Do Not Anchor on Vasculitis: Pancreatic Cancer Presenting With Isolated Celiac/Superior Mesenteric Artery Thickening

OBJECTIVE: Medium-vessel vasculitis involving the visceral vasculature in adults is rare. Pancreatic ductal adenocarcinoma (PDAC) has been implicated in medium artery vascular thickening secondary to extravascular migratory metastasis with involvement of the celiac and superior mesenteric vessels. METHODS: Patients presenting to the rheumatology vasculitis subspecialty clinic were retrospectively identified using an electronic health record data exploration tool evaluating for diagnosis of pancreatic cancer, periaortitis, and vasculitis between January 2015 and December 2024. RESULTS: We retrospectively identified four patients with PDAC initially presenting with periarterial thickening of the celiac and superior celiac and superior mesenteric vessels (100% White, 50% male, median age 70.5 years). All four patients had abdominal pain with significant unintentional weight loss, with a median weight loss of 25 pounds (range 25-50 pounds). The median time to correct diagnosis was 221 days (range 162-340 days). All four patients had an elevated carbohydrate antigen 19-9 level (range from 114 to 10,702, with a median of 341.5 U/mL). All four patients were diagnosed with endoscopic ultrasound-guided fine-needle aspirations. The median number of biopsies required to make the diagnosis was three. CONCLUSION: Isolated celiac and superior mesenteric periarterial thickening or "cuffing" is a vasculitis mimic that should prompt a comprehensive malignancy workup. Expedited referral to a tertiary center is essential given difficulty in tissue sampling with conventional methods and to avoid further delays in diagnosis.