Pancreatic acinar cell carcinoma with multiple liver metastases presented with pancreatic panniculitis

This 68-year-old man with a diagnosis of multiple hepatic and pancreatic tumors with obstructive jaundice and portal vein thrombosis 2 months ago. Initially, hepatocellular carcinoma was suspected based on CT findings showing early arterial phase enhancement, delayed phase hypodensity, presence of portal vein thrombosis, and elevated alpha-fetoprotein (AFP) levels (182.4 ng/mL). However, the patient hesitated about further treatment. Four weeks later, he complained of painful cutaneous nodules on the bilateral lower legs (Figure 1A). Based on the characterization of the skin lesion, the initial clinical suspicion pointed towards panniculitis. Previous CT scan revealed a pancreatic tumor. Consequently, we conducted a biochemical test as part of the panniculitis workup. A subsequent investigation revealed marked lipasemia (1274 U/L, normal range 11–82 U/L), leading to a skin biopsy showing lobular panniculitis with saponification and enzymatic necrosis of fat cells (ghost cell) that confirmed pancreatic panniculitis (Figure 1B). CEA levels were within normal limits for a smoker (3.90 ng/mL), while CA199 levels were elevated (102.26 U/mL). Further imaging via MRI revealed a 6.8-cm mass in the uncinate process of the pancreas with multiple liver masses and enlarged lymph nodes at the mesenteric root (Figure 2). Endoscopic ultrasound (EUS) with fine-needle biopsy of both the pancreatic tumor and lymph nodes was arranged. The pathology results confirmed the diagnosis of pancreatic acinar cell carcinoma (ACC). Pancreatic panniculitis, characterized by painful subcutaneous nodules mainly on the lower extremities, is a rare dermatologic condition often linked to pancreatitis or pancreatic tumors.1 While its exact cause remains uncertain, pancreatic enzyme release likely triggers microcirculation permeability, leading to fat necrosis.2 Notably, pancreatic acinar cell carcinoma (ACC) is frequently associated with pancreatic panniculitis, affecting about 16% of ACC patients.3 ACC can also present with elevated AFP levels,1 as observed in this case. Additionally, dermatologic signs like acanthosis nigricans, palmo-plantar keratoderma, acrokeratosis paraneoplastica, and Leser-Trélat syndrome may signal underlying gastrointestinal malignancies.4 This complicated medical case highlights the importance of recognizing dermatologic manifestations as potential indicators of underlying malignancies. I declare that I have participated in the preparation of the article “Pancreatic acinar cell carcinoma with multiple liver metastases presented with pancreatic panniculitis.” Po-Han Haung wrote this article. Ming-Jen Chen and Chen-Wang Chang conducted the literature review. YS Lin supported this work by performing a critical reading of the manuscript and supervising the final editing. All authors read and approved the final manuscript. The authors declare no conflicts of interest. The case report was approved by the Institutional Review Board (24MMHIS123e) of Mackay Memorial Hospital.