St. Elizabeth's Medical Center, Tufts University School of Medicine Boston, MA
Tahnee K. Sidhu, MD, MPH1, Erik Holzwanger, MD2, Rohit Dhingra, MD2, Christopher G. Stallwood, MD3; 1St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA; 2Tufts University Medical Center, Boston, MA; 3Tufts University School of Medicine, St. Elizabeth's Medical Center, Brighton, MA
Introduction: Pancreatic tumors are typically primary neoplasms, with the majority consisting of ductal adenocarcinomas. Primary squamous cell carcinoma (SCC) of the pancreas is extremely rare, and therefore if found, metastatic disease should be considered. Metastasis to the pancreas is also uncommon with an incidence from 0.7% to 11.1%. Diagnostic evaluation can be challenging as the diagnosis itself can be unreliable based on immunohistochemical staining. We hereby present a case of an esophageal mass found incidentally during workup of a known pancreatic mass, both ultimately proven to be SCC.
Methods: A 64-year old male with past medical history of prior smoking, gastroesophageal reflux disease, esophageal stricture, and prostate cancer presented with 2 months of intermittent periumbilical abdominal pain and nausea. Work-up was noteworthy for CT of the abdomen and pelvis which showed an ill-defined 4.5 x 3.4 cm pancreatic tail mass with peripancreatic stranding, and upper abdominal lymphadenopathy. Serum tumor markers CA 19-9 and CEA were normal. EGD revealed a 2 cm friable, non-obstructing mass in the middle third of the esophagus (figure 1). On EUS, the mass was noted to invading the muscularis propria. EUS was further notable for a 42 mm by 39 mm hypoechoic mass in the pancreatic tail (figure 2) and peri-aortic lymphadenopathy. Biopsy and immunohistochemical staining of the esophageal mass, pancreatic mass, and per-aortic lymph nodes are illustrated in figure 3. The clinical picture was thought to be most likely metastatic SCC of esophageal origin. Palliative chemotherapy with FOLFOX was initiated. Discussion: Primary SCC of the pancreas is extremely rare, and thus requires extensive workup for metastatic disease including CT of the head and chest, upper endoscopy, colonoscopy, pelvic exam with pap smear, and a detailed skin examination. Pancreatic metastasis from another primary site is also rare. Esophageal SCC metastasis to the pancreases is particularly uncommon, with an incidence of 0% to 4.8%. As highlighted by this case, appropriate diagnosis of SCC of a pancreatic mass for treatment guidance remains challenging as metastatic SCC may mimic primary pancreatic malignancy both clinically and cytologically. Therefore, even with tissue diagnosis, primary pancreatic SCC cannot be cytologically distinguished from metastatic SCC through immunohistochemistry and often requires clinical correlation after an extensive workup.
EGD revealed a 2 cm friable, non-obstructing mass in the middle third of the esophagus.
EUS showed a 42 mm by 39 mm hypoechoic mass in the pancreatic tail.
Findings of the biopsies and immunohistochemical staining of the esophageal mass, pancreatic mass, and per-aortic lymph nodes.
Disclosures: Tahnee Sidhu indicated no relevant financial relationships. Erik Holzwanger indicated no relevant financial relationships. Rohit Dhingra indicated no relevant financial relationships. Christopher Stallwood indicated no relevant financial relationships.