Pancreatic Cancer Presenting as New-Onset Diabetes
A 53-year-old African American female with a medical history significant for stage IB, grade 1 endometrial adenocarcinoma status-post total abdominal hysterectomy and bilateral salpingoophorectomy 7 years ago presented to the Henry Ford Hospital Emergency Department upon instruction from her oncologist after her serum glucose was found to be severely elevated. She had no history of diabetes with fasting blood sugars <126 as recent as 6 months prior to presentation. She led a sedentary lifestyle and had a BMI of 31.8. She was experiencing polydipsia and polyuria for 3 weeks with associated blurry vision and distal extremity paresthesias. Six months prior to presentation, she began experiencing persistent, non-exertional, left-sided chest wall pain. Her pain was managed as an outpatient for several months as costochondritis without resolution. She was a former smoker with a 15 pack-year smoking history. Her family history was significant for type 2 diabetes and hypertension, but she denied a family history of any cancers.\nLaboratory findings on admission were significant for serum blood glucose 608 mg/dl, white blood cell count 11.9 K/μl, bicarbonate 27 mmol/l, anion gap 10, and beta hydroxybutyrate 0.13 mmol/l. Serum glycated hemoglobin was 12.7%. Further laboratory studies were significant for an elevated CA 19-9 (349.9 U/ml), normal CA-125 (15 U/ml), and normal C-peptide (1.4 ng/ml). A bone scan for the persistent left-sided chest pain performed shortly after admission was concerning for increased uptake in the left scapula and L5 vertebral body. The patient subsequently underwent a CT scan of the chest, abdomen, and pelvis with IV contrast that showed a 3.6 × 2.5 cm mass extending from the body into the tail of the pancreas and a single 1-cm low attenuation lesion in the liver with minimally enlarged hepatic and portacaval lymph nodes. A biopsy of the hepatic lesion was performed and was suggestive of metastatic pancreatic adenocarcinoma (fig. ). Pathology showed neoplastic glands surrounded by prominent desmoplastic stroma and lined by cuboidal epithelium with marked nuclear pleomorphism, loss of polarity, and frequent apoptotic bodies. The tumor cells stained positive for cytokeratin 7 and 19 and stained negative for estrogen receptor and cytokeratin 20.\nThese findings, along with the newly discovered pancreatic mass, were consistent with stage IV adenocarcinoma of pancreatobiliary origin. After extensive discussion with the patient and her family, she decided to proceed with the FOLFIRINOX chemotherapy regimen for palliative purposes. Her diabetes was treated with a regimen of Lantus 50 units once daily and with Aspart 15 units before meals. She has completed four cycles of chemotherapy and has been experiencing elevated blood sugars despite compliance with her insulin regimen.