Pancreatic Masses Clinically Diagnosed as Tuberculosis: A Case Series

Aims Pancreatic masses are not uncommonly encountered in clinical practice, with concern for the possibility of cancer that may indicate poor prognosis. Pancreatic tuberculosis can present as masses that may be difficult to differentiate from cancer, both clinically and radiologically. Thus, tissue sampling or outright surgical resection are part of the options for patients with pancreatic masses. However, surgical resection such as pancreaticoduodenectomy has been reported to be unnecessarily performed in patients with pancreatic masses that turned out to be benign. It would therefore be worthwhile to look into less invasive management options for pancreatic masses that may potentially be benign, such as tuberculosis, in order to avoid overtreatment of patients. The aims of this study are as follows: to present patients with pancreatic masses suspected to be cancer, to demonstrate that pancreatic tuberculosis may masquerade as cancer, and to show that clinical diagnosis and treatment for tuberculosis may be an option for patients presenting with pancreatic masses in an endemic region.

Methods The patient database in our institution from 2022 to 2023 was reviewed for patients presenting with pancreatic masses initially suspected to be malignant but later diagnosed as tuberculosis without direct evidence via tissue sampling. Pertinent clinical characteristics for each patient were obtained. Features of the pancreatic masses initially detected in each patient on abdominal imaging were reviewed, including those from abdominal CT scan and endoscopic ultrasound (EUS). The clinical response of each patient to anti-tuberculosis treatment was then assessed. Surveillance EUS looking into the status of the pancreatic masses after treatment was also checked for each patient.

Results Three adult Filipino patients, two males and one female, were noted to present with at least one of these symptoms: weight loss, epigastric pain, jaundice, and fever. The two males were smokers and had no prior history of tuberculosis treatment. The female patient had a family history of breast cancer. On workup, all three patients had pancreatic masses detected on abdominal CT scan and/or EUS. Malignancy was suspected in all three cases, with two of the patients having pancreatic masses exhibiting vascular encasement on imaging. Two of them also had elevated CA 19-9 level. Anti-tuberculosis treatment was eventually given to all three patients due to concomitant diagnoses of extrapancreatic tuberculosis in the absence of any direct evidence of pancreatic tuberculosis via tissue sampling. All three improved clinically after treatment, with EUS documentation of resolution of the pancreatic masses in all three cases. Common characteristics among the patients include age less than 60 years old and presence of extrapancreatic tuberculosis. [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11]

Conclusions In endemic regions, clinical diagnosis of pancreatic tuberculosis and treatment without tissue sampling may be a management option for patients presenting with pancreatic masses, especially if relatively young and with diagnosis of tuberculosis in other organs. This approach may potentially avoid overtreatment such as unnecessary surgical resection.

Publikationsverlauf

Artikel online veröffentlicht:
15. April 2024

• References

• 1 Sun P, Lin Y, Cui X.. Isolated pancreatic tuberculosis with elevated CA 19-9 levels masquerading as a malignancy: A rare case report and literature review. Medicine (Baltimore) 2018; 97 (52) e13858
• 2 McGuigan A. et al. Pancreatic cancer: A review of clinical diagnosis, epidemiology, treatment and outcomes. World J Gastroenterol 2018; 24 (43) 4846-4861
• 3 Hu JX. et al. Pancreatic cancer: A review of epidemiology, trend, and risk factors. World J Gastroenterol 2021; 27 (27) 4298-4321
• 4 Rana SS. et al. Vascular invasion does not discriminate between pancreatic tuberculosis and pancreatic malignancy: a case series. Ann Gastroenterol 2014; 27 (04) 395-398
• 5 Sharma V. et al. Pancreatic tuberculosis. J Gastroenterol Hepatol 2016; 31 (02) 310-8 10.111/jgh.13174
• 6 Dong Y. et al. Ultrasound imaging features of isolated pancreatic tuberculosis. Endosc Ultrasound 2018; 7 (02) 119-127 PMID: 28721972; PMCID: PMC5914183
• 7 Panic N. et al. Pancreatic tuberculosis: a systematic review of symptoms, diagnosis and treatment. United European Gastroenterol J 2020; 8 (04) 396-402
• 8 Feldman M, Friedman L, Brandt L.. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease 11th Edition. 2021. Elsevier, Inc; Philadelphia, PA:
• 9 Sun SL. et al. Isolated pancreatic tuberculosis in non-immunocompromised patient treated by Whipple's procedure: a case report. Chin Med Sci J 2014; 29 (01) 58-60
• 10 Singh DK. et al. Primary pancreatic tuberculosis masquerading as a pancreatic tumor leading to Whipple's pancreaticoduodenectomy. A case report and review of the literature. JOP 2009; 10 (04) 451-6
• 11 Chen CH. et al. Pancreatic tuberculosis with obstructive jaundice–a case report. Am J Gastroenterol 1999; 94 (09) 2534-6