S1830 Spontaneous Fistulization of Walled-Off Necrosis Into Duodenum Requiring Video-Assisted Retroperitoneal Debridement: A Rare Complication of Acute Necrotizing Pancreatitis

Abstract

Introduction: Any mass lesion in the pancreas typically raises concern of undiagnosed pancreatic malignancy. Presence of synchronous multiple pancreatic masses is a rare finding. In this case series, patients presented with two or more synchronous solid masses as a result of pancreatic cancer (PC), autoimmune pancreatitis (AIP), and sarcoidosis. Case Description/Methods: Case1:65-year-old female presented with abdominal pain and 20lbs unintentional weight loss over 4 months. CT scan revealed two suspicious solid masses in the body/tail of the pancreas (Figure A). IgG4 level was normal, but CA19-9 was elevated at 75u/mL. EUS with individual fine needle biopsies (FNB) of both masses confirmed infiltrative PC. Due to the significant cardiac history, the patient was deemed not a surgical candidate and was referred to oncology for chemoradiation/palliative therapy. Case2:76-year-old male presented to the hospital with postprandial abdominal discomfort and unintentional weight loss. CT Abdomen demonstrated localized inflammation in the pancreatic tail (Figure B). EUS showed mass-like lesions in the pancreatic head and tail. Immunohistochemistry was positive for IgG4-positive plasma cells. He was diagnosed with AIP and was started on steroids. Case3:54-year-old male with complicated sarcoidosis (pulmonary/extrapulmonary involvement), presented with an abnormal PET scan showing focal increased uptake in the head/tail of the pancreas. His CT scan did not show any mass or duct dilation. EUS demonstrated ill-defined, infiltrative masses involving the pancreatic head and the tail. FNB showed scattered non-necrotizing granulomas (Figure C). After excluding other causes of granulomatous diseases, he was diagnosed with pancreatic sarcoidosis. Discussion: Only a few examples of synchronous pancreatic masses have been recorded in the medical literature. Our case series includes three distinct pancreatic diseases that result in multiple mass lesions with similar appearance on imaging (Table ). The clinical course for all of the patients differed greatly depending on the pathology. The plurality of solid masses and comparable imaging features of each with PC, which is the 4th highest cause of cancer-related deaths in the United States is the highlight of this series. When encountering such individuals, a broad differential should be examined, as the clinical history of the illness varies. The whole pancreas should be investigated with multimodal imaging and EUS-guided acquisition histopathology to reach a clear diagnosis.