Pancreatic Collision Tumor of Ductal Adenocarcinoma and Neuroendocrine Tumor

An Unusual Case of Dual Pancreatic Tumors

We report a simultaneous occurrence of pancreatic adenocarcinoma and pancreatic neuroendocrine tumor. A 64-year-old woman presented with abdominal pain and weight loss. Abdominal computed tomography revealed a pancreatic head mass with a mesenteric artery encasement. Endoscopic ultrasound revealed a second mass in the tail of the pancreas. Pathology reported adenocarcinoma of the head of the pancreas and a neuroendocrine tumor in the tail of the pancreas. The neuroendocrine tumor was nonfunctional, with no symptoms or signs present on assessment. The patient had advanced unresectable carcinoma, so she was treated with chemotherapy.

A case report of a collision tumor composed of pancreatic ductal adenocarcinoma and peri-pancreatic mucosa-associated lymphoid tissue lymphoma

BACKGROUND

Collision tumors are composed of two distinct tumor components. Collision tumors composed of pancreatic ductal adenocarcinoma and malignant lymphoma occurring in the pancreas have not been previously described in the scientific literature. In this case report, we describe a unique patient with a collision tumor composed of pancreatic ductal adenocarcinoma and peri-pancreatic mucosa-associated lymphoid tissue (MALT) lymphoma occurring in the pancreas.

CASE PRESENTATION

An 82-year-old woman presented to our hospital complaining of dizziness. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a large lymphoid lesion spreading from the peri-pancreatic tissue heading to the hepatic hilar plate, involving the hepatoduodenal ligament and the entire duodenum, also showing a hard tumor in the pancreas head. We performed echo-guided needle biopsies for each tumor and diagnosed a collision tumor composed of pancreatic ductal adenocarcinoma and low-grade B cell lymphoma. The patient underwent pancreaticoduodenectomy. The resected specimen showed an elastic hard tumor, 90 × 75 mm in size, located in the pancreatic head, and a whitish-yellow hard tumor involving the lower bile duct, 31 mm in size, located in the center of the pancreatic head. Pathological and immunohistochemical examination proved that pancreatic ductal adenocarcinoma and MALT lymphoma originating from the peri-pancreatic head collided in the pancreatic head.

CONCLUSIONS

To best of our knowledge, this is the first report of a surgically resected collision tumor of pancreatic ductal adenocarcinoma and MALT lymphoma originating from the peri-pancreatic head. A needle biopsy is useful when inconsistent findings are observed on diagnostic CT and MRI of tumor lesions since there is the possibility of a collision tumor.

Mixed neuroendocrine–nonneuroendocrine neoplasms of the gastrointestinal system: An update

Mixed neuroendocrine-nonneuroendocrine neoplasms (MiNENs) of the digestive tract are a rare heterogeneous group of tumors that present many challenges in terms of diagnosis and treatment. Over the years, the diagnostic criteria, classification, and clinical behavior of these tumors have been the subjects of ongoing debate, and the various changes in their nomenclature have strengthened the challenges associated with MiNENs. This review is performed to provide an understanding of the key factors involved in the evolution of the designation of these tumors as MiNEN, highlight the current diagnostic criteria, summarize the latest data on pathogenesis and provide information on available treatments. Moreover, this work seeks to increase the awareness about these rare neoplasms by presenting the clinicopathological features and prognostic factors that play important roles in their behavior and discussing their different regions of origin in the gastrointestinal system (GIS). Currently, the MiNEN category also includes tumors in the GIS with a nonneuroendocrine component and epithelial tumors other than adenocarcinoma, depending on the organ of origin. Diagnosis is based on the presence of both morphological components in more than 30% of the tumor. However, this value needs to be reconfirmed with further studies and may be a limiting factor in the diagnosis of MiNEN by biopsy. Furthermore, available clinicopathological data suggest that the inclusion of amphicrine tumors in the definition of MiNEN is not supportive and warrants further investigation. The diagnosis of these tumors is not solely based on immunohistochemical findings. They are not hybrid tumors and both components can act independently; thus, careful grading of each component separately is required. In addition to parameters such as the metastatic state of the tumor at the time of diagnosis and the feasibility of surgical resection, the aggressive potential of both components has paramount importance in the choice of treatment. Regardless of the organ of origin within the GIS, almost MiNENs are tumors with poor prognosis and are frequently encountered in the elderly and men. They are most frequently reported in the colorectum, where data from molecular studies indicate a monoclonal origin; however, further studies are required to provide additional support for this origin.

Pancreatic collision tumor of ductal adenocarcinoma and neuroendocrine tumor-A rare case report

A collision tumor is composed of two adjacent histological distinct neoplasms without the histological admixture of cell types in the same organ or tissue. It is rare in pancreas. Herein we report an unusual case of a mixed malignant neuroendocrine tumor (NET) and ductal adenocarcinoma of pancreas in a 24 year old male who presented with history abdomen pain. A clinicoradiological diagnosis of chronic calcific pancreatitis with carcinoma body of pancreas was made. Distal pancreaticosplenectomy specimen showed a grey white, nodular growth measuring 2 x 2 x 1.2 cm on the cut surface of pancreas. Histopathology revealed a composite tumor consisting of ductal and neuroendocrine origin. Immunohistochemistry showed complementary staining for CK7 in adenocarcinoma and chromogranin A in NET areas confirming a collision tumor. Accurate evaluation of the radiologic pointers, histomorphologic evaluation to recognize and quantitate the individual components, appropriate immunohistochemical evaluation and correlation is essential for diagnosis.

A pancreatic mixed neuroendocrine-non-neuroendocrine neoplasms (MiNEN) (NET and undifferentiated carcinoma of the pancreas with osteoclast-like giant cells) with metastatic neuroendocrine component to the liver

Undifferentiated carcinoma of the pancreas with osteoclast-like giant cells (UCOGCs) is an extremely rare morphologically and clinically distinct variant of pancreatic ductal adenocarcinoma (PDAC), exhibiting a characteristic component of reactive osteoclast-like giant cells admixed with neoplastic mononuclear cells. Sommers and Meissner first described it in 1954 as an “unusual carcinoma of the pancreas”. Later it acquired many different names. In 2010, the WHO classified these tumors as a variant of PDAC under the heading of “undifferentiated carcinoma with osteoclast-like giant cells”. Here we describe the first case of pancreatic mixed neuroendocrine-non-neuroendocrine neoplasms (MiNEN) composed of UCOGC and pancreatic neuroendocrine tumor (NET), which occurred in a 78-year-old man with biliary colic and pancreatitis. The mass did not respond to the chemotherapy, and he soon developed liver metastasis from the NET component, and unfortunately, the patient passed away 10 months later. Since UCOGC is extremely rare, and its association with NET has not been reported yet, our case expands the knowledge regarding its unusual presentation and poor prognosis.

Collision of a pancreatic ductal adenocarcinoma and a pancreatic neuroendocrine tumor associated with multiple endocrine neoplasm type 1

A 54-year-old man with pancreatic head tumor had undergone pancreaticoduodenectomy and was diagnosed with pancreatic neuroendocrine tumor (P-NET) associated with sporadic multiple endocrine neoplasm type 1. Five years after the resection, P-NET recurred and liver metastases were observed. He was treated with a somatostatin analog. Eleven years after the resection, computed tomography revealed a new pancreatic hypodense and hypovascular mass adjacent to the P-NET that was diagnosed as pancreatic adenocarcinoma via endoscopic ultrasound-guided fine-needle aspiration. He underwent a total remnant pancreatectomy. Pathological examination showed that the lesion was constituted by a pancreatic ductal adenocarcinoma (PDAC) and a neuroendocrine tumor. Additionally, the invasive ductal carcinoma collided with the neuroendocrine tumor. Both PDAC and P-NET cells were observed in the collision area. We could observe the onset of PDAC during the treatment of P-NET. Moreover, we are the first to report the case of a collision of pancreatic endocrine and exocrine tumors diagnosed preoperatively.

Looking into digestive mixed neuroendocrine - nonneuroendocrine neoplasms: subtypes, prognosis, and predictive factors

Mixed neuroendocrine - nonneuroendocrine neoplasms (MiNENs) of the digestive system represent a challenge for both pathologists and clinicians. Their nomenclature has changed several times, and their diagnostic criteria, classification and clinical behaviour have been matter of debate over the years. Although several attempts have been made to elucidate the pathogenesis and biology of MiNENs, some issues remain open. This review will provide: a historical background that helps in understanding the evolution of the concept and nomenclature of mixed neoplasms; a revision of the knowledge on this topic, including molecular aspects, to give the reader a comprehensive and practical overview on this challenging field of pathology; a focus on the diagnostic criteria and on the determination of prognostic and predictive factors; and a description of the different tumour types in the different sites of origin.

Concurrent ductal adenocarcinoma, pseudocyst, and neuroendocrine tumor of the pancreas: A case report

INTRODUCTION

Pancreatic pseudocyst is one of the most common cystic lesions. It always occurs following pancreatitis and is rarely found in combination with pancreatic adenocarcinoma. The coexistence of exocrine and neuroendocrine tumors of the pancreas is also infrequent. We herein report a case of simultaneous occurrence of a pancreatic ductal adenocarcinoma (PDAC), pseudocyst, and neuroendocrine tumor (NET), showing a "side-by-side pattern."

PATIENT CONCERN

A 74-year-old man was hospitalized for epigastric pain and poor appetite. He had no history of pancreatitis, alcohol consumption, or smoking.

DIAGNOSIS AND INTERVENTION

Abdominal enhanced computed tomography and magnetic resonance imaging revealed a 15 × 8 cm cystic lesion with poor enhancement located in the tail of the pancreas. The distal aspect of the main pancreatic duct was dilated. The pancreatic parenchyma adjacent to the cystic lesion showed slightly heterogeneous enhancement on computed tomography and magnetic resonance imaging. Laboratory examination showed an elevated carbohydrate antigen 19-9 serum level. The patient was preoperatively diagnosed with intraductal papillary mucinous neoplasm and subsequently underwent laparotomy. During the operation, a hard white tumor measuring about 4 × 3 cm was palpated adjacent to the cystic lesion on the duodenal side, and a 0.6-cm nodule was simultaneously found in the pancreatic tail. Therefore, total pancreatectomy and splenectomy were performed. Histopathological examination showed that the tumor was PDAC with an adjacent pseudocyst, and the small nodule was suggestive of a NET.

OUTCOMES

The patient survived without recurrence or metastasis in the follow-up visit 10 months after the operation and adjuvant chemotherapy.

CONCLUSIONS

The concomitant occurrence of a PDAC, pseudocyst, and NET has not been previously reported. We suggest that if a pancreatic cyst is found, the coincidental occurrence of a malignant tumor should be considered, especially if the carbohydrate antigen 19-9 level is increased. Additionally, dilation of the pancreatic duct may be a diagnostic clue. Furthermore, the simultaneous occurrence of pancreatic endocrine and exocrine tumors is very uncommon. Preoperative diagnosis becomes difficult because of the lack of specific symptoms and radiological features.

A Rare Case of Recurrent Pituitary Collision Tumors

Pituitary collision tumors are sporadically reported and rare. We present a case of pituitary collision tumors with nonfunctioning pituitary adenoma (NFPA) and craniopharyngioma. In order to look for any common activated pathway, we examined WNT/β-CATENIN signaling activation, known to be involved in tumorigenesis in both craniopharyngioma and NFPA. We found nuclear accumulation of β-CATENIN protein and expression of LEF1 protein, markers of active β-CATENIN signaling in the craniopharyngioma but not in the pituitary adenomas. In our case, the NFPA is invasive macroadenoma, which is a frequently identified type of pituitary adenoma in collision tumor cases. Recurrence of this tumor was first observed after 8 years of follow-up. Based on this case, we suggest that pituitary collision tumors require long-term follow-up.

Mixed neuroendocrine-non-neuroendocrine neoplasms (MiNEN) of pancreas: a rare entity-worth to note

Mixed adenocarcinoma with neuroendocrine tumour of pancreas has been reported infrequently and consists of both epithelial and neuroendocrine component. We encountered an 81-year-old male patient who presented with clinical features of painful progressive jaundice for 1 month. Contrast-enhanced CT abdomen reported a mass in the pancreatic head with dilated common bile duct and pancreatic duct. He underwent pancreatoduodenectomy and histopathological examination revealed two different tumours: ductal adenocarcinoma admixed with neuroendocrine tumour of pancreas. He received adjuvant chemotherapy, and at the end of 1-year follow-up, he has no recurrence. Here, we reported this rare malignancy of pancreas for which pancreatoduodenectomy was done and diagnosed on histopathology with immunohistochemistry.