bile duct indentation which was suspicious for distal bile duct stricture. Shelving was also noted with poor drainage of the contrast for which a plastic biliary stent was placed. Brushing from the common bile duct showed atypical ductal proliferation. CT of the chest revealed 2.5 cm irregular mass in the superior hilar aspect of the right lower lobe of lung with irregular margins. A CT guided biopsy of the liver lesions showed malignant cells with immunostaining positive for TTF-1, chromogranin and synaptophysin; Ki67 revealed nuclear reactivity for about 95% of tumor cells. Flow cytometric studies demonstrated that the tumor cells expressed CD56 (neuroendocrine marker) but were negative for lymphohemotopoietic markers. All these findings were compatible with a diagnosis of metastatic SCLC
DISCUSSION: SCLC having acute pancreatitis as the initial presentation is a rare event. Literature review revealed 11 other cases of similar presentation (Table). Possible mechanisms for metastatic cancer inducing pancreatitis include obstruction of the pancreatic duct by metastases or peripancreatic compression secondary to regional lymph node or vascular compromise by neoplastic destruction1. However in some patients there is no evidence of pancreatic metastasis raising the question if this is a paraneoplastic manifestation2.
CONCLUSIONS: Small cell carcinoma of lung can present as acute pancreatitis secondary to metastatic or paraneoplatic manifestation.
Reference #1: Muranaka T, Teshima K, Honda H, Nanjo T Computed tomography and histologic appearance of pancreatic metastases from distant sources Acta Radiol. 1989 Nov-Dec; 30(6):615-9.
Reference #2: Ugur Gonlugur, Arzu Mirici, Muammer Karaayvaz. Pancreatic involvement in small cell lung cancer Radiol Oncol. Mar 2014; 48(1): 11-19.
DISCLOSURE: The following authors have nothing to disclose: Faraz Khan Luni, Muhammad Ali Khan, Luis De Las Casas, Yaseen Alastal, Abdullah Alwardi, Youngsook Yoon
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