Teaching Case

An obese 56-year-old male presented to the hospital with obstructive jaundice and underwent further radiologic investigation. One year earlier, he presented to the ER and was admitted for dull epigastric abdominal pain with unremarkable physical exam and mildly elevated lipase. The patient is a non-smoker and non-drinker.

During the initial hospital encounter in the ER, a contrast-enhanced CT obtained at 3 mm increments demonstrated a mildly edematous head of the pancreas likely from interstitial pancreatitis (Fig. 1). Follow-up endoscopic ultrasound (EUS) and biopsy indicated a heterogeneous pancreatic head and body with no evidence of a cancerous mass lesion or abnormal pancreatic duct. Upon return one year later, CT scan showed hypodensity in the head of the pancreas with possible pancreatic duct stricture and common bile duct (CBD) dilation to 2.5 cm. A thrombus in the portal vein was noted as well (Fig. 2). Percutaneous transhepatic cholangiogram (PTC) further demonstrated dilated intrahepatic ducts and an irregular wall of the distal CBD (Fig. 3). EUS-guided biopsy revealed tumor cells positive for adenocarcinoma.

Background:

Pancreatic adenocarcinoma is an aggressive disease with a dismal prognosis that ranks third in cancer-related mortality in the United States [1]. Early on in the course of the disease, a pancreatic mass may be difficult to find on imaging. Yet, it is imperative to diagnose the disease early as this allows for more effective interventions to minimize the morbidity and mortality associated with the disease. Acute pancreatitis has been found to be a common early, yet rare manifestation of pancreatic cancer [2]. As was noted in this case, it can occur several weeks to months prior to the official diagnosis [4.5].

Clinical Perspective:

Pancreatic adenocarcinoma presents with abdominal pain, asthenia, weight loss and jaundice, but this typically represents later stages of the disease [2]. Acute pancreatitis can present with similar symptoms, particularly abdominal pain. Our patient presented with this symptom and underwent biopsy which came back negative. However, a year later, he presented with obstructive jaundice secondary to advanced pancreatic cancer. When dealing with possible pancreatic cancer, avoiding diagnostic error when assessing initial symptom presentation is extremely important given its high mortality rate. If pancreatic adenocarcinoma is a consideration, one should not stop after one negative biopsy. Close monitoring with follow-up biopsy or imaging should be done a few months later [3].

Imaging Perspective:

Diagnostic imaging of patients with acute pancreatitis could potentially help in diagnosing more patients with early-stage pancreatic cancer. A radiologist should try to look for etiologies for acute pancreatitis utilizing CT which is the most clinically useful and preferred tool, and if needed other adjunctive modalities like ultrasound or MRI [6]. If the clinician has any suspicion for adenocarcinoma, we recommend close follow-up with thin-section, multiphasic CT scans or MRI [7]. This is imperative as we often see the initial scans obtained in the emergency department may not be protocolled adequately and screened by radiologists. Interdepartmental conferences for interesting cases should be considered to advance the imaging perspective of clinicians as well.

Outcome:

Surgical resection with or without adjuvant chemotherapy is considered the treatment of choice for patients with early-stage pancreatic cancer, but only <20% of patients present early enough. The majority of patients present with unresectable, metastasized disease and thus are relegated to chemotherapy and palliative care [8,9]. Unfortunately, in this case, due to a delay in diagnosis, the patient succumbed to advanced spread of pancreatic cancer with obstructive jaundice and peritoneal carcinomatosis.

Take-Home Message / Teaching Points:

Pancreatitis as the initial presenting symptom of pancreatic adenocarcinoma though rare should be kept in mind. If the suspicion for cancer is high, an MRI or 2-phase CT scan of the pancreas with thin sections should be ordered by the clinician in the initial workup of unexplained pancreatitis. Subsequent follow-up with close monitoring should be considered as well.

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