Article

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
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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.
1-6
In a review of all pub-
lished cases of SCCP, 91% were metastatic at the time of initial diag-
nosis.
5
The most common sites for metastases are peripancreatic
lymph nodes, liver, lungs, bone marrow, bone, colon, and adrenal
gland.
5,7
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.
JOURNAL OF CLINICAL ONCOLOGY
DIAGNOSIS IN ONCOLOGY
VOLUME 28 NUMBER 36 DECEMBER 20 2010
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.
8
Presenting symp-
toms are most often abdominal pain, weight loss, and jaundice.
5,7
Other rare symptoms include Cushing-like syndrome and hypercal-
cemia.
9,10
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.
5
However,
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,
5
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.
5,11-14
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.
15
Conversely, the 5-year overall survival
after surgical resection in localized pancreatic ductal adenocarcinoma
is 18% to 24%.
16
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
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
The author(s) indicated no potential conflicts of interest.
REFERENCES
1. Schulz HJ: Pathogenetic correlation between chronic pancreatitis and
pancreatic carcinoma [in German]. Zentralbl Allg Pathol 131:553-561, 1986
2. Reyes CV, Wang T: Undifferentiated small cell carcinoma of the pancreas:
A report of five cases. Cancer 47:2500-2502, 1981
3. Miller JR, Baggenstoss AH, Comfort MW: Carcinoma of the pancreas;
Effect of histological types and grade of malignancy on its behavior. Cancer
4:233-241, 1951
4. Cubilla AL, Fitzgerald PJ: Cancer of the pancreas (nonendocrine): A
suggested morphologic classification. Semin Oncol 6:285-297, 1979
5. Vos B, Awada A, Hendlisz A: Primary small-cell carcinoma of the pancreas:
An extensive review of the literature with emphasis on therapy and prognosis.
Cancer Therapy 6:857-864, 2008
6. Levenson RM Jr, Ihde DC, Matthews MJ, et al: Small cell carcinoma
presenting as an extrapulmonary neoplasm: Sites of origin and response to
chemotherapy. J Natl Cancer Inst 67:607-612, 1981
7. Ordo´n˜ ez NG, Cleary KR, Mackay B: Small cell undifferentiated carcinoma
of the pancreas. Ultrastruct Pathol 21:467-474, 1997
8. Matsubayashi H, Fujiwara S, Kobayashi Y, et al: A small cell carcinoma of
the pancreas with a high level of serum ProGRP. J Clin Gastroenterol 38:834-835,
2004
9. Corrin B, Gilby ED, Jones NF, et al: Oat cell carcinoma of the pancreas with
ectopic ACTH secretion. Cancer 31:1523-1527, 1973
10. Hobbs RD, Stewart AF, Ravin ND, et al: Hypercalcemia in small cell
carcinoma of the pancreas. Cancer 53:1552-1554, 1984
11. Fry WA, Menck HR, Winchester DP: The National Cancer Data Base report
on lung cancer. Cancer 77:1947-1955, 1996
12. Murray N, Coy P, Pater JL, et al: Importance of timing for thoracic
irradiation in the combined modality treatment of limited-stage small-cell lung
cancer: The National Cancer Institute of Canada Clinical Trials Group. J Clin Oncol
11:336-344, 1993
13. Ja¨ nne PA, Freidlin B, Saxman S, et al: Twenty-five years of clinical research
for patients with limited-stage small cell lung carcinoma in North America. Cancer
95:1528-1538, 2002
14. National Cancer Institute: Small Cell Lung Cancer Treatment. http://
www.cancer.gov/cancertopics/pdq/treatment/small-cell-lung/HealthProfessional/
page2
15. National Cancer Institute: Pancreatic Cancer Treatment. http://www.cancer
.gov/cancertopics/pdq/treatment/pancreatic/HealthProfessional/page2
16. Yeo CJ, Abrams RA, Grochow LB, et al: Pancreaticoduodenectomy for
pancreatic adenocarcinoma: Postoperative adjuvant chemoradiation improves
survival. A prospective, single-institution experience. Ann Surg 225:621-633,
1997 (discussion 633-636)
DOI: 10.1200/JCO.2010.30.4600; published online ahead of print at
www.jco.org on September 13, 2010
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Diagnosis in Oncology
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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. "
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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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