Shady Double Crosser

The patient underwent a liver biopsy. Pathology revealed moderately differentiated adenocarcinoma. The immunohistochemical profile of the tumor was CK7+, CK19+,CK20-, CDX2 focally +, TTF1-, consistent with a pancreatico-biliary or upper GI origin. A subsequent biopsy of the clival mass showed identical pathology. Pancreatic cancer is a fatal disease, with a 5 year survival rate of 5%. Patients often present with nodal and/or metastases to liver, lung or bone. Cranial and brain metastases are extremely rare. In a 2003 review of 1229 consecutive patients with pancreatic adenocarcinoma, Park et al found only 4 (0.33%) with cerebral metastases. There have been only 23 reported cases of ante mortem intracranial metastases. Of these, 17 had metastases to the brain parenchyma (usually multiple), 5 presented with carcinomatous meningitis, and one with epidural metastasis. In only 3 of these cases were the intracranial lesions the primary manifestation of pancreatic adenocarcinoma. This woman is the fourth such patient, and is unique in that she presented with a single, large metastatic lesion to the skull base, with symptoms that have never been associated with pancreatic adenocarcinoma: severe photophobia and diplopia from sixth nerve compression at the clivus. The median survival when pancreatic carcinoma metastasizes to the brain is less than 3 months. However, Lemke et al reported 2 unusual patients with brain metastases presenting 11 months and 6 years after their primary tumors had been resected. The brain metastases were microsurgically resected, and these patients survived more than 6 and 10 years, respectively.