Denise Mai, MD, Mary Krinsky, DO, Anand Jagannath, MD; University of California San Diego, San Diego, CA
Introduction: Pancreatic adenocarcinoma is the most likely diagnosis in a patient with obstructive jaundice and pancreatic mass. Tissue diagnosis is important with atypical clinical features since treatment strategies can differ significantly.
Methods: A 35-year-old man presented with abdominal pain, pruritus, and 30-pound weight loss. No fever or night sweats. On exam, he was jaundiced, abdomen was tender; absent Murphy’s sign. Labs showed alk phos 302, ALT 55, AST 63, Tbili 15, LDH > 2,700. CT showed heterogeneous pancreatic head mass, biliary dilation, adrenal nodules, and lymphadenopathy. The patient underwent EUS-guided biopsy of the pancreatic mass and left adrenal, ERCP with biliary plastic stent placement. Cytology revealed seminoma. Scrotal ultrasound demonstrated calcification in the right testis, consistent with a burned-out tumor. Chemotherapy with bleomycin, etoposide, and cisplatin was initiated, with plan for right orchiectomy. Discussion: Pancreatic adenocarcinoma accounts for the diagnosis of obstructive pancreatic head mass in about 90% of patients. These patients are predominantly male over age 55 with a smoking history. Alternative diagnoses include autoimmune pancreatitis, neuroendocrine tumor, lymphoma, and metastases – latter accounts for 2-5% of diagnoses. Imaging cannot always distinguish between primary pancreatic cancer and metastases. EUS-guided tissue acquisition can determine the diagnosis. Seminoma is the most common solid malignancy in men aged 15-35 and usually presents with a unilateral testicular mass. Seminoma rarely metastasizes to the pancreas. It is sensitive to radiotherapy and chemotherapy, with an expected curative outcome and a 90% survival rate, even in metastatic disease. Conversely, node-positive pancreatic adenocarcinoma has a 10% five-year survival rate, even after pancreaticoduodenectomy. In our patient, EUS FNA provided the unexpected diagnosis of metastatic seminoma. This finding was critical to avoid unnecessary surgery or placement of a permanent metal biliary stent. Because of seminoma’s high survival rate and response to chemotherapy, a temporary plastic stent was most appropriate and cost-effective for short-term biliary drainage. Costly metal stents are known to have longer patency rates, however this benefit may not be realized if used for a short time. An uncoated metal stent is permanent and contraindicated. An accurate histopathological diagnosis is critical to determine the appropriate management of pancreaticobiliary malignancies.
CT scan revealing pancreatic mass and common bile duct dilation.
US visualization of the periampullary mass, found to be seminoma.
Disclosures: Denise Mai indicated no relevant financial relationships. Mary Krinsky indicated no relevant financial relationships. Anand Jagannath indicated no relevant financial relationships.