Metastatic Pancreatic Small-Cell Carcinoma Presenting As Acute Pancreatitis

University of Wisconsin Hospital and Clinics, Madison, WI, USA.
Journal of Clinical Oncology (Impact Factor: 18.43). 12/2010; 28(36):e748-9. DOI: 10.1200/JCO.2010.30.4600
Source: PubMed


Available from: Christina Fitzmaurice, Feb 06, 2015
Metastatic Pancreatic Small-Cell Carcinoma
Presenting As Acute Pancreatitis
A 77-year-old woman presented with nausea and acute onset of
severe epigastric pain with radiation to her back. Physical examination
revealed epigastric tenderness without rebound or guarding. Labora-
tory analysis showed lipase at 1,970 U/L (reference range, 23 to 300
U/L) and amylase at 220 U/L (reference range, 30 to 110 U/L) with
normal liver chemistries, including bilirubin at 0.3 mg/dL (reference
range, 0.2 to 1.3 mg/dL), alkaline phosphatase at 100 U/L (reference
range, 38 to 136 U/L), ALT at 22 U/L (reference range, 9 to 72 U/L),
and AST at 35 U/L (reference range, 14 to 59 U/L). She was diagnosed
with acute pancreatitis, and gastroenterology consultation was
obtained for further evaluation and management. A right upper quad-
rant ultrasound demonstrated a 2.3 cm 1.9 cm area of hypoechoge-
nicity in the pancreatic head suggestive of a primary pancreatic
neoplasm. An abdominal computed tomography (CT) scan con-
firmed an ill-defined 2.2-cm low-attenuation mass in the pancreatic
head. Also seen were bilateral adrenal masses measuring up to 5 cm in
size. Her cancer antigen 19-9 (CA 19-9) was 26 U/L (reference range,
37 U/L). The liver appeared normal without evidence of metastatic
disease. An endoscopic ultrasound with fine-needle aspiration of the
pancreatic head (Fig 1) and adrenal (Fig 2) masses revealed small-cell
carcinoma (Fig 3). Immunohistochemistry was performed, and thy-
roid transcription factor 1, synaptophysin, and chromogranin were
positive, confirming the diagnosis. The patient did not have any respi-
ratory complaints but was a long-time smoker with a 55-pack-year
history. A chest CT demonstrated enlarged axillary, mediastinal, and
hilar lymph nodes as well as a solitary 8-mm sclerotic lesion in the
midthoracic spine but was notably negative for pulmonary nodules or
masses. Further staging work-up included a brain CT scan that
showed several small enhancing masses consistent with diffuse brain
metastasis. Given the extent of her disease she elected not to undergo
chemotherapy or radiation treatment and succumbed to her disease
within 2 months of her initial diagnosis.
Small-cell carcinoma of the pancreas (SCCP) is a rare and aggres-
sive tumor with a high metastasis rate. Only 1% of all primary pancre-
atic neoplasms are small-cell carcinomas and 4% of all small-cell
carcinomas have an extrapulmonary origin.
In a review of all pub-
lished cases of SCCP, 91% were metastatic at the time of initial diag-
The most common sites for metastases are peripancreatic
lymph nodes, liver, lungs, bone marrow, bone, colon, and adrenal
Bilateral adrenal metastases from a primary small-cell carci-
noma of the pancreas, as described in our patient, is exceedingly rare
Fig 1.
Fig 2.
Fig 3.
e748 © 2010 by American Society of Clinical Oncology
Journal of Clinical Oncology, Vol 28, No 36 (December 20), 2010: pp e748-e749
Page 1
and has been described on only one other occasion.
Presenting symp-
toms are most often abdominal pain, weight loss, and jaundice.
Other rare symptoms include Cushing-like syndrome and hypercal-
The main treatment for SCCP is chemotherapy. Cisplatin,
etoposide, and fluorouracil have been used, with the most common
regimen being a combination of cisplatin and etoposide.
no consensus exists because of the limited number of cases. Rarely,
surgical resection or external radiation therapy has been coupled with
chemotherapy. In a recent review by Vos et al,
no survival difference
was found between chemotherapy alone and chemotherapy with local
treatment (radiation therapy or surgery). Long-term survival in pa-
tients with SCCP is poor, with a median survival of 3 months, and
appears to be worse when compared with that of small-cell carcinoma
of the lung.
In addition, survival in SCCP is worse when com-
pared with ductal adenocarcinoma of the pancreas, the most common
tumor of the exocrine pancreas. For patients with advanced pancreatic
ductal adenocarcinoma, the 5-year overall survival is 1% and most
patients die within 1 year.
Conversely, the 5-year overall survival
after surgical resection in localized pancreatic ductal adenocarcinoma
is 18% to 24%.
Thus, SCCP portends a significantly worse prognosis
than either localized pancreatic ductal adenocarcinoma or small-cell
carcinoma of the lung and should be considered before undertaking
aggressive treatment.
Christina Fitzmaurice, Daniel D. Cornett, Bret J. Spier,
and Patrick Pfau
University of Wisconsin Hospital and Clinics, Madison, WI
The author(s) indicated no potential conflicts of interest.
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DOI: 10.1200/JCO.2010.30.4600; published online ahead of print at on September 13, 2010
Diagnosis in Oncology © 2010 by American Society of Clinical Oncology e749
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    • "Each paper was inspected and the reference lists of the selected articles were also screened systematically for additional studies of interest. More than 20 cases of primary small cell carcinoma of the pancreas were excluded.1–6 Additionally, some cases with small cell cancer in the studies were analysed just to some extent because they did not describe the detailed clinical findings 7–18 Information regarding patient presentation, site of primary neoplasia, characteristics of metastasis in the pancreas, treatment, and patient demographics were summarised using descriptive statistics. "
    [Show abstract] [Hide abstract] ABSTRACT: Few data are available concerning incidence, clinical picture, and prognosis for pancreatic metastases of small cell lung carcinoma. In this paper we review the related literature available in English language. Although pancreatic metastases are generally asymptomatic, they can rarely produce clinical symptoms or functional abnormalities. The widespread use of multi-detector computerised tomography (CT) in contemporary medical practice has led to an increased detection of pancreatic metastases in oncology patients. Tissue diagnosis is imperative because radiological techniques alone are incapable of differentiating them from primary pancreatic tumours. Pancreatic metastases occur in the relative end stage of small cell lung cancer. The main complications of these lesions, although rare, are acute pancreatitis and obstructive jaundice. Early chemotherapy can provide a survival benefit even in patients with mild acute pancreatitis or extrahepatic biliary obstruction.
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    • "It was presented one case of a pancreatic small-cell carcinoma presenting as acute pancreatitis[7]. "
    [Show abstract] [Hide abstract] ABSTRACT: Pancreatic cancer is still considered to be one of the leading causes of cancer deaths. The most common of all the different types of pancreatic cancer is ductal original malignant tumors, and their clinical features are commonly characterized. However, for the rare tumors in the pancreatic region, the clinical features often vary, and detection of the cancers are detected late. Limited data are available to guide the management of very rare neoplasms of the pancreas. Therefore, to recognize or detect the rare tumors in the pancreatic region are of importance for the clinical practice.
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    [Show abstract] [Hide abstract] ABSTRACT: Small cell carcinoma (SCC) of lung is a highly malignant tumour and is notorious for early and widespread metastasis at the time of presentation. However, metastasis to pancreas occurs uncommonly. Metastatic lesions comprise of 3% of all pancreatic malignancies. We hereby present a rare case report where patient presented with symptoms of acute pancreatitis & diagnosed with SCC of lung, retrospectively. This case emphasize that acute pancreatitis can be a manifestation of malignancy and fine needle aspiration cytology can play a diagnostic role in such cases.
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