S3481 Undifferentiated Carcinoma With Osteoclast-Like Giant Cells of the Pancreas After Double Lung Transplantation: The Role of Immunosuppression in Carcinogenesis

Introduction: Undifferentiated carcinoma with osteoclast-like giant cells (UCOGC) of the pancreas is an extremely rare tumor, accounting for less than 1% of all pancreatic malignancies. Medical literature on UCOGC of the pancreas remains limited to sporadic case reports. We report the first case of UCOGC of the pancreas in a double lung transplant recipient. The role of immunosuppression in carcinogenesis is reviewed. Case Description/Methods: Patient was a 72-year-old man with a history of double lung transplantation for idiopathic pulmonary fibrosis 4 years ago. He had been immunosuppressed with tacrolimus and mycophenolate. He presented with 1 week of epigastric pain, nausea, vomiting, early satiety, poor oral intake, and weight loss. Blood work showed Hgb 10, platelet 75K, bilirubin 1.3, AST 29, ALT 60, AP 66. Computed tomography and magnetic resonance imaging showed a mass arising from the head of the pancreas measuring 3.4 cm, a 2.4 cm necrotic portacaval lymph node, and multiple low-attenuation lesions in the liver. EGD showed complete duodenal stenosis due to extrinsic compression. Endoscopic ultrasound showed a 6 cm × 5 cm heterogeneous mass in the pancreatic head with invasion into the portal vein and metastatic lesions throughout the liver. Fine needle biopsy of the pancreatic mass showed UCOGC. Fine needle aspiration of the liver lesions confirmed metastases from the pancreatic cancer. Patient deteriorated rapidly with respiratory distress and gastric outlet obstruction. Oncology offered port placement followed by gemcitabine-based chemotherapy, but patient declined due to his grave prognosis. He requested palliative intervention for the gastric outlet obstruction. Patient underwent a Roux-en-Y gastrojejunostomy which relieved the GI obstruction. He was discharged to home hospice. Discussion: Immunosuppression after solid organ transplantation is an established risk factor for carcinogenesis, with a 20-fold increased risk compared to the general population. Calcineurin inhibitors such as tacrolimus increase cytokine-transforming growth factor-beta levels. Immunosuppression leads to decreased activity of anti-neoplastic natural killer cells. Opportunistic viral infections such as Epstein-Barr virus can also increase the risk of carcinogenesis. Given that malignancy is a significant obstacle to long-term survival in this patient population, future research should focus on understanding how immunosuppression increases malignancy risk, developing novel diagnostic tools that allow for early detection, and providing targeted treatments.