Cavitary Lung Metastases in Pancreatic Cancer: A Rare Presentation in a Patient With Altered Anatomy Post-Duodenal Switch

Document Type

Conference Proceeding

Publication Date

10-2025

Publication Title

Chest

Abstract

INTRODUCTION: Metastatic cavitary lung lesions are rare, with only two prior case reports documenting pancreatic cancer causing such metastases. We present a case of pancreatic adenocarcinoma with cavitary lung metastases in a patient post-duodenal switch surgery, highlighting the diagnostic complexities and procedural challenges posed by altered anatomy. CASE PRESENTATION: A 66-year-old female with prior duodenal switch surgery presented with two weeks of jaundice, pruritus, nausea, epigastric pain, shortness of breath, and a productive yellow cough. Notable findings included significant obstructive jaundice (total bilirubin 24.7 mg/dL) and elevated liver enzymes (ALP 1134 U/L, AST 266 U/L, ALT 254 U/L).Initial CT imaging revealed a 3.9 cm pancreatic head mass with severe biliary and pancreatic ductal dilation. Chest imaging demonstrated multiple bilateral cavitary pulmonary nodules, including a mostly solid right lower lobe lesion measuring approximately 1.3 x 1.1 cm with a small amount of central cavitation, and a dominant left lower lobe lesion measuring up to 2.0 x 1.0 cm with large central cavitation. Infectious workup, including AFB, Quantiferon, and fungal cultures, was negative. PET/ CT confirmed an FDG-avid pancreatic head mass and FDG-avid cavitary pulmonary nodules. A successful CT-guided biopsy of the right lower lobe nodule was performed. However, altered anatomy from her duodenal switch surgery made ERCP for stenting or biopsy unfeasible, leading to PTBD placement for biliary obstruction relief. Pathology from the biopsied cavitary lung lesion revealed adenocarcinoma, favoring a metastatic origin from the pancreatobiliary system. Given the confirmed metastatic disease, the pancreatic cancer was deemed unresectable, and systemic treatment was initiated. DISCUSSION: Pulmonary metastasis from pancreatic cancer typically presents as rounded, solid nodules rather than cavitary lesions. Multiple cavitary metastases from pancreatic cancer are even more uncommon—only two prior cases describing such a pattern has been reported in the literature. These very low numbers likely stem from the preponderance of pancreatic ductal adenocarcinoma to spread to the liver and peritoneum. When cavitary nodules are encountered on imaging, the differential diagnosis is broad. Infectious causes (e.g., fungal infections, tuberculosis, septic emboli), inflammatory conditions (e.g., granulomatosis with polyangiitis), and primary lung malignancies must be considered. Although up to 9.5% of metastatic adenocarcinomas can cavitate, metastatic pancreatic adenocarcinomas are still less commonly associated with cavitation compared to metastases from other primaries (e.g., squamous cell carcinomas of the head and neck or lung).In this patient, negative infectious workup alongside PET/CT findings of FDG-avid cavitary lung lesions raised suspicion for a metastatic process rather than an infectious or inflammatory cause. Confirmation via CT-guided biopsy of a cavitary pulmonary nodule revealed adenocarcinoma, supporting a metastatic pancreatobiliary origin. This tissue diagnosis was pivotal, especially in the context of the patient's altered GI anatomy that precluded standard ERCP-based interventions. CONCLUSIONS: Biopsy results were pivotal in confirming the diagnosis and guiding therapy, underscoring the importance of histopathological confirmation in atypical radiographic presentations. Moreover, this case highlights the necessity of thoroughly evaluating cavitary lung lesions in patients with suspected pancreatic cancer, as early recognition of these rare metastases can significantly affect prognosis and treatment.

Volume

168

Issue

4S

First Page

6257A

Comments

American College of Chest Physicians CHEST Annual Meeting, October 19-22, 2025, Chicago, IL

Last Page

6258A

DOI

10.1016/j.chest.2025.07.3501

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