Abstract
Pancreatic cancer complicated by active pulmonary tuberculosis (TB) presents a therapeutic dilemma because timely oncologic treatment must be balanced against infection control. Evidence guiding the curative-intent management of pancreatic cancer complicated by active TB remains extremely limited. An 81-year-old man with a history of tuberculous peritonitis and diabetes mellitus presented with weight loss and poor glycemic control. Contrast-enhanced CT revealed a 14-mm pancreatic head tumor and multiple nodular lesions in the right upper lobe. Sputum examination was positive for acid-fast bacilli and Mycobacterium tuberculosis. After 4 weeks of initial 4-drug anti-TB therapy, sputum smear conversion and drug-susceptible TB were confirmed. Re-evaluation imaging revealed enlargement of the tumor to 21 mm with less than 180° portal vein abutment, and endoscopic US-guided fine-needle aspiration confirmed pancreatic ductal adenocarcinoma (PDAC). Although the tumor was anatomically resectable, active pulmonary TB was considered a host-related risk, and treatment was planned according to a strategy analogous to the International Association of Pancreatology concept of borderline resection on the basis of conditional factors. Following multidisciplinary discussion and shared decision-making with the patient, concurrent maintenance anti-TB therapy and 6 cycles of neoadjuvant gemcitabine plus nab-paclitaxel (GnP) were administered. The planned treatment was completed successfully without TB reactivation, resulting in a partial radiological response that permitted subtotal stomach-preserving pancreatoduodenectomy with portal vein resection. Histopathological examination revealed an R0 resection with a Grade 1b therapeutic response. After completing adjuvant chemotherapy, the patient developed a local recurrence 16 months after surgery but remained alive with stable disease under systemic chemotherapy 33 months after the initiation of anti-TB therapy, without TB reactivation. Although further accumulation of similar cases is needed, this case demonstrates that curative-intent treatment of PDAC complicated by active TB can be achieved through careful multidisciplinary management.