Pancreatic Adenocarcinoma Presenting with Biliary Ureteral Stones: A Case Report

Document Type : Case Report

Authors

1 Department of Urology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran

2 Pediatric Urology and Regenerative Medicine Research Center, Children’s Medical Center, Tehran University of Medical Sciences, Tehran, Iran

3 Department of Urology, Velayat Hospital, Ghazvin University of Medical Sciences, Ghazvin, Iran

4 Aja University of Medical Sciences, Tehran, Iran

Abstract

Introduction: calcium oxalate, phosphate, struvite, uric acid, and cysteine make up the majority of urinary stones. Moreover, only 0.5 -3.5 percent of urinary stones have a different composition. A thorough history, physical examination, along with urinary stone analysis helps to diagnose the cause of rare urinary stones.
Case presentation: We herein report a case of pancreatic cancer with the unusual presentation of renal colic and ureteral stones. After removing the stones with ureterolithotripsy, the stone analysis revealed bilirubin crystal composition. Upon further follow-up, the patient has diagnosed with adenocarcinoma of the head of the pancreas.
Conclusions: This case highlights the importance of stone analysis, while many urologists do not consider this, and this is my result in miss diagnosis of some dangerous diseases that may present with the uncommon presentation.

Highlights

  • Pancreatic cancer is common with meager survival rates, and early diagnosis can increase the chance of survival.
  • We herein report a case of pancreatic cancer with the unusual presentation of renal colic and ureteral stones. After removing the stones with ureterolithotripsy, the stone analysis revealed bilirubin crystal composition. Upon further follow-up, the patient was diagnosed with adenocarcinoma of the head of the pancreas.
  • This case highlights the crucial role physicians play in primary and emergency settings in investigating subtle or secondary presentations and encourages a higher degree of suspicion for less common disease manifestations.

Keywords

Main Subjects


Introduction

Calcium oxalate, calcium phosphate, struvite, uric acid, and cysteine make up the majority of urinary stones. Moreover, only 0.5 -3.5 percent of urinary stones have different compositions. A thorough history, physical examination, and urinary stone analysis help diagnose the cause of rare urinary stones (1). Pancreatic cancer is the 12th most common cancer and the 7th leading cause of cancer-related deaths worldwide (2). The most common initial presentation is pain, followed by jaundice, dyspepsia, and weight loss. Other less common signs and symptoms may include nausea and vomiting, abdominal mass, or pruritus, depending on the tumor site. Due to these non-specific symptoms and their insidious course, the disease is usually detected at late stages, and almost all patients die from it. An earlier diagnosis can lead to earlier intervention and improve overall survival (3). Here we present a case of pancreatic adenocarcinoma with the unusual presentation of renal colic and ureteral stones composed of bilirubin crystals.

 

Case Report

A 62-year-old man presented to the emergency department complaining of right-sided colicky flank pain that had started two days prior. Upon admission, the patient was pale and slightly jaundiced. He had no other relevant physical findings, past medical history, or family or drug history.

Subsequent ultrasound imaging revealed two calculi measuring 5*7 and 5*5 mm on the distal part of the right ureter, with concomitant right hydronephrosis. Afterward, the patient underwent transurethral ureterolithotripsy with rigid ureteroscopy, and the stones were removed from the distal ureter. The stones were green and were sent for analysis (Table 1). Further investigation revealed elevated total and direct serum bilirubin, prothrombin time, CEA, and CA 19-9 levels (Table 2), and a computed tomography (CT) scan of the abdomen with contrast revealed a 25 mm mass at the head of the pancreas (Figure 1). Unfortunately, the patient had no previous imaging that could be useful compared to the new ones. After discharge, the patient underwent Whipple surgery and was immediately started on chemotherapy with gemcitabine plus S-1. At 12 months after the surgery, the patient died of complications related to the tumor spread, leading to bowel obstruction.

 

 

Table 1. Analysis of renal calculi composition

Composition

Percentage

Calcium oxalate

 

30%

Calcium phosphate

 

28%

Calcium bilirubinate

 

22%

Bilirubin

 

15%

Calcium carbonate

 

5%

 

 

Table 2.  Lab results on follow-up testing after the operation

Test

Result

Unit

Normal Range

ALP

417

U/L

80-306

Bilirubin (total)

4.0

mg/dL

0.1-1.2

Bilirubin (direct)

1.8

mg/dL

<0.3

Amylase

18

U/L

<100

Na

132

mEq/L

135-145

K

3.7

mEq/L

3.5-5.5

Ca

9.5

mg/dL

8.5-10.4

PTT

39

Seconds

25-40

PT

13.3

Seconds

11-14

INR

1.1

-

Control = 12.6

CEA

6.90

µg/L

Non-smoker: <3.8        Smoker: <5.5

CA-19.9

601.8

U/mL

<39

 

 

 

 

 

Discussion

Early diagnosis and treatment of pancreatic cancer are crucial in determining disease outcomes. Nevertheless, most symptoms the patients initially present with are either vague or non-specific. Among these signs and symptoms, jaundice has the highest positive predictive value. It is, therefore, the most likely presentation which could lead us to an earlier diagnosis, provided that the primary care physician has enough expertise and is attentive to performing a thorough physical examination (3). In this case, although our patient did not complain of any more common symptoms of pancreatic cancer, a minimal degree of jaundice and scleral icterus was evident upon his first physical examination, which warranted further investigation. Kidney stones inflict an estimated 9% of individuals at least once in their lifetimes and have had an increasing prevalence trend in recent years (4).

A system to classify renal stones gives us more unified data to better understand the nature of an underlying illness. To classify different types of kidney stones in terms of composition, we need to agree on two premises: firstly, the categories of stone composition are mutually exclusive —meaning that a stone of several components will be classified into only one category—; and secondly,, a stone made of a rare compound and another more common compound is organized by the rare compound (5). Therefore, the stones’ primary composition in this patient will be classified as bilirubin.  

After an extensive literature review, we did not find any reports of renal stones with a biliary composition; nor any case of pancreatic cancer presenting initially with renal colic. On the other hand, pancreatic cancer and renal calculi can coincide in multiple endocrine neoplasias (MEN) 1 patient as these patients are susceptible to pancreatic, pituitary, and parathyroid carcinomas, where high serum calcium levels can lead to oxalate stone formation (6-8). In our case, serum calcium levels were normal (9.5 mg/dL), and the patient mentioned no other relevant family history or past medical history. Nevertheless, a full workup of his pituitary and parathyroid function could have led us to understand the mechanism behind such a presentation better. We also propose a possible role for a factor secreted by tumor cells to initiate a cascade of events leading to stone formation.

 

Conclusions

This case highlights the importance of stone analysis. At the same time, many urologists do not consider this; this may result in a missed diagnosis of some dangerous disease that may present with an uncommon presentation.

 

Authors’ contributions

HD and MM researched the literature and conceived the study. FN and MKH were involved in protocol development, patient recruitment, and data analysis. ZA and SD, and AK wrote the first draft of the manuscript. All authors reviewed and edited the manuscript and approved the final version of the manuscript.


Acknowledgments
None.


Conflict of interest
The author declares that there is no conflict of interest.


Funding
There is no funding.


Ethics statement
Not Applicable.


Data availability
None.


Abbreviations

µg/dL      Micrograms per decilitres

CA           Carbohydrate antigen

CEA         Carcinoembryonic antigen

CT          Computed tomography

mm        Millimetre

MRI        Magnetic resonance imaging

  1. Lowry PS, Nakada SY. Urinary Stones of Unusual Etiology. In: Stoller ML, Meng MV, editors. Urinary Stone Disease: The Practical Guide to Medical and Surgical Management. Totowa, NJ: Humana Press; 2007. p. 345-67.
  2. Luo W, Tao J, Zheng L, Zhang T. Current epidemiology of pancreatic cancer: Challenges and opportunities. Chinese journal of cancer research = Chung-kuo yen cheng yen chiu. 2020;32(6):705-19.
  3. Keane MG, Horsfall L, Rait G, Pereira SP. A case-control study comparing the incidence of early symptoms in pancreatic and biliary tract cancer. BMJ open. 2014;4(11):e005720.
  4. Scales CD, Jr., Smith AC, Hanley JM, Saigal CS. Prevalence of kidney stones in the United States. European urology. 2012;62(1):160-5.
  5. Thongprayoon C, Krambeck AE, Rule AD. Determining the true burden of kidney stone disease. Nature reviews Nephrology. 2020;16(12):736-46.
  6. Ibrahim MN, Liem J, ElKady A. Multiple endocrine neoplasia type 1 (MEN1) presenting with renal stones: Case report and review. Radiology case reports. 2020;15(12):2503-9.
  7. Jensen RT, Norton JA. Treatment of Pancreatic Neuroendocrine Tumors in Multiple Endocrine Neoplasia Type 1: Some Clarity But Continued Controversy. Pancreas. 2017;46(5):589-94.
  8. Trouillas J, Labat-Moleur F, Sturm N, Kujas M, Heymann MF, Figarella-Branger D, et al. Pituitary tumors and hyperplasia in multiple endocrine neoplasia type 1 syndrome (MEN1): a case-control study in a series of 77 patients versus 2509 non-MEN1 patients. The American journal of surgical pathology. 2008;32(4):534-43.
Volume 4, Issue 4
November 2022
Pages 154-157
  • Receive Date: 13 February 2022
  • Revise Date: 16 April 2022
  • Accept Date: 14 June 2022
  • First Publish Date: 26 October 2022