A 62-year-old man comes to the office due to gnawing epigastric pain radiating to the back, which started 3 months ago and has become increasingly intense. He has also experienced a 10-kg (22-lb) weight loss and yellowing of the eyes. The patient has smoked 4 or 5 cigarettes a day for most of his life. Vital signs are within normal limits. The patient appears cachectic. Examination shows scleral icterus. The abdomen is tender to deep palpation. Abdominal CT scan is shown in the image below: This patient's abdominal lesion most likely originated from which of the following?

Question

A 62-year-old man comes to the office due to gnawing epigastric pain radiating to the back, which started 3 months ago and has become increasingly intense.  He has also experienced a 10-kg (22-lb) weight loss and yellowing of the eyes.  The patient has smoked 4 or 5 cigarettes a day for most of his life.  Vital signs are within normal limits.  The patient appears cachectic.  Examination shows scleral icterus.  The abdomen is tender to deep palpation.  Abdominal CT scan is shown in the image below:  This patient's abdominal lesion most likely originated from which of the following?

Quizplus · Accepted Answer

11ec160b_3958_9263_9249_edf21e8943e6_MD0001_00 This patient's CT scan shows a mass in the body of the pancreas, which is concerning for malignancy in the setting of gnawing epigastric pain, jaundice, and unexpected weight loss. Jaundice is more common in cancers of the pancreatic head due to obstruction of extrahepatic bile ducts but can also occur in large tumors of the pancreatic body or tail. Other manifestations include back pain (especially if body/tail tumor), steatorrhea (due to exocrine pancreatic insufficiency), and new-onset diabetes mellitus (due to destruction of islet cells). The majority of pancreatic cancers are derived from the pancreatic ductal system (ie, pancreatic ductal adenocarcinoma [PDAC]). On gross examination, they appear as firm, whitish-yellow masses, often with cystic features. On CT scan, they often appear as ill-defined hypoattenuating lesions within the pancreatic parenchyma. PDAC is microscopically characterized by haphazardly arranged pleomorphic glandular cells surrounded by dense stromal fibrosis (eg, desmoplasia). (Choice A) Cholangiocarcinoma is a cancer derived from bile duct epithelial cells. Although abdominal pain, jaundice, and weight loss are common in cholangiocarcinoma, this patient's CT scan clearly shows a mass in the pancreas, not the biliary tree. (Choice B) Hepatocellular carcinoma originates from hepatocytes and most commonly occurs in patients with chronic liver disease (eg, viral hepatitis, cirrhosis). A pancreatic mass without liver involvement is not consistent with this diagnosis. (Choice C) Cancers derived from pancreatic acinar cells (eg, acinar cell carcinoma) can cause symptoms similar to those of PDAC and may have similar CT findings; however, acinar cell carcinoma is extremely rare compared to PDAC and is therefore less likely in this patient. (Choice E) Hemangiomas are benign hepatic tumors that arise from vascular endothelium; they do not typically develop within the pancreas. Educational objective: Pancreatic ductal adenocarcinoma is the most common pancreatic malignancy and typically presents with epigastric pain, weight loss, jaundice (more common if in the pancreatic head), or back pain (more common if in the pancreatic body/tail). It appears radiographically as an ill-defined hypoattenuating lesion within the pancreatic parenchyma. It is characterized microscopically by haphazardly arranged pleomorphic glandular cells surrounded by dense stromal fibrosis (eg, desmoplasia).

A 62-Year-Old Man Comes to the Office Due to Gnawing