DOI: 10.1097/01.mpa.0000232329.35822.3a
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PMID: 16868495
Issn Print: 0885-3177
Publication Date: 2006/08/01
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Excerpt
Case report: A 62-year-old man was admitted to our hospital with a palpable mass on a lower left rib. He had noticed a hard, elastic, walnut-sized, and slightly tender mass in the left side of the chest several months earlier. The patient visited our hospital 1 week before admission, where chest radiography and thoracic computed tomography (CT) were performed. Pathological fracture of the left sixth rib and multiple nodules in bilateral lung fields were identified. Bronchoscopy and bone biopsy were performed. Specimens from transbronchial lung biopsy and bone biopsy represented adenocarcinoma. About 10 years earlier, the patient had been diagnosed with diabetes mellitus, which had subsequently been controlled using α-glucosidase-inhibitor and metformin. No history of collagen disease was present. He had smoked 1 pack/d of cigarettes for 20 years and drank alcohol occasionally. On physical examination, temperature was 36.5°C, heart rate was 88 beats/min, and blood pressure was 120/60 mm Hg. The lungs and heart appeared normal. A hard, elastic, nontender mass occupied the left lower thorax. Complete blood cell counts were within normal limits. Levels of urea nitrogen, creatinine, conjugated and total bilirubin, electrolytes, aspartate aminotransferase, amylase, and alkaline phosphatase were normal. Levels of CA19-9 were increased (101 U/mL; normal, 0-37 U/mL). Abdominal CT with contrast medium revealed an irregular mass measuring 2 cm in the body of the pancreas and dilatation of the main pancreatic duct. Endoscopic retrograde pancreatography (ERP) showed irregular dilatation of the main pancreatic duct in the body and tail of the pancreas, and disappearance of branch ducts due to tumor invasion in the pancreatic body. Cytology of the duct in the pancreatic body showed adenocarcinoma, compatible with pancreatic cancer. Conversely, no mass was detected in the head of the pancreas on intraductal ultrasonography or CT. The ERP revealed diffuse narrowing of the main pancreatic duct in the pancreatic head, but branch ducts were clearly revealed (Fig. 1A). In addition to ERP, endoscopic retrograde cholangiography revealed narrowing of the lower bile duct (Fig. 1B). These results were due to autoimmune mechanisms rather than tumor. Serum was positive for antinuclear antibody (×640, speckled pattern). The IgG4 fraction was increased to 138 mg/dL (21.5% of total IgG level; normal, <70 mg/dL). Pancreatic cancer with metastases in bone and lung concomitant with autoimmune pancreatitis (AIP) was diagnosed. No symptoms from AIP were noted, such as abdominal pain, fever, or obstructive jaundice. Amylase, C-reactive protein, and bilirubin levels were within normal limits despite increases of IgG4 and antinuclear antibody. The decision was made not to treat AIP using steroids. Systemic chemotherapy was performed intravenously with a regimen of gemcitabine 1000 mg/m2/wk for 3 weeks, followed by a 1-week rest. The patient tolerated treatment well.
