VCOM Research Day Program Book 2023

Medical Resident Research Case Reports

10 A Case Report Highlighting the Inherent Diagnostic Complexities of Pancreatic Tail Cancer

Dr. Anthony Conforti; Vincent Conforti; Dr. Michael Caplan Corresponding author: anthony.conforti@lpnt.net

SOVAH Health Internal Medicine Residency Program

revealed bilateral acute pulmonary emboli with associated right ventricular heart strain. CT abdomen/ pelvis showed a 3.9 x 2.8 cm inhomogeneous mass of the distal pancreatic tail, scattered low-density lesions of varying sizes in the liver with surrounding lymphadenopathy, and rectosigmoid colonic wall thickening. The patient was placed on a heparin drip and recommended for follow-up outpatient to evaluate the incidental findings of suspected malignancy. After discharge, the patient presented to his primary care physician complaining of fatigue, poor appetite, and an eight-pound weight loss over a period of three weeks. The physician ordered tumor markers and placed a Gastroenterology referral. CA 19-9 came back elevated at 96,095. Initially, Gastroenterology was unable to obtain a pancreatic biopsy due to the location of the mass. Therefore, Oncology was consulted to see if they would provide palliative treatments without a formal tissue sample. Shortly thereafter, Gastroenterology confirmed malignancy by sampling a suspected metastatic lesion in the liver. Two days later, the patient returned to the hospital, septic and encephalopathic, complaining of lethargy.

Labs (six weeks after the initial set of labs) showed: AST 404, ALT 106, Alkaline Phosphatase 446, and total bilirubin 4.6. The patient was placed on comfort measures only and was pronounced the next day. Conclusion: This case report is significant because it highlights the barriers to definitively diagnosing pancreatic tail cancer. While the insidious patient presentation often delays an initial workup, the atypical location can prevent an endoscopic ultrasound-guided biopsy. Although pancreatic adenocarcinoma remains the third most common cause of cancer death, there are currently no screening guidelines in place. Consequently, the prognosis of pancreatic tail cancer is often abysmal.

Context: Pancreatic adenocarcinoma is a lethal malignancy that rarely develops in the organ's body or tail. Due to its peripheral location, pancreatic tail cancer seldom presents with pathognomonic obstructing symptoms, including jaundice, abdominal pain, or significant weight loss. As a result, this pathology is frequently detected at later stages of growth, leading to worse prognoses and detrimental outcomes. The case presented here exemplifies some of the diagnostic challenges associated with this condition. Case Presentation: A 72-year-old man presented to the hospital for evaluation of left-sided chest pain and shortness of breath after a recent 9-hour car drive. Past medical history was significant for prostate cancer in remission. Upon examination, the patient denied abdominal pain, nausea/vomiting, constipation, or significant weight loss. Labs: AST 39, ALT, 30, Alkaline Phosphatase 358, total bilirubin 0.6. Lower extremity ultrasound ruled out deep vein thrombosis bilaterally. Chest CT angiogram

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