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A 55-year-old man with no significant medical history presented with several weeks of malaise and a 6.8-kg weight loss associated with poor appetite. He reported no fevers, night sweats, abdominal pain, emesis, and diarrhea. Physical examination revealed a thin habitus; no palmar erythema, spider angiomas, or gynecomastia were observed. Laboratory tests showed normal complete blood cell count and chemistry panel findings. Hepatic panel showed an elevated alkaline phosphatase level (209 U/L; upper limit of normal [ULN], 150 U/L [3.49 μkat/L; ULN, 2.5 μkat/L]), normal total bilirubin level (0.4 mg/dL [6.84 μmol/L]), elevated alanine aminotransferase level (41 U/L; ULN, 35 U/L [0.68 μkat/L; ULN, 0.58 μkat/L]), and normal aspartate aminotransferase level (27 U/L [0.45 μkat/L]). A single-phase computed tomography (CT) scan of the abdomen revealed multiple hypoattenuating masses with rim enhancement throughout the liver, intussusception of the small bowel, and normal liver contour with no signs of portal hypertension (Figure 1, left). α-Fetoprotein (AFP) level was elevated (1252 ng/mL; ULN, 9 ng/mL); levels of carbohydrate antigen 19-9 (<2 U/mL) and carcinoembryonic antigen (2.8 ng/mL) were normal. A triple-phase CT scan was obtained to further evaluate the small bowel, which revealed no small bowel abnormalities but instead demonstrated a 3.3 × 2.8-cm heterogeneously enhancing pancreatic tail mass not seen on the previous single-phase CT (Figure 1, right).
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Pancreatic neuroendocrine tumor
D. Perform an endoscopic ultrasound of the pancreas with fine-needle aspiration
The key to the correct diagnosis is recognizing that the presence of multifocal liver masses in the background of normal liver parenchyma is unlikely to represent hepatocellular carcinoma (HCC), despite the significant elevation in serum AFP level,1 which was misleading in this case. Given the pancreatic tail mass subsequently discovered, a primary pancreatic malignancy metastasizing to the liver was the likely diagnosis. Thus, endoscopic ultrasound with fine-needle aspiration of the pancreatic mass would be the appropriate next step.2 FOLFIRINOX would be indicated for metastatic pancreatic adenocarcinoma and sorafenib would be indicated for unresectable or metastatic HCC, but a histologic diagnosis should be obtained before starting either of these agents. An 18F-FDG PET scan would not be useful in identifying the histologic type of mass.
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Corresponding Author: Adam E. Mikolajczyk, MD, University of Illinois at Chicago, 840 S Wood St, 735 CSB, MC 716, Chicago, IL 60612 (email@example.com).
Published Online: December 13, 2018. doi:10.1001/jama.2018.18435
Conflict of Interest Disclosures: Dr Pillai reported receiving personal fees from Simply Speaking Hepatitis, BTG, and Eisai. No other authors reported disclosures.
Additional Contributions: We thank the patient for providing permission to share his information.
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