S3327 Ureteral Obstruction Secondary to Pancreatic Adenocarcinoma: A Rare Clinical Presentation

Introduction: Pancreatic cancer is the twelfth most prevalent malignancy globally, with a steadily increasing incidence in recent decades. Pancreatic adenocarcinoma accounts for about 90% of cases and is often associated with poor prognosis. Early-stage disease is often asymptomatic, contributing to delayed diagnosis. When present, symptoms may include weight loss, jaundice, abdominal discomfort, and steatorrhea. While the liver, lungs, brain and lymph nodes are common sites of metastasis, we report a rare case of pancreatic adenocarcinoma with metastatic spread to the ureter. Case Description/Methods: A 74-year-old woman with a medical history of diabetes, iron deficiency anemia, hypertension, and esophagitis initially presented with 5 to 6 weeks of abdominal discomfort, nausea, postprandial emesis, and an unintentional 7-pound weight loss. Computed tomography of the abdomen revealed a 2.7 cm pancreatic tail mass causing duodenal obstruction. A nasogastric tube was placed for decompression, followed by successful duodenal stenting via esophagogastroduodenoscopy (EGD). Biopsy of the pancreatic mass confirmed primary pancreatic adenocarcinoma. The patient later underwent surgical resection, which revealed metastatic disease of regional lymph nodes. A few weeks later, the patient reported persistent flank pain and intermittent fevers. Surveillance computed tomography imaging revealed left-sided hydronephrosis secondary to a distal ureteral mass. The patient underwent urologic evaluation, including cystoscopy and placement of left ureteral stent. Intraoperative examination demonstrated multiple areas of left ureteral narrowing. Biopsies of these sites revealed tumor cells positive for CK7 and CDX2 (while negative for CD20, SMAD4, GATA3, ER, and PAX8), consistent with metastatic pancreatic adenocarcinoma. Discussion: Ureteral metastasis is a rare complication of pancreatic cancer, typically presenting with flank pain, urinary obstruction, and hydronephrosis. A review of the literature yielded around 10 documented cases of ureteral involvement secondary to pancreatic malignancy. Approximately 90% of patients diagnosed with ureteral metastasis also have evidence of advanced systemic metastasis. The prognosis for such patients is poor, with 3-fourths succumbing within 6 months of diagnosis. Management of ureteral metastasis typically involves stent placement to alleviate the obstruction, while systemic chemotherapy is the mainstay of treatment for these advanced cases.