Upon further review of the pathology, the diagnosis was established as metastatic adenocarcinoma of pancreaticobiliary origin. The patient tolerated the TURBT well and was discharged from the hospital. On subsequent follow-up, the patient was started on FOLFIRINOX, a chemotherapy regimen consisting of 4 therapeutic agents for metastatic pancreatic cancer.
Pancreatic cancer has an annual incidence of approximately 12.5 cases per 100,000 people.6 It is more common in men than in women, and with increasing age. Although the exact causes of pancreatic cancer remain unknown, tobacco use has been shown to increase the risk of developing pancreatic cancer. The risk of pancreatic cancer is 2.5–3.6 times greater in smokers than in nonsmokers, and the overall 5-year survival rate among patients with pancreatic cancer is <4%.3,7 The most common symptoms of pancreatic cancer include jaundice, weight loss, and epigastric pain.
CA 19–9 is a common tumor marker that has been studied to diagnose pancreatic cancer. According to a study in 2006, the sensitivity and specificity of CA 19–9 are 80.8% and 89.1%, respectively, ranging from 70–92% and 68–92%, respectively.8 Our patient had a minimally elevated CA 19–9 level, which can be seen in benign pathology as well, such as in acute cholangitis and cirrhosis. Other malignancies that can express CA 19–9 include cholangiocarcinoma, hepatocellular carcinoma, and gastric, ovarian, and colorectal cancers.
Metastasis from the pancreas to the bladder is exceedingly rare; this is only the third reported case since 1953. The bladder is not a common site for metastasis of cancer, and when it does occur, the primary cancer is usually from elsewhere in the genitourinary tract or from a colorectal malignancy. There have been 2 case reports of hematuria and urinary blood clots as the presenting symptom of metastatic pancreatic cancer to the bladder, but this requires mucosal ulceration of the bladder wall.9 Our patient did not have any urinary symptoms, and her urinalysis was negative for microscopic hematuria. The diagnosis of pancreatic cancer necessitates histological confirmation. EUS with FNA has a sensitivity and specificity of 89% and 96%, respectively.10 Even though the EUS with FNA is regarded as the best modality to obtain a sample of pancreatic tissue, the FNA in this case revealed only atypical cells, resulting in a diagnostic challenge in determining the primary source of the malignancy.
The definitive diagnosis of metastatic pancreatic cancer to the bladder was not established until the pathology of the bladder tumor confirmed pancreatic adenocarcinoma. Our case highlights the importance of considering metastases when distinct masses are found in various organs. It is imperative to distinguish the primary malignancy in such patients as it may change management and treatment options.
Author contributions: A. Shah wrote the manuscript. P. Korrapati, J. Siegel, and F. Kasmin edited the manuscript. F. Kasmin is the article guarantor.
Financial disclosure: None to report.
Informed consent was obtained for this case report.
Received December 1, 2017; Accepted February 2, 2018
2. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2017. CA Cancer J Clin.
3. Hidalgo M, Cascinu S, Kleeff J, et al. Addressing the challenges of pancreatic cancer: Future directions for improving outcomes. Pancreatology.
4. Velcheti V, Govindan R. Metastatic cancer involving bladder: A review. Can J Urol.
5. Cellini M, Deighton DA. Radiological case: Non-papillary bladder metastasis from pancreatic adenocarcinoma. Appl Radiol.
6. Howlader N, Noone AM, Krapcho M, et al. SEER Cancer Statistics Review, 1975-2014. National Cancer Institute website. https://seer.cancer.gov/csr/1975_2014
. Updated June 28, 2017. Accessed March 5, 2018.
7. Hassan MM, Bondy ML, Wolff RA, et al. Risk factors for pancreatic cancer: Case-control study. Am J Gastroenterol.
8. Cwik G, Wallner G, Skoczylas T, Krzyzanowski M, Ciechainski A, Madro P. Elevated tumor marker CA 19-9 in the differential diagnosis of pancreatic mass lesions. Ann Univ Mariae Curie Sklodowska.
9. Chiang KS, Lamki N, Athey PA. Metastasis to the bladder from pancreatic adenocarcinoma presenting with hematuria. Urol Radiol.
© 2018 by Lippincott Williams & Wilkins, Inc.
10. Puli SR, Bechtold ML, Buxbaum JL, Eloubeidi MA. How good is endoscopic ultrasound-guided fine-needle aspiration in diagnosing the correct etiology for a solid pancreatic mass?: A meta-analysis and systematic review. Pancreas.