Beta-HCG-Positive Pancreatic Duct Adenocarcinoma Initially Presenting with Cutaneous Metastases

Excerpt

A 59-year-old Caucasian male with no significant past medical history presented to the clinic with multiple cutaneous lumps over his body which all appeared around the same time. He denied significant weight loss or travel history. On examination, there were several skin lesions. The largest lesion (2 cm) on his chest was solid and firm (Fig. 1A). Computer tomography scans showed multiple subcutaneous nodules (Fig. 1B). A skin punch biopsy of the upper chest nodule showed subcutaneous infiltrative poorly differentiated carcinoma involving middle and deep dermis (Fig. 1C, D). By immunohistochemistry, the tumor was strongly and diffusely positive for beta-HCG (Fig. 2A), positive for CK7, CA19-9, and Gata 3, negative for CEA, CD30, SALL4 (Fig. 2B), OCT4, S-100, CK20, CDX-2, TTF-1, synaptophysin, chromogranin, D2-40, p63, CD117, breast mix (GCDFP-15 and mammoglobulin), uroplakin, calponin, and estrogen receptor. The additional immunohistochemical stains showed the tumor to be positive for CK 19 (Fig. 2C). His tumor marker serology studies showed his serum level of HCG was also significantly elevated (574 mIU/ml) and tumor marker CA19-9 was 1453 U/ml. His serology CEA was in the normal range. A PET/CT showed widespread hypermetabolic soft tissue masses, multiple sub-centimeter non-FDG avid lung nodules, hypermetabolic liver masses, and a 7.5 cm pancreatic tail mass (SUV 8.0) with extension to the splenic hilar (Fig. 2D).

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