Pancreatic panniculitis as a presentation symptom of acinar cell carcinoma

Germline BRCA2 variants in advanced pancreatic acinar cell carcinoma: A case report and review of literature

BACKGROUND

Pancreatic acinar cell carcinoma (PACC) is a rare tumor. Up to 45% of PACCs have alterations in the DNA damage repair pathway and 23% harbor rearrangements in the BRAF or RAF1 genes. We present a PACC case with a germline BRCA2 likely pathogenic variant (LPV) to highlight the impact of genomic testing on treatment decisions and patient outcomes. In our larger case series, we provide clinic-based information on additional 10 PACC patients treated in our center.

CASE SUMMARY

A 70-year-old male was diagnosed with advanced PACC. At presentation, he was cachectic with severe arthralgia despite prednisolone and a skin rash that was later confirmed to be panniculitis. He was treated with modified FOLFIRINOX (mFFX) with the knowledge of the germline BRCA2 LPV. Following 11 cycles of mFFX, a computed tomography (CT) scan demonstrated significant tumor response in the pancreatic primary and hepatic metastases, totaling 70% from baseline as per Response Evaluation Criteria in Solid Tumors. Resolution of the skin panniculitis was also noted. We identified two additional PACCs with druggable targets in our case series. Our data contribute to practical evidence for the value of germline and somatic profiling in the management of rare diseases like PACC.

CONCLUSION

This patient and others in our larger case series highlight the importance of genomic testing in PACC with potential utility in personalized treatment.

Imaging and Clinicopathological Features of Acinar Cell Carcinoma

Background

Acinar cell carcinoma (ACC) is a rare pancreatic epithelial malignancy that poses a significant threat. However, there are few related clinical studies. The present study aimed to analyze the imaging and pathological features of ACC to provide a reference for better diagnosis and treatment planning.

Methods

Thirty-nine with ACC, referred to Qianfoshan Hospital, Qilu Hospital and Provincial Hospital in Shandong Province from December 2012 to December 2020, were enrolled. Their imaging and clinicopathological features were analyzed. They were followed up for 1 year, and Cox regression was used to analyze the factors affecting patient prognosis.

Results

ACC was more common in the middle-aged and elderly and peaked at approximately 60 years. The clinical manifestations of the patients were mostly flatulence and upper abdomen pain. The tumor was located in the head of the pancreas in 19 cases, with an average size of 5.8 cm. We found nerve invasion and liver metastasis in one case each. 8 patients showed irregular amorphous tumor calcification on plain computed tomography and 5 showed high and low signals on T1- and T2-weighted images, respectively. Immunohistochemistry revealed 100.0% positive rates for CK, β-catenin, and Ki-67. Thirty-three patients underwent surgical resection, and the 2-year overall mortality rate was 25.6%. Cox analysis revealed that smoking was an independent risk factor affecting patient prognosis.

Conclusion

An in-depth understanding of the imaging and clinicopathological features of ACC is conducive to better diagnosis and treatment planning for ACC and subsequent improvement in patient prognosis.

Pancreatic panniculitis

Pancreatic panniculitis (PP) is an infrequent manifestation of pancreatic pathology (2%). This condition has mainly been described in association with acute and chronic pancreatitis, in males aged 40-60 years with chronic alcoholism, as was the case of this patient. However, it might also be the outset manifestation of a pancreatic neoplasm.

Cutaneous Manifestations in Pancreatic Diseases-A Review

Pancreatic pathology, comprising acute and chronic pancreatitis, autoimmune pancreatitis and pancreatic neoplasms, primarily presents with gastrointestinal symptoms and signs; however, it is well recognized that it can also associate a wide range of extra-digestive features. Among these systemic manifestations, cutaneous involvement plays an important role both as a diagnostic clue for the pancreatic disease itself and serving as a prognostic factor for the severity of the condition. Recognition of these cutaneous signs is, however, far from being satisfactory, all the more as some of them are relatively rare. In the current review, we discuss skin involvement in pancreatic diseases, referring to pancreatic panniculitis, cutaneous hemorrhagic manifestations, skin metastasis, acanthosis nigricans, livedo reticularis, necrolytic migratory erythema and cutaneous fistula. We highlight the clinical characteristics, treatment and prognostic value of these lesions. Better awareness among medical specialties other than dermatology is needed for detection of the skin clues associated with pancreatic pathology.