S3647 A Pancreas's Tail, a Spleen's Hilum, and a Squamous Cell Cancer

Introduction: Primary squamous cell carcinoma of the pancreas (SCCP) is an extremely rare clinical entity, comprising anywhere between 0.5 to 5% of all pancreatic malignancies, with rising incidence. Pancreatic tissue, normally devoid of squamous cells, must undergo squamous metaplastic changes of its columnar ductal cells, either secondary to inflammation or within a pre-existing adenocarcinoma. Clinical data is poor for SCCP, with diagnostic pathways and treatment options limited, making this area ripe for standardization. Case Description/Methods: Our patient is a 76-year-old man with no significant past medical history who presented to his primary care physician’s office with a 4-month history of unintentional weight loss and left upper quadrant abdominal pain. He also noticed anorexia, early satiety, and night sweats. Examination was only notable for splenomegaly. Comprehensive metabolic panel was normal. Magnetic resonance imaging abdomen showed a large splenic cystic/solid lesion with possible invasion of the pancreas. GI was consulted for endoscopic ultrasound with FNA of the left upper quadrant mass, which resulted in multiple biopsies along the splenic hilum and pancreatic tail. Pathology only showed rare, atypical changes, without a clear diagnosis. A few weeks later, he was evaluated by surgical oncology and taken to the OR for removal of a 17 cm tumor with distal pancreatectomy, splenectomy, omentectomy and transverse colon resection, positive for squamous cell carcinoma of the pancreas. He is currently undergoing adjuvant chemotherapy. Discussion: For our patient, a SCCP that quickly metastasized from the pancreatic tail to the hilar spleen promoted confounding symptoms derived from splenic involvement. Endoscopic ultrasound with FNA of this splenic lesion was productive of nondiagnostic pathology, despite multiple sites biopsied, likely resultant of cystic aspiration, and points to the difficulty of transgastric biopsy of the left upper quadrant. Typically, magnetic resonance imaging imaging and surgical intervention, at least in early-stage cancers, are the most common management strategies amongst the roughly 50 cases of SCCP present in the literature. The gastroenterologist also has a role in mediating risk factors for SCCP, including mitigation of inflammatory states, like chronic pancreatitis, and careful pancreatic duct intervention, mostly related to stent placement, which have been implicated in many of the cases reviewed for this report. Our case should serve as further example for the need for continued clinical study of SCCP.