Justin Wagner, DO1, Aaron Douen, MD1, Nikolas St. Cyr, MD1, Mohammad Choudhry, MD1, Logan Gonsalves, 2, John Trillo, MD1, Vera Platsky, 1 1Coney Island Hospital, Brooklyn, NY; 2St. George's University School of Medicine, Brooklyn, NY
Introduction: Late onset diabetes (over age 50) may be one of the first signs of pancreatic cancer, and usually precedes painless jaundice. Evidence supports an association between patients diagnosed with late onset diabetes and the development of pancreatic cancer from time of diagnosis as described by the END-PAC model. The END-PAC model is a risk-stratifying algorithm that uses onset of diabetes, change in weight, and change in glucose levels to determine the risk of developing pancreatic cancer. The following cases highlight the association between pancreatic cancer and newly diagnosed Type 2 DM.
Case Description/Methods: The first case is a 65-year-old man with newly diagnosed diabetes mellitus type 2, which rapidly progressed to insulin use, who presented to the ED with elevated blood glucose of 400 mg/dL, dizziness, headache, and crampy abdominal pain that radiated to the left shoulder. CT Abdomen/Pelvis revealed a heterogeneously enhancing lesion in the pancreatic tail, a heterogenous enhancement of the spleen, and innumerable heterogenous hepatic lesions. Follow-up biopsy of lesions were performed and showed a well-differentiated neuroendocrine tumor, G2. The second case is a 70-year-old woman with hypertension, hyperlipidemia, and diabetes mellitus type 2 diagnosed within two years, who presented to the ED with painless jaundice of about a week duration. CT Abdomen/Pelvis revealed a questionable filling defect in the CBD, and MRCP revealed a CBD dilated up to 2 cm with the distal CBD questionable for impacted stone vs mass lesion. ERCP with biliary stent placement for decompression along with brush cytology collection and mass biopsy were performed with results positive for malignant cells and moderately differentiated adenocarcinoma. A pancreaticoduodenectomy was then performed, which the patient tolerated well.
Discussion: The mechanism that explains the association between Type 2 DM and pancreatic cancer includes insulin resistance with compensatory hyperinsulinemia and elevated levels of circulating Insulin-like growth factors, which lead to metabolic, hormonal, and immunological changes that affect tumor growth. Some studies have validated that there are biomarkers with or without imagining that can help with early diagnosis of pancreatic cancer. These cases may provide an example of introducing combined screening tools such as the END-PAC model with biomarkers and imagining for screening high-risk patients to detect early pancreatic tumors, which can decrease morbidity and mortality.
Figure: Figure 1: CT Abdomen/Pelvis without contrast revealing an ill-defined heterogeneously enhancing lesion in the pancreatic tail, measuring 6.6 x 4.6 x 4.2 cm (blue arrow). Figure 2: MRCP revealing a CBD dilated up to 2 cm with the distal CBD questionable for impacted stone vs mass lesion, diffuse pancreatic duct dilatation measuring up to 1.2 cm in the region of the neck and up to 7 mm in the downstream portion with suggestion of abrupt termination at the ampulla. Figure 3: H&E Stain x100 of liver biopsy revealing solid sheets of neuroendocrine tumor cells with large nuclei and scant cytoplasm (black arrow) compared to normal liver cells (white arrow). Figure 4: H&E Stain x100 of duodenum revealing intestinal glands and villi (black arrows), papillary tumor invading muscularis propria of duodenum (thick white arrows), and uninvolved muscularis propria (thin white arrow).
Justin Wagner indicated no relevant financial relationships.
Aaron Douen indicated no relevant financial relationships.
Nikolas St. Cyr indicated no relevant financial relationships.
Mohammad Choudhry indicated no relevant financial relationships.
Logan Gonsalves indicated no relevant financial relationships.
John Trillo indicated no relevant financial relationships.
Vera Platsky indicated no relevant financial relationships.
Justin Wagner, DO1, Aaron Douen, MD1, Nikolas St. Cyr, MD1, Mohammad Choudhry, MD1, Logan Gonsalves, 2, John Trillo, MD1, Vera Platsky, 1. P1115 - Metastatic Neuroendocrine Pancreatic Cancer and Pancreatic Adenocarcinoma Found Incidentally in Two Late-Onset Diabetic Patients, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.