Pancreatitis from Metastatic Small Cell Lung Cancer: Successful Treatment with Endoscopic Intrapancreatic Stenting
A 45-year-old female was admitted to the Kyung Hee Medical Center in April 2005 with a 20-day history of gnawing epigastric pain radiating to the back. In November 2001, she visited our hospital complaining of a chronic cough. Bronchoscopic washing cytology results revealed a SCLC in the left lower lung field, which was treated with chemotherapy and radiation therapy. It appeared that the SCLC responded to the therapy at that time, but follow-up computed tomography (CT) showed a new mass at the right lower lung field. A biopsy revealed that the SCLC had relapsed and she was admitted for additional chemotherapy treatments. Unfortunately, she did not respond to therapy, and a right lung lobectomy was performed. In July 2004, a submandibular mass was found incidentally, and a biopsy indicated metastatic SCLC. Another chemotherapy treatment was started. One month later, PET/CT revealed a left adrenal gland mass suggestive of a metastatic lesion. Additional chemotherapy regimens were provided with no improved response. In January 2005, chemotherapy was discontinued and the patient received only supportive care.\nThe patient had a history of heavy drinking and a 15-pack-year smoking history. However, she had stopped drinking and smoking during the last four years. In addition, she was not taking any other medication. She appeared acutely ill and dehydrated. On physical examination, the patient's body temperature was 38.5℃, blood pressure was 120/80 mmHg, her pulse was 78/minute and her respiratory rate was 20/minute. The breath sounds were decreased in the right lung field. Mild tenderness was noted at the epigastrium but there was no palpable mass. The initial laboratory data were as follows: WBC 6,710/mm3 (82.1% neutrophils, 9.6% lymphocytes, and 4.5% monocytes), hematocrit 36.3%, platelets 170,000/mm3, glucose 110 mg/dL, BUN 7 mg/dL, creatinine 0.6 mg/dL, sodium, 139 mmol/L, potassium 3.9 mmol/L, and calcium 8.4 mg/dL. Serum AST 27 IU/L, serum ALT 15 IU/L, serum gamma glutamyl transpeptidase 13 IU/L, serum alkaline phosphatase 66 IU/L, and amylase 2,650 U/L (normal, 25 to 125 U/L). The chest X-ray revealed the right lower lobectomy and lymph node calcifications at the anterior posterior window area. The abdominal CT revealed multiple low attenuated masses in the pancreatic head, a dilated upstream pancreatic duct and a left adrenal metastasis (6.8 × 5.3 cm) (). No peripancreatic infiltration or fluid collection was noted. Endoscopic ultrasonography (EUS) showed several, well demarcated, irregular hypoechoic masses at the head portion of the pancreas, which compressed the pancreatic duct resulting in a dilatation of the upstream pancreatic duct (). The patient was initially treated with intravenous fluids, dietary restrictions and intravenous analgesics. However, her pain continued unabated. Therefore, endoscopic retrograde cholangiopancreatography (ERCP) was performed to relieve the pancreatic ductal pressure. The ERCP (JF-240, Olympus, Tokyo, Japan) showed an irregular stricture of the pancreatic duct at the head portion of the pancreas along with mild dilatation of the upstream pancreatic duct (). Accordingly, a naso-pancreatic drainage tube (5 Fr, Wilson-Cook, USA) was inserted across the stricture up to the tail of the pancreatic duct. After the pancreatic drainage procedure, the patient's epigastric pain dramatically improved. In addition, the serum amylase and lipase level decreased to 189 U/L and to 143 U/L respectively, one day after the pancreatic drainage procedure. On the sixth day of hospitalization, a second ERCP was done to replace the naso-pancreatic drainage tube with a plastic pancreatic stent. However, selective cannulation of the pancreatic duct was impossible due to the subcutaneous edema of the major papilla caused by incorrect injection of the dye used. Fortunately, the patient did not complain of any discomfort for several days, even after eating regular meals. The patient was discharged without any problems.\nA few days later the patient was readmitted with epigastric pain. On physical examination, she presented with epigastric tenderness and equivocal rebound tenderness. The serum amylase level was 1,867 U/L. Recurrent acute pancreatitis due to a pancreatic metastasis was suspected. An emergency ERCP was performed. The pancreatography showed a short stenosis of the main pancreatic duct, which was identical to the portion found during the first ERCP. A 5 Fr pancreatic stent, 9 cm in length, was inserted at the pancreatic duct through the stenotic area (). After inserting the stent, the patient's abdominal pain continued to decrease and she could take food po; she was discharged without problems.