Question: Dr Grzegorz, in December we discussed my back pain and my cysts in the pancreas. Since that time I had a bad case of Ileus and abdominal pain that required two visits to the ER. Also since February 8th I had 2 CT scans and a lot of blood work. I lost my appetite and lost 14 pounds. My cysts in the pancreas have not changed since 2014 and are considered stable, but on the last CT scan, 16 days from the scan on Feb 8th, showed a stable soft tissue around the Celiac Artery. My GI has scheduled a EUS because he is not sure what the tissue represents but is very concerned. I also had a MRI this morning that my PCP ordered because he thinks I do not have cancer. I have had severe Diarhhea, high anxiety, and overall not feeling well since February. And, since I discussed with you my back pain, I have been taking one Vicodin or Percocet every night to help with sleep and pain. I also spoke to another Pancreatic specialist and she also seems very confused regarding the tissue that strands the Celiac Artery because she is convinced it was not on the CT scan on Feb 8th. The pancreas in the last two scans were unremarkable but for the stable 1cm and 7mm IPMN lesions. I still have some back pain and a very little abdominal pain, but it is the loss of weight and loss of appetite that is very concerning. Please respond, I am freaking out.

Dr Stanko, the mass around the Celiac Artery shows as a gray area on the scan that should be black. The radiologist describes it as a stable soft tissue. No stones in the ducts,No fatty Diarhhea, and I am pretty sure it is not pancreatitis. The tissue does not appear to be a node and the radiologist did not appear to be concerned. I also had extension lab work that included the Antigen CA 19.9, which was 16.3. They tell me EUS is the gold standard for this kind of a test. All the blood work and stool tests were normal. I just don't understand how a tumor could spread to this area form the pancreas if my cysts are stable.

The Ileus was blamed on Percocet, but it is really unknown where it came from. No one mentioned ERCP and I understand it could be risky. The only thing my GI said that the gray area around the Celiac Artery was abnormal. Does the good blood work, especially the Antigen 19.9 and all the other pancreatic test, like Lipase and others were all normal?

I will discuss ERCP with my doctor. My alkaline phosphatase was 49 IU/L, I did not see the GGTF test. My AST was 30 and my ALT was 66, a tad high, if you were thinking liver.

Dr Stanko, thanks for your help, I am in a scary place. I did want to ask something. I understand the Mesenteric artery supplies blood to the head and neck of the pancreas and the Celiac artery supplies blood to the body of the pancreas. I also understand it is unlikely my IPMN would be cancerous and they are located in the head and neck. I have no lesions at all in the body and tail of the pancreas where the celiac artery supplies the blood. This soft tissue is stranding the celiac artery. Lastly, could my overwhelming anxiety contribute to my loss of appetite.

Dr Stanko, please review the results from my MRI on Saturday. my EUS is tomorrow.
Narrative
Clinical History: 70 year old male found to have soft tissue infiltration along the celiac artery on recent CT scan. COMPARISON: CT abdomen pelvis dated 2/24/2017 and 1/22/2014. TECHNIQUE: Mulipanar multiech echo MR of the abdomen was performed before and after the intravenous administration of 17cc MultiHance. The following sequences were obtained: Three plane localizer, coronal and axial T2 haste, axial true fist, Axiel T2 fat-sat, axial in and out of phase axial DW 1, axial T1 fat-sat, dynamic post contrast axial T1 fat sat during arterial phase one minute, three minutes and coronal. T1 fat-sat. FINDINGS: within the pancreatic head is a 1.5 cm T2 hypericin tense lesion which demonstates no internal enhancement on post contrast imaging. Also identified is a 1 cm lesion within the superior aspect of the pancreatic neck which appears to rise from a nondilated main pancreatic duct. This also demonstrates no internal enhancement. These are favored to represent side branch IPMNs. The remainder of pancreatic parenchyma is normal in signal and morphology. There is no evidence of pancreas divisum. The gallbladder is nondistended. There is no biliary ductal dilation. There is a subtle decrease in signal intensity within the hepatic parenchyma on opposed phase imaging,suggesting mild hepatic steatosis. There is a small T2 hyper intense focus within the periphery of the right hepatic lobe which demonstrates enhancement of post contrast imaging. This may represent a small flash filling hemangioma. a small T2 hyper intense lesion within the left hepatic lobe demonstrates in internal enhancements and is most compatible with a cyst. The major hepatic vessels are patent. The Spleen and adrenal glands appear unremarkable. Several nonenhancing T2 hyper intense lesions within both kidneys are compatible with cortical and parapelvic cysts. The abdominal aorta is normal in caliber. There is mild enhancing soft tissue along the celiac artery. Subtle soft tissue extends extends along the proximal and mid Mesenteric artery as well. This was present on the recent prior CT scan but has increased in extent from the 2014 examination. The arteries do appear to remain patent. A few prominent upper abdominal lymph nodes are also identified. For example, one lymph node to the left of the celiac artery measures 1.3 X 1.0cm. This is unchanged from the prior examination but has mildly increased since 2014. A prominent lymph node superior to the pancreatic neck measuring 1.6 x 1.1 is unchanged dating back to 2014. A small but prominent gastro hepatic lymph node measuring 1.1 is stable as well. These are nonspecific.
IMPRESSION, 1. 1.5 cm hyper intense lesion within the pancreatic head. A 1cm T2 hyper intense lesion is seen within the the superior aspect of the pancreatic neck. This appears to rise from the nondilated pancreatic duct. These lesions demonstrate on internal enhancement on post contrast imaging and are favored to represent side branch IPMNs. 2. mild enhancing soft tissue density along the celiac artery. There is subtle soft tissue density along the proximal mid portions of the superior Mesenteric artery as well. Whike this finding is unchanged from the more recent examination, this has increased since 2014. This is unclear etiology and continued follow up is recommended. There are several prominent gastro hepatic, retro peritoneal, peripancreatic lymph nodes as well. While one lymph node to the left if the celiac artery has mildly increased in size since. 2014, the remainder are not significantly changed. 3. small T2 hyper intense focus within the periphery of the right hepatic lobe demonstrating enhancement on post contrast imaging. This is a small to definitively characterize but may represent a small flas filling hemangioma. A small cyst is present within the left hepatic lobe.4. Bilateral renal cortical and parapelvic cysts.

Dr Stanko, sadly the EUS did discover cancer around the celiac Artery, my family is devastated. You and my PCP were very certain I had no cancer. And what is so mysterious is the EUS did not find a tumor in the pancreas and in fact the pancreas was totally unremarkable. Adenoma carcinoma around the celiac artery is always from the Pancreas. No body at the hospital can explain what happened. The final pathology is yet to be finalized but the report said the soft tissue around the celiac artery is highly suspicious, meaning they are pretty certain. I have a meeting with a team of doctors tomorrow to discuss a game plan from UPMC. I also am considering Johns XXXXXXX Any suggestions on clinical trials or hospitals.

Dr Stanko, EUS was used and the first preliminary pass was adencarcinoma around the celiac artery. Final results are still pending. But the Pancreas was normal and many of the doctors involved are very puzzled because they can't find the origination of the cancer, although I understand most of the time cancer that cuffs the celiac artery is from the pancreas. One of the top Pathologist is meeting with doctors today to discuss case. The strains should show where the tumor originated. Again, I repeat the pancreas and all other organs appear normal. If the Pathologist determines it is from the pancreas then I will need to take another EUS so they can biopsie where the Pathologist indicates where the tumor is located. Please respond and also if no tumors are visible in the pancreas could cancer of the pancreas still cause enzyme deficiencies?I continue to lose weight and the doctors gave me a script for enzymes and the dietician gave me info also.

We have no pathology report, but the doctor and the radiologist reviewed the tissue and they were pretty certain it was adencarcinoma. The report uses the language suspicious, pending results. But we have no primary tumor, yet. And when they find one it will need to be miniscule. As I said, they are referring to this case as most unusual.