Matthew D. Grunwald, MD, Richard M. Fazio, MD, Marina Landa, BSc, Omar P. Azar, MD, Maryanne Ruggiero Delliturri, MD, Danny A. Sherwinter, MD, Kadirawel Iswara, MD, FACG, Dmitriy O. Khodorskiy, MD; Maimonides Medical Center, Brooklyn, NY
Introduction: Pancreatic cancer (PC) is one of the deadliest malignancies, and represents the fourth leading cause of cancer death in the United States. According to the Surveillance, Epidemiology, and End Results (SEER) registry, fewer than 2 percent of patients with PC are under the age of 45. Those who are diagnosed with PC at a younger age consistently show better outcomes, including overall, progression-free and disease-free survivals.
Methods: We present a case of a 35-year-old woman with past medical history of cholelithiasis status post endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and extraction of choledocholiths followed by cholecystectomy at the age of 20 and morbid obesity status post laparoscopic gastric sleeve at the age of 30 who was referred for ERCP with extraction of choledocholiths. She underwent a magnetic resonance imaging (MRI) which revealed a 3.1 x 2.8 cm mildly heterogeneously enhancing pancreas head mass (Figure 1a) associated with marked upstream dilation of the biliary tree (Figure 1b). Endoscopic ultrasonography (EUS) revealed a 23.7 x 22.1 mm hypoechoic heterogeneous pancreas head mass with ill-defined borders. Fine needle biopsy (FNB) was performed (Figure 2a) with pathology revealing adenocarcinoma (Figure 2b). Due to external compression of pancreas mass on duodenum, major ampulla was not visualized, and ERCP was performed by rendezvous technique in conjunction with interventional radiology (Figure 3a). A transpapillary fully covered self-expanding metal stent (FC-SEMS) was successfully deployed resulting in biliary decompression (Figure 3b). As there was no imaging evidence of metastatic disease, patient was referred for resection with curative intent after neoadjuvant chemotherapy administration. Discussion: PC prevalence in patients under the age of 50 remains rare. Certain risk factors for early onset are similar to those for late onset PC. These include alcohol use, tobacco use, chronic pancreatitis, diabetes mellitus, obesity and previous cholecystectomy or gastrectomy. In early onset PC, special attention should be paid to molecular genetics. The typical oncogenes, such as KRAS and c-Myc, and tumor suppressor genes, such as TP53, CDKN2a and SMAD4, still play a role, however, special attention should be paid to BRCA 1 and BRCA 2 germline mutations, as these patients show a particularly early disease onset. Surgical resection is the only curative therapeutic approach, and early detection is essential to ensure resectability.
Figure 1: (a) MRI axial image displaying pancreatic head mass; (b) MRCP coronal image displaying biliary ductal dilation upstream from pancreatic mass
Figure 2: (a) EUS image with FNB of pancreatic head mass; (b) pathology slide displaying high magnification image of pancreatic adenocarcinoma
Figure 3: (a) Biliary access achieved by rendezvous technique with interventional radiology; (b) Transpapillary fully covered self expanding metal stent successfully deployed
Disclosures: Matthew Grunwald indicated no relevant financial relationships. Richard Fazio indicated no relevant financial relationships. Marina Landa indicated no relevant financial relationships. Omar Azar indicated no relevant financial relationships. Maryanne Ruggiero Delliturri indicated no relevant financial relationships. Danny Sherwinter indicated no relevant financial relationships. Kadirawel Iswara indicated no relevant financial relationships. Dmitriy Khodorskiy indicated no relevant financial relationships.