Pancreatic metastases: An increasing clinical entity

Solid pancreatic masses: What’s hidden beneath? Insights into rare pancreatic lesions

The diagnostic approach to solid pancreatic masses has significantly evolved from the era when a focal pancreatic mass was almost synonymous to pancreatic ductal adenocarcinoma, to a wide spectrum of pancreatic lesions, some of which have good prognosis. With the advent of advanced diagnostic tools, particularly refined imaging and tissue acquisition techniques, a broader spectrum of differential diagnoses has been recognized, encompassing conditions ranging from neuroendocrine tumors or inflammatory masses, to rare entities like metastatic clear cell sarcoma or solitary fibrous tumors. We herein discuss case reports of some rare pancreatic lesions, which were diagnosed by combining clinical and imaging features and endoscopic ultrasound-guided tissue sampling and confirmed on surgical specimens. Further reports on these rare pancreatic tumors will contribute to a better understanding of their pathogenesis and effective management.

Secondary Tumors of the Pancreas: A Multicenter Analysis of Clinicopathological and Endosonographic Features

Many tumors may secondarily involve the pancreas; however, only retrospective autopic and surgical series are available. We retrospectively collected data from all consecutive patients with histologically confirmed secondary tumors of the pancreas referred to five Italian centers between 2010 and 2021. We described clinical and pathological features, therapeutic approach and treatment outcomes. EUS characteristics of the lesions and the tissue acquisition procedures (needle, passages, histology) were recorded. A total of 116 patients (males/females 69/47; mean age 66.7) with 236 histologically confirmed pancreatic metastases were included; kidney was the most common primary site. EUS was performed to confirm the diagnosis in 205 lesions which presented as predominantly solitary (59), hypoechoic (95) and hypervascular (60), with a heterogeneous (n = 54) pattern and well-defined borders (n = 52). EUS-guided tissue acquisition was performed in 94 patients with an overall accuracy of 97.9%. Histological evaluation was possible in 88.3% of patients, obtaining final diagnosis in all cases. When cytology alone was performed, the final diagnosis was obtained in 83.3% of cases. A total of 67 patients underwent chemo/radiation therapy, and surgery was attempted in 45 (38.8%) patients. Pancreatic metastases are a possible event in the natural history of solid tumors, even long after the diagnosis of the primary site. EUS-guided fine needle biopsy may be suggested to implement the differential diagnosis.

Portomesenteric Reconstruction during Whipple Procedure Using Autologous Left Renal Vein Patch Graft in a Patient with a Gastric Cancer Recurrence

The case of vascular reconstruction of the superior mesenteric and portal vein confluence using a left renal vein (LRV) graft has been researched in this paper. The patient was a 66-year-old female who presented with features of biliary obstruction. A contrast-enhanced computed tomography scan revealed bile duct dilatation and a common bile duct tumor mass. Four years ago, she underwent stomach resection with subsequent Billroth II gastrojejunostomy due to gastric cancer. After surgical resection, on histopathological and immunohistochemistry examination, a recurrence of previously resected poorly cohesive gastric cancer was found.

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.

The role of resection for melanoma metastases to the pancreas

BACKGROUND

Among patients with distant metastatic melanoma, the site of metastases is the most significant predictor of survival and visceral-nonpulmonary metastases hold the highest risk of poor outcomes. However, studies demonstrate that a significant percentage of patients may be considered candidates for resection with improved survival over nonsurgical therapeutic modalities. We aimed at analyzing the results of resection in patients with melanoma metastasis to the pancreas by assessing the available evidence.

METHODS

The PubMed/MEDLINE, WoS, and Embase electronic databases were systematically searched for articles reporting on the surgical treatment of pancreatic metastases from melanoma. Relevant data from included studies were assessed and analyzed. Overall survival was the primary endpoint of interest. Surgical details and oncological outcomes were also appraised.

RESULTS

A total of 109 patients treated surgically for pancreatic metastases were included across 72 articles and considered for data extraction. Overall, patients had a mean age of 51.8 years at diagnosis of pancreatic disease. The cumulative survival was 71%, 38%, and 26% at 1, 3 and 5 years after pancreatectomy, with an estimated median survival of 24 months. Incomplete resection and concomitant extrapancreatic metastasis were the only factors which significantly affected survival. Patients in whom the pancreas was the only metastatic site who received curative resection exhibited significantly longer survival, with a 1-year, 3-year, and 5-year survival rates of 76%, 43%, and 41%, respectively.

CONCLUSION

Within the limitations of a review of non-randomized reports, curative surgical resection confers a survival benefit in carefully selected patients with pancreatic dissemination of melanoma.

Solitary pancreatic metastasis from squamous cell lung carcinoma: A case report and review of literature

BACKGROUND

Pancreatic metastases from squamous cell lung carcinoma (SCLC) are unusual. These lesions are often asymptomatic and detected incidentally or during follow-up investigations, occasionally several years after removal of the primary tumor.

CASE SUMMARY

A 56-year-old male with SCLC developed jaundice 1 mo after the cancer diagnosis. An abdominal computed tomography (CT) scan showed a mass in the pancreatic head with distention of both intra- and extrahepatic biliary ducts. Endoscopic retrograde cholangiopancreatography and sphincterotomy were performed first, culminating with plastic biliary stent placement. Cytological examination of the pancreatic mass sample collected by fine-needle aspiration (FNA) under endoscopic ultrasound (EUS) guidance revealed the presence of malignant cells compatible with well-differentiated squamous cell carcinoma. After liver function normalized, chemotherapy was initiated with carboplatin and paclitaxel; however, 4 d later, the patient presented dysphagia. Cervico-thoraco-abdominal CT showed tracheoesophageal fistula and stent migration. After replacement with a 10 cm/10 mm uncovered metallic biliary stent and treatment of the tracheoesophageal fistula with a fully covered esophageal stent, the patient was able to start oral feeding progressively. He died 9 mo after the initial diagnosis.

CONCLUSION

The diagnosis of pancreatic metastasis from SCLC is challenging for clinicians. EUS-FNA is the primary exam for confirmatory diagnosis.

Pancreatic resections for metastases: A twenty-year experience from a tertiary care center

BACKGROUND

Literature data about pancreatic resections for metastases are limited to small series, so that the role of surgery in this setting remains unclear. We herein report our experience from a tertiary care center, analyzing the outcomes of patients who underwent pancreatic resections for metastases and discussing the role of surgical resection in their management.

MATERIALS AND METHODS

From January 1999 to January 2019, 26 patients underwent pancreatic resections for metastases from renal cell carcinoma (RCC-group) or other primitive tumors (non-RCC-group). Details regarding pre-, intra-, post-operative course, and follow-up, prospectively collected in a database of pancreatic resection, were retrospectively analyzed and compared.

RESULTS

RCC-group was composed of 21 patients, non-RCC-group of 5 patients. RCC-group presented a longer disease-free interval: 96.4 vs. 5.4 months (p < 0.001). In 9/21 patients (42.9%) of RCC-group the surgical resection of other organs or vascular structures was performed, while in non-RCC-group pancreatic resection alone was performed in all cases, p = 0.070. No local recurrence was reported in all cases. The systemic recurrence rate was 42.9% (9/21 patients) in RCC-group and 80% (4/5 patients) in non-RCC-group, p = 0.135. RCC-group presented a longer DFS and OS: 107.5 vs. 25.2 months (p = 0.002), and 109.1 vs. 36.2 months (p = 0.016), respectively.

CONCLUSIONS

Radical pancreatic resection may confer a survival benefit for RCC metastases, while for other primitive tumors it should be applied more selectively. For RCC pancreatic metastases, an aggressive surgical approach, even in patient with locally advanced tumors, or associated extra-pancreatic localizations, or recurrent metastases should be taken in consideration.

Resection of pancreatic metastatic renal cell carcinoma: experience and long-term survival outcome from a large center in China

Purpose

This study aimed to determine the outcome of pancreatic metastatic renal cell carcinoma (PmRCC) after treatment and share the relevent results.

Methods

In total, 13 patients with PmRCC were diagnosed and treated in our institution from December 2013 to October 2017. We retrospectively reviewed the records and analyzed the patient demographics, perioperative outcomes, and overall survival. Simultaneously, our experience including treatment and misdiagnosis was shared.

Results

The median time between nephrectomy and reoperation for pancreatic recurrence was 11 years (range 1–20 years). Four patients had multiple tumors and nine patients had solitary tumor. Five patients accepted distal pancreatectomy, and five patients underwent pancreaticoduodenectomy. One patient underwent total pancreatectomy, one patient underwent duodenum-preserving pancreatic head resection plus distal pancreatectomy, and one patient underwent exploratory laparotomy and gastrointestinal bypass due to widespread metastasis with clear obstructive symptoms. The misdiagnosis rate of preoperative diagnosis at our center was 69.2% (9/13). The median follow-up duration was 26 months (range 7–53 months, until June 2018). By the end of follow-up, 12 patients were alive and one patient died of gastrointestinal bleeding within 1 month after surgery.

Conclusions

PmRCCs are uncommon, but pancreatic metastasectomy has a relatively good prognosis and may, therefore, be a good therapeutic choice for patients with PmRCCs. Because PmRCC occurs long after the primary tumor resection, long-term follow-up is necessary. Besides, detailed medical history and specific manifestation in imaging features could contribute to avoiding misdiagnosis.

Solitary pancreatic metastasis of extremity myxoid liposarcoma: a case report and literature review

BACKGROUND

Myxoid liposarcoma has a distinct migration aptitude; however, pancreatic metastasis is rare.

CASE PRESENTATION

We report on the case of a 40-year-old female patient who suffered solitary pancreatic metastasis of myxoid liposarcoma and had a right thigh myxoid liposarcoma radical resection 5 years ago. The patient underwent a medial pancreatectomy and pancreaticojejunostomy for solitary pancreatic metastasis of myxoid liposarcoma. After 12 months of disease-free survival, the patient underwent an extended radical resection for the recurrence of the right thigh primary myxoid liposarcoma and received postoperative radiotherapy. Currently, the disease-free survival time after the last operation has been 22 months.

CONCLUSIONS

We reviewed the relevant literature and suggest that radical surgery might result in a good prognosis for patients with solitary pancreatic metastasis of myxoid liposarcoma.

Solitary pancreatic head metastasis from tibial adamantinoma: a rare indication to pancreaticoduodenectomy

Pancreatic metastases are rare, <2% of all pancreatic neoplasia. This is the first case of pancreatic metastasis from adamantinoma, a rare, low grade and slow growing tumor which is frequently localized in long bones. We describe a case of a 45-year-old woman presenting with increased bilirubin level. Computed tomography and ecoendoscopic ultra sonography revealed a pancreatic head mass. Fine-needle aspiration biopsy was consistent with metastatic adamantinoma. The patient was submitted to a standard pancreaticoduodenectomy. As in the case presented, standard pancreatic resections are safe and feasible options to treat non-pancreatic primary tumor improving patient’s survival and quality of life.

Clinical diagnosis and detection of genetic mutations of pancreatic metastases: A report of four cases and review of the literature

The present study aimed to report our clinical experience regarding the diagnosis and detection of genetic mutations of pancreatic metastases, and to review the relevant literature to expand knowledge of this disease. A total of 4 cases involving pancreatic metastases, which were treated at The First Affiliated Hospital of Soochow University between January 2013 and July 2016, were retrospectively analyzed. This retrospective study considered the clinicopathological variables of the 4 patients, and compared this data with those from the literature, which was searched using PubMed, EMBASE and the Cochrane Library. All 4 patients with pancreatic metastases were diagnosed by computed tomography (CT) scan and confirmed by pathological staining and immunohistochemistry. Mutation analysis was performed in 3 patients to obtain precise mutation information for guiding and evaluating the use of molecularly targeted drugs. In summary, pancreatic metastases are rare and the majority of pancreatic metastases develop from renal cell carcinoma. Diagnoses of pancreatic metastases predominantly rely on CT, pathology and immunohistochemistry. Detection of mutations has clinical value in auxiliary diagnosis and therapy of pancreatic metastases. Based on mutation information, molecularly targeted drugs may prolong the survival of patients with unresectable pancreatic metastases.

Primary Leiomyosarcoma of the Pancreas-a Case Report and a Comprehensive Review

Purpose

Primary mesenchymal tumors of the pancreas are rare, with leiomyosarcomas the most encountered entities among the pancreatic sarcomas. With few exceptions, single case reports published over the last six decades constitute the entire scientific literature on this topic. Thus, evidence regarding clinical decision-making is scant.

Methods

Based on a case report and an extensive literature search in PubMed, we discuss the clinical aspects and current management of this rare malignancy.

Results

We identified only two papers with more than a single case presentation; these institutional patient series were limited to five and nine patients. Additionally, a few papers sought to summarize the individual case reports published in the English and/or Chinese language. The clinical presentation is rather non-specific. Moreover, modern imaging modalities are insufficiently accurate to diagnose leiomyosarcoma of the pancreas. Treatment goals include a complete resection with free margins. Proper morphologic examination using immunohistochemistry and the application of a grading system are clinically important for prognostication. The efficacy of adjuvant treatments has not been established.

Conclusion

Primary pancreatic leiomyosarcoma is extremely rare, and the scientific literature is primarily based on single case reports. Conclusions on management and prognosis should be drawn with caution. A multidisciplinary team consultation is warranted to discuss a thorough individual treatment plan based on the available scientific literature, despite its low evidence level.

Gastrointestinal bleeding due to pancreatic metastasis of non-small cell lung cancer: A report of two cases and a literature review

The current study presents two cases of gastrointestinal (GI) bleeding due to pancreatic metastasis of non-small cell lung cancer (NSCLC). The two patients had a history of lung adenocarcinoma prior to pancreatic metastasis. The first patient presented with melena, epigastric pain and weight loss, and the second patient presented with melena and weight loss. The diagnoses were confirmed by biopsy of the metastatic lesions. Immunohistochemistry is useful for managing the differential diagnosis between lung cancer and pancreatic carcinoma in patients with a history of lung cancer. Chemotherapy prolonged the survival of the second patient. However, the first patient received no chemotherapy and succumbed to NSCLC six weeks after the diagnosis of metastatic pancreatic cancer. GI bleeding as a result of pancreatic metastasis of NSCLC is extremely rare; including the present two cases, only three cases have been reported in the English literature. The current study is presented in order to increase the awareness of GI hemorrhage as a manifestation of this relatively rare condition.

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.

Gastrointestinal metastases from prostate cancer: a review of the literature

ABSTRACT 

The availability of active new drugs for the treatment of advanced castration-resistant prostate cancer has significantly prolonged overall survival, thus changing the natural history of the disease and raising the likelihood of observing metastases in atypical sites. This review of the literature describes the frequency, clinical-pathological features and presenting symptoms of non-liver gastrointestinal metastases (GIm) from prostate cancer. Its purpose is to increase clinical awareness of the increasing incidence of such GIm, contributing to the early detection, accurate diagnosis and, when feasible, appropriate management.

Results of surgical management of renal cell carcinoma metastatic to the pancreas

AIM OF THE STUDY

Metastases from renal cell carcinoma represent between 0.25% and 3.00% of all resected pancreatic tumours. The aim of this study was to review 13 patients with renal cell carcinoma metastatic to the pancreas.

MATERIAL AND METHODS

Clinical data, time from initial presentation, operative outcome, long-term survival, tumour size, presence of lymphatic invasion, and surgical margin status were evaluated.

RESULTS

The median age of the patients was 62 years (mean 60.9). The median time for appearance of metastatic disease following resection of the primary tumour was 9 years (mean 8.38). Pancreatic metastases were located in the head of the pancreas in four patients, in the body in three, in the tail in two patients, and four patients had multiple pancreatic localisations. Four (30.7%) pancreatoduodenectomies, 5 (38.5%) distal resections, 2 (15.3%) total pancreatectomies, 1 (7.6%) enucleation, and 1 (7.6%) Roux duodenojejunostomy were performed. Two patients (15.3%) had postoperative complications. Operative mortality was 0%. Surgical margins were microscopically positive in 1 (8.3%) patient, and lymph nodes were positive in 2 (16.6%) patients. In our group of 7 deceased patients the mean survival was 19 months (median 16 months).

CONCLUSIONS

Renal cell carcinoma metastatic to the pancreas can occur several years after nephrectomy. In our series a large number of patients with occurrence of symptoms, advancement of tumours, metastases to lymph node, and positive margin were connected with short survival period. Early detection of primary tumour, long and thorough patient care, and radical resections give patients a chance for a prolonged life.

Metastatic tumors to the pancreas: The role of surgery

Pancreatic metastases from other primary malignancies are a rare entity. By far, the most common primary cancer site resulting in an isolated pancreatic metastasis is the kidney, followed by colorectal cancer, melanoma, breast cancer, lung carcinoma and sarcoma. Only few data on the surgical outcome of pancreatic resections performed for metastases from other primary tumor have been published, and there are no guidelines to address the surgical treatment for these patients. In this study, we performed a review of the published literature, focusing on the early and long-term results of surgery for the most frequent primary tumors metastasizing to the pancreas. Results for the Literature’s analysis show that in last years an increasing number of surgical resections have been performed in selected patients with limited pancreatic disease. Pancreatic resection for metastatic disease can be performed with acceptable mortality and morbidity rates. The usefulness of pancreatic resection is mainly linked to the biology of the primary tumor metastasizing to the pancreas. The benefit of metastasectomy in terms of patient survival has been observed for metastases from renal cell cancer, while for other primary tumors, such as lung and breast cancers, the role of surgery is mainly palliative.

Resection of isolated renal cell carcinoma metastases of the pancreas: outcomes from the Johns Hopkins Hospital

PURPOSE

This study aims to assess outcomes and characteristics associated with resection of metastatic renal cell carcinoma (mRCC) to the pancreas.

MATERIALS AND METHODS

From April 1989 to July 2012, a total of 42 patients underwent resection of pancreatic mRCC at our institution. We retrospectively reviewed records from a prospectively managed database and analyzed patient demographics, comorbidities, perioperative outcomes, and overall survival. Cox proportional hazards models were used to evaluate the association between patient-specific factors and overall survival.

RESULTS

The mean time from resection of the primary tumor to reoperation for pancreatic mRCC was 11.2 years (range, 0-28.0 years). In total, 17 patients underwent pancreaticoduodenectomy, 16 underwent distal pancreatectomy, and 9 underwent total pancreatectomy. Perioperative complications occurred in 18 (42.9%) patients; there were two (4.8%) perioperative mortalities. After pancreatic resection, the median follow-up was 7.0 years (0.1-23.2 years), and median survival was 5.5 years (range, 0.4-21.9). The overall 5-year survival was 51.8%. On univariate analysis, vascular invasion (hazard ratio, 5.15; p = 0.005) was significantly associated with increased risk of death.

CONCLUSIONS

Pancreatic resection of mRCC can be safely achieved in the majority of cases and is associated with long-term survival. Specific pathological factors may predict which patients will benefit most from resection.

Pancreatic metastasis from renal cell carcinoma

BACKGROUND

Pancreatic metastases from renal cell carcinoma are uncommon.

METHODS

Retrospective study of 8 patients with a diagnosis of pancreatic metastasis from renal cell carcinoma observed in our Institute.

RESULTS

Patients were 6 (75%) males and 2 (25%) females. Mean age was 65.3 years. In 5 patients (57.1%), symptoms were present. The median interval of onset from nephrectomy was 10 years. No cases of synchronous pancreatic metastases were observed. Surgical resection was performed in 7 (87.5%) patients. At pathological examination, solitary metastases were identified in 5 patients (71.4%). No post-operative mortality was observed; the morbidity rate was 42.8%. In the group of patients who underwent pancreatic resection, median overall survival was 43.0 months (range 12.9-74.5), median disease-free survival was 23.6 months (range 9.9-74.5).

CONCLUSIONS

Pancreatic metastasis from renal cell carcinoma typically occurs after a long period from the initial nephrectomy, and seems to be related to a good prognosis.

Metastases to the pancreas: the experience of a high volume center and a review of the literature

BACKGROUND

Metastasis to the pancreas (PM) is uncommon. Several types of cancers were reported to metastasize to the pancreas. Surgery is advocated in selected patients when technically feasible and if the patient can be rendered disease free.

METHODS

A retrospective review of PM patients at the University of Cincinnati Pancreas Database was performed over a 7-year time period.

RESULTS

Twenty patients with a median age of 62.5 years were identified. Fifteen patients (75%) were males and (50%) presented with abdominal pain. Nine patients (45.0%) were offered surgical resection, distal pancreatectomy was the most common procedure (n = 4, 44.4%). The commonest pathology was RCC (60%), followed by lung (20%), colon (15%), and breast (5%). Median disease free interval (DFI) was 96 months for RCC, 7 months for other pathologies. Median survival was 19 months for RCC, 8.5 months for other pathologies. Based on DFI, short DFI patients (≤12 months) had worse prognosis (2-year survival of 40%), as opposed to (2-year survival of 80%) in longer DFI patients (P = 0.01). RCC patients with a DFI longer than 94 months had a better survival (P = 0.01). Survival of resected PM tended to be longer than non-resected PM (P = 0.11).

CONCLUSIONS

PM from RCC carries a consistently favorable prognosis compared to other pathologies. Surgical resection of PM is a safe and viable option, and, in selected patients, may improve survival. However, a period of expectant management in patients with short DFI may be considered.

Metastasis to the pancreas and the spleen: an increasing diagnostic and therapeutic challenge

We have reviewed the electronic biopsies database files of the Department of Surgical Pathology, Fundación Jiménez Díaz in Madrid (Spain). In this time period (1998–2010) we have found 3 pancreatic metastasis and 5 splenic metastasis. Two of the pancreatic metastases were originated in clear cell renal cell carcinomas. The last pancreatic metastasis was from a malignant cutaneous melanoma diagnosed and treated 8 years before. As for splenic metastasis, three of them were diagnosed during the abdominal surgery for primary therapy of the tumour (2 ovaries and one endometrium), while the remaining 2 corresponded to metastasis from a lung primary diagnosed 1 year before and a colonic primary diagnosed 6 years before. The patients with splenic metastasis died on the short term with progression of the disease despite resection of the splenic lesions, while the patients with pancreatic metastasis have survived longer.