Pancreatic tumours in patients with previous malignancy

Metastases to the pancreas diagnosed by fine-needle aspiration

BACKGROUND

Metastatic cancer infrequently involves the pancreas. When the pancreas hosts a metastatic tumor, cytopathological evaluation of fine-needle aspirate material is a crucial part of the diagnostic process. In this study, we show two institutions' experience with cytopathological diagnosis of pancreatic metastasis.

METHODS

Databases of institutional experience at The Johns Hopkins Hospital and Ohio State University Medical Center were queried for cases of metastatic tumors in the pancreas that underwent fine-needle aspiration. Demographic and pathological features were compiled and the cytomorphology was reviewed.

RESULTS

Forty-two cases of tumor metastasis to the pancreas were found. Over the time of this review, 5,495 aspirates were performed, and 43% (2,389/5,495) had malignant cytological findings. Thus, the 42 cases of metastatic disease to the pancreas comprised 0.8% of all pancreas aspirates and 1.8% of the malignant ones. Renal cell carcinoma was the most common metastasis, followed by melanoma and non-small cell lung carcinoma. Among the other tumors in this series, 2 cases each of rare metastases such as the fibrolamellar variant of hepatocellular carcinoma and solitary fibrous tumor were also seen.

CONCLUSION

The pancreas is rarely involved with metastatic disease, but when it is involved the most common tumor is renal cell carcinoma followed by melanoma and non-small cell lung cancer. Clinical history and awareness of the primary pancreatic mimickers are necessary for arriving at the correct diagnosis. As conventional pancreatic adenocarcinoma is uncommon in children and young adults, history of other tumors - even ones that usually follow an indolent course - is essential.

Systematic review of pancreatic surgery for metastatic renal cell carcinoma

BACKGROUND

This study examined the clinical outcome of patients with pancreatic metastases from renal cell carcinoma (RCC).

METHODS

A systematic literature search produced individual data for 311 surgically and 73 non-surgically treated patients with pancreatic RCC metastases. A further ten patients underwent resection at the authors' institution.

RESULTS

In the resected group, pancreatic metastases were solitary in 65.3 per cent, symptomatic in 57.4 per cent, and were preceded and/or accompanied by extrapancreatic disease in 22.3 per cent. Respective values in the unresected group were 59, 60 and 58 per cent. Disease-free survival rates were 76.0 and 57.0 per cent respectively at 2 and 5 years after resection, and overall survival rates were 80.6 and 72.6 per cent. The only significant risk factor for disease-free survival after pancreatic resection was extrapancreatic disease (P = 0.001), and that for overall survival was symptomatic RCC metastasis (P = 0.031). Two- and 5-year overall survival rates were 41 and 14 per cent respectively in unresected patients.

CONCLUSION

The actuarial 5-year overall survival rate following pancreatic surgery for RCC metastases was 72.6 per cent, as determined by pooled analysis from published series. Extrapancreatic disease was an independent risk factor for recurrence, but had no significant impact on overall survival.

Aportación de la ecoendoscopia al diagnóstico de las metástasis pancreáticas del carcinoma renal: a propósito de dos casos

Pancreatic metastases represent 2% of pancreatic tumors. The neoplasms most frequently metastasizing to the pancreas are breast, lung, melanoma and kidney tumors. We present the cases of two patients with pancreatic metastases from renal carcinoma diagnosed 4 and 8 years after the diagnosis and surgical treatment of the primary renal tumor. In both patients, endoscopic ultrasound was useful in the detection and characterization of these pancreatic lesions and allowed fine-needle aspiration for cytological study to be performed.

[Pancreas. Part II: Tumors]

Adenocarcinoma is the most common malignant pancreatic tumor, affecting the head in 60-70% of cases. By the time of diagnosis, approximately 80% of tumors are unresectable. Helical CT is very effective in detection and staging of adenocarcinoma, with a sensitivity of 76-92% for detection and an accuracy of 80-90% for staging, but it has limitations in the detection of small cancers (< or =2 cm). Multidetector CT (MDCT) has brought substantial improvements with its inherent 3D imaging capability. Mangafodipir-enhanced MRI is a problem-solving tool in the depiction of small cancers following an equivocal CT imaging result. Gadolinium-enhanced 3D gradient-echo MRI is helpful in the assessment of vascular invasion of cancer and in determining the etiology of cystic lesions. Serous cystadenoma is benign, has a lobulated contour and contains innumerable small cysts of 0.1-2 cm in diameter. Mucinous cystic neoplasms are unilocular or multilocular (fewer than six cysts), and the cyst diameter exceeds 2 cm. The presence of solid nodular components should alert the radiologist to suspect cystadenocarcinoma. Neuroendocrine tumors are mostly hypervascular. Diagnosis of insulinoma is a challenge: they are <2 cm in 90% of cases and mostly hypervascular at CT or MRI. A combination of contrast-enhanced MDCT, MRI, endosonography, and/or somatostatin receptor scintigraphy is used to detect these small tumors. This review summarizes the imaging features of the most common pancreatic tumors and discusses the limitations of CT, MRI and endosonography.

Obstructive jaundice caused by secondary pancreatic tumor from malignant solitary fibrous tumor of pleura: A case report

A 77-year-old man on systemic chemotherapy against postoperative bilateral multiple lung metastases of malignant solitary fibrous tumor of the pleura suffered from pruritus and jaundice. Blood examination showed elevated levels of hepatobiliary enzymes. Abdominal computed tomography showed a tumor with peripheral enhancement in the pancreatic head, accompanied with the dilatation of intra- and extra-hepatic bile ducts. He was diagnosed as having obstructive jaundice caused by a pancreatic head tumor. The pancreatic head tumor was presumably diagnosed as the metastasis of malignant solitary fibrous tumor of the pleura, because the findings on the pancreatic head tumor on abdominal CT were similar to those on the primary lung lesion of malignant solitary fibrous tumor of the pleura. The pancreatic tumor grew rapidly after the implantation of metallic stent in the inferior part of the common bile duct. The patient died of lymphangitis carcinomatosa of the lungs. Autopsy revealed a tumor that spread from the pancreatic head to the hepatic hilum. Microscopically, spindle-shaped cells exhibiting nuclear atypicality or division together with collagen deposition were observed. Immunohistochemically the pancreatic head tumor cells were negative for staining of α-smooth muscle actin (α-SMA) or CD117, but positive for vimentin, CD34 and CD99. These findings are consistent with those on malignant solitary fibrous tumor of the pleura. We report the first case of obstructive jaundice caused by a secondary pancreatic tumor from malignant solitary fibrous tumor of the pleura.

Solitary and multiple isolated metastases of clear cell renal carcinoma to the pancreas: an indication for pancreatic surgery

BACKGROUND

Isolated pancreatic metastases (isPMs) of clear cell renal carcinoma are rare. Most of them are solitary; some are multiple. The reported rates and the clinical implications of multiple isPMs from clear cell renal cancer vary. Therefore, the available literature was analyzed to shed light on the clinical significance of these extremely rare metastatic lesions.

METHODS

A literature search brought to light 236 cases of isPMs (both solitary and multiple) from renal cell carcinoma. These were analyzed.

RESULTS

A total of 12% of the metastases were synchronous with the primary tumor, and 88% were metachronous, occurring 10.0 +/- 6.5 years (mean +/- SD) after nephrectomy. A predilection for a specific part of the pancreas was not identifiable. The localization of the renal cell cancer (left or right kidney) did not have any effect on the site of the metastases. Seventy-four (39%) of the metastases to the pancreas were multiple (3.2 +/- 1.5). Their epidemiology did not differ from that of solitary metastatic lesions. Actuarial 3- and 5-year survival rates after radical resection were 78% and 78%, respectively, for multiple versus 75% and 64% for solitary metastases.

CONCLUSIONS

The epidemiological data do not support a direct local lymphogenous or venous spread from the primary tumor to the pancreas. They rather suggest a systemic spread. Because of the positive outcome, radical removal of both solitary and multiple metastases should be attempted in eligible patients.

Pancreatic metastases: a multicentric study of 22 patients

AIMS OF THE STUDY

To evaluate the diagnosis, treatment and outcome of patients with pancreatic metastases.

PATIENTS AND METHODS

We retrospectively reviewed the records of patients with pancreatic metastasis managed in the Paris area between 1990 and 2000.

RESULTS

The series analyzed included 22 patients, 10 men and 12 women, mean age 61 years (range: 35-76). The primary tumors were renal-cell carcinoma (N=10), colorectal cancer (N=4), lung cancer (N=4), breast cancer (N=2), cutaneous melanoma (N=1) and ileal carcinoid (N=1). The mean interval between primary treatment and presentation was 73.5 months (range: 2-151). Diagnosis was established because of clinical symptoms (N=15) or during surveillance (N=7). Computed tomography (N=19) and endoscopic ultrasound (EUS) (N=18) mainly showed solitary and hypodense/or hypoechoic masses. Histological diagnosis was obtained before surgery by EUS-guided fine needle aspiration (N=6), ultrasound-guided biopsy (N=3) or duodenoscopy (N=3). Among 10 patients with primary renal-cell carcinoma, 7 were treated by surgery. Median global survival was 33 months. Median survival was 61 months in the event of surgical treatment and 20 months in the other patients (ns). Mean survival depended on the type of primary tumor, 61 months for renal-cell carcinoma and 33 for colorectal cancer (P=0.06).

CONCLUSIONS

Most pancreatic metastases develop from renal-cell carcinoma and can occur several years after nephrectomy. Histological diagnosis is often obtained before surgery. Surgical resection must be discussed as it can allow long-term survival.

Single pancreatic metastasis from a previously resected carcinoma of the cecum: a case report

OBJECTIVE

To report a case of an isolated pancreatic metastasis from a primary cecum carcinoma.

BACKGROUND

Carcinoma of the colon and rectum commonly metastasizes to distant sites such as liver, lung, bone, brain, and ovaries. Only a few cases of pancreatic metastasis from a primary colonic carcinoma had been reported. Metastasic lesions to the pancreas are found only in 3% to 12% of autopsies from advanced malignancies. Primary tumors that commonly metastasize to the pancreas are lung and kidney. Most of the patients with metastatic lesions to pancreas also had extrapancreatic metastatic disease.

CASE

We report a case of a 86-year-old woman with a single pancreatic metastasis from a primary cecum carcinoma resected 8 months before.

CONCLUSIONS

The finding of an isolated metastasis to the pancreatic body from a primary cecum adenocarcinoma is extremely rare.

Differentiation of a pancreatic metastasis of a renal cell carcinoma from a primary pancreatic carcinoma by echo-enhanced power Doppler sonography

In a 70-year-old patient who had been treated for a renal cell carcinoma, a pancreatic mass was detected on CT scan. To differentiate a pancreatic metastasis of the renal cell carcinoma from a pancreatic carcinoma, an echo-enhanced power Doppler sonography was performed. The pancreatic mass demonstrated a strong echo enhancement, proving its hypervascularization. This behaviour favoured the diagnosis of a pancreatic metastasis of the renal cell carcinoma which was confirmed by histology. The principles and the role of echo-enhanced power Doppler sonography in the differential diagnosis between a primary pancreatic carcinoma and a metastasis of a renal carcinoma in the pancreas are discussed. We conclude that this technique can provide an important contribution to the diagnosis in this special instance. However, histology is the standard in the differential diagnosis of pancreatic tumours.

Solitary metastasis from renal cell carcinoma presenting as diffuse pancreatic enlargement

Late metastasis of renal cell carcinoma (RCC) to the pancreas is uncommon. Diffuse pancreatic metastasis of any carcinoma rarely causes global enlargement of the pancreas. We present the case of a 73-year-old man diagnosed with metastatic RCC of the pancreas 9 years after radical nephrectomy had been performed and describe our radiologic findings. The disease involved the entire pancreas, which was hypoechoic on sonography, hypodense on CT without contrast enhancement, and markedly hyperdense after intravenous administration of a contrast agent. Color Doppler sonography showed that the involved areas of the pancreas had increased color flow signals, indicating that the metastatic tumor was characteristically hypervascular. In patients with a history of RCC, color or power Doppler sonographic demonstration of diffuse enlargement of the pancreas with evidence of hypervascularity may indicate metastasis of RCC to the pancreas.

Renal cell carcinoma to the pancreas in surgical pathology material

BACKGROUND

Clear cell carcinomas of the pancreas are rare and more likely represent metastatic renal cell carcinoma (RCC).

METHODS

Twenty-one cases of metastatic RCC to the pancreas were retrieved from the files of the Endocrine Registry of the Armed Forces Institute of Pathology. Histologic features were reviewed, special stains and immunohistochemical studies were performed, and patient follow-up data were obtained.

RESULTS

The patients included 9 women and 12 men ages 47-76 years (mean, 64.4 years). Patients experienced weight loss, abdominal pain, or a mass lesion. The tumors occurred anywhere within the pancreas. The mean size of the tumors was 4.0 cm. Histologically, the tumors were comprised of clear cells with a rich vascular network. The RCC was diagnosed before (n = 17 patients; ages up to 32.7 years) or after (n = 4 patients; ages up to 13.2 years) the pancreatic metastases were discovered. Surgery was used in all patients. Adjuvant chemotherapy was used in 4 patients. From the date of the diagnosis of pancreatic metastasis, 13 patients were dead with disseminated disease (DD) (mean, 4.5 years), and 8 patients were without disease (mean, 9.0 years). From the date of the diagnosis of primary RCC, 13 patients were DD (mean, 12.7 years), and 8 patients were without disease (mean, 24.7 years).

CONCLUSIONS

Although histochemical and immunohistochemical studies may help in the distinction between patients with primary versus metastatic clear cell tumors of the pancreas, clinical confirmation should be obtained. Surgical resection of the pancreatic metastatic disease is suggested, because the patient may still have a prolonged survival.

Renal cell carcinoma metastatic to the pancreas: clinical and radiological features

OBJECTIVE

To review the clinical features, computed tomographic (CT) appearance, and treatment outcomes in a case series of patients with renal cell carcinoma (RCC) metastatic to the pancreas.

PATIENTS AND METHODS

We retrospectively reviewed the records of 23 patients (15 men and 8 women) with RCC metastatic to the pancreas, detected by CT examination between 1986 and 1996. All patients had undergone a previous nephrectomy for RCC.

RESULTS

Isolated mild elevation in liver function test results (in 5 patients) or in serum amylase level (in 8 patients) was observed. New-onset diabetes was detected in 3 patients. The CT characteristics of the pancreatic metastases generally resembled those of primary RCC with well-defined margins and greater enhancement than normal pancreas with a central area of low attenuation. The mean interval between resection of the primary RCC and detection of the pancreatic metastases was 116 months (range, 1-295 months). In 18 patients (78%), the pancreatic metastases were diagnosed more than 5 years after nephrectomy. The pancreas was the initial metastatic site in 12 patients (52%). Survival was shortened with higher tumor grade (mean survival time of 41 months and 10 months in patients with grade 2 and 3, respectively). Surgical resection was carried out in 11 patients (7 distal and 3 total pancreatectomies and 1 distal pancreatectomy followed 4 years later by total pancreatectomy), with 8 patients alive at a mean follow-up of 4 years, 6 of whom remained free of recurrence. Overall, 12 patients (52%) were alive at a mean of 42 months after diagnosis of metastatic disease.

CONCLUSIONS

The appearance of metastatic RCC lesions in the pancreas closely resembles the appearance of primary RCC on CT images. Pancreatic metastases from RCC are frequently detected many years after nephrectomy. Patient survival correlates with tumor grade. Histologic analysis of pancreatic masses in patients with a history of resected primary RCC is important since the prognosis for RCC metastatic to the pancreas is much better than that for primary pancreatic adenocarcinoma.

Metastases to the pancreas

Disparity in prognosis and management between primary and secondary pancreatic tumours makes recognition of metastases to the pancreas on CT and MRI an important goal. Three different patterns of secondary pancreatic tumours may be seen: localized, multifocal, or diffuse enlargement. CT findings include hypodense lesions, which show rim enhancement following intravenous contrast medium. On MR examination, the lesions are usually hypointense on T1 weighted and hyperintense on T2 weighted images.

Fine-needle aspiration cytology of metastatic clear-cell renal carcinoma presenting as a solitary mass in the head of the pancreas

In nearly 25% of patients with primary renal-cell carcinoma, metastasis is not uncommon and usually does not give rise to difficulties in diagnosis. However, its presentation as a mass in the head of the pancreas following an elapse of several years after the initial diagnosis of renal carcinoma is not only uncommon but may be confused clinicoradiologically with a primary pancreatic adenocarcinoma. The case presented here illustrates such an example with an emphasis on the usefulness of fine-needle aspiration cytology (FNAC) in the diagnosis.

Pancreatic metastasis from a lung cancer. Preoperative diagnosis and management

A case of a surgically resectable solitary metastasis to the pancreas from a lung cancer, confirmed by immunohistochemical staining (PE-10), is reported. ERCP revealed meniscoid interruption of the main pancreatic duct, which is uncommon in patients with primary pancreatic cancers of the pancreas in our hospital. This patient lived for 29 mo after the surgical resection of the pancreatic lesion. Therefore when metastasis limited to the pancreas is evident on clinical imaging, surgical management may be more optimal than other treatment approaches.

Surgical treatment of a solitary pancreatic metastasis from renal cell carcinoma: report of a case

The pancreas is a rare site of metastasis from renal cell carcinoma (RCC). We present herein the case of a 47-year-old male in whom a solitary pancreatic metastasis was treated by a pylorus-preserving pancreatoduodenectomy (PpPD), 3 years after a radical nephrectomy for a RCC. The few reported cases of surgically treated pancreatic metastases from RCC are reviewed following the presentation of this case.

Solitary pancreatic metastasis occurring eight years after nephrectomy for renal cell carcinoma. A case report and surgical review

CONCLUSION

Pancreatic metastasis from renal cell carcinoma is extremely rare. The average time between nephrectomy and the diagnosis of metachronous metastases is reported to exceed 10 yr. Therefore, the initial diagnosis may be neglected in the cases of prolonged disease-free interval. When it does occur simultaneously or metachronously, aggressive surgical resection, when possible, seems to be the most effective treatment for this metastatic lesion.

BACKGROUND

An 81-yr-old female patient, who 8 yr previously had undergone right radical nephrectomy for renal cell carcinoma, presented with solitary pancreatic metastasis, which was successfully treated with a distal pancreatectomy. Only 66 cases of clinically diagnosed renal cell carcinoma metastatic to the pancreas are reported in the world literature and 49 of the patients (including ours) underwent a definitive surgical resection. Our case, treated by distal pancreatectomy, and a review of the relevant literature including all reported cases of renal cell carcinoma metastatic to the pancreas, are presented.

RESULTS

The patient was well without any evidence of recurrence at 22 mo after the operation.

Osteosarcoma metastatic to the pancreas in young patients

Two rare cases of pancreatic metastases from osteosarcoma are reported. Metastatic spread occurred after treatment with chemotherapy. This unusual phenomenon represents an alternation in the natural history of osteosarcoma with increased long-term survival of patients who are successfully treated with chemotherapy.

Ultrasound and computed tomographic findings in pancreatic metastases

This is a retrospective study of a series of seven patients with pancreatic metastases studied by ultrasonography and computed tomography. They were detected during tumor staging, or in the follow-up period of over 10 years of patients with advanced known malignancy. Lesions were multiple in two patients and solitary in five; solid in six cases and cystic in one. Clinically, four cases were asymptomatic and three cases presented with jaundice or epigastric pain. Ultrasonography and computed tomography findings were non-specific. Consequently it was not possible to differentiate solitary metastases from primary solid adenocarcinoma and cystadenocarcinoma of the pancreas. In these cases, computed tomography- or ultrasonography-guided biopsies had to be performed to obtain histological proof. However, multiple lesions discovered in a patient with a known malignancy can be assumed to be due to metastases.

Pancreatic metastases of renal cell carcinoma: report of two cases

Two cases of renal cell carcinoma, metastatic to the pancreas, are presented. The lesions were hypoechoic with ultrasound examination, and were mixed iso- and hypodense with computed tomography. Angiography was performed in one case, and showed a typical hypervascular pattern of the metastatic tumor.

A case report of pancreatic metastasis of an intracranial angioblastic meningioma (hemangiopericytoma) and a review of metastatic tumor to the pancreas

The authors report a case of solitary metastasis to the pancreas from an intracranial angioblastic meningioma (hemangiopericytoma) and discuss secondary (metastatic) tumors of the pancreas. A 65-year-old man developed a pancreatic tumor 15 years after the craniotomy was performed for a parasagittal meningioma. Histological investigation of the pancreatic tumor excised as a biopsy on exploratory laparotomy revealed a tumor identical to the intracranial meningioma. It was concluded that the intracranial angioblastic meningioma had recurred and metastasized to the pancreas.