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Gómez-Puerta JA, Gente K, Katsumoto TR, Leipe J, Reid P, van Binsbergen WH, Suarez-Almazor ME. Mimickers of Immune Checkpoint Inhibitor-induced Inflammatory Arthritis. Rheum Dis Clin North Am 2024; 50:161-179. [PMID: 38670719 DOI: 10.1016/j.rdc.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
The differential diagnosis of inflammatory arthritis as an immune-related adverse event can be challenging as patients with cancer can present with musculoskeletal symptoms that can mimic arthritis because of localized or generalized joint pain. In addition, immune checkpoint inhibitors can exacerbate joint conditions such as crystal-induced arthritis or osteoarthritis, or induce systemic disease that can affect the joints such as sarcoidosis. This distinction is important as the treatment of these conditions can be different from that of immune-related inflammatory arthritis.
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Affiliation(s)
- José A Gómez-Puerta
- Department of Rheumatology, Hospital Clínic; University of Barcelona, Escala 11-2, Barcelona, Villarroel 170, Barcelona 08036, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
| | - Karolina Gente
- Department of Internal Medicine V - Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Im Neuenheimer Feld 410, Heidelberg 69120, Germany
| | - Tamiko R Katsumoto
- Division of Immunology and Rheumatology, Department of Medicine, 300 Pasteur Drive Suite H305, Stanford, CA 94305, USA
| | - Jan Leipe
- Division of Rheumatology, Department of Medicine V, University Hospital Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, Mannheim, Heidelberg 68167, Germany
| | - Pankti Reid
- Division of Rheumatology, Department of Medicine, University of Chicago, 5841 S. Maryland Avenue, Chicago, IL 60637, USA
| | - Wouter H van Binsbergen
- Department of Rheumatology & Clinical Immunology, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Center, Meibergdreef 9, 1105AZ (AMC) & De Boelelaan 1117, Amsterdam 1081 HV (VUmc), The Netherlands
| | - Maria E Suarez-Almazor
- Department of Health Services Research, MD Anderson Cancer Center, The University of Texas, 1515 Holcombe Boulevard, Houston, TX 77030, USA
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2
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Narita K, Okuno M, Natsume S, Asano T, Saito H, Negita M, Ito S, Komori K, Abe T, Hara K, Okuno N, Hosoda W, Shimizu Y. A case of acinar cell carcinoma originating from the accessory papilla of the duodenum. Surg Case Rep 2024; 10:87. [PMID: 38625458 PMCID: PMC11019189 DOI: 10.1186/s40792-024-01872-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 03/16/2024] [Indexed: 04/17/2024] Open
Abstract
CASE PRESENTATION A 61-year-old female was referred to our hospital with a neoplastic lesion in the duodenum. Computed tomography with contrast enhancement revealed a 10-mm tumor in the duodenum. Upper gastrointestinal endoscopy revealed a submucosal tumor-like lesion in the descending part of the duodenum. Endoscopic ultrasound revealed a well-defined hypoechoic tumor. Biopsy and immunohistochemical findings including negative Synaptophysin and Chromogranin A staining and positive Trypsin and BCL10 staining suggested a carcinoma with acinar cell differentiation. Pancreatoduodenectomy was performed, and the resected specimen had a 15-mm solid nodule in the submucosal layer of the duodenum. Pancreatogram of the resected specimen revealed a tumor localized in the accessory papilla region. In histopathological examination, the tumor was found in the submucosa of the duodenum with pancreatic tissue present nearby, and these were separated from the pancreatic parenchyma by the duodenal muscle layer. These findings led to a diagnosis of acinar cell carcinoma originating from the accessory papilla of the duodenum. CONCLUSION Acinar cell carcinoma originating from the accessory papilla of the duodenum is exceptionally rare, with no reported cases to date. The origin was considered to be pancreatic tissue located in the accessory papilla region.
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Affiliation(s)
- Kiyoshi Narita
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa, Nagoya, Aichi, 464-8681, Japan
| | - Masataka Okuno
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa, Nagoya, Aichi, 464-8681, Japan.
| | - Seiji Natsume
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa, Nagoya, Aichi, 464-8681, Japan
| | - Tomonari Asano
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa, Nagoya, Aichi, 464-8681, Japan
| | - Hisafumi Saito
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa, Nagoya, Aichi, 464-8681, Japan
| | - Masashi Negita
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa, Nagoya, Aichi, 464-8681, Japan
| | - Seiji Ito
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa, Nagoya, Aichi, 464-8681, Japan
| | - Koji Komori
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa, Nagoya, Aichi, 464-8681, Japan
| | - Tetsuya Abe
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa, Nagoya, Aichi, 464-8681, Japan
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa, Nagoya, Aichi, 464-8681, Japan
| | - Nozomi Okuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa, Nagoya, Aichi, 464-8681, Japan
| | - Waki Hosoda
- Department of Pathology and Molecular Diagnostics, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa, Nagoya, Aichi, 464-8681, Japan
| | - Yasuhiro Shimizu
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa, Nagoya, Aichi, 464-8681, Japan
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3
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Kumar R, Cichelli K, Brent L. Pancreatitis, Panniculitis, and Polyarthritis Syndrome as the First Symptom of Necrotizing Pancreatitis. Cureus 2024; 16:e55362. [PMID: 38562324 PMCID: PMC10982830 DOI: 10.7759/cureus.55362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/29/2024] [Indexed: 04/04/2024] Open
Abstract
Pancreatitis, panniculitis, and polyarthritis (PPP) syndrome is a very rare cutaneous manifestation found in patients with acute pancreatitis. We report the case of a 44-year-old man presenting with erythematous, painful lesions on the lower extremities and ankle swelling. The rheumatology service was consulted for possible erythema nodosum. Extensive workup revealed elevated lipase and amylase levels, and computed tomography of the abdomen and pelvis revealed acute pancreatitis with necrotizing lesions and peripancreatic thoracic collections. There were also changes of chronic pancreatitis. The original skin manifestations were eventually identified as pancreatic panniculitis by skin biopsy. The patient was treated for pancreatitis and pleural effusions, and his skin and joint symptoms completely resolved. Pancreatic panniculitis with polyarthritis is rare but may be the first presenting symptom of pancreatic disease. Rheumatology may be consulted for these patients especially if there are only skin and joint manifestations and no abdominal pain. Misdiagnosis of pancreatitis can lead to poorer outcomes and delay in care. Therefore, pancreatic disease should be on the differential for any patient with panniculitis and polyarthritis.
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Affiliation(s)
- Raagni Kumar
- Internal Medicine, Temple University Hospital, Philadelphia, USA
| | | | - Lawrence Brent
- Rheumatology, Temple University Hospital, Philadelphia, USA
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4
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Zhu WF, Fang S, Qiao JJ. Pancreatic panniculitis as the first presentation of pancreatic ductal adenocarcinoma. Hepatobiliary Pancreat Dis Int 2024; 23:106-108. [PMID: 37640576 DOI: 10.1016/j.hbpd.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 08/18/2023] [Indexed: 08/31/2023]
Affiliation(s)
- Wei-Fang Zhu
- Department of Dermatology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Shan Fang
- Department of Dermatology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Jian-Jun Qiao
- Department of Dermatology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China.
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5
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Sun T, Gilani S, Jain D, Cai G. Cytomorphologic, immunophenotypical and molecular features of pancreatic acinar cell carcinoma. Diagn Cytopathol 2023; 51:674-683. [PMID: 37469257 DOI: 10.1002/dc.25196] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/06/2023] [Accepted: 07/07/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVES As a rare tumor in pancreas, pancreatic acinar cell carcinoma (PACC) possesses a distinct molecular feature from pancreatic ductal carcinoma (PDAC). Though the diagnosis of PACC is often established based on cytology specimens, its cytologic diagnosis can be challenging. Furthermore, the correlation between PACC cytomorphology and its unique different molecular alterations have not been fully explored. METHODS Cytology features were analyzed in 8 histologically proven PACC and cytohistological correlation was performed. Immunocytochemistry for trypsin, chymotrypsin, BCL10, synaptophysin, chromogranin A, INSM1, β-catenin, and Ki-67 was assessed. Comprehensive molecular profiling and additional targetable treatment biomarker assessment were also performed. RESULTS The cohort included 4 mixed acinar-neuroendocrine carcinomas, 3 pure PACCs, and 1 mixed acinar-ductal carcinoma. Immunophenotypical features are consistent with diagnoses of PACC or PACC with neuroendocrine features. Identified genetic alterations included somatic mutations of CTNNB1, TP53, MAP2K1, PTEN, RAC1, germline mutations of NBN and BRAC2, and gene fusion of CCDC6-RET. CONCLUSIONS The current study is the first attempt to explore the correlation between the cytomorphology characteristics and molecular features of PACC and a few intriguing findings were observed. Further validation in larger cohorts is warranted.
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Affiliation(s)
- Tong Sun
- Departments of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Syed Gilani
- Departments of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Dhanpat Jain
- Departments of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Guoping Cai
- Departments of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
- Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut, USA
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6
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El Brihi J, Chee P. Serial lipase measurements in pancreatic panniculitis. BMJ Case Rep 2023; 16:e254370. [PMID: 37899080 PMCID: PMC10619051 DOI: 10.1136/bcr-2022-254370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023] Open
Abstract
Pancreatic panniculitis is a rare cutaneous manifestation of pancreatic disease with only scant case reports available to guide management. In this report, a woman in her 60s developed a painful, erythematous and indurated, nodular rash after an episode of acute pancreatitis postendoscopic retrograde cholangiopancreatography (ERCP). While clinically and radiologically the pancreatitis improved with standard conservative management, the panniculitis remained severely debilitating. Repeat testing of serum pancreatic enzymes revealed persistent and marked elevation. Octreotide was started to inhibit pancreatic enzyme release, and the lesions improved, with resolution of the panniculitis correlating with falling serum pancreatic enzyme levels. Hence, serial pancreatic enzyme testing may have utility in monitoring and management of pancreatic panniculitis.
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Affiliation(s)
- Jason El Brihi
- Department of Dermatology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Paul Chee
- Department of Dermatology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
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7
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Devineni GS, Zackariah NM, Surendran S, Eapen M. Pancreatitis, panniculitis and polyarthritis (PPP) syndrome. BMJ Case Rep 2023; 16:e254732. [PMID: 37751979 PMCID: PMC10533739 DOI: 10.1136/bcr-2023-254732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023] Open
Abstract
A young male presented with intermittent high-grade fever, asymmetric polyarthritis and erythematous, tender nodules over left shin for 2 months duration. He had a history of alcohol dependence with multiple episodes of acute pancreatitis. With polyarthritis progressing relentlessly, unresponsive to non-steroidal anti-inflammatory drugs and steroids, a provisional diagnosis of sarcoidosis was considered. Indeed, he was treated with azathioprine and rituximab with no effect. Biopsy of the skin nodule revealed subcutaneous fat necrosis, foam cells, deposition of eosinophilic amorphous material and calcification. Synovial fluid aspiration from the arthritic knee obtained purulent but surprisingly culture-negative material, rich in triglycerides. Abdominal CT confirmed chronic pancreatitis. Final diagnosis of pancreatitis, panniculitis and polyarthritis (PPP) syndrome was made. He underwent surgical pancreatic ductal drainage leading to complete remission of symptoms. PPP syndrome triad occurs due to leakage of pancreatic enzymes into systemic circulation and subsequent fat necrosis. Surgical drainage of pancreatic duct is often curative.
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Affiliation(s)
- Geetha Swarna Devineni
- Department of General Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Nafiya Muhammed Zackariah
- Department of Gastrointestinal Surgery and Solid Organ Transplantation, Amrita Institute of Medical Sciences and Research Centre, Cochin, Kerala, India
| | - Sudhindran Surendran
- Department of Gastrointestinal Surgery, Amrita Institute of Medical Sciences and Research Centre, Cochin, Kerala, India
| | - Malini Eapen
- Department of Pathology, Amrita Institute of Medical Sciences and Research Centre, Cochin, Kerala, India
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8
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Parperis K, Constantinidou A, Panos G. Paraneoplastic Arthritides: Insights to Pathogenesis, Diagnostic Approach, and Treatment. J Clin Rheumatol 2021; 27:e505-e509. [PMID: 31743270 DOI: 10.1097/rhu.0000000000001202] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Paraneoplastic arthritides are a group of inflammatory rheumatic syndromes induced by an occult and manifest malignancy, characterized by a wide range of musculoskeletal signs and symptoms that masquerade other rheumatic diseases such as rheumatoid arthritis. Although the pathogenesis of paraneoplastic arthritides is unknown, immune-mediated mechanisms can induce a paraneoplastic syndrome, with a dominant feature the polyarthritis. Common entities of paraneoplastic arthritides include paraneoplastic polyarthritis, hypertrophic osteoarthropathy, remitting seronegative symmetrical synovitis with pitting edema, palmar fasciitis and polyarthritis, and polyarthritis and panniculitis associated with pancreatic carcinoma. The electronic databases PubMed and Scopus were scrutinized using the following terms: paraneoplastic arthritis, paraneoplastic polyarthritis, or paraneoplastic rheumatic diseases. Abstracts, full articles, and selected references were reviewed. The aim of the present narrative review article was to describe the clinical characteristics, diagnostic evaluation, and management of paraneoplastic arthritides, and highlight the challenges that health care providers may encounter, distinguishing those conditions from other autoimmune rheumatic disorders. Future studies are needed to give insight into the mechanisms associated with paraneoplastic arthritides, leading to the development of novel diagnostic biomarkers.
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Affiliation(s)
- Konstantinos Parperis
- From the Division of Rheumatology, Department of Internal Medicine, University of Arizona College of Medicine/Maricopa Integrated Health System, Phoenix, AZ; and University of Cyprus Medical School
| | | | - George Panos
- Department of Internal Medicine, University of Cyprus Medical School, Nicosia, Cyprus
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9
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Ariga H, Yonezaki S, Kashimura J, Takayashiki N. Pancreatic panniculitis in a patient with pancreatic adenosquamous carcinoma. Clin J Gastroenterol 2020; 14:382-385. [PMID: 33124679 DOI: 10.1007/s12328-020-01269-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 10/10/2020] [Indexed: 11/26/2022]
Abstract
Pancreatic panniculitis is a rare complication of pancreatic diseases. We aimed to evaluate a case of pancreatic panniculitis. A 58-year-old woman was referred to our hospital with complaints of painful cutaneous nodules on her limbs. Various diagnostic tests confirmed pancreatic panniculitis and pancreatic adenosquamous carcinoma. We diagnosed pancreatic panniculitis by a skin nodule biopsy that revealed fine basophilic material within anucleate cells and neutrophil infiltration. Abdominal imaging detected a tumor with necrosis on the pancreas and endoscopic ultrasound-guided fine-needle aspiration revealed it as an adenocarcinoma. The patient underwent pancreatoduodenectomy after neoadjuvant chemotherapy. The tumor was composed of differentiated adenocarcinoma and squamous cell carcinoma and diagnosed as adenosquamous carcinoma. This is the first report of pancreatic panniculitis in a patient with adenosquamous cell carcinoma of the pancreas.
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Affiliation(s)
- Hiroyuki Ariga
- Department of Gastroenterology, Mito Kyodo General Hospital, 3-2-7 Miya-machi, Mito, Ibaraki, 310-0015, Japan.
| | - Syun Yonezaki
- Department of General Medicine, Mito Kyodo General Hospital, Mito, Japan
| | - Junya Kashimura
- Department of Gastroenterology, Mito Kyodo General Hospital, 3-2-7 Miya-machi, Mito, Ibaraki, 310-0015, Japan
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10
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Kasamatsu H, Oyama N, Hasegawa M, Oku Y, Inoue G, Kimura M, Kanno M, Kawakami T, Ohta H, Yoneshima M. Fatal case of pancreatic panniculitis caused by occult neuroendocrine tumor in the corresponding organ: A case report and review of the published work. J Dermatol 2020; 48:237-241. [PMID: 33073392 DOI: 10.1111/1346-8138.15646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/31/2020] [Accepted: 09/15/2020] [Indexed: 11/28/2022]
Abstract
Pancreatic panniculitis (PP) is a rare clinical variant of subcutaneous fat necrosis, developing in patients with a variety of pancreatic diseases such as acute or chronic pancreatitis, tumors and cysts. The tumor-associated PP represents a noteworthy skin manifestation of underlying internal malignancies, also known as dermadrome. Among causative pancreatic tumors, acinar cell carcinoma is the most frequent malignancy; however, little is known about how the origin of tumor cells and progression stage of pancreatic tumors potentially contribute to the establishment of panniculitis. Here, we present a 69-year-old Japanese male case of clinically aggressive PP on the bilateral legs, whose skin lesions developed prior to the diagnosis of occult pancreatic tumor and liver metastasis. Moreover, the immunopathology of the pancreatic lesion revealed neuroendocrine tumor (NET), a rare pathological variant. Skin lesions immediately spread to the upper limbs with extensive ulcerations and necrosis, accompanied by high levels of serum lipase and elastase, but not with other pancreatic enzymes. He died 2 months after the initial development of the skin lesion due to rapid deterioration of general condition. We reviewed 14 cases, including ours, of PP with NET in the pancreas thus far reported, to identify the clinicopathological characteristics regarding to what extent this rare complication could reflect the clinical course of pancreatic tumors and overall prognosis. Our published work review found that the disease has a significant male predominance (male : female, 13:1) and cases with occult pancreatic tumors died within 4 months after the development of their skin lesions. Our case was the poorest prognostic outcome. This report emphasizes that dermatologists should recognize PP with NET, reflecting a fatal prognosis, and to make a prompt diagnosis.
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Affiliation(s)
- Hiroshi Kasamatsu
- Department of Dermatology, Municipal Tsuruga Hospital, Tsuruga, Japan.,Department of Dermatology, Faculty of Medical Sciences, University of Fukui, Yoshida-gun, Japan
| | - Noritaka Oyama
- Department of Dermatology, Faculty of Medical Sciences, University of Fukui, Yoshida-gun, Japan
| | - Minoru Hasegawa
- Department of Dermatology, Faculty of Medical Sciences, University of Fukui, Yoshida-gun, Japan
| | - Yohei Oku
- Department of Gastroenterology, Municipal Tsuruga Hospital, Tsuruga, Japan
| | - Genki Inoue
- Department of Gastroenterology, Municipal Tsuruga Hospital, Tsuruga, Japan
| | - Makiko Kimura
- Department of Gastroenterology, Municipal Tsuruga Hospital, Tsuruga, Japan
| | - Masataka Kanno
- Department of Gastroenterology, Municipal Tsuruga Hospital, Tsuruga, Japan
| | - Takumi Kawakami
- Department of Gastroenterology, Municipal Tsuruga Hospital, Tsuruga, Japan
| | - Hajime Ohta
- Department of Gastroenterology, Municipal Tsuruga Hospital, Tsuruga, Japan
| | - Manabu Yoneshima
- Department of Gastroenterology, Municipal Tsuruga Hospital, Tsuruga, Japan
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11
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Clarke EM, Stevens SG, Bennett T, Crowley P, Starkey G. The surgical management of metastatic pancreatic acinar cell carcinoma and associated pancreatic panniculitis-A case report and literature review. Int J Surg Case Rep 2020; 76:539-544. [PMID: 33207427 PMCID: PMC7599369 DOI: 10.1016/j.ijscr.2020.10.062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/13/2020] [Accepted: 10/13/2020] [Indexed: 02/07/2023] Open
Abstract
Pancreatic acinar cell carcinoma (ACC) may present with pancreatic panniculitis. Complete surgical resection of ACC can successfully treat pancreatic panniculitis. Aggressive surgery for ACC can lead to prolonged disease-free survival.
Introduction Pancreatic panniculitis is a rare manifestation of benign and malignant pancreatic disease. The presentation of pancreatic panniculitis is non-specific and thus diagnosis is often delayed. When associated with malignancy, pancreatic panniculitis confers a poor prognosis. This case demonstrates the successful surgical management of this paraneoplastic phenomenon following resection of the underlying pancreatic acinar cell carcinoma and associated liver metastasis. Presentation of case A 71-year-old female with debilitating subcutaneous lower limb lesions had a delayed diagnosis of pancreatic panniculitis. A formal diagnosis of pancreatic acinar cell carcinoma with liver metastasis was established and the disease was determined to be resectable. Pre-operatively, serum lipase measured 10,825 U/L. The patient proceeded to an open left hemihepatectomy and radical distal pancreatectomy with complete resection of malignant disease. Six days post-operatively the serum lipase levels normalised, and the panniculitis began to settle. The patient proceeded to adjuvant FOLFORINOX chemotherapy. Twenty months post-surgery, the patient remains disease-free and without any evidence of panniculitis. Discussion Due to the rarity of pancreatic acinar cell carcinoma, guidelines based on prospective data do not exist. Most management is based on retrospective analyses. A survival benefit may be achieved with more aggressive surgical management compared to other pancreatic cancer types. Pancreatic acinar cell carcinoma may show a slower rate of disease progression, an increased likelihood of resectability of disease at presentation and is more likely to undergo potentially curative resection. Conclusion Aggressive surgical management of resectable metastatic pancreatic acinar cell carcinoma can treat pancreatic panniculitis and provide sustained disease-free survival from pancreatic cancer.
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Affiliation(s)
- Edward M Clarke
- Department of Surgery, Austin Hospital, Melbourne, Victoria, Australia.
| | - Sean G Stevens
- Department of Surgery, Austin Hospital, Melbourne, Victoria, Australia
| | - Tim Bennett
- Department of Rheumatology, Eastern Health, Box Hill, Melbourne, Australia
| | - Peter Crowley
- Dorevitch Pathology, Heidelberg Laboratory, Melbourne, Australia
| | - Graham Starkey
- Department of Surgery, Austin Hospital, Melbourne, Victoria, Australia; Department of Surgery, Warringal Private Hospital, Heidelberg, Melbourne, Australia
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Yamashita Y, Joshita S, Ito T, Maruyama M, Wada S, Umemura T. A case report of pancreatic panniculitis due to acute pancreatitis with intraductal papillary mucinous neoplasm. BMC Gastroenterol 2020; 20:286. [PMID: 32831035 PMCID: PMC7445916 DOI: 10.1186/s12876-020-01430-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 08/17/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Pancreatic panniculitis is a rare skin manifestation in pancreatic disease patients that most frequently develops on the lower legs. We report the unique case of a 68-year-old man who suffered from pancreatic panniculitis on his trunk associated with acute pancreatitis due to an intraductal papillary mucinous neoplasm. CASE PRESENTATION A 68-year-old man complained of a 2-day history of a tender subcutaneous nodule on his trunk. Laboratory tests and abdominal contrast computed tomography were consistent with acute pancreatitis due to an intraductal papillary mucinous neoplasm. A skin biopsy of the nodule histologically displayed lobular panniculitis with characteristic "ghost cells", which indicated pancreatic panniculitis. CONCLUSIONS In order to avoid a missed or delayed diagnosis, clinicians should bear in mind that pancreatic panniculitis can be the first manifestation of pancreatic disease when encountering subcutaneous nodules on the trunk.
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Affiliation(s)
- Yuki Yamashita
- Department of Gastroenterology, Nagano Red Cross Hospital, Nagano, Japan
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Satoru Joshita
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan.
| | - Tetsuya Ito
- Department of Gastroenterology, Nagano Red Cross Hospital, Nagano, Japan
| | - Masafumi Maruyama
- Department of Gastroenterology, Nagano Red Cross Hospital, Nagano, Japan
| | - Shuichi Wada
- Department of Gastroenterology, Nagano Red Cross Hospital, Nagano, Japan
| | - Takeji Umemura
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
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13
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Knitza J, Schett G, Manger B. Rheumatologische paraneoplastische Syndrome. AKTUEL RHEUMATOL 2020. [DOI: 10.1055/a-1201-2407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
ZusammenfassungRheumatologische paraneoplastische Syndrome sind selten, stellten jedoch eine
wichtige Differenzialdiagnose zu klassischen rheumatologischen Krankheitsbildern
dar. Durch das Erkennen der eindrücklichen Syndrome mit typischen Labor-
und Untersuchungsbefunden ist oftmals eine beschleunigte Diagnose der
zugrundeliegenden Malignität und kurative Therapie möglich. In
dieser Übersichtsarbeit werden die Charakteristika rheumatologischer
paraneoplastischer Syndrome vorgestellt.
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Affiliation(s)
- Johannes Knitza
- Medizinische Klinik 3 – Rheumatologie und Immunologie,
Universitätsklinikum Erlangen, Erlangen
| | - Georg Schett
- Medizinische Klinik 3 – Rheumatologie und Immunologie,
Universitätsklinikum Erlangen, Erlangen
| | - Bernhard Manger
- Medizinische Klinik 3 – Rheumatologie und Immunologie,
Universitätsklinikum Erlangen, Erlangen
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14
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Abstract
Rheumatic paraneoplastic syndromes are paraneoplastic arthritis, palmar fasciitis and polyarthritis syndrome, remitting seronegative symmetrical synovitis with pitting edema, pancreatic panniculitis with polyarthritis, paraneoplastic vasculitis, cancer-associated myositis, hypertrophic osteoarthropathy (Marie-Bamberger disease) and tumor-induced osteomalacia. Typical clinical manifestations, pathogenesis, prognosis, and treatment of this entity are presented. Knowledge of these disease entities can lead to timely diagnosis of the underlying malignant disease and to a higher probability of a cure. Response of the paraneoplastic inflammatory manifestations to corticosteroids, non-steroidal anti-inflammatory drugs or immunosuppressants is often insufficient. Curative removal of the malignant disease is crucial for the course of the paraneoplastic syndrome. When a paraneoplastic etiology of rheumatic symptoms is suspected, a step-wise diagnostic strategy is advisable.
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Taskin OC, Adsay V. Lipase hypersecretion syndrome: A distinct form of paraneoplastic syndrome specific to pancreatic acinar carcinomas. Semin Diagn Pathol 2019; 36:240-245. [PMID: 31300257 DOI: 10.1053/j.semdp.2019.07.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Lipase hypersecretion syndrome (LHS) is a paraneoplastic syndrome seen exclusively as a result of pancreatic acinar cell carcinoma (ACC). In LHS, acinar enzymes (lipase, trypsin and chymotrypsin) which are normally secreted to the duodenum for digestive purposes, are instead released to the blood by the carcinoma cells. In a way, it is "endocrine-ization" of an "exocrine" function. These circulating enzymes, especially lipase, exerts its digestive action on other tissues, especially on the subcutaneous tissues in the pressure poins of legs, creating a picture often mistaken as erythema nodosum or rheumatic nodules. The bone and joints may also be effected, which mostly appears to be secondary to the complications and super-infection of the skin lesions. Eosinophilia also often accompanies this syndrome. The accurate diagnosis of LHS requires the identification of the pancreatic primary as well as its correct classification as acinar because a variety of pancreatic tumors can be associated with skin lesions, ranging from rare metastasis of adenocarcinoma to the necrolytic migratory erythema caused by glucagon-producing neuroendocrine tumors. Towards this differential, the diagnostic characteristics of acinar cell carcinomas that have been better elucidated in the past decade often need to be employed in increasingly smaller specimens and the liver, especially since most LHS cases also have liver metastasis (presumably due to the by-pass of the "first-pass" liver metabolism phenomenon). ACC (and LHS) occur in patients in their 60's. The pancreatic mass is often large, round, demarcated and closely resemble neuroendocrine and solid-pseudopapillary neoplasms but are more atypical/proliferative, and commonly show single prominent nucleoli and a distinctive chromophilia. Immunostaining with trypsin/chymotrypsin, negativity of beta-catenin help in the differential; as a caveat, neuroendocrine differentiation is common in ACCs. In conclusion, LHS is a rare type of paraneoplastic syndrome specific to ACC. The accurate diagnosis requires attention to their subtle diagnostic characteristics.
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Affiliation(s)
- Orhun Cig Taskin
- Department of Pathology, Koç University Hospital, Davutpasa Caddesi No:4, Topkapi, 34010 Istanbul, Turkey
| | - Volkan Adsay
- Department of Pathology, Koç University Hospital, Davutpasa Caddesi No:4, Topkapi, 34010 Istanbul, Turkey.
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Somalanka S, Udo I, Nair H, Baikunje S. Pfeifer-Weber-Christian disease and successful treatment with mycophenolate mofetil: a case report. BMJ Case Rep 2019; 12:12/5/e229167. [PMID: 31122958 DOI: 10.1136/bcr-2018-229167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Inflammatory conditions manifest with a broad spectrum of signs and symptoms. Panniculitis is such a condition affecting the subcutaneous fat and presents as tender erythematous nodules. It is also associated with a systemic response and has been described in the literature as early as in 1892 by Pfeifer and in the 1920s by Weber and Christian. We present an unusual case of a Caucasian man with recurrent febrile illness, systemic inflammatory response and renal dysfunction requiring acute high dependency care. The authors successfully treated him with an antiproliferative agent, mycophenolate mofetil, which resulted in preventing him from having further episodes.
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Affiliation(s)
- Subash Somalanka
- South West Thames Renal & Transplantation Unit and South West Thames Institute for Renal Research, Saint Helier Hospital, Carshalton, Surrey, UK
| | - Ini Udo
- General Medicine, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Hari Nair
- Renal Medicine, Glan Clwyd Hospital, Rhyl, Denbighshire, UK
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de Frutos Rosa D, Espinosa Taranilla L, González de Canales de Simón P, Vélez Velázquez MD, Guirado Koch C. Pancreatic panniculitis as a presentation symptom of acinar cell carcinoma. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018. [PMID: 29527901 DOI: 10.17235/reed.2018.5203/2017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Pancreatic panniculitis is a rare skin manifestation associated with pancreatic conditions. This condition has similar characteristics to those of other panniculitis types and its course parallels the triggering condition and may occasionally precede it. We report the case of a female patient with asymptomatic pancreatic panniculitis; the etiologic study identified a pancreatic acinar cell carcinoma with liver metastases.
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18
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Montes de Oca MK, Jamison RA. Pancreatic panniculitis as the initial presentation of intrahepatic cholangiocarcinoma. JAAD Case Rep 2018; 4:528-530. [PMID: 30023419 PMCID: PMC6047103 DOI: 10.1016/j.jdcr.2018.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Mary Katherine Montes de Oca
- University of South Carolina School of Medicine Greenville, Greenville, South Carolina
- Samford University, Birmingham, Alabama
| | - Richard Andrew Jamison
- University of South Carolina School of Medicine Greenville, Greenville, South Carolina
- Division of Dermatology, Greenville Health System, Greenville, South Carolina
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20
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Guanziroli E, Colombo A, Coggi A, Gianotti R, Marzano AV. Pancreatic panniculitis: the "bright" side of the moon in solid cancer patients. BMC Gastroenterol 2018; 18:1. [PMID: 29301491 PMCID: PMC5755411 DOI: 10.1186/s12876-017-0727-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 12/14/2017] [Indexed: 12/11/2022] Open
Abstract
Background Pancreatic panniculitis is a rare complication of pancreas disorders occurring in 0.3–3% of patients, most often accompanied by the pancreatic acinar carcinoma. It presents multiple, painful, deep, ill-defined, red-brown, migratory nodules and plaques of hard elastic consistency; often ulcerated and typically located on the lower proximal and distal extremities. The pathogenesis is not fully understood, but it is thought to result from lipolysis and fat necrosis with secondary tissue inflammation induced by pancreatic enzymes. Histopathology shows subcutaneous lobular fat necrosis with anuclear adipocytes (called ghost cells) surrounded by a mixed inflammatory infiltrate. Focal calcification may also be seen. The treatment is directed to the underlying disorder, which may result in regression of skin lesions. Case presentation We present two cases of pancreatic panniculitis with similar clinical, laboratory, and histopathological features associated with different internal malignancy. The first case, after extensive investigations showed the presence of a pancreatic carcinoma with multiple liver metastases and a poor prognosis. The second one instead is the first case in literature where painful subcutaneous nodules of the legs were the early manifestation of a neuroendocrine carcinoma of the adrenal gland. Conclusions Although subcutaneous fat necrosis usually occurs late in the course of a malignancy, recognition of the association with pancreatic panniculitis may prevent a long delay in the diagnosis and management of the occult neoplasm. It should be primarily considered when panniculitis is widespread and persistent, and frequent relapses or tendency to ulcerate of the nodules are regarded as red flags.
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Affiliation(s)
- Elena Guanziroli
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Unità Operativa di Dermatologia, I.R.C.C.S. Fondazione Cà Granda, Ospedale Maggiore Policlinico, via Pace 9, 20122, Milan, Italy.
| | - Antonella Colombo
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Unità Operativa di Dermatologia, I.R.C.C.S. Fondazione Cà Granda, Ospedale Maggiore Policlinico, via Pace 9, 20122, Milan, Italy
| | - Antonella Coggi
- Unità Operativa di Dermatologia, I.R.C.C.S. Fondazione Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Raffaele Gianotti
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Unità Operativa di Dermatologia, I.R.C.C.S. Fondazione Cà Granda, Ospedale Maggiore Policlinico, via Pace 9, 20122, Milan, Italy
| | - Angelo Valerio Marzano
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Unità Operativa di Dermatologia, I.R.C.C.S. Fondazione Cà Granda, Ospedale Maggiore Policlinico, via Pace 9, 20122, Milan, Italy
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21
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Rheumatic paraneoplastic syndromes – A clinical link between malignancy and autoimmunity. Clin Immunol 2018; 186:67-70. [DOI: 10.1016/j.clim.2017.07.021] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 07/19/2017] [Indexed: 12/31/2022]
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22
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A FISH assay efficiently screens for BRAF gene rearrangements in pancreatic acinar-type neoplasms. Mod Pathol 2018; 31:132-140. [PMID: 28884748 DOI: 10.1038/modpathol.2017.106] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 06/09/2017] [Accepted: 06/29/2017] [Indexed: 12/19/2022]
Abstract
Approximately 1-2% of pancreatic neoplasms are acinar cell carcinomas. Recently, BRAF gene rearrangements were identified in over 20% of acinar-type neoplasms, which included both pure acinar cell carcinomas and mixed carcinomas with acinar differentiation, using next-generation sequencing-based platforms, providing a potential therapeutic target for patients with these neoplasms. Thus, it is clinically important to develop a rapid, cost- and material-efficient assay to screen for BRAF gene fusions in pancreatic acinar-type neoplasms. We developed a dual color, break-apart FISH assay to detect BRAF gene rearrangements in these neoplasms and evaluated its performance in comparison to next-generation sequencing-based studies. A blinded BRAF rearrangement FISH investigation was performed on 31 acinar-type neoplasms that had been studied previously by next-generation sequencing-based analysis as well as on 18 additional acinar-type neoplasms that were accrued over the past 2 years. In total, BRAF fusions were identified in 12/49 (24%) acinar-type neoplasms by FISH. BRAF fusion partners were uncovered by using targeted next-generation sequencing studies in 11 FISH-positive cases that had sufficient material for next-generation sequencing studies. SND1 was the most frequent fusion partner involved in BRAF-fusion acinar-type neoplasms (50%), followed by HERPUD1 (18%). No BRAF fusions were identified by next-generation sequencing in any of the FISH-negative cases investigated. FISH analysis showed that BRAF rearrangements were diffusely present across tumor-rich areas in BRAF-fusion acinar-type neoplasms, which is consistent with an oncogenic driver alteration pattern. Thus, we demonstrated that, in comparison to targeted next-generation sequencing-based technologies, the FISH assay is highly sensitive and specific as well as time- and cost-efficient in the detection of BRAF fusions in acinar-type neoplasms. The FISH assay can be easily implemented in diagnostic settings to identify acinar-type neoplasms patients potentially suitable for targeted therapy to inhibit MAPK pathway activity.
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Plier M, Durez P, Komuta M, Raptis A. Severe panniculitis and polyarthritis caused by acinar cell carcinoma arising from an ectopic pancreas. BMJ Case Rep 2017; 2017:bcr-2017-222241. [PMID: 29167188 DOI: 10.1136/bcr-2017-222241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The pancreatitis, panniculitis and polyarthritis (PPP) syndrome is a rare condition caused by pancreatic diseases, such as acute or chronic pancreatitis or pancreatic carcinoma. We report the first case of PPP syndrome caused by metastatic acinar cell carcinoma from an ectopic pancreas. The symptoms were successfully managed by the treatment of the metastatic carcinoma. Pancreatic cytosteatonecrosis should be always considered in a patient who is showing symptoms of panniculitis and polyarthritis.
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Affiliation(s)
- Marc Plier
- Department of Rheumatology, Cliniques Universitaires Saint-Luc, Bruxelles, Belgium
| | - Patrick Durez
- Department of Rheumatology, Cliniques Universitaires Saint-Luc, Bruxelles, Belgium
| | - Mina Komuta
- Department of Pathology, Cliniques Universitaires Saint-Luc, Bruxelles, Belgium
| | - Alexandros Raptis
- Department of Pathology, Cliniques Universitaires Saint-Luc, Bruxelles, Belgium
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24
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Plier M, Durez P, Komuta M, Raptis A. Severe panniculitis and polyarthritis caused by acinar cell carcinoma arising from an ectopic pancreas. BMJ Case Rep 2017. [PMID: 29167188 DOI: 10.1136/bcr-2017-222241]] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The pancreatitis, panniculitis and polyarthritis (PPP) syndrome is a rare condition caused by pancreatic diseases, such as acute or chronic pancreatitis or pancreatic carcinoma. We report the first case of PPP syndrome caused by metastatic acinar cell carcinoma from an ectopic pancreas. The symptoms were successfully managed by the treatment of the metastatic carcinoma. Pancreatic cytosteatonecrosis should be always considered in a patient who is showing symptoms of panniculitis and polyarthritis.
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Affiliation(s)
- Marc Plier
- Department of Rheumatology, Cliniques Universitaires Saint-Luc, Bruxelles, Belgium
| | - Patrick Durez
- Department of Rheumatology, Cliniques Universitaires Saint-Luc, Bruxelles, Belgium
| | - Mina Komuta
- Department of Pathology, Cliniques Universitaires Saint-Luc, Bruxelles, Belgium
| | - Alexandros Raptis
- Department of Pathology, Cliniques Universitaires Saint-Luc, Bruxelles, Belgium
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25
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Evans AC, Singhi AD, Zeh HJ, Bahary N, Brand RE. An Unexpected Etiology of Pancreatic Panniculitis: A Case Report. J Pancreat Cancer 2017; 3:1-4. [PMID: 29082362 DOI: 10.1089/crpc.2016.0021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Pancreatic panniculitis is a rare cause of subcutaneous fat necrosis secondary to elevated serum levels of pancreatic enzymes. It is most often associated with pancreatic acinar cell carcinoma, but has also been seen in patients with pancreatitis. CASE REPORT We present a case of a 64 year old Caucasian man without symptoms of pancreatitis who presents with pancreatic panniculitis manifesting in multiple subcutaneous ulcerating nodules of the bilateral lower extremities, discovered to have a previously unreported etiology for this condition. He had no evidence of pancreatitis or malignancy, but instead a pancreatic-portal fistula resulting in panniculitis. CONCLUSION Peripancreatic vascular lesions must also be considered in the differential diagnosis of pancreatic panniculitis. The diagnosis, pathology, and treatment of pancreatic panniculitis are reviewed herein.
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Affiliation(s)
- A C Evans
- Division of Gastroenterology and Hepatology, University of Pittsburgh School of Medicine, UPMC Presbyterian, 200 Lothrop Street, Pittsburgh, PA 15213
| | - A D Singhi
- Department of Pathology, University of Pittsburgh School of Medicine, 200 Lothrop Street, Scaife Hall A616.2, Pittsburgh, PA 15213
| | - H J Zeh
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, 5150 Centre Ave, Suite 414, Pittsburgh, PA 15232
| | - N Bahary
- Department of Medical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213
| | - R E Brand
- Division of Gastroenterology and Hepatology, University of Pittsburgh School of Medicine, UPMC Presbyterian, 200 Lothrop Street, Pittsburgh, PA 15213
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27
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Kim EJ, Chu MS, Sohn KC, Cho DH, Na GH, Kim HC, Cho EY. [Pancreatic Panniculitis in Patients with Chronic Pancreatitis: Case Report and Review of Literature]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2017; 69:83-86. [PMID: 28135797 DOI: 10.4166/kjg.2017.69.1.83] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Pancreatic panniculitis is a rare complication characterized by subcutaneous fat necrosis associated with pancreatic disease. It has been postulated that pancreatic panniculitis is caused by the systemic activity of pancreatic enzymes that lead to microcirculatory disturbances. We report a 41-year-old heavy alcoholic woman with pancreatic panniculitis that coexisted with acute and chronic pancreatitis. She was diagnosed with chronic pancreatitis and alcoholic liver cirrhosis 5 years ago. She presented with multiple, tender, erythematous, subcutaneous nodules with heat sensation on both lower legs. Laboratory evaluation revealed an increase in the serum blood amylase and lipase. Histopathologic findings showed fat necrosis with inflammation around the necrotic subcutaneous fat tissue. The lesions subsided gradually with an improvement of acute pancreatitis.
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Affiliation(s)
- Eui Joong Kim
- Department of Internal Medicine, Wonkwang University College of Medicine, Iksan, Korea
| | - Min Su Chu
- Department of Internal Medicine, Wonkwang University College of Medicine, Iksan, Korea
| | - Ki Chang Sohn
- Department of Internal Medicine, Wonkwang University College of Medicine, Iksan, Korea
| | - Dong Ho Cho
- Department of Internal Medicine, Wonkwang University College of Medicine, Iksan, Korea
| | - Ga Hye Na
- Department of Dermatology, Wonkwang University College of Medicine, Iksan, Korea
| | - Haak Cheoul Kim
- Department of Internal Medicine, Wonkwang University College of Medicine, Iksan, Korea
| | - Eun Young Cho
- Department of Internal Medicine, Wonkwang University College of Medicine, Iksan, Korea
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Yoshihiro T, Nio K, Tsuchihashi K, Ariyama H, Kohashi K, Tsuruta N, Hanamura F, Inadomi K, Ito M, Sagara K, Okumura Y, Nakano M, Arita S, Kusaba H, Oda Y, Akashi K, Baba E. Pancreatic acinar cell carcinoma presenting with panniculitis, successfully treated with FOLFIRINOX: A case report. Mol Clin Oncol 2017; 6:866-870. [PMID: 28588779 PMCID: PMC5451886 DOI: 10.3892/mco.2017.1240] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 03/29/2017] [Indexed: 12/14/2022] Open
Abstract
Pancreatic acinar cell carcinoma (PACC) is a rare tumor of the exocrine pancreas, representing only 1% of all pancreatic malignancies. A 50-year-old man presented with edema of the thumb joints bilaterally, followed by an appearance of masses in the bilateral lower extremities and fever (38°C). The masses were diagnosed as panniculitis by skin biopsy, and multiple intraperitoneal masses were incidentally detected on pelvic magnetic resonance imaging performed to investigate the leg abnormalities. The patient was referred to the Kyushu University Hospital for further investigation, and fluorodeoxyglucose-positron emission tomography/computed tomography (CT) revealed high-uptake tumors in the pancreatic tail, in the periphery of the liver, and in the pelvis. Laboratory examinations revealed high serum concentrations of pancreatic exocrine enzymes, such as lipase, trypsin, elastase 1 and pancreatic phospholipase A2. Histological examination of a bioptic specimen obtained from a hepatic lesion revealed proliferation of atypical cells arranged in a tubular or glandular pattern. Immunohistochemical staining revealed that the atypical cells were positive for cytokeratin (CK)7, CK19 and lipase, but negative for CK20 and thyroid transcription factor-1, leading to a final diagnosis of acinar cell carcinoma of the pancreatic tail (T4bN0M1, stage IV according to the 7th edition of the TNM Classification of Malignant Tumors). Combined chemotherapy with oxaliplatin, irinotecan and fluorouracil (FOLFIRINOX) was administered and fever was soon alleviated. The serum levels of lipase also declined and panniculitis completely resolved. As of the start of the 8th course of chemotherapy, the levels of the pancreatic exocrine enzymes were within normal ranges and CT revealed partial response. Therefore, the severe lipase hypersecretion syndrome was well controlled by the FOLFIRINOX regimen and shrinkage of the mass was also achieved. Thus, the FOLFIRINOX regimen may represent an effective treatment option for advanced PACC.
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Affiliation(s)
- Tomoyasu Yoshihiro
- Department of Hematology and Oncology, Kyushu University Hospital, Fukuoka 812-8582, Japan
| | - Kenta Nio
- Department of Hematology and Oncology, Kyushu University Hospital, Fukuoka 812-8582, Japan
| | - Kenji Tsuchihashi
- Department of Hematology and Oncology, Kyushu University Hospital, Fukuoka 812-8582, Japan
| | - Hiroshi Ariyama
- Department of Hematology and Oncology, Kyushu University Hospital, Fukuoka 812-8582, Japan
| | - Kenichi Kohashi
- Department of Anatomical Pathology, Pathological Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Nobuhiro Tsuruta
- Department of Hematology and Oncology, Kyushu University Hospital, Fukuoka 812-8582, Japan
| | - Fumiyasu Hanamura
- Department of Hematology and Oncology, Kyushu University Hospital, Fukuoka 812-8582, Japan
| | - Kyoko Inadomi
- Department of Hematology and Oncology, Kyushu University Hospital, Fukuoka 812-8582, Japan
| | - Mamoru Ito
- Department of Hematology and Oncology, Kyushu University Hospital, Fukuoka 812-8582, Japan
| | - Kosuke Sagara
- Department of Hematology and Oncology, Kyushu University Hospital, Fukuoka 812-8582, Japan
| | - Yuta Okumura
- Department of Hematology and Oncology, Kyushu University Hospital, Fukuoka 812-8582, Japan
| | - Michitaka Nakano
- Department of Hematology and Oncology, Kyushu University Hospital, Fukuoka 812-8582, Japan
| | - Shuji Arita
- Department of Comprehensive Clinical Oncology, Faculty of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Hitoshi Kusaba
- Department of Hematology and Oncology, Kyushu University Hospital, Fukuoka 812-8582, Japan
| | - Yoshinao Oda
- Department of Anatomical Pathology, Pathological Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Koichi Akashi
- Department of Hematology and Oncology, Kyushu University Hospital, Fukuoka 812-8582, Japan
| | - Eishi Baba
- Department of Comprehensive Clinical Oncology, Faculty of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
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29
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Evans AC, Singhi AD, Zeh HJ, Bahary N, Brand RE. An Unexpected Etiology of Pancreatic Panniculitis: A Case Report. J Pancreat Cancer 2017. [PMID: 29082362 PMCID: PMC5656292 DOI: 10.1089/pancan.2016.0021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background: Pancreatic panniculitis is a rare cause of subcutaneous fat necrosis secondary to elevated serum levels of pancreatic enzymes. It is most often associated with pancreatic acinar cell carcinoma, but has also been seen in patients with pancreatitis. Case report: We present a case of a 64-year-old Caucasian man without symptoms of pancreatitis, who presents with pancreatic panniculitis manifesting in multiple subcutaneous ulcerating nodules of the bilateral lower extremities, discovered to have a previously unreported etiology for this condition. He had no evidence of pancreatitis or malignancy, but instead a pancreatic-portal fistula resulting in panniculitis. Conclusion: Peripancreatic vascular lesions must also be considered in the differential diagnosis of pancreatic panniculitis. The diagnosis, pathology, and treatment of pancreatic panniculitis are reviewed herein.
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Affiliation(s)
- Anna C. Evans
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, UPMC Presbyterian, Pittsburgh, Pennsylvania
- Address correspondence to: Anna C. Evans, MD, Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, UPMC Presbyterian, Mezzanine Level, 200 Lothrop Street, Pittsburgh, PA 15213, E-mail:
| | - Aatur D. Singhi
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Herbert J. Zeh
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Nathan Bahary
- Department of Medical Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Randall E. Brand
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, UPMC Presbyterian, Pittsburgh, Pennsylvania
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30
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Kruger S, Haas M, Burger PJ, Ormanns S, Modest DP, Westphalen CB, Kleespies A, Angele MK, Hartwig W, Bruns CJ, Kirchner T, Werner J, Heinemann V, Boeck S. Acinar cell carcinoma of the pancreas: a rare disease with different diagnostic and therapeutic implications than ductal adenocarcinoma. J Cancer Res Clin Oncol 2016; 142:2585-2591. [PMID: 27629876 DOI: 10.1007/s00432-016-2264-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 09/06/2016] [Indexed: 02/07/2023]
Abstract
PURPOSE Acinar cell carcinoma (ACC) of the pancreas is a very rare cancer, constituting 1 % of all malignant non-endocrine pancreatic tumors. Only very limited data exist to guide treatment in patients with advanced ACC. METHODS Between 2000 and 2015, 15 patients with ACC were diagnosed and/or treated at our high-volume comprehensive cancer center. Medical records and correlating serum levels of the potential serum tumor markers CA 19-9, CEA and lipase were analyzed retrospectively. RESULTS A substantial antitumor activity was observed for treatment regimens containing 5-FU and oxaliplatin with partial responses or prolonged disease stabilizations (>12 months) observed in 6 out of 7 patients (86 %). Activity was also observed for single-agent 5-FU and its oral prodrugs. Serum lipase levels were elevated in 7 of 12 patients with advanced disease (58 %), whereas CEA and CA 19-9 seemed to be of minor importance for ACC (elevated pre-treatment levels in 4/12 and 3/12 cases, respectively). In selected patients, repeated serum lipase measurements were available and accurately predicted response to chemotherapy and relapse after surgery. CONCLUSIONS 5-FU- and oxaliplatin-containing regimens are active in advanced ACC. Lipase kinetics may be a useful novel tool to monitor the course of disease as well as treatment effects in ACC.
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Affiliation(s)
- Stephan Kruger
- Department of Internal Medicine III, Comprehensive Cancer Center, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Michael Haas
- Department of Internal Medicine III, Comprehensive Cancer Center, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Philipp Johannes Burger
- Department of Internal Medicine III, Comprehensive Cancer Center, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Steffen Ormanns
- Institute of Pathology, Ludwig-Maximilians-University of Munich, 81377, Munich, Germany
| | - Dominik Paul Modest
- Department of Internal Medicine III, Comprehensive Cancer Center, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Christoph Benedikt Westphalen
- Department of Internal Medicine III, Comprehensive Cancer Center, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Axel Kleespies
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, 81377, Munich, Germany
| | - Martin Kurt Angele
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, 81377, Munich, Germany
| | - Werner Hartwig
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, 81377, Munich, Germany
| | - Christiane Josephine Bruns
- Department of General, Visceral and Tumor Surgery, University of Cologne, 50937, Köln-Lindenthal, Germany
| | - Thomas Kirchner
- Institute of Pathology, Ludwig-Maximilians-University of Munich, 81377, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, 81377, Munich, Germany
| | - Volker Heinemann
- Department of Internal Medicine III, Comprehensive Cancer Center, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Stefan Boeck
- Department of Internal Medicine III, Comprehensive Cancer Center, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Marchioninistr. 15, 81377, Munich, Germany.
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