S4550 A Case of Upper GI Adenocarcinoma Preceded by Pyoderma Gangrenosum

Introduction: Solid organ malignancies in patients with established pyoderma gangrenosum (PG) are rare, and few reported cases have been from an upper gastrointestinal (GI) source. In a recent prospective cohort study in the US, of 356 individuals with PG, 23 patients had solid organ malignancies. The exact relationship of PG and malignancy is unknown and current cancer screening guidelines make no adjustment for this population. This case highlights the importance of conducting a thorough review of symptoms for patients with PG to improve management. Case Description/Methods: A 71-year-old man with a recent diagnosis of biopsy proven PG presented for evaluation of a 10-day history of acute progressive dysphagia associated with unintentional weight loss. Labs remarkable for erythrocyte sedimentation rate: 32, C-reactive protein: 1.84, carcinoembryonic antigen <0.5. Computed tomography scan upon admission was pertinent for a left hepatic lobe cyst measuring 1.6 × 1.2 cm and a pancreatic tail irregular hypodense lesion. Esophagogastroduodenoscopy (EGD) revealed multiple round subepithelial nodules, some with central umbilication. One nodule removed by cold snare polypectomy revealed poorly differentiated carcinoma with features indicating adenocarcinoma, and overlying squamous mucosa suggesting it may secondarily be involving the site. The tissue also stained Positive with CDX2 and CK7 suggesting it was from upper GI or pancreaticobiliary source. EUS of the pancreatic lesions revealed a thick-walled, regular, anechoic pancreatic lesion which was biopsied and revealed a mucinous cystic neoplasm. Colonoscopy revealed no inflammatory bowel disease (IBD) or malignancy. The patient followed up with Oncology who performed a PET scan which showed no obvious source of malignancy. Collective findings suggest that this patient had adenocarcinoma from an unknown primary source, however thought to be Upper GI related as his pancreatic biopsies were not remarkable for adenocarcinoma. He was later started on therapy for Upper GI adenocarcinoma by his Oncologist. Discussion: PG has been strongly related to other diseases such as IBD, arthritis, and hematological malignancies. PG connection to paraneoplastic processes such as solid organ malignancies has not been well established, but have been previously reported through case reports. While dysregulated neutrophilic inflammation may lead to solid organ malignancies the direct relationship is unknown. Current United States Preventive Services Taskforce Cancer screening recommendations make no adjustments for this population. We submit that patients with PG who are experiencing GI symptoms should be evaluated with EGD and colonoscopy to screen for malignancy.