Pancreatic metastases: a multicentric study of 22 patients

Isolated Pancreatic Metastases of Renal Cell Carcinoma-Clinical Particularities and Seed and Soil Hypothesis

A meta-analysis of 1470 isolated pancreatic metastases of renal cell carcinoma revealed, that, in addition to the unusual exclusive occurrence of pancreatic metastases and the favourable treatment results, the isPMRCC is characterised by further peculiarities of the clinical course: The lack of prognostic significance of volume and growth rate dependent risk factors and the independence of treatment results from standard or local resections. As an explanation for all these peculiarities, according to today's knowledge, a strong acting seed and soil mechanism can serve, which allows embolized tumour cells to grow to metastases only in the pancreas, and prevents them definitively or for years in all other organs. The good prognosis affects not only isolated PM, but also multi-organ metastases of the RCC, in which the additional occurrence of PM is also associated with a better prognosis. Genetic studies revealed specific changes in cases of PM of RCC: Lack of loss of 9p21.3 and 14q31.2, which are otherwise specific gene mutations at the onset of generalization, a low weight genome instability index, i.e., high genetic stability, and a low rate of PAB1 and a high rate of BPRM1 alterations, which signal a more favourable course. The cause of pancreatic organotropism in isPMRCC is still unclear, so only those factors that have been identified as promoting organotropism in other, more frequent tumour entities can be presented: Formation of the pre-metastatic niche, chemokine receptor-ligand mechanism, ability to metabolic adaptation, and immune surveillance.

Isolated Pancreatic Metastasis from a Lung Adenocarcinoma Primary: A Case Report and Literature Review

Isolated pancreatic metastasis is a rare occurrence and is commonly misdiagnosed as primary pancreatic malignancy. We present a case of a 65-year-old female patient with a history of stage IIIA lung adenocarcinoma, who developed significant epigastric pain 27 months after diagnosis and treatment of a primary lung adenocarcinoma. This patient was found to have a pancreatic head lesion initially suspected to be a primary pancreatic neoplasm but eventually discovered to be a metastatic lesion from the previously treated primary lung adenocarcinoma.

Isolated Pancreatic Metastases of Renal Cell Cancer: Genetics and Epigenetics of an Unusual Tumour Entity

Isolated pancreatic metastases of renal cell carcinoma (isPMRCC) are a rare manifestation of metastatic renal cell carcinoma (mRCC) characterized by two peculiarities: (1). The definite or at least long-term exclusive occurrence of metastases in the pancreas and (2). an unusual low tumour aggressiveness with slow tumour progression and consecutive, good treatment results. According to current knowledge, the exclusive occurrence of pancreatic metastases is due to a highly specific and highly selective seed and soil mechanism, which does not allow metastases settlement outside the pancreas, and whose detailed genetic/epigenetic causes are not yet elucidated. Recent studies have shed light on some of the pathways involved for the protracted course of the disease and highlighted a special genetic profile (lack of loss of 9p, lower weight genome instability index, low frequency of BAP1 alterations, and a high frequency of PBRM1 loss), which deviates from the conventional mRCC profile. Finally, the question of the reasons for the long-term relative genetic stability of the involved cell clones, which is an essential prerequisite for a favourable prognosis, remains unanswered.

Metastatic Lobular Carcinoma of the Male Breast Masquerading as a Pancreatic Head Mass, a Diagnostic Dilemma—Rare Case and Literature Review

Male breast cancer comprises of 1% of all and invasive lobular carcinomas (ILC) are even rarer in males. ILC are known to have unusual metastatic sites. We report a case of a 51-year-old male diagnosed with breast cancer, who presented with a recurrent chest wall nodule and icterus after 24 months of disease-free interval. On further investigations, he was found to have pancreatic head mass associated with conjugated hyperbilirubinemia suggestive of obstructive jaundice and a left parasternal soft tissue recurrence. A self-expandable metallic stent was inserted for recurrent cholangitis. Biopsy from the chest wall nodule was recurrence of ILC and pancreatic head mass was suspected to be either a second primary or an isolated pancreatic head metastasis of ILC on imaging. In either case surgical resection if operable and localized was planned. However, on staging laparoscopy, the patient was found to have mild ascites and multiple peritoneal nodules, which on biopsy proved to be metastases from ILC. Patient was treated with second-line hormonal therapy with luteinizing hormone-releasing hormone agonist and an aromatase inhibitor. ILC may present with unusual sites of metastasis leading to diagnostic dilemma. A high index of suspicion of metastases and appropriate biopsies can help one embark upon the most appropriate plan.

A Surgical Case of Pancreatic Metastasis from Lung Cancer

Introduction

Most patients with pancreatic metastasis from lung cancer are not candidates for surgical treatment because they have widespread systemic disease at the time of diagnosis. But it was reported that some patients with long-term survival were resected for pancreatic metastasis from lung cancer. We herein report a surgical case of pancreatic metastasis from lung cancer.

Case Presentation

A 61-year-old man was admitted to our hospital because of a lung tumor. He underwent right middle lobectomy. A histopathologic examination showed poorly differentiated adenocarcinoma. About 1 year after lung resection, brain metastasis was demonstrated and radiation therapy was subsequently performed. Seven years after lung resection, his serum carcinoembryonic antigen levels were again elevated. FDG–PET (fluorodeoxyglucose-positron emission tomography) showed a slight uptake by the pancreatic head. Computed tomography (CT) showed an irregular and poorly enhanced tumor in the pancreatic head. EUS–FNA (endoscopic ultrasonography fine-needle aspiration) of the tumor in the pancreatic head was performed. A histopathologic examination showed thyroid transcription factor (TTF)-1 positive adenocarcinoma. The preoperative diagnosis was pancreatic metastasis from lung cancer. We performed subtotal stomach-preserving pancreaticoduodenectomy for the pancreatic head tumor because the primary lung cancer and brain metastasis responded to chemoradiation. A histopathologic examination of the resected specimen revealed moderately differentiated adenocarcinoma. Immunohistochemistry revealed TTF-1 positive cells in the tumor. The patient was discharged from the hospital on the 12th day after surgery. He is currently alive 22 months after pancreatic surgery.

Conclusion

Resection of pancreatic metastasis from lung cancer may improve the patient outcome when the metastasis is localized in the pancreas or other organ metastases are controlled.

How Should We Treat Pancreatic Metastases from Renal Cell Carcinoma? A Meta-Analysis

BACKGROUND

The treatment strategy for pancreatic metastasis (PM) from renal cell carcinoma (RCC) is unclear due to its rarity. The aim of this study was to reveal the role of surgery for PM from RCC.

METHODS

A systematic literature search was conducted using PubMed and the Cochrane Library. The effectiveness of surgery for PM was evaluated based on the primary outcome of overall survival (OS), which was investigated in relation to surgical procedures and metastatic sites via subgroup analyses.

RESULTS

There was no significant difference in the rate of 2-year OS between the surgery and control group (OR 0.43, 95% CI 0.14-1.26, P = 0.12). However, the rate of 5-year OS was significantly higher in the surgery group than the control group (OR = 0.41, 95% CI 0.18-0.93, P = 0.03). The rates of the complications and OS were not significantly different between radical and conservative pancreatectomies. The rate of 5-year OS of the patients with PM was higher than that with other metastases (OR 0.38, 95% CI 0.20-0.74, P = 0.004).

CONCLUSION

Surgical resection for PM from RCC is associated with good prognosis. Limited surgery may be a useful option depending on the location of the lesion.

Tumour Evolution and Seed and Soil Mechanism in Pancreatic Metastases of Renal Cell Carcinoma

In metastatic renal cell carcinoma, pancreatic metastases can appear in two clinical manifestations: (a) very rarely as isolated pancreatic metastases and (b) in the context with multi-organ metastatic disease. Both courses are characterised by rare, unusual clinical features. For isolated pancreatic metastases, the literature shows no effect on survival in all 11 publications that examined the effect of singular versus multiple pancreatic metastases; a lack of effect on survival time was also present in all 8 studies on pancreatic metastases size, in 7 of 8 studies on the influence of disease-free interval (DFI), and in 6 of 7 studies on the influence of synchronous versus metachronous metastases. In multi-organ site metastases observations, on the other hand, all five available references showed significantly better results in patients with concurrent pancreatic metastases compared to those without pancreatic metastases, although the total number of affected organs in the pancreatic metastases cohort was larger. Tumour volume-dependent risk factors thus remain surprisingly ineffective in both groups, which contradicts the usual behaviour of solid tumours. The reasons for this unusual behaviour and possible relations to tumour evolution and the hypothesis of an influence of a seed and soil mechanism in the occurrence of pancreatic metastases in metastatic renal cell carcinoma are discussed.

Long-term survival after pancreatic metastasis resection from breast cancer: a systematic literature review

Background

Patients with advanced-stage breast cancer often demonstrate pancreatic metastases. However, pancreatic metastases resection from breast cancer has been rarely performed, with only 20 cases having been reported to date.

Case presentation

A 49-year-old woman presented to our hospital in September 2003 with complaints of uncontrollable oozing from her left breast tumor. Computed tomography revealed a left breast tumor approximately 9.3 cm in diameter as well as heterogeneously enhanced solid mass lesions with necrotic foci in the pancreatic tail and body, up to 6.2 cm, which were radiologically diagnosed as pancreatic metastases from breast cancer. An emergent left simple mastectomy was performed to control bleeding. After epirubicin and cyclophosphamide hydrate treatment failed to improve her condition, the pancreatic metastases responded to weekly paclitaxel treatment, but eventually regrew. The patient underwent distal pancreatectomy with splenectomy, left adrenalectomy, partial stomach resection, and paraaortic lymph nodes excision in December 2004 after no other metastasis was confirmed. Furthermore, she received radiation therapy for left parasternal lymph node metastasis 6 months later. The patient recovered well. Consequently, she has no evidence of disease > 15 years after pancreatectomy.

Conclusions

This is the first reported case of pancreatectomy for pancreatic metastases from breast cancer, which was simultaneously diagnosed. Patients with no metastasis other than resectable pancreatic metastases and breast cancer and who possess some sensitivity for chemotherapy may benefit from pancreatectomy.

Solid Tumor Metastases to the Pancreas Diagnosed Using Fine-Needle Aspiration

OBJECTIVES

Solid tumor metastases to the pancreas are rare, and only limited literature on the topic is available. In this retrospective study, we reviewed 107 cases of solid tumor metastases to the pancreas diagnosed by fine-needle aspiration (FNA) from 2005 to 2019.

METHODS

Information including the patients' clinical histories, radiologic and pathologic findings, treatments, and follow-up were collected.

RESULTS

The mean age of the patients was 62.4 years. The mean tumor size was 2.64 cm with even distribution throughout the pancreas (head, neck and body, and tail). The most common primary site was the kidney, followed by the lung, skin, and breast and the gynecologic, gastrointestinal, and genitourinary tracts. The most common tumor type was carcinoma, followed by melanoma and sarcoma. In comparison to patients with nonkidney primary cancers, those with primary renal cell carcinoma had a longer median interval between primary diagnosis and metastasis (8.5 vs 4.0 years; P < .01), less often had metastasis outside the pancreas (38% vs 74%; P < .01), and had a significantly longer 5-year survival rate (65.7% vs 24.8%; P < .01).

CONCLUSIONS

FNA plays a crucial role in diagnosing metastases to the pancreas. Metastases originating from kidney and nonkidney primary tumors have distinct clinicopathologic features and prognoses.

Diagnosis and Treatment of Metastatic Disease to the Pancreas

Introduction: Metastatic disease to the pancreas is a rare entity from all malignant pancreatic masses. Its diagnosis is very challenging, but with the introduction of endoscopic ultrasound (EUS)-fine needle aspiration (FNA), now there is a feasible way to make an accurate histopathological and definitive diagnosis. Materials and Methods: This is a retrospective review of 11 patients with metastasis to the pancreas diagnosed with EUS-FNA in a tertiary referral center over a period of 3 years. We describe our institutional experience in diagnosing metastatic disease to the pancreas through EUS-FNA. Results: Between January 2015 and June 2018, 115 patients were diagnosed with pancreatic malignancy by EUS-FNA and only 11 (10%) with metastatic disease to the pancreas. Most common primary malignancy was renal cell carcinoma, followed by colon carcinoma, squamous/small cell carcinoma of the lung, and urothelial carcinoma. Five of 11 patients presented as a solitary pancreatic mass on initial imaging without any evidence of primary or metastatic disease elsewhere. Conclusions: In our experience, metastatic disease to the pancreas can represent up to 10% of solid pancreatic masses, which is lower compared to the reported incidence in previous literature. Our findings reveal that early identification and diagnosis help patient management and limit surgical morbidity and mortality.

Isolated Pancreatic Metastases of Renal Cell Carcinoma-A Paradigm of a Seed and Soil Mechanism: A Literature Analysis of 1,034 Observations

Previously documented arguments, in favor of the suspected impact of a seed and soil mechanism, in the development and progression of isolated pancreatic metastasis of renal cell carcinomas (isPM) are: (1) uniform and independent from the side of the primary tumor distribution of isPM within the pancreas and, (2) the similar survival rates for singular and multiple isPM. In addition, the present study adds new arguments that further confirm the importance of an seed and soil mechanism in isPM: (1) Within the singular isPM, the size of the metastasis does not affect the overall survival; (2) Within the group of multiple isPMs, the overall survival does not depend on the number of metastases; (3) For synchronous and metachronous isPM, survival rates are also not different, and (4) Within the group of metachronous isPM there is also no correlation between the overall survival and interval until metastases occurs. This unusual ineffectiveness of otherwise known risk factors of solid cancers can be explained plausibly by the hypothesis of a very selective seed and soil mechanism in isPM. It only allows embolized renal carcinoma cells in the pancreas to complete all steps required to grow into clinically manifest metastases. In all other organs, on the other hand, the body is able to eliminate the embolized tumor cells or at least put them into a dormant state for many years. This minimizes the risk of occult micrometastases in distant organs, which could later—after isPM treatment—grow into clinically manifest metastases, so that the prognosis of the isPM is only determined by an adequate therapy of the pancreatic foci, and prognostic factors, such as total tumor burden or interval until the occurrence of the isPM remain ineffective.

Evaluation of metastases to the pancreas with fine needle aspiration: A case series from a single centre with review of the literature

OBJECTIVE

Fine needle aspiration (FNA) is a minimally invasive albeit highly effective modality used to detect solid and cystic pancreatic lesions. This manuscript aims to present our experience in diagnosing metastases to the pancreas and highlight the importance of immunocytochemistry in the diagnostic process. It also aims to provide a brief review of the literature on this topic.

METHODS

We retrospectively searched our archives for cases of metastatic deposits to the pancreas diagnosed with FNA over a 5-year period. We also reviewed the literature for such cases.

RESULTS

We describe seven cases from our archives that metastasised to the pancreas. Three of them (43%) represented metastatic renal cell carcinoma while the rest four comprised deposits from a lung adenocarcinoma, a colon adenocarcinoma, an adrenal leiomyosarcoma, and a small cell carcinoma of the urinary bladder, respectively. History of primary malignancy was available for all seven patients. All diagnoses were confirmed with the use of immunostains. In our literature review, similar to our case series, renal cell carcinoma was the most common metastasis to the pancreas managed with FNA (around one out of three patients; 35%). Of interest, our endoscopic ultrasound-FNA case of pancreatic metastasis from urinary bladder small cell carcinoma is the first reported.

CONCLUSIONS

As metastases to the pancreas are commonly accompanied by diverse prognostic signatures and management strategies compared to primary pancreatic malignancies, their accurate identification is imperative. Pancreatic FNA is a diagnostic modality that can confirm or exclude metastasis to the organ, especially when immunocytochemistry is applied.

Observations on Solitary Versus Multiple Isolated Pancreatic Metastases of Renal Cell Carcinoma: Another Indication of a Seed and Soil Mechanism?

Isolated pancreas metastases are a rare type of metastasis of renal cell carcinoma, characterized by the presence of pancreatic metastases, while all other organs remain unaffected. In a previous study, we determined arguments from the literature which (a) indicate a systemic-haematogenic metastasis route (uniform distribution of the metastases across the pancreas and independence of the metastatic localization in the pancreas of the side of the renal carcinoma); and (b) postulate a high impact of a seed and soil mechanism (SSM) on isolated pancreatic metastasis of renal cell carcinoma (isPM) as an explanation for exclusive pancreatic metastases, despite a systemic haematogenous tumor cell embolization. The objective of the study presented was to search for further arguments in favor of an SSM with isPM. For that purpose, the factor's histology, grading, and singular/multiple pancreas metastases were analyzed on the basis of 814 observations published up to 2018. While histology and grading allowed for no conclusions regarding the importance of an SSM, the comparison of singular/multiple pancreas metastases produced arguments in favor of an SSM: 1. The multiple pancreas metastases observed in 38.1% prove that multiple tumor cell embolisms occur with isPM, the exclusive "maturation" of which in the pancreas requires an SSM; 2. The survival rates (SVR), which are consistent with singular and multiple pancreas metastases (despite the higher total tumor load with the latter), prove that the metastasized tumor cells are not able to survive in all other organs because of an SSM, which results in identical SVR when the pancreatic foci are treated adequately.

Surgical Resection for Metastatic Tumors in the Pancreas: A Single-Center Experience and Systematic Review

BACKGROUND

Metastatic lesion to the pancreas accounts for approximately 2% of pancreatic neoplasms. There is no prospective, randomized or case-controlled study evaluating the role of pancreatic metastasectomy.

METHODS

The PubMed, EMBASE, and Cochrane Library electronic databases were searched for studies published between January 1, 2001 and December 31, 2017. Studies with five or more patients who received pancreatic metastasectomy and data from our institution (29 patients) were included. The Kaplan-Meier method was used for survival analysis.

RESULTS

A total of 414 patients from 20 institutions who underwent pancreatic resections were included. Of the reported 31 kinds of primary neoplasms, renal-cell carcinoma (RCC) comprised the most (54.3%). At the time of diagnosis, although 40.3% patients were asymptomatic, abdominal pain (34.8%) and jaundice (20.6%) were relatively common. As for surgical type, pancreatoduodenectomy, total pancreatectomy, distal pancreatectomy, and enucleation took up 37.9%, 11.4%, 43.5%, and 7.2% respectively. The mortality and morbidity rates were 1.4% and 48.3% respectively. Patients with symptoms at the time of diagnosis had significantly shorter survival compared with asymptomatic patients (p = 0.017). Those with RCC as primary tumor had significantly longer survival compared with non-RCC patients (p < 0.001). Positive margin also predicts worse prognosis (p = 0.035).

CONCLUSIONS

Pancreatic metastasectomy is safe and associated with acceptable short- and intermediate-term results. In the conditions of RCC as the primary tumor, being asymptomatic, or negative resection margin, a better prognosis after resection can be achieved.

Solitary pancreatic metastasis from breast cancer: case report and review of literature

CONTEXT

Pancreatic metastases from primary malignant tumors at other sites are rare, constituting about 2% of the neoplasms that affect the pancreas. Pancreatic metastasis from breast cancer is extremely rare and difficult to diagnose, because its clinical and radiological presentation is similar to that of a primary pancreatic tumor.

CASE REPORT

A 64-year-old female developed a lesion in the pancreatic tail 24 months after neoadjuvant therapy, surgery and adjuvant radiation therapy for right-side breast cancer (ductal carcinoma). She underwent distal pancreatectomy with splenectomy and left adrenalectomy, and presented an uneventful outcome. The immunohistochemical analysis on the surgical specimen suggested that the lesion originated from the breast.

CONCLUSION

In cases of pancreatic lesions detected in patients with a previous history of breast neoplasm, the possibility of pancreatic metastasis should be carefully considered.

Robotic treatment of oligometastatic kidney tumor with synchronous pancreatic metastasis: case report and review of the literature

Background

The management of metastatic Renal Cell Carcinoma (RCC) has changed dramatically in the last 20 years, and the role of surgery in the immunotherapy’s era is under debate. Metastatic lesions interesting pancreas are infrequent, but those harbouring from RCC have an high incidence. If metachronous resections are not rare, synchronous resection of primary RCC and its pancreatic metastasis is uncommonly reported, and accounts for a bad prognosis.

Case presentation

We report the case of a 68 years old woman, who presented hematuria at hospital incoming, with radiological appearance of a 13 cm left renal mass, with a 2.5 cm single pancreatic tail metastasis. Work-up of staging ruled out other distant metastases, urothelial cancer and there was no evidence of inferior vena cava thrombosis. We choose a 5-port trans-peritoneal robotic approach using lazy right lateral decubitus. Synchronous robotic radical nephrectomy and spleen-sparing pancreatic resection was performed. The pancreatic mass was completely enucleated from pancreatic parenchyma using a latero-medial dissection. Peri-operative hemoglobine loss was 2.4 g/dL. Total operative time was 213 min. No post-operative complications were recorded and patient was discharged in 7th post-operative day. Histopathological examination showed a pT2b N0 M1 RCC, Fuhrman grade II, with pancreatic tail metastasis; both, primary and metastatic lesions had the same histological characteristics with negative surgical margins. After 9 months patient had no evidence of disease recurrence at radiological studies.

Conclusions

The rationale for surgical removal of disseminated tumor, followed by immunotherapy, includes improving prognosis and enhancing the potential of an immune-mediated response to systemic treatment. A spleen-sparing procedure can adequately preserve post-operative immunologic capabilities. In our experience, the correct assessment of pre-operative imaging data and surgeon skills in robotic surgery seem to play a key role in the success of these procedures. Robotic surgery seems to enhance the possibility to control multiple vessels encountered during dissection. Such a conservative approach may be helpful in future research aimed at uncovering biological features, and also leading to better targeted preventive interventions and more individualized and effective treatments.

Electronic supplementary material

The online version of this article (10.1186/s12893-018-0371-x) contains supplementary material, which is available to authorized users.

Surgery for metastatic tumors of the pancreas

Metastatic lesion of the pancreas originated from other organs is uncommon. The aim of this report was to evaluate the outcome of surgery in patients with isolated metastases to the pancreas. Nine patients underwent pancreatic resection for metastatic malignant disease from 2000 to 2015 at the Department of Gastroenterological Surgery of the Kumamoto University Hospital. The primary lesion was renal cell carcinoma in 7 cases, colon cancer in 1 and malignant melanoma in 1. The median interval from the initial operation to pancreatic resection was 138 months. Operative procedure was distal pancreatectomy in 6 cases, pancreaticoduodenectomy in 2 and total pancreatectomy in 1. Two patients with renal cell carcinoma and 1 patient with malignant melanoma died 131, 108, and 4 months after the pancreatic resection, respectively. Other 6 patients have survived until now with 23.5 months of observation periods after pancreatic resection. In conclusion, pancreatic metastasis can develop years after the treatment of primary lesion. Pancreatic resection can achieved long-term survival, at least in the patients who had primary renal carcinoma.

Pancreatic involvement by metastasizing neoplasms as determined by endoscopic ultrasound-guided fine needle aspiration: A clinicopathologic characterization

BACKGROUND

Pancreatic tumors often represent primary neoplasms, however organ involvement with metastatic disease can occur. The use of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) to determine the underlying pathology provides guidance of clinical management.

METHODS

25 cases were identified in a retrospective review of our institution's records from 2006 to 2016. Clinical parameters and prognosis are described.

RESULTS

Metastatic lesions to the pancreas diagnosed by EUS-FNA accounted for 4.2% of all pancreatic neoplastic diagnoses, each lesion had a median greatest dimension of 1.5 cm, were most often located in the head of the pancreas, and by EUS were typically hypoechoic masses with variably defined borders. Patients were of a median age of 64 years old at diagnosis of the metastatic lesion(s) and the mean interval from primary diagnosis to the diagnosis of metastasis to the pancreas was 58.7 months (95% confidence interval, CI, 35.4 to 82.0 months). The rates of 24-month overall survival after diagnoses of metastatic renal cell carcinoma or all other neoplasms to the pancreas were 90% and 7% respectively. The origin of the neoplasms included the kidney (n = 10), colon (n = 4), ovary (n = 3), lung (n = 2), et al. Smear-based cytomorphology, and a combination of histomorphology and immunohistochemical studies from cell block preparations showed features consistent with the neoplasm of derivation.

CONCLUSION

Metastases to the pancreas can be diagnosed via EUS-FNA, with enough specimen to conduct immunohistochemical studies if necessary to delineate origin. The determination of metastatic disease to the pancreas alters management and prognosis of the patient. Diagn. Cytopathol. 2017;45:418-425. © 2017 Wiley Periodicals, Inc.

Pretest prediction and diagnosis of metastatic lesions to the pancreas by endoscopic ultrasound-guided fine needle aspiration

BACKGROUND AND AIM

Early diagnosis of solid pancreatic lesions (SPLs) enables prompt treatment. The study aims to identify factors differentiating metastatic lesion to the pancreas (PMET) from pancreatic ductal adenocarcinoma (PDAC) and pancreatic neuroendocrine tumors (PNETs).

METHODS

This is a retrospective study at a tertiary cancer center. Consecutive patients referred for endoscopic ultrasound (EUS) of SPLs from 2004 to 2011 were reviewed. The main outcomes were pre-EUS-FNA (endoscopic ultrasound-guided fine needle aspiration) predictors and diagnostic accuracy of EUS-FNA for PMETs.

RESULTS

Among a total of 1108 EUS-FNAs for pancreatic lesions, 672 patients had neoplastic SPLs (PMETs = 53; PDACs = 528, PNETs = 91). The sensitivity, specificity, positive predictive value, and accuracy of EUS-FNA for diagnosis of PMETs were 84.9%, 100%, 100%, and 98.8%, respectively. The mean number of EUS-FNA passes for diagnosis of PMET was 3.1 per patient. For each endosonographer, preceding 3-year EUS volume (mean/year) significantly correlated with fewer needle passes (rs [-0.30], P = 0.03). The most common PMET was renal cell carcinoma. Stratified multivariate analyses were performed. Compared with patients with PDACs, PMETs were more common in men (odds ratio [OR] = 2.0; 95% confidence interval [CI] = 1.0-4.0); located in the pancreatic tail (OR = 2.4; 95%CI = 1.1-5.2); and were less likely with increasing age (OR = 0.95; 95%CI = 0.92-0.99), presence of major symptoms (abdomen pain/diarrhea/weight loss; OR = 0.2; 95%CI = 0.1-0.4), elevated bilirubin (OR = 0.3; 95%CI = 0.13-0.69), and imaging evidence of arterial invasion (OR = 0.15; 95%CI = 0.03-0.67). Compared with PNETs, PMETs were more common with increase age (OR = 1.05; 95%CI = 1.02-1.08) and increasing lesion size (OR = 1.03; 95%CI = 1.0-1.1), and were less likely in patients with diabetes (OR = 0.34; 95%CI = 0.11-0.99).

CONCLUSION

Among the largest numbers of neoplastic SPLs evaluated at a single center, pre-test features reliably characterize, and EUS-FNA provides a highly specific diagnosis of PMETs.

Prognosis of patients with metastatic renal cell carcinoma and pancreatic metastases

OBJECTIVES

To identify the clinical outcomes of patients with metastatic renal cell carcinoma (mRCC) with pancreatic metastases (PM) treated with either pazopanib or sunitinib and assess whether PM is an independent prognostic variable in the current therapeutic environment.

PATIENTS AND METHODS

A retrospective review of patients with mRCC in an outpatient clinic was carried out for the period January 2006 to November 2011. Patient characteristics, including demographics, laboratory data and outcomes, were analysed. Baseline characteristics were compared using chi-squared and t-tests and overall survival (OS) and cancer-specific survival (CSS) rates were estimated using Kaplan-Meier methods. Predictors of OS were analysed using Cox regression.

RESULTS

A total of 228 patients were reviewed, of whom 44 (19.3%) had PM and 184 (81.7%) had metastases to sites other than the pancreas. The distribution of baseline characteristics was equal in both groups, with the exception of a higher incidence of previous nephrectomy, diabetes and number of metastatic sites in the PM group. Four patients had isolated PM, but the majority of patients (68%) with PM had at least three different organ sites of metastases, as compared with 29% in patients without PM (P < 0.01). The distribution of organ sites of metastases was similar, excluding the pancreas, in those with and those without PM (P > 0.05). The median OS was 39 months (95% confidence interval [CI] 24-57, hazard ratio 0.66, 95% CI 0.42-0.94; P = 0.02) for patients with PM, compared with 26 months (95% CI 21-31) for patients without PM (P < 0.01). CSS was 42 months (95% CI 30-57) in the PM group and 27 months (95% CI 22-33) in the control group (P = 0.05).

CONCLUSIONS

Despite a higher number of affected organ sites in the PM cohort, mRCC behaviour in this cohort appears to be more indolent, as demonstrated by a higher median OS. These findings suggest that host or tumour features associated with PM may represent a less aggressive tumour phenotype.

Resection of oligometastatic lung cancer to the pancreas may yield a survival benefit in select patients--a systematic review

OBJECTIVES

To conduct a systematic review of the existing literature regarding surgical therapy for oligometastatic lung cancer to the pancreas.

METHODS

Data was collected on patients with singular pancreatic metastases from lung cancer from papers published between January 1970 and June 2014. This was performed following the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) guidelines. Kaplan-Meier and Cox Regression analyses were then used to determine and compare survival.

RESULTS

There were 27 papers that fulfilled the search criteria, from which data on 32 patients was collected. Non-small cell lung cancer (NSCLC) was the most prevalent type of primary lung malignancy, and metachronous presentations of metastases were most common. Lesions were most frequently located in the pancreatic head and consequently the most common curative intent metastasectomy was pancreaticoduodenectomy. There was a statistically significant survival benefit for patients whose metastasis were discovered incidentally by surveillance CT as opposed to those whose metastasis were discovered during a work up for new somatic complaints (p = 0.024). The overall median survival for patients undergoing curative intent resection was 29 months, with 2-year and 5-year survivals of 65% and 21% respectively. Palliative surgery or medical only management was associated with a median survival of 8 months and 2-year and 5-year survivals of 25% and 8% respectively.

CONCLUSIONS

Curative intent resection of isolated pancreatic metastasis from lung cancer may be beneficial in a select group of patients.

Solid tumor metastases to the pancreas diagnosed by FNA: A single-institution experience and review of the literature

BACKGROUND

Pancreatic fine-needle aspiration (FNA) is useful for diagnosing pancreatic masses. This article describes the experience of a single institution with metastases to the pancreas sampled by FNA and provides a review of the literature.

METHODS

Medical records were retrospectively searched for pancreatic FNA that showed metastatic disease. Data were gathered for the tumor size, focality, and time period between the primary tumor and the metastasis. A literature search using PubMed was performed.

RESULTS

Pancreatic FNA was performed 2327 times in 14 years at the authors' institution. Twenty-two cases showed metastatic disease. The average size of the metastatic lesions in their greatest dimension was 3.7 cm (range, 1.5-6.5 cm). The majority of the tumors were unifocal (16 of 22 or 73%). A rapid onsite adequacy evaluation was performed for 13 patients (4 were diagnostic of metastasis, 3 were positive for malignant cells, 6 were atypical, and none were negative). There were 14 renal cell carcinomas, 2 colonic adenocarcinomas, 1 urothelial carcinoma, 1 non-small cell lung carcinoma, 1 ovarian serous carcinoma, 1 prostatic adenocarcinoma, 1 papillary thyroid carcinoma, and 1 mesenchymal chondrosarcoma. The median time between the diagnosis of the primary tumor and the initial pancreatic metastasis was 9 years (range, concurrent diagnosis to 21 years). A literature review yielded 12 case series with a variety of metastases to the pancreas diagnosed by FNA and surgical pathology specimens.

CONCLUSIONS

In agreement with prior series, the most common metastasis to the pancreas was renal cell carcinoma. A variety of other primary malignancies were also documented in this study and in the literature. Also, this article reports the first case of metastatic mesenchymal chondrosarcoma to the pancreas diagnosed by FNA.

Pancreatic involvement in small cell lung cancer

Background

Few data are available concerning incidence, clinical picture, and prognosis for pancreatic metastases of small cell lung carcinoma. In this paper we review the related literature available in English language.

Conclusions

Although pancreatic metastases are generally asymptomatic, they can rarely produce clinical symptoms or functional abnormalities. The widespread use of multi-detector computerised tomography (CT) in contemporary medical practice has led to an increased detection of pancreatic metastases in oncology patients. Tissue diagnosis is imperative because radiological techniques alone are incapable of differentiating them from primary pancreatic tumours. Pancreatic metastases occur in the relative end stage of small cell lung cancer. The main complications of these lesions, although rare, are acute pancreatitis and obstructive jaundice. Early chemotherapy can provide a survival benefit even in patients with mild acute pancreatitis or extrahepatic biliary obstruction.

Pancreatectomy for metastatic disease: a systematic review

AIM

Tumours rarely metastasise to the pancreas. While surgical resection of such metastases is believed to confer a survival benefit, there is limited data to support such management. We present a systematic review of case series of pancreatic metastasectomy and analysis of survival outcomes.

METHODS

A literature search was performed using the PubMed and Cochrane databases and the reference lists of relevant articles, searching for sizeable case series of pancreatic metastasectomy with curative intent. Data extracted included basic demographics, histological primary tumour, presentation, operative management, complications and survival, while the MINORS index was used to assess study quality.

RESULTS

18 studies were found which met our inclusion criteria, involving 399 patients. Renal cell carcinoma (RCC) was the commonest malignancy metastasising to the pancreas, responsible for 62.6% of cases, followed by sarcoma (7.2%) and colorectal carcinoma (6.2%). While survival data was not uniformly reported, the median survival post-metastasectomy was 50.2 months, with a one-year survival of 86.81% and five-year survival of 50.02%. Median survival for RCC was 71.7 months with 70.4% five-year survival. Median survival was similar in patients with synchronous and metachronous pancreatic metastases, but patients with additional extrapancreatic metastases had a significantly shorter survival than patients with isolated pancreatic metastases (26 versus 45 months). Study quality was poor, with a median MINORS score of 10/16.

CONCLUSIONS

Within the limitations of a review of non-randomised case series, it would appear that pancreatic metastasectomy confers a survival benefit in selected patients. Better evidence is required, but may prove difficult to acquire.

Pancreatic solitary and synchronous metastasis from breast cancer: a case report and systematic review of controversies in diagnosis and treatment

Background

Metastases from breast cancer cause the frequent involvement of lung, bone, liver, and brain, while the occurrence of metastases to the gastrointestinal tract is rare, and more frequently discovered after a primary diagnosis of breast cancer. Solitary pancreatic metastases from breast cancer, without widespread disease, are actually unusual, and only 19 cases have been previously described; truly exceptional is a solitary pancreatic metastasis becoming evident together with the primary breast cancer.

Case presentation

A 68-year-old woman reported general fatigue, lethargy, and jaundice. Abdominal ultrasound (US) and magnetic resonance imaging (MRI) showed an ampulloma of Vater’s papilla; moreover, a neoplastic nodule in the left breast was diagnosed. She underwent surgery for both breast cancer and ampulloma of Vater’s papilla. Pathological examination of pancreatic specimen, however, did not confirm primary carcinoma of the duodenal papilla, but showed a metastatic involvement of pancreas from lobular breast cancer. Immunohistochemistry has been essential to confirm the origin of the malignancy: hormone receptors and mammaglobin were expressed in both the primary breast tumor and the pancreatic metastasis.

Conclusions

This is one of the few reported cases in literature of an isolated and synchronous pancreatic metastasis from breast cancer, where the definitive diagnosis was obtained only after surgery. We discuss the controversies in this diagnosis and the choice of correct treatment. The surgical resection of solitary metastases can be performed in the absence of disseminated disease.

Breast cancer metastases to the pancreas

INTRODUCTION

The pancreas can serve as the destination for metastatic spread of malignancies from multiple organ sites. Breast cancer metastases to the pancreas are part of this spectrum and surgeons evaluate such patients as part of their practice. Uniform clinical guidelines for these cases do not exist and care is primarily driven by the personal experience of the treating surgeon.

DISCUSSION

We present two patients with breast cancer metastases to their pancreas and review their workup and clinical management in light of our experience and the existing published literature. We propose that metastatic disease to the pancreas has to remain in the differential diagnosis for any patient with a new pancreatic mass and prior cancer history. Surgical resection is a viable treatment option for patients with isolated metastatic disease to the pancreas if the underlying biology of the metastatic tumor is favorable.

Accuracy of endoscopic ultrasound-guided fine-needle aspiration in the suspicion of pancreatic metastases

Background

Metastases to the pancreas are rare, and usually mistaken for primary pancreatic cancers. This study aimed to describe the histology results of solid pancreatic tumours obtained by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for diagnosis of metastases to the pancreas.

Methods

In a retrospective review, patients with pancreatic solid tumours and history of previous extrapancreatic cancer underwent EUS-FNA from January/1997 to December/2010. Most patients were followed-up until death and some of them were still alive at the end of the study. The performance of EUS-FNA for diagnosis of pancreatic metastases was analyzed. Symptoms, time frame between primary tumour diagnosis and the finding of metastases, and survival after diagnosis were also analyzed.

Results

37 patients underwent EUS-FNA for probable pancreas metastases. Most cases (65%) presented with symptoms, especially upper abdominal pain (46%). Median time between detection of the first tumour and the finding of pancreatic metastases was 36 months. Metastases were confirmed in 32 (1.6%) cases, 30 of them by EUS-FNA, and 2 by surgery. Other 5 cases were non-metastatic. Most metastases were from lymphoma, colon, lung, and kidney. Twelve (32%) patients were submitted to surgery. Median survival after diagnosis of pancreatic metastases was 9 months, with no difference of survival between surgical and non-surgical cases. Sensitivity, specificity, positive and negative predictive values, and accuracy of EUS-FNA with histology analysis of the specimens for diagnosis of pancreatic metastases were, respectively, 93.8%, 60%, 93.8%, 60% and 89%.

Conclusion

EUS-FNA with histology of the specimens is a sensitive and accurate method for definitive diagnosis of metastatic disease in patients with a previous history of extrapancreatic malignancies.

Endoscopic ultrasound-guided biopsy of pancreatic metastases: a large single-center experience

OBJECTIVES

This study aimed to describe a single-center experience with endoscopic ultrasound (EUS) features as well as the diagnostic role and clinical impact of EUS-guided fine-needle aspiration (EUS-FNA) and Trucut biopsy (EUS-TCB) in patients with pancreatic metastases.

METHODS

Demographic, clinical, EUS, pathological, clinical outcome, and follow-up data of patients who underwent EUS at our institution between October 1998 and March 2010 for a known or suspected pancreatic metastasis were abstracted.

RESULTS

Forty-nine patients (23 males; median age, 63 years; range 30-83 years) with 72 pancreatic masses were identified. Primary tumor sites included kidney (21), lung (8), skin (6), colon (4), breast (3), small bowel (2), stomach (2), liver (1), ovary (1), and bladder (1). Of the 72 pancreatic lesions, EUS-FNA of 49 was performed (median, 4.1 passes; range, 2-9 passes) without complications. An EUS-TCB after EUS-FNA was performed in 2 patients and confirmed renal cell carcinoma in one and was nondiagnostic in one. The EUS-FNA provided the first diagnosis of "recurrent malignancy" in all the 44 patients at a median time of 65 months (range, 1-348 months) after diagnosis of the primary tumor.

CONCLUSIONS

Endoscopic ultrasound-FNA and EUS-TCB may assist with the cytological diagnosis of pancreatic metastases and may have a major clinical impact.

Role of endoscopic ultrasonography in evaluation of metastatic lesions to the pancreas: a tertiary cancer center experience

OBJECTIVES

Metastatic lesions to the pancreas pose diagnostic challenges with regards to their differentiation from primary pancreatic cancer. Data on the yield of endoscopic ultrasonography (EUS)-guided fine-needle aspiration in detection of these lesions are limited.

METHODS

This is a retrospective review of 23 patients referred to a tertiary referral center for further evaluation of suspected pancreatic metastases. Main outcome measures were diagnostic yield of endoscopic ultrasonography-guided fine-needle aspiration in evaluation of metastatic lesions to the pancreas.

RESULTS

Of 644 patients, 23 (3.6%) undergoing EUS of the pancreas were diagnosed to have metastatic disease to the pancreas based on clinical, radiological, and cytological results. Mean (SD) age was 64.3 (11.7) years. Of the 23 patients, 18 (78.3%) were asymptomatic. Mean (SD) size of lesion on EUS was 39.1 (19.9) mm. A diagnosis of malignant lesion was made in 21 of 23 cases, with a diagnostic accuracy of 91.3%.

CONCLUSIONS

Metastatic lesions to the pancreas present as incidental, solitary mass lesions on staging or surveillance imaging. Endoscopic ultrasonography-guided fine-needle aspiration is an important tool in the characterization and further differentiation of metastatic lesions to the pancreas from primary pancreatic cancer.

[Pancreatic metastases. Report of four cases and literature review]

The authors present the history of 4 patients with pancreatic metastases revealed by CT and MR during the last 2 years. In 2 patients pancreatic metastases developed more than 10 years after the primary renal neoplasm was diagnosed. In the other two patients (one with non small cell lung cancer and one with non-Hodgkin disease) pancreatic metastases developed shortly after the diagnosis of the primary malignancy. According to literature data metastases in the pancreas are rare. The authors conclude that the symptoms and imaging features of pancreatic metastases are variable and, therefore, non-invasive imaging diagnosis is difficult. To resolve this problem a thorough scrutiny of the medical history of the patients and functional imaging methods may be helpful.

A pancreatic metastasis from a colon cancer

Pancreatic metastases from colorectal cancer are extremely rare. We report the case of a 74-years-old patient presented with a metachronous pancreatic metastasis, which was treated by segmental pancreatectomy. After reviewing literature, diagnosis and management of pancreatic metastasis from colorectal carcinoma are discussed.

Endoscopic ultrasound-guided fine-needle aspiration of metastases to the pancreas: A study of 25 cases

Background:

Metastases to the pancreas are an uncommon cause of pancreatic masses seen on endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA). The purpose of this study is to retrospectively review the cytomorphology, clinical findings, and results of ancillary studies in a large series of these unusual cases.

Materials and Methods:

We searched our institution's pathology database for EUS-guided FNAs of the pancreas that were diagnostic of metastatic tumor over a 5-year period. The final cytologic diagnosis, results of ancillary studies, corresponding histological material, and clinical follow-up data were reviewed in these cases.

Results:

A total of 1172 pancreatic EUS-guided FNAs were identified, of which 25 cases (2.1%) had a confirmed diagnosis of a pancreatic metastasis. This included 12 (48%) cases of renal cell carcinoma, 3 (12%) melanomas, 3 (12%) small cell carcinomas, and 7 (28%) other malignancies. In these metastatic tumors involving the pancreas, 20 (80%) of the lesions were solitary. Four (16%) cases had no prior history of malignancy. The average time to diagnosis of pancreatic metastasis was 5.3 years. Immunohistochemistry and special stains were performed in 22 (88%) and 9 (36%) cases, respectively.

Conclusions:

Our data shows that although metastases to the pancreas are rare, they can present as a solitary mass many years after the primary malignancy is diagnosed and can even be the first manifestation of an extrapancreatic primary in a small number of cases. It is important to consider the possibility of a metastatic lesion in the pancreas because this may require a different management than a primary pancreatic tumor.

Characterization of pancreatic metastases from primary lung cancer using magnetic resonance imaging

AIM

To evaluate magnetic resonance (MR) imaging of pancreatic metastases secondary to primary lung cancers.

MATERIALS AND METHODS

Eleven cases included T1-weighted, T2-weighted, and spectral presaturation attenuated inversion recovery T2-weighted images.

RESULTS

Of the 21 total pancreatic lesions evaluated, 10 exhibited a peripheral rim of high signal intensity, 9 displayed a homogeneous signal intensity, and 2 lesions demonstrated a heterogeneous pattern of contrast enhancement.

CONCLUSION

Limitations in evaluating pancreatic metastases by MR imaging require definitive diagnoses to rely on both clinical data and MR imaging.

Value of pancreatic resection for cancer metastatic to the pancreas

BACKGROUND

Cancer metastatic to the pancreas from other primary sites is uncommon, and it has been treated with an aggressive surgical approach in fit patients when the primary tumor is controlled and the pancreas is the only site of metastatic disease. The value of pancreatic resection in this setting is unclear. The purpose of this study was to review cases of cancer metastatic to the pancreas.

METHODS

We reviewed our experience with cancer metastatic to the pancreas and the literature regarding resection of pancreatic metastases. Patient and tumor characteristics were summarized using descriptive statistics.

RESULTS

A total of 220 patients with pancreatic metastasis were analyzed. Three patients were selected from our own experience, and 217 were selected from a literature review. In the 127 patients whose symptoms were recorded at the time of presentation, the most common presenting symptoms were jaundice (n = 32, 25.2%) and abdominal pain (n = 25, 19.7%). In the 189 patients for whom the location of the metastasis in the pancreas was revealed, the most common location was the head of the pancreas (n = 79, 41.8%). The primary tumor site was most commonly kidney (n = 155, 70.5%). Surgical resection was attempted in 177 of 220 patients; 135 patients suffering from RCC metastasis also underwent pancreatic resection. In the latter group, a median survival of 70 months was seen, as well as 78% and 65% 2- and 5-year survival rates, respectively.

CONCLUSION

Survival after resection of RCC with isolated metastasis to the pancreas is favorable. However, a more detailed analysis considering outcomes without surgery for each primary tumor site is needed before the value of this aggressive surgical approach can be completely assessed in the general occurrence of pancreatic metastasis.

Analysis of prognostic factors in metastatic tumors of the pancreas: a single-center experience and review of the literature

OBJECTIVES

Pancreatic metastases are rare. The role of surgery is poorly defined, and data on long-term survival are lacking.

METHODS

Data from patients with pancreatic metastases observed in our division from 2003 to 2008 were retrospectively analyzed. In addition, the recent English medical literature was reviewed regarding series of patients with pancreatic secondary tumors.

RESULTS

Data from 234 patients including 9 consecutive patients observed in our division were retrieved. Metastasis from renal cell carcinoma accounted for 67.9% of all cases. Factors predictive of worse survival, as determined by multivariate analysis, were symptoms at diagnosis, synchronous tumors, radical-intent surgery not performed, and pathologic diagnosis of the primary tumor. Compared with pancreatic metastases from renal cell cancer, metastases from melanoma (P < 0.001) and lung cancer (P = 0.002) were associated with worse survival. The differences in survival of patients with renal cell cancer metastases and those with breast cancer, colorectal, or sarcoma metastases did not reach statistical significance.

CONCLUSIONS

There may be a subset of patients with pancreatic metastases who are able to benefit from surgery with respect to improved long-term survival. Symptoms at diagnosis, presentation with primary tumor, surgical resection, and pathologic diagnosis seem to be important prognostic factors.

Acute cholangitis due to pancreatic metastasis from squamous cell lung carcinoma: a case report and review of literature

Introduction

The pancreas is a well-documented but relatively uncommon site of non-small-cell cancer metastases. However, at the time of diagnosis the disease is usually locoregionally advanced, therefore therapeutic management is mostly palliative and symptomatic.

Case Presentation

We report the case of a 77-year-old Caucasian male patient who presented initially with a clinical picture of acute cholangitis approximately 2 years after a left lower lobectomy for a low-grade squamous lung carcinoma. CT scan imaging of the abdomen and chest revealed an abnormal growth of the pancreatic head and distention of both the intra- and extra-hepatic billiary tree, whereas osteolytic abnormalities were observed of the 5th left rib, consistent with secondary deposits. Initially an endoscopic retrograde cholangio-pancreatography (ERCP) and sphincterectomy was performed and a plastic stent was placed in the common bile duct to decompress the biliary tree. Cytological examination of the aspirate collected by FNA of the pancreatic lession under EUS guidance revealed cells consistent with a low grade squamous lung carcinoma. Two months later an open cholecystectomy along with a gastrojejunostomy was performed to relieve the patient's gastric outlet obstruction symptoms. Following remission of the patient's attack of acute cholangitis and excessive vomiting he was released from the hospital and instructed to initiate chemotherapy with vinorelbine. The patient succumbed to disseminated disease almost 5 months later.

Conclusion

Symptomatic metastatic lesions of the pancreas from squamous cell carcinoma of the lung are infrequent. Typically, the patients remain asymptomatic until their disease reaches a fairly advanced stage and therapeutic options are limited to palliative measures. A high index of suspicion is the only way of early detection and potentially effective treatment for this rare localization of metastatic squamous lung carcinoma.

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.

Value of pancreatic resection for cancer metastatic to the pancreas

BACKGROUND

Cancer metastatic to the pancreas from other primary sites is uncommon, and it has been treated with an aggressive surgical approach in fit patients when the primary tumor is controlled and the pancreas is the only site of metastatic disease. The value of pancreatic resection in this setting is unclear. The purpose of this study was to review cases of cancer metastatic to the pancreas.

METHODS

We reviewed our experience with cancer metastatic to the pancreas and the literature regarding resection of pancreatic metastases. Patient and tumor characteristics were summarized using descriptive statistics.

RESULTS

A total of 220 patients with pancreatic metastasis were analyzed. Three patients were selected from our own experience, and 217 were selected from a literature review. In the 127 patients whose symptoms were recorded at the time of presentation, the most common presenting symptoms were jaundice (n=32, 25.2%) and abdominal pain (n=25, 19.7%). In the 189 patients for whom the location of the metastasis in the pancreas was revealed, the most common location was the head of the pancreas (n=79, 41.8%). The primary tumor site was most commonly kidney (n=155, 70.5%). Surgical resection was attempted in 177 of 220 patients; 135 patients suffering from renal cell carcinoma (RCC) metastasis also underwent pancreatic resection. In the latter group, a median survival of 70 mo was seen, as well as 78% and 65% 2- and 5 y survival rates, respectively.

CONCLUSION

Survival after resection of RCC with isolated metastasis to the pancreas is favorable. However, a more detailed analysis considering outcomes without surgery for each primary tumor site is needed before the value of this aggressive surgical approach can be completely assessed in the general occurrence of pancreatic metastasis.

Surgery for secondary tumors of the pancreas

BACKGROUND

The majority of pancreatic tumors are primary. The pancreas can however be the site of metastasis from renal cell cancer, lung, colon and breast cancers. The value of surgical treatment is unclear in such situations. The aim of this study was to evaluate the outcome of surgical therapy in patients with isolated metastases to the pancreas.

METHODS

All patients who underwent pancreatic surgery for malignant disease from 1999 to 2005 (n=338) at the department of hepatobiliary and pancreatic surgery, the Royal London Hospital, London, were evaluated from a retrospective pancreatic database. Five patients had metastatic pancreatic cancer. Surgical outcome and survival were examined in this subset of patients.

RESULTS

The primary cancer was renal cell carcinoma (n=2), breast (n=1), colon (n=1) and ovarian (n=1). The two patients with renal cell carcinoma developed pancreatic metastases years from the primary diagnosis. Both patients are alive 56 and 36 months post surgery. Two patients with breast and ovarian primary presented years after diagnosis of the primary but had advanced unresectable disease. There was one patient with colonic primary and synchronous pancreatic metastasis, and had a colectomy and Whipple's operation, and is alive 64 months postoperatively.

CONCLUSION

The pancreas is an uncommon site for metastasis. Patients can present years after the treatment of primary. Long-term survival can be achieved with pancreatic resection in a highly selected subset of patients, and patients with primary renal cell carcinoma seem to have a favorable prognosis.

Lung adenocarcinoma presenting as obstructive jaundice: a case report and review of literature

BACKGROUND

Lung cancer is known to metastasize to the pancreas with several case reports found in the literature, however, most patients are at an advanced stage and receive palliative treatment.

CASE PRESENTATION

We describe the case of a 56 year old male patient who presented with a picture of obstructive jaundice. Investigations revealed an obstructing lesion in the pancreas and a further lesion in the lung with benign appearances. The patient underwent a pancreatectomy and, unexpectedly, the histology of the resected specimen demonstrated metastatic adenocarcinoma of bronchogenic origin. He was referred to a cardiothoracic team who proceeded to resect the patient's thoracic lesion before administration of adjuvant chemotherapy. The patient was reviewed 18 months post operatively and remains symptom free with no clinical or radiological evidence of recurrence. We were unable to identify any previous case reports (of lung adenocarcinoma) with such a presentation which were ultimately treated with resection of both lesions.

CONCLUSION

Similar situations are bound to arise again in the future and we believe that this report could demonstrate that there is a case for aggressive surgical management in a highly selected group of patients: those with NSCLC and a synchronous solitary pancreatic deposit.

Thyroid metastases of renal cell carcinoma: clinical course in 45 patients undergoing surgery. Assessment of factors affecting patients' survival

BACKGROUND

Metastases of renal cell carcinoma (RCC) to the thyroid gland are uncommon. There is no clear consensus regarding the role of surgery in metastatic disease to the thyroid since most clinical studies include small numbers of patients. Also, risk factors associated with disease progression following thyroidectomy are not yet defined. We examined the determinants of the outcome in patients undergoing surgery for thyroid metastases of RCC.

METHODS

The medical records of 45 patients undergoing resection of thyroid metastases of RCC at 15 institutions in Germany and Austria were reviewed retrospectively. The outcome parameters assessed were overall survival and tumor-related survival. Factors associated with disease progression following thyroid surgery have been calculated.

RESULTS

The overall 5-year survival rate following thyroid metastasectomy was 51%. Nineteen patients died during the study: 14 of disseminated disease and 5 of non-tumor-related causes. In the multivariate analysis, the prognosis was significantly worse in patients older than > or = 70 years and in patients who had undergone nephrectomy for metastases in the contralateral kidney during the course of the disease. Nine patients developed a thyroid recurrence following surgery. No local disease relapse occurred if resection margins were documented to be free of the tumor. Of the 45 patients with thyroid metastases, 14 (31%) developed pancreatic metastases during the course of disease. Ten of these patients also underwent pancreatic surgery with a 5-year survival rate of 43% in this subgroup.

CONCLUSIONS

The overall survival of patients undergoing thyroidectomy for metastases of RCC is affected rather by general health status than by tumor-related factors. There is a significant coincidence of thyroid and pancreatic metastases of RCC.

Metastatic disease to the pancreas and spleen

Isolated metastases to the pancreas and spleen are a rare occurrence. When they are diagnosed, pancreatic metastases are most often from renal cell carcinoma, lung cancer, and breast cancer. The most common source of splenic metastases is gynecological in origin; the overwhelming majority is ovarian. If extensive staging studies reveal these metastases to be isolated, then curative resection may be warranted. This review will demonstrate that long-term survival may be achieved in patients with isolated metastases and a prolonged disease-free interval.