University of Rochester Medical Center Rochester, NY
Sarah Enslin, PA-C1, Samantha Gross2, Raseen Tariq, MD3, Vivek Kaul, MD, FACG1; 1University of Rochester Medical Center, Rochester, NY; 2Horace Greeley High School, Chappaqua, NY; 3Rochester General Hospital, Rochester, NY
Introduction: Carbohydrate antigen 19-9 (CA 19-9) is a modified Lewis blood group antigen which is commonly utilized in the diagnosis and prognostication of pancreaticobiliary malignancies. On rare occasion, it may also be significantly elevated in benign conditions. We present two benign case scenarios of a significantly elevated CA 19-9 which normalized after appropriate management.
Methods: Case 1: A 57-year-old female with history of breast cancer presents with back pain and dyspepsia. Labs revealed total bilirubin of 8 mg/dL, AST 168 U/L, ALT 274 U/L, ALK 128 U/L, and CA 19-9 of 24000 U/mL. CT abdomen revealed choledocholithiasis. EUS showed normal appearing pancreas without mass lesion, common bile duct (CBD) stones and a thickened CBD wall. ERCP was performed with removal of CBD stones. CBD brushings were performed; cytology was unremarkable. Post-procedure, liver tests improved and CA 19-9 normalized to 15 U/mL within 4 weeks. She underwent elective uncomplicated laparoscopic cholecystectomy. Patient has remained symptom free with normal labs in follow-up 18 months later.
Case 2: A 48-year-old male with history of chronic heavy alcohol use presents with abdominal pain, jaundice, abnormal liver tests (total bilirubin 22 mg/dL, ALK 1400 U/L, AST 841 U/L, ALT 458 U/L), WBC 16,500 cells/mcL and CA 19-9 of 27,800 U/mL. CT scan and MRCP revealed a cirrhotic liver, ascites, normal bile and pancreatic ducts and no masses. EUS of the pancreas was normal. A clinical diagnosis of acute alcoholic hepatitis was entertained and patient was treated with methylprednisolone with significant improvement in clinical and laboratory assessment over the next 6 weeks. CA 19-9 returned to near normal levels at 3 months follow-up (110 U/mL). Repeat abdominal imaging and CA 19-9 has remained stable over the last 9 months. Discussion: Significant elevation of serum CA 19-9 levels usually portends an ominous prognosis concerning for pancreaticobiliary malignancy. Our case series demonstrates certain benign biliary pathology can also lead to this finding. The absence of a mass lesion, lack of a tissue diagnosis of malignancy and normalization of serum CA 19-9 levels favors a benign process, especially when an alternate pathology is found (stones, hepatitis, etc). However, when a clear alternate (non-malignant) etiology is not found, the search for malignancy must continue and may include diagnostic laparoscopy, PET scan or repeat serial multi-modal imaging, until pathology discovered.
Disclosures: Sarah Enslin indicated no relevant financial relationships. Samantha Gross indicated no relevant financial relationships. Raseen Tariq indicated no relevant financial relationships. Vivek Kaul indicated no relevant financial relationships.