alpha-Fetoprotein-producing adenocarcinoma of the pancreas presenting focal hepatoid differentiation

Case report and literature analysis: pancreatic hepatoid carcinoma with multiple lymph node metastases progressing to liver metastasis after pancreaticoduodenectomy

Hepatoid carcinoma is an extrahepatic primary tumor displaying characteristics reminiscent of hepatocellular carcinoma differentiation, which is found in various organs, such as the stomach, ovaries, gallbladder, and pancreas. Reports of pancreatic hepatoid carcinoma remain scarce. Consequently, understanding of this disease remains a priority, with no established consensus on its diagnosis and management. Here, we reported the case of a 45-year-old woman diagnosed with hepatoid carcinoma located in the pancreatic head, accompanied by multiple lymph node metastases. Following pancreaticoduodenectomy, the patient developed liver metastases within 3 months. Subsequently, she underwent adjuvant therapy consisting of Teysuno and Durvalumab following microwave ablation for the liver metastases. Remarkably, the patient has survived for one year without significant disease progression. This case underscores the potential efficacy of immunotherapy as a promising treatment option for pancreatic hepatoid carcinoma. Further research and clinical trials are warranted to explore the optimal management strategies for this rare and challenging malignancy.

Mixed pancreatic hepatoid carcinoma: A surgical case report and literature review

BACKGROUND

Hepatoid carcinoma (HC) is a rare type of malignant tumor that shared similar features of morphology and immunohistochemistry with hepatocellular carcinoma (HCC). Pancreatic HC exists as either pure or mixed type. Mixed pancreatic HC is extremely rare, with only a few cases reported in the literature to date. Because of the rarity of mixed pancreatic HC, its clinical features including incidence, characteristics, and prognosis remain unclear. We herein report a case of a 49-year-old man who was diagnosed with mixed pancreatic HC with neuroendocrine differentiation and was treated with pancreaticoduodenectomy and adjuvant chemotherapy. We also review the existing case reports in literature.

PRESENTATION

A 49-year-old man was admitted to our hospital after a chronic abdominal pain in the upper right quadrant. Abdominal ultrasound revealed only one low-density retroperitoneal mass measured at 20 × 48mm in size in the pancreatic-duodenal junction, whereas contrast-enhanced computed tomography (CT) revealed three lymphatic neoplasms measured at 28 × 22 × 30 mm, 27 × 33 × 38 mm and 22 × 35 × 48 mm in size in the retroperitoneal pancreatic-duodenal junction. Ultrasound-guided tumor biopsy was performed. Pathological reading of tumor biopsy suspected of Paraganglioma/pheochromocytoma. Laparotomic retroperitoneal tumoral resection and lymphadenectomy was then performed. Histological reading was lymphatic metastasis of primary pancreatic hepatocellular carcinoma with neuroendocrine differentiation, which were immunohistochemically positive for CKAE1/AE3, Hepatocyte paraffin 1, Chromogranin. After three weeks of the first surgery, the patient was assigned with Positron Emission Tomography - Computed Tomography (PET-CT) before adjuvant chemotherapy, revealing a low-density high-metabolism mass, 26 × 28 mm in size within the parenchyma of pancreatic head. Laparotomic pancreaticoduodenectomy and standard lymphadenectomy was performed to resect one mass, which revealed the same immunohistology features with the first mass. The patient was followed up with FOLFIRINOX protocol, and after 12 cycles, there was no evidence of postoperative recurrence.

DISCUSSION

There are few reported cases describing pancreatic hepatoid carcinoma, especially mixed form with other histological associated component. Neuroendocrine differentiation is the majority associated component with 62.5% of all cases of mixed - type form.

CONCLUSION

Primary pancreatic hepatocellular carcinoma with neuroendocrine differentiation was rare, biopsy and immunohistochemistry appeared with high diagnostic value in this case. The prognosis of pancreatic HC depends on the extent and tumor eradication, and in this case we recorded no postoperative complications and no recurrence in the 6-month follow-up period.

Pancreatic Ductal Adenocarcinoma and Its Variants: Pearls and Perils

Pancreatic ductal adenocarcinoma (PDAC), an epithelial neoplasm derived from the pancreatic ductal tree, is the most common histologic type of pancreatic cancer and accounts for 85%-95% of all solid pancreatic tumors. As a highly lethal malignancy, it is the seventh leading cause of cancer death worldwide and is responsible for more than 300 000 deaths per year. PDAC is highly resistant to current therapies, affording patients a 5-year overall survival rate of only 7.2%. It is characterized histologically by its highly desmoplastic stroma embedding tubular and ductlike structures. On images, it typically manifests as a poorly defined hypoenhancing mass, causing ductal obstruction and vascular involvement. Little is known about the other histologic subtypes of PDAC, mainly because of their rarity and lack of specific patterns of disease manifestation. According to the World Health Organization, these variants include adenosquamous carcinoma, colloid carcinoma, hepatoid carcinoma, medullary carcinoma, signet ring cell carcinoma, undifferentiated carcinoma with osteoclast-like giant cells, and undifferentiated carcinoma. Depending on the subtype, they can confer a better or even worse prognosis than that of conventional PDAC. Thus, awareness of the existence and differentiation of these variants on the basis of imaging and histopathologic characteristics is crucial to guide clinical decision making for optimal treatment and patient management.

Hepatoid carcinoma of the pancreas: A case report and review of the literature

BACKGROUND

Hepatoid carcinoma (HC) is an extremely rare neoplasm that is morphologically similar to hepatocellular carcinoma. HC has been described in various organs; however, HC of the pancreas is extremely rare. To our knowledge, only 38 cases have been reported. We present a case of HC of the pancreas in a 36-year-old male patient.

CASE SUMMARY

A 36-year-old cachexic man with no significant past medical history was transferred to our hospital with a history of painless jaundice, elevated blood glucose and significant weight loss. Lab tests showed elevated serum transaminases, bilirubin and alpha-fetoprotein levels. Magnetic resonance imaging of the upper abdomen showed a diffusely enlarged pancreas, appearing “sausage-shaped”. Magnetic resonance cholangiopancreatography showed upstream ductal dilation secondary to stricture of the main pancreatic duct and the common bile duct, which were not visible. Immunohistochemistry of biopsied tissue from a percutaneous pancreatic biopsy showed tumor cell positivity for HepPar1, polyclonal carcinoembryonic antigen and CK19, suggestive of HC of the pancreas. The characteristics of 39 patients with HC of the pancreas were reviewed.

CONCLUSION

HC of the pancreas is more prevalent in males, and patients have a median age of 57 years. It is most commonly asymptomatic or presents as abdominal back pain, and the pancreatic tail is the most common location. At the time of diagnosis, liver metastasis is often present.

Circulating MiR-210 and MiR-1246 as Potential Biomarkers for Differentiating Hepatocellular Carcinoma from Metastatic Tumors in the Liver

Background

To date few reports have pointed out the role of circulating miRNAs in discriminating metastatic liver tumors from primary hepatocellular (HCC) tumors. Such discrimination will have significant therapeutic and prognostic implications. The purpose of this study was to evaluate the potential value of a panel of HCC-related circulating miRNAs (miR-142, miR-182, miR-200a, mir-210, miR-211, miR-302b, miR-324, miR-338, miR-340 and miR-1246) as noninvasive biomarkers for discriminating primary HCC from metastatic tumors in the liver.

Methods

The expression level of the selected miRNAs was quantified by quantitative real time PCR in 33 patients with HCC, 22 patients with metastatic tumors in the liver, and 30 healthy volunteers as control. Mann-Whitney U test was used to evaluate the difference in miRNAs expression between primary and metastatic liver tumors and to study the associations between their relative expression levels and the clinicopathological factors. Receiver operating characteristic curve was used to evaluate the diagnostic value of the individual miRNAs.

Results

Statistical analyses revealed a differential expression in the level of serum miR-210 and miR-1246 between the two groups of patients. The sensitivity and specificity of miR-210, for differentiating HCC from metastatic malignancies in the liver were found to be 73.7% and 64.28%, respectively. Whilst, of miR-1246 were 72.2% and 67.8%, respectively. In addition, the differential expression of the two miRNAs was also found to be associated with clinicopathological parameters in the two studied groups.

Conclusions

Serum miR-210 and miR-1246 have some diagnostic value for discriminating patients with metastatic tumors to patients with primary HCC

Primary Hepatoid Carcinoma of the Pancreas: A Clinicopathological Study of 3 Cases With Review of Additional 31 Cases in the Literature

Primary pancreatic hepatoid carcinoma (PHC) is very rare. Here, we reported 3 such cases with review of additional 31 cases in the literature. Our 3 patients were male (83, 72, and 54 years old, respectively). Serum α-fetoprotein (AFP) was elevated in 1 patient (case 3, 8338 ng/mL) and not measured in the other two. The PHC in patient 1 (pathological stage pT2N0M0) and patient 2 (pT3N0M0) showed pure hepatocellular carcinoma (HCC)-like morphology, whereas in case 3 it was a PHC with true glandular differentiation (pT4N0M0). The diagnosis of PHC was confirmed with positive immunohistochemical staining in the tumor cells for AFP (2/3), Hep Par 1 (3/3), glypican-3 (2/3), arginase-1 (2/3), and Sal-like protein 4 (1/3). CD10 and polyclonal carcinoembryonic antigen stains show focal canalicular pattern in 2/3 tumors. Patient 1 did not receive further treatment after resection and was alive with no evidence of disease at 107 months. Patient 2 died of postoperative complications, whereas patient 3 received postsurgical chemoradiation and died of disease at 29 months. Our findings and literature review indicate that PHCs can be divided into 4 histological subtypes: with pure HCC-like morphology (n = 22), with neuroendocrine differentiation (n = 8), with true glandular differentiation (n = 3), and with acinar cell differentiation (n = 1). On univariate analysis, pure HCC-like morphology was associated with better disease-specific survival (DSS; P = .04), whereas lymph node and distant metastases were associated with worse DSS ( P = .002 for both). Age, gender, presenting symptoms, serum AFP level, and T stage were not associated with DSS. On multivariate analysis, none of these parameters was significantly associated with DSS.

Hepatoid Carcinoma of the Pancreas: Case Report, Next-Generation Tumor Profiling, and Literature Review

Fewer than 25 cases of hepatoid carcinoma of the pancreas have been reported in the literature. We present a case in a 61-year-old male with a remote history of Hodgkin's lymphoma and gastric neuroendocrine cell hyperplasia. On surveillance endoscopic ultrasound, an 8 × 5 mm cystic lesion was seen in the tail of the pancreas. MRI showed a focal pancreatic duct cut-off with mild ductal dilation. Fine needle aspiration was performed, which was concerning for acinar cell carcinoma. The patient underwent distal pancreatectomy and recovered uneventfully. Final pathology demonstrated a 1.3-cm hepatoid carcinoma of the pancreas, with a final clinicopathological stage of T1N0M0. Next-generation nucleic acid sequencing of the tumor did not suggest a viable adjuvant chemotherapeutic agent, and no adjuvant therapy was administered. The patient has no evidence of disease 6 months following resection. A further characterization and description of the outcomes of these rare tumors is warranted to help guide providers and counsel patients.

Pancreatic Hepatoid Carcinoma Mimicking a Solid Pseudopapillary Neoplasm: A Challenging Case on Endoscopic Ultrasound-guided Fine-needle Aspiration

A 59-year-old man was admitted to our hospital for treatment of a 45 mm pancreatic mass found during a medical examination. Endoscopic ultrasound-guided fine-needle aspiration cytology showed polygonal cells with pseudopapillary structures. The tumor cells were positive for nuclear/cytoplasmic β-catenin and CD10, and negative for chromogranin A. After a tentative diagnosis of a solid pseudopapillary neoplasm, middle pancreatectomy was performed. Histologically, polygonal cells with abundant eosinophilic cytoplasm formed in the trabeculae and were immunohistochemically positive for HepPar1 and protein induced by vitamin K absence or antagonist-II. The tumor was finally diagnosed to be pancreatic hepatoid carcinoma. No recurrence occurred for 12 months, even without adjuvant chemotherapy.

Hepatoid carcinoma of the pancreas combined with serous cystadenoma: a case report and review of the literature

Pancreatic hepatoid carcinoma (HC) is an extremely uncommon neoplasm of pancreas that resembles hepatocellular carcinoma (HCC). We report a case of incidentally detected pancreatic HC combined with a serous microcystic cystadenoma, in a 47-year-old man, while he was being evaluated for renal calculi. Contrast enhanced computed tomography (CECT) of abdomen revealed a lesion with mild heterogeneous enhancement in the tail of pancreas and another proximal lesion having moderate enhancement, and a calculus in the neck of gallbladder. Serum chromogranin, carcinoembryonic antigen (CEA) and CA 19-9 levels were within normal limits. He underwent laparoscopic distal pancreatectomy with splenectomy and cholecystectomy. Pathologically the distal tumor was encapsulated and characterized by eosinophilic cytoplasm, vesicular nucleus with prominent nucleolus and intranuclear eosinophilic inclusions. The cells were arranged in trabecular pattern separated by sinusoids. Canalicular and intercellular bile plugs were seen. On immunohistochemistry tumor cells were positive for hepatocyte specific antigen and weakly positive for alpha fetoprotein (AFP). The proximal tumor showed features of serous microcystic adenoma. Based on these findings, the case was diagnosed as hepatoid tumor of pancreas combined with serous microcystic cystadenoma. Post operative AFP was 1.75 IU/mL. The patient is on follow up for the last eight months and there is no evidence of recurrence.

Hepatoid carcinoma of the pancreas with lymphoid stroma: first description of the clinical, morphological, immunohistochemical, and molecular characteristics of an unusual pancreatic carcinoma

We report a case of tumour in the head of the pancreas observed in a 57-year-old man with a history of worsening jaundice and elevated alpha-fetoprotein (AFP) serum level, who underwent Whipple pancreatoduodenectomy. Histologically, the tumour was predominantly composed of solid sheets of large eosinophilic cells with a prominent lymphoid infiltration without association neither with DNA microsatellite instability nor Epstein-Barr virus infection. The tumour was diffusely and strongly positive for hepatocyte paraffin-1 (Hep Par-1) and glypican-3 leading to the diagnosis of hepatoid carcinoma. Strong cytoplasmic staining for AFP was focally observed. Moreover, tumour cells showed countless cytoplasmic eosinophilic globules immunoreactive for the stress protein p62. A primary hepatocellular carcinoma of the liver was ruled out by careful clinical analysis. Hepatoid carcinoma is an extremely rare pancreatic neoplasm, and here, we describe the first case of such variant associated with lymphoid stroma. The characteristic histologic features and the immunophenotypic profile help in distinguishing this carcinoma from other pancreatic tumours, notably from medullary carcinoma.

Pancreatic hepatoid carcinoma: a rare form of pancreatic neoplasm

Primary pancreatic hepatoid carcinoma (PHC) is extremely rare, resembling hepatocellular carcinoma (HCC) in terms of morphology and immunohistochemical features. Hepatoid carcinoma can present in other organs, most noticeably in the stomach. PHC is present in two forms either a pure form like HCC or admixed with other histologic tumor components characteristic of the underlying primary site (endocrine tumors, ductal, or acinar adenocarcinomas). Here, we report a 69-year-old male patient with distal pancreatic mass incidentally found during a CT scan workup for a pulmonary nodule suspicious for metastatic prostate adenocarcinoma. We described the clinical, cytological, and histological finding and conducted a literature review.

A rare case of metastatic pancreatic hepatoid carcinoma treated with sorafenib

BACKGROUND

Hepatoid carcinoma (HC) is a rare histopathological tumor type with prominent features of hepatoid differentiation, and while most of the reported cases are of gastric origin, ten cases of pancreatic HC have been reported to date. The majority of HC cases are metastatic at presentation, mainly to the liver, lymph nodes, and lungs. They are aggressive, invading, and proliferating in the venous and lymphatic systems, with a behavior similar to that of hepatocellular carcinoma. Diagnosis is challenging: alpha-Fetoprotein, the most useful marker, is not always positive.

METHODS

We present the first case of metastatic pancreatic HC treated with sorafenib, an oral multikinase inhibitor approved for advanced hepatocellular carcinoma that has antiangiogenic, pro-apoptotic, and raf-kinase inhibitory properties.

RESULTS

The patient, a 37-year-old male, was diagnosed with hepatoid carcinoma of the pancreas that had metastasized to liver, lungs, and lymph nodes. The cytokeratin (CK) profile was useful for the diagnosis: Both the hepatoid and adenocarcinoma components of the tumors were CK18+, CK19+, and CK20+/-, whereas normal and neoplastic hepatocytes are CK18+, CK19-, and CK20-. Amylase, lipase, and liver enzyme levels were elevated, but bilirubin was normal. Treatment with sorafenib resulted in more than 7 months of progression-free survival. Therapy was discontinued after 8 months when his bilirubin level increased dramatically. Signs of liver failure resolved temporarily with insertion of a biliary stent, but his condition deteriorated and he died 3 months later, 1 year after diagnosis.

CONCLUSION

In the absence of evidence-based experience with this rare and aggressive tumor and given its similarities with hepatocellular carcinoma, sorafenib should be considered as a possible treatment.

Hepatoid carcinoma of the pancreas penetrating into the gastric cavity: a case report and literature review

A 79-year-old Japanese woman was admitted to our hospital for treatment of a pancreatic tumor measuring approximately 7 × 5 cm. The tumor had invaded the left adrenal gland and gastric wall and had penetrated into the gastric cavity. Surgical resection was performed. The tumor was composed of a brown to whitish solid area and a zone of hemorrhage, necrosis, and cystic degeneration resembling the gross features of solid pseudopapillary tumor (SPT). Histologically, the tumor showed a heterogeneous growth pattern with a combination of seat-like, trabecular, papillary and hemorrhagic-necrotic areas in various proportions. The differential diagnoses first considered were acinar cell carcinoma, neuroendocrine carcinoma and SPT with malignant transformation. Immunohistochemistry showed tumor cells were negative for pancreatic exocrine enzymes and endocrine markers. Tumor cells diffusely expressed cytokeratin 19, alpha-fetoprotein, carcinoembryonic antigen and glypican-3, but lacked vimentin or β-catenin expression. Small proportions of tumor cells expressed hepatocyte paraffin-1. Although typical morphological features of well-differentiated hepatocellular carcinoma (HCC) were not distinctly apparent, the tumor morphology partly resembled poorly differentiated HCC. Given these findings and considerations, the tumor was finally diagnosed as poorly differentiated hepatoid carcinoma of the pancreas.

Alpha-fetoprotein-producing adenocarcinoma in which the metastatic route was determined from calcified lesions

Alpha-fetoprotein (AFP)-producing adenocarcinoma is known for its rapid progression and poor prognosis, and chemotherapy regimens are yet to be standardized. Here we describe the first report of AFP-producing adenocarcinoma with calcification. The metastatic route was visualized from the calcification, and combination chemotherapy was performed. A 77-year-old Japanese man was transferred to our hospital for treatment of liver tumors. Computed tomography (CT) revealed multiple liver tumors with portal vein tumor thrombosis. The tumors were highly attenuated before enhancement, suggesting various degrees of calcification. Serum levels of carcinoembryonic antigen (CEA), AFP, and the proportion of fucosylated AFP were considerably elevated. Gastroduodenoscopy revealed an elevated tumor occupying the duodenal bulb with an ulcerative lesion in the vicinity of the gastroduodenal junction, and biopsy specimens from the duodenum and liver revealed medullary adenocarcinoma with calcification. Three-dimensional reconstruction of CT images clearly showed that the calcified lesions had spread from the gastroduodenal junction to the liver via a route comprising the corresponding local vein, the superior mesenteric vein, and portal vein. The patient was accordingly diagnosed with calcified AFP-producing adenocarcinoma with multiple liver metastases. Combination chemotherapy using TS-1 and cisplatin (CDDP) resulted in a striking response for the initial 4 months in terms of tumor markers and CT findings. This is the first report of AFP-producing adenocarcinoma with calcification. A metastatic route from the primary tumor to the liver was clearly visualized by tracing the calcified lesions. Combination chemotherapy based on 5-fluorouracil and CDDP may have the potential to prolong survival.

Soft-Tissue Localization of Hepatoid Adenocarcinoma: First Case Report

Hepatoid adenocarcinoma (HAC) is a rare type of extrahepatic cancer, whose pathologic features are indistinguishable from those of hepatocellular carcinoma. About thirty cases, nearly half of which occurring in the lung, have been described in patients with a normal liver. No imaging features are typical enough to allow a correct diagnosis. A localization of HAC in the soft tissues of the shoulder with invasion of the scapula in a woman without other symptoms is reported in this paper; soft-tissue HACs have never been described to date. An associate pulmonary HAC was eventually found in this patient.

Hepatoid carcinoma of the pancreas: a case report and literature review of a heterogeneous group of tumors

Hepatoid carcinomas are tumors that display, at least focally, cytologic and/or architectural features of hepatocellular carcinoma. They have been described in several organs, most notably in the stomach and ovary. We report a case of hepatoid carcinoma of the pancreas that developed in a 41-year-old woman in association with a pancreatic endocrine carcinoma. The fine needle aspiration material was characterized by the presence of monotonous, small-to-medium sized tumor cells with round nuclei and finely granular chromatin, intermixed with more atypical tumor cells displaying larger nuclei with coarse clumped chromatin, prominent nucleoli, and moderate amounts of foamy cytoplasm. The excised specimen displayed a poorly differentiated pancreatic endocrine carcinoma associated with well-defined islands of larger tumor cells growing in a perisinusoidal pattern which, based on their immunohistochemical profile and the demonstration of bile, proved to represent a hepatoid component. This case and prior examples in the literature suggest that hepatoid carcinomas of the pancreas appear to be a heterogeneous group of tumors (pure or associated with another histologic component) that are often associated with early liver metastasis and a short survival, although those arising as a component of endocrine tumors seem to fare slightly better. Hepatoid carcinoma of the pancreas should be included in the differential diagnosis of pancreatic tumors composed of large eosinophilic cells.

Hepatoid carcinoma of the pancreas producing protein induced by vitamin K absence or antagonist II (PIVKA-II) and alpha-fetoprotein (AFP)

We describe a rare case of hepatoid carcinoma of the pancreas with production of protein induced by vitamin K absence or antagonist II (PIVKA-II) and alpha-fetoprotein (AFP). The patient was a 49-year-old woman admitted because of high serum levels of PIVKA-II (1.63 AU/ml) and AFP (623 ng/ml) and abnormal ultrasonographic findings of the pancreas, found incidentally at medical checkup. Both ultrasonography and computed tomography showed swelling of the pancreas with small areas of low density, but no hepatic lesions. The serum levels of carcinoembryonic antigen and carbohydrate antigen 19-9 were not increased. A PIVKA-II and AFP-producing pancreatic cancer was strongly suspected, and total pancreatectomy was performed. Pathological examination showed that the tumor cells were arranged in trabecular and solid patterns with bile production, and were immunohistochemically positive for PIVKA-II and AFP, resembling hepatocellular carcinoma cells. The tumor was diagnosed as hepatoid carcinoma of the pancreas, and the patient has survived 48 months after initial diagnosis. It is important that hepatoid carcinoma be considered as a possible malignant tumor of the pancreas, and simultaneous measurement of the serum levels of AFP and PIVKA-II will enable earlier diagnosis. This is the first report describing hepatoid carcinoma of the pancreas producing PIVKA-II.

Origin of hepatocellular carcinoma: role of stem cells

The question of whether hepatocellular carcinoma (HCC) arises from the differentiation block of stem cells or dedifferentiation of mature cells remains controversial. Recently, researchers suggested that HCC may originate from the transdifferentiation of bone marrow cells. Interestingly, there are four levels of cells in the hepatic stem cell lineage: bone marrow cells, hepato-pancreas stem cells, oval cells and hepatocytes. Hematopoietic stem cells and the liver are known to have a close relationship in early development. Bone marrow stem cells could differentiate into oval cells, which could differentiate into hepatocytes and duct cells. The development of pancreatic and liver buds in embryogenesis suggests the existence of a common progenitor cell to both the pancreas and liver. Cellular events during hepatocarcinogenesis illustrate that HCC may arise from cells at various stages of differentiation in the hepatic stem cell lineage.

Hepatoid carcinoma of the pancreas

Background

Hepatoid carcinoma of the pancreas is extremely rare. This article tries to summarize the clinical features and outcomes of pancreatic hepatoid carcinoma.

Methods

The data pool for analysis includes the case we encountered with hepatoid carcinoma of the pancreas and the reported cases in the literature.

Results

Twenty-three cases of hepatoid carcinoma of the pancreas were analyzed. This tumor occurred more frequently in male than in female patients (69.6 vs. 30.4 %). Tumor sizes range from 0.5 to 11.0 cm with median of 6.0 cm. The most common symptom was epigastric pain (36.4 %). When the tumor locates at pancreatic head, nausea/vomiting (62.5 %) is more common, followed by jaundice and epigastric pain (50.0 %). For those at pancreatic body-tail, 42.9 % of the patients presented no symptom. Alpha-fetoprotein (AFP) was abnormally elevated in 60 % of the cases. Hepatoid carcinoma in the pancreas could be either pure form or mixed form with other malignancy (40.9 %), with the most common coexisted pathology of malignant neuroendocrine tumor (22.7 %). Metastasis occurred in 36.4 % of the cases at the diagnosis of this tumor, including liver metastasis in 31.8 % and lymph node metastasis in 21.1 %. The overall 1-year survival rate was 71.1 % and 5-year 40.4 %, with a median of 13.0 months. Unresectability, hepatic, and lymph node metastases are associated with negative impact on survival outcome.

Conclusions

Elevation of serum AFP may be a clue leading to the diagnosis of pancreatic hepatoid carcinoma. This tumor could be mixed form with other malignancy. Surgical resection should be the treatment of choice whenever possible.

Increased expression of alpha-1-antitrypsin, glutathione S-transferase pi and vascular endothelial growth factor in human pancreatic adenocarcinoma

BACKGROUND

This study was designed to investigate abnormalities in gene expression in ductal adenocarcinoma of the pancreas using cDNA arrays.

METHODS

Gene expression in pancreatic ductal adenocarcinoma was compared with normal pancreatic tissue controls. Specimens from 5 patients with pancreatic adenocarcinoma were taken fresh at operation and analyzed using commercially prepared cDNA arrays evaluating approximately 2,000 genes. Immunohistochemical staining was used to confirm protein expression of selected genes.

RESULTS

Alpha-1-antitrypsin (A1AT) and glutathione S-transferase pi (GSTP) were significantly up-regulated in all 5 tumors. Vascular endothelial growth factor (VEGF) was up-regulated in 4 of the 5 patients. Immunohistochemical staining verified the overexpression of each of these genes.

CONCLUSIONS

A1AT, GSTP, and VEGF are overexpressed in human pancreatic adenocarcinoma specimens taken fresh at operation. To our knowledge, this is the first study of human pancreatic ductal adenocarcinoma demonstrating the up-regulation of these genes using gene expression arrays.

Malignant insulinoma with hepatoid differentiation: a unique case with alpha-fetoprotein production

Hepatoid carcinomas are uncommon extra-hepatic neoplasms exhibiting features of hepatocellular carcinoma and they are most frequently described in the stomach. We report a 64-year-old woman with a malignant insulinoma showing focal hepatoid differentiation and biochemical evidence of alpha-fetoprotein (AFP) production. The current case is the first malignant insulinoma with hepatoid differentiation. Resection of the primary tumor followed by regional embolization was peformed. The patient died 22 months after initial presentation. Thus, the presence of hepatoid differentiation in pancreatic tumor should be noted as the tumor may be associated with elevated AFP. The features of pancreatic hepatoid carcinomas are discussed.