BEST PRACTICES FOR PANCREATIC MASSES OF UNKNOWN ETIOLOGY

Purpose: A 76 year-old Caucasian male presented with painless jaundice which progressively worsened over one week. The only other complaints the patient stated was an unexplained 10 pound weight loss in the past 2 months and mild fatigue for 1 day. His past medical history was significant for non-small cell lung cancer status post left lower lobe lung resection 8 months ago, hyperlipidemia, COPD, and a past smoking history of 260 pack years. After his lung resection, he had a follow up PET scan that showed a possible nonspecific gallbladder lesion which had never been fully worked up. Methods: Evaluation of the patients mass was performed with an ultrasound of the abdomen that showed a dilated common bile and intra hepatic duct dilation with no stones. A subsequent CT of his abdomen showed a 4cm pancreatic mass with a 1.1cm pancreatic duct dilation. ERCP was attempted for brushings of cells and a stent placement was attempted but was unsuccessful for both. Further workup of his mass with an endoscopic ultrasound and biopsy of the pancreas revealed adenocarcinoma. Results: The differential diagnosis for this patients jaundice was choledocholithiasis versus pancreatic mass that was possibly a metastatic spread from his primary lung cancer several months prior. The ultrasound revealed no stones, which helped rule out the choledocholithiasis. However, the ERCP was attempted and unsuccessful which led to a delay in his definitive diagnosis, as well as the inability to place a stent to relieve his original complaint of jaundice. Conclusions: The evaluation of a patient when pancreatic cancer is suspected should start with a CT scan with IV contrast. This method has a high level of sensitivity for mass and allows for assessment for possible surgical resection of the mass. This patient's PET scan was never worked up by his original physician, which may have led to a delay of his diagnosis which could potentially lead to a less favorable outcome. There is currently no recommended screening method for pancreatic cancer. This leads to only 20% of pancreatic cancers diagnosed when they are localized and potentially cured by surgical resection. Once pancreatic cancer has advanced locally and invaded local vasculature or metastasized it is no longer curative with surgery and there are no set guidelines for treatment.