An Uncommon Presentation of Pancreatic Carcinoma

A 70-year-old male previous intravenous drug user was admitted to the Department of Internal Medicine of the University of Genova on July 2018 with persistent cough, change in voice, hoarseness, and nocturnal sweating. A physical examination showed edema in the upper right limb and face, turgor of the jugular veins, and right supraclavicular lymphadenomegaly. Laboratory tests were performed showing normal serum creatinine (0.9 mg/dL), urea nitrogen (15 mg/dL), and glucose (88 mg/dL). Urinalysis revealed normal urine pH (5.5), specific gravity (1.015), and absence of microalbuminuria and proteinuria. Serum total protein, albumin levels, and lactic dehydrogenase were within the normal range (6.8 g/dL, 3.4 g/dL, 220 U/L respectively). Testing for tuberculosis with QuantiFERON was negative. A thoracic computed tomography (CT) scan showed multiple mediastinal lymphadenopathy, which was confirmed by a ^18F-fluorodeoxyglucose positron emission tomography. Lymph node biopsy showed poorly differentiated adenocarcinoma. In the following month, dyspnea set in and a thoracic-abdominal CT scan revealed a heteroplastic mass (18 × 15 mm) at the uncinate process of the pancreas. The patient died of cardiac complications.

Pancreatic carcinoma is associated with poor prognosis, as no characteristic symptoms appear for a considerable length of time even when the tumor has spread. Therapeutic options are, as yet, limited, though new drugs are becoming available. Contrary to other solid tumors, such as breast carcinoma or uterus malignancy, screening measures for pancreatic carcinoma are still under discussion.¹ Pancreatic carcinoma may occur with jaundice, weight loss, abdominal pain, nausea, vomiting, new-onset diabetes, pruritus, lethargy, and back and shoulder pain.² Although localized disease is a favorable condition, as surgery may positively impact patient prognosis, metastatic presentation is frequent. Indeed, peripancreatic and celiac lymph node metastases of pancreatic carcinoma are frequent, whereas mediastinal lymph node metastases are rare. Agarwal et al³ focused on detecting malignant mediastinal lymph node metastases through endoscopic ultrasound staging in patients with pancreaticobiliary carcinoma. None of the enrolled patients presented with mediastinal involvement as a first symptom. Abdominal CT scan is deemed to be the gold standard when detecting pancreatic carcinoma. Although 2 distinct meta-analyses show that ^18F-fluorodeoxyglucose positron emission tomography is of no advantage, we opted in favor due to suspected lymphoma.^4, 5 Indeed, to the best of our knowledge, this is the first case of mediastinal lymph node metastasis as an initial occurrence of pancreatic carcinoma.

With no analogous cases reported in the literature, this one is deemed interesting, as it describes the uncommon presentation with pancreatic carcinoma—one that further illustrates and confirms the difficulties of early diagnosis.