Pancreatic adenosquamous carcinoma and intraductal papillary mucinous neoplasm in a CDKN2A germline mutation carrier.

A 69-year-old woman from a kindred with familial atypical multiple mole melanoma and carrier of a germline mutation in CDKN2A, presented with abdominal pain caused by a solid-cystic pancreatic mass. The patient had an abdominal computed tomography three years before in which there was no evidence of pancreatic lesion. The endoscopic ultrasound guided fine needle aspiration showed adenocarcinoma with squamous component. After surgical resection the final diagnosis was adenosquamous pancreatic carcinoma (ASPC) arising in an intraductal papillar mucinous neoplasm (IPMN). Adenosquamous carcinomas are uncommon in the pancreas and have rarely been described in association with IPMNs. It has worse prognosis than the ordinary pancreatic ductal adenocarcinoma and some distinct features. We review the clinical, imaging, pathologic and molecular aspects of ASPC. Differential diagnosis with contamination, squamous metaplasia and pancreatic metastases from a distant squamous carcinoma is discussed. Besides, the case is an accelerated model of the adenoma (IPMN)-carcinoma sequence probably due to the CDKN2A germline mutation. Somatic CDKN2A mutations are common events in the early steps of sporadic pancreatic cancer, but germline mutation carriers have a significantly higher risk of pancreatic carcinoma.

Metabolic acidosis as a complication of intravenous dextrose administration in a patient with insulinoma.

There are few cases published in literature in which the use of intravenous dextrose as treatment for an insulinoma resulted in a metabolic acidosis. This is due perhaps to the usual method of administration, which is usually at low concentrations, for limited periods or low volumes. We present the case of a woman with suspected insulinoma by laboratory findings in which an endogenous hyperinsulinism was observed. During hospitalization, the patient required a progressive increase of the glucose infusion to prevent severe hypoglycemia. Two days before surgery, the patient presented symptoms of malaise and muscle weakness and a metabolic acidosis with hypokalemia became apparent in the blood analysis. This metabolic imbalance was attributed to a long period of treatment with high volume of intravenous dextrose infusion. If large doses of dextrose are required in a patient with an insulinoma, then the possibility of a metabolic imbalance must be considered during the follow-up. When the suspicion of an insulinoma is high, and all the attempts of pre-operative localization fail, patients should be derived early to specialized centers with modern imaging techniques, so that surgery is not delayed, and this rare and threatening complication could be avoided.