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MEDICAL PRACTICE
Pancreatic cancer continues to be one of the most tor was increased 1 month before his first visit for
lethal of cancers. It is the 7th leading cause of the cough. There were no changes in his physical
cancer in the United States and the 4th leading examination, and his ACE inhibitor was discontin-
cause of cancer-related death.1 Although pulmo- ued. He continued without improvement and was
nary metastases of pancreatic cancer is not uncom- evaluated by a second doctor in September 2001.
mon, a nonproductive cough as the only complaint This physician documented that the patient’s lungs
for greater than 6 months has not been previously continued to be clear to auscultation and found no
reported. other abnormalities on physical examination. The
patient’s chest radiograph (Figure 1) was read as
Case Reports having “diffuse nodular infiltrates seen throughout
A 49-year-old African American man presented to both lungs. Etiology unknown. However, due to
the family medicine clinic in July 2001 complaining the nodular nature, the possibility of metastatic
of a persistent nonproductive cough not relieved by disease cannot be ruled out entirely.”
over-the-counter medications. He denied fever, The chest radiograph was reviewed with the
chills, weight loss, pain, or other complaints. He radiologist and a pulmonologist and a spiral com-
continued to work at his job as a railroad engineer. puted tomograph (CT) was ordered (Figure 2).
The patient had a past medical history of hyper- The spiral CT showed multiple bilateral nodules
tension, obesity, and hypercholesterolemia. He had scattered throughout both lungs in all fields. No
never undergone surgery or been hospitalized. He adenopathy was seen in either the hilar region or
had never smoked, nor had his wife, and he re- the rest of the mediastinum. No axillary or supra-
ported drinking less than 1 alcoholic beverage per clavicular adenopathy was evident. Examination
month. There was no obvious history of exposure through the upper abdomen showed the visualized
to infectious or occupational hazards. Family his- liver, spleen, suprarenal, and kidneys to be normal.
tory was significant only for paternal cardiac dis- The CT report stated “the differential diagnosis for
ease. The patient’s lungs were clear to auscultation, scattered, diffuse bilateral pulmonary nodules in-
and results of the heart and abdominal examination cludes sarcoidosis and fungal infections. [Tubercu-
were unremarkable. He did exhibit posterior pha- losis] is a possibility but unlikely in proper settings.
ryngeal nasal drip and clear rhinorrhea. Conse- The appearance is not of metastasis or primary
quently, he was diagnosed with allergic rhinitis, tumor.”
treated with a nonsedating antihistamine, and told Follow-up laboratory tests for ACE, HIV, and
to return to clinic if he worsened. purified protein derivative were negative. Anti-
In August 2001, his wife insisted that he return
nuclear antibody titers were negative, rapid plasma
to the clinic. The patient’s cough had not im-
reagin was nonreactive, erythrocyte sedimentation
proved. A chart review indicated that the dosage of
rate was 60, and cytidine monophosphate and com-
his angiotensin-converting enzyme (ACE) inhibi-
plete blood cell count (CBC) were normal. The
patient continued to have a bothersome cough, not
even improved with narcotics at this point, and
Submitted, revised 7 March 2003.
From the Forest Park Family Medicine Residency, Forest agreed to undergo a bronchoscopy in early October
Park Hospital, St. Louis, Missouri. Address correspondence 2001. The bronchoscopy showed no abnormalities
to R. Todd Richwine DO, MS, UNTHSC–Westside Fam-
ily Practice, 5944 River Oaks Blvd., Fort Worth, TX 76114 on visualization. Biopsies showed normal tissue bi-
(e-mail: rrichwin@hsc.unt.edu). laterally. Cultures for bacteria, fungus, and tuber-
stent was placed with considerable difficulty to re- gastrointestinal malignancy. Only 1000 patients of
lieve the obstruction. CA 19-9 level was then or- the approximately 28,000 new diagnoses each year
dered and was found to be 39,900 (normal ⬍15). A survive an additional 5 years. One-year survival
repeat spiral CT showed a small pancreatic duct from presentation is less than 20%, and 6-month
mass with minimal but significant posterior perito- survival is less than 50%.3
neal involvement. A positron emission tomography Unfortunately, by the time patients present with
scan showed characteristic and identical signatures symptoms they are often found to have local inva-
in the pancreatic head and the lung. He was diag- sion or distant metastasis. The classic Virchow
nosed with metastatic, nonoperable pancreatic car- Triad of pancreatic cancer is typically found in
cinoma. A CT-guided biopsy of a lung nodule masses in the head of the pancreas. The triad com-
further confirmed metastatic pancreatic adenocar- prises abdominal pain, anorexia, and weight loss.
cinoma. Abdominal pain is typically epigastric, constant,
dull, and may radiate to the back. Pain is often
Discussion worse at night and when the patient is supine. Pain
The incidence of pancreatic cancer rises above the will often decrease when the patient leans forward,
age of 45; 80% of cases are found between the ages bringing the mass off the celiac plexus.4 Pain is
of 60 and 80. Men are twice as likely as women to found as the initial symptom in 70% to 80% of
develop it, and mortality is increased in African patients and is typically secondary to mass effect,
Americans and Japanese Americans. Smoking is by obstruction of outflow from the liver, or local in-
far the most reducible risk factor accounting for up vasion of nerves. Anorexia and weight loss are the
to 25% of pancreatic cancer in a dose-dependent initial presenting symptoms in 10% of patients and
relationship. Long-term alcohol consumption, are thought to be secondary to malabsorption and
high-fat diet, and chronic pancreatitis are more decreased caloric intake. Jaundice is a frequent and
questionable risk factors.2 Pancreatic cancer con- common symptom, usually secondary to obstruc-
tinues to have the lowest 5-year survival of any tion of the biliary tree. Patients can develop diabe-
bronchoscopy was nondiagnostic. Of the few cases Diagnosing pancreatic cancer is challenging for
found in the literature,5,6,9,10,11 our patient’s lung family practitioners. However, early diagnosis is
metastases were multiple (not solitary), his cancer the patient’s only chance for a surgical cure. Our
was in the pancreatic head (tail is 90% more com- family practice clinic cares for 2 patients with inci-
mon in patients with lung metastases), and he was dentally detected cancers, one patient 5 years out
never a smoker. Even after presentation with epi- from diagnosis and the other 10 years out. Physi-
gastric pain, a helical CT scan (the test of choice) cians should always maintain a high index of suspi-
was nondiagnostic. All the reported cases had other cion for pancreatic cancer, especially in older pa-
symptoms at presentation, metastases were found tients. The classic triad of abdominal pain, anorexia
only at autopsy, or were previously diagnosed as with weight loss, and jaundice should never be
having pancreatic cancer before they developed ignored. Spiral CT scans with rapid contrast com-
lung symptoms. It was not until the liver obstruc- bined with a CA 19-9 level used in suspicious cases
tion became severe enough to require an ERCP seems to be the most useful diagnostic tests and are
that carcinoma was considered. A CA 19-9 level also able to stage the cancer if found.
was then ordered. A positron emission tomography At the date of submission, the patient is receiv-
scan, a test not readily available in nonspecialty ing continual home oxygen and enjoying the time
centers, indicated the similar signal between the with his family. He is free from pain after a celiac
lung and pancreatic cancer. ablation, is being treated by “salvage chemother-