Metastatic tumors to the pancreas: The role of surgery

The Role of Endoscopic Ultrasonography (EUS) in Metastatic Tumors in the Pancreas: 10 Years of Experience from a Single High-Volume Center

BACKGROUND

Metastatic pancreatic lesions (MPLs) are relatively uncommon, constituting 2 to 5% of all pancreatic tumors. They often manifest as solitary lesions without distinct clinical symptoms, usually identified incidentally during radiologic imaging for the surveillance of prior malignancies. Differentiating these lesions from primary pancreatic tumors presents a significant challenge due to their nonspecific presentation.

METHODS

We aimed to prospectively assess the effectiveness of endoscopic ultrasound (EUS) and EUS-guided fine needle aspiration/biopsy (EUS-FNA/B) in diagnosing MPLs in a carefully selected cohort of patients presenting with pancreatic masses. Additionally, we sought to examine the relevance of specific EUS findings in supporting the initial diagnosis of MPLs and their agreement with the definitive cytological diagnosis. This study retrospectively analyzed data from 41 patients diagnosed with MPLs between 2013 and 2023, focusing on their clinical and pathological characteristics, the echogenic features of the pancreatic lesions, and the techniques used for tissue acquisition.

RESULTS

The incidence of MPLs in our cohort was 3.53%, with the most frequent primary tumors originating in the kidney (43.90%), colorectum (9.76%), lung (9.76%), lymphoma (9.76%), and breast (4.88%). MPLs typically presented as hypoechoic, oval-shaped lesions with well-defined borders and were predominantly hypervascular. Interestingly, 68.29% of the cases were discovered incidentally during follow-up of the primary tumors, while the involvement of the common bile duct was uncommon (19.51%).

CONCLUSIONS

EUS and EUS-FNA/B have been validated as valuable diagnostic tools for identifying MPLs. While our findings are promising, further multicenter studies are necessary to corroborate these results and elucidate the predictive value of specific EUS characteristics in determining the metastatic origin of pancreatic lesions.

A case report of a prostate cancer metastasis in the pancreas exhibiting vascular encasement

We report a patient who presented with a 4-month history of intermittent epigastric pain. Computed tomography (CT) angiography of the abdomen demonstrated a stenotic celiac trunk but also encasement of the common proper hepatic artery, gastroduodenal artery, and proper hepatic artery by an ill-defined hypoattenuating mass of the pancreatic head. Biopsy confirmed metastatic prostate cancer to the pancreas that occurred 4 years after radiation and androgen deprivation therapy. A follow-up staging study demonstrated an osseous metastasis at the T4 spinous process. This case demonstrates an unusual case of prostate metastasis to the pancreas with the involvement of a main abdominal vessel. With treatment improvements leading to longer survival rates from prostate cancer, radiologists should be aware of atypical metastases that may arise in the long term.

Pancreatic resection for metastasis from renal cell carcinoma: A single institution experience and meta-analysis of survival outcomes

AIMS

To evaluate short-term clinical and long-term survival outcomes of pancreatic resection for pancreatic metastasis from renal cell carcinoma (RCC).

METHODS

A retrospective evaluation of patients undergoing pancreatic resection for metastasis from RCC over a 12-years period was conducted. Furthermore, a systematic search of electronic data sources and bibliographic reference lists were conducted to identify studies investigating the same clinical question. Short-term clinical and long-term survival outcomes were evaluated. Kaplan-Meier survival plots were constructed for survival outcomes. Cox-proportional regression analysis was performed to determine factors associated with survival. Finally, meta-analysis of survival outcomes was conducted using random-effects modelling.

RESULTS

Eighteen patients underwent pancreatic resections for RCC pancreatic metastasis within the study period. The mean age of the included patients was 63.8 ± 8.0 years. There were 10(55.6 %) male and 8(44.4 %) female patients. Pancreatectomy was associated with 4(25.0 %) Clavien-Dindo (C-D) I, 5(31.3 %) C-D II, and 7(43.7 %) C-D III complications, 7(38.8 %) pancreatic fistula, 3(16.7 %) post-pancreatectomy acute pancreatitis, 1(5.6 %) delayed gastric emptying, and 1(5.6 %) chyle leak. The mean length of hospital stay was 18 ± 16.3 days. The median survival was 64 months (95 % CI 60-78). The 3-and 5-year disease-free survival rates were 83.3 % and 55.5 %, respectively. The 3-and 5-year survival rates were 100 % and 55.6 %, respectively. The pooled analyses of 553 patients demonstrated 3-and 5-year survival rates of 77.6 % and 60.7 %, respectively.

CONCLUSIONS

Pancreatectomy for RCC metastasis is associated with acceptable short-term clinical and promising long-term survival outcomes. Considering the rarity of the entity, escalation of level of evidence in this context is challenging.

A Late Recurrent Metastatic Breast Cancer Mimicking Primary Pancreatic Cancer: Case Report

Metastasis to the pancreas from malignant tumors is a rare event, representing only 1% to 2% of all pancreatic neoplasms. They occur in 2 different clinicopathological settings: as a manifestation in widespread metastatic disease or as an isolated mass in the pancreas. We report the case of a 41-year-old woman who had a history of invasive lobular breast cancer treated with radical surgery, chemotherapy, and radiotherapy. After 21 years of total remission, she presented for severe lower back pain with jaundice, nausea, and loss of 9 kg in 3 months. Abdominal computed tomography demonstrated a hyper vascularized, irregular solid lesion of 2.6 cm × 2.1 cm in the head of the pancreas with discreet biliary duct dilatation and coelio-mesenteric enlarged lymph nodes measuring 2 cm. The diagnosis of pancreatic metastasis from a lobular breast carcinoma was made by percutaneous biopsy of pancreatic lesion. The multidisciplinary committee decided a palliative treatment. The patient received chemotherapy. The take home message from his case is that we should keep in mind the hypothesis of a solitary metastasis to the pancreas, when the pancreatic lesion develops in a patient who had a clinical history of previous neoplasm especially in those which is known to potentially metastasize to pancreas.

Solitary Pancreatic Metastasis from an Ovarian Carcinoma: A Diagnostic Perplexity

Ovarian cancer presenting as an isolated pancreatic metastasis after years of treatment is extremely rare. Most such patients are easily misdiagnosed as a case of primary pancreatic cancer. We herein describe a unique case of posttreatment high-grade serous papillary ovarian carcinoma metastasizing to the pancreas that mimicked primary pancreatic cancer and caused a diagnostic dilemma. The approach to such a case, pathogenesis, differential diagnosis, management, and a brief literature review is also presented.

Comments on and Illustrations of the EFSUMB CEUS Guidelines: Transabdominal and Endoscopic Ultrasound Features of Intrapancreatic Metastases and the Role of Multiparametric Imaging and EUS-Guided Sampling in Rare Pancreatic Tumors

A definite pathologic diagnosis of intrapancreatic metastasis is crucial for the management decision, i.e., curative or palliative surgery versus chemotherapy or conservative/palliative therapy. This review focuses on the appearance of intrapancreatic metastases on native and contrast-enhanced transabdominal ultrasound and endoscopic ultrasound. Differences and similarities in relation to the primary tumor, and the differential diagnosis from pancreatic carcinoma and neuroendocrine neoplasms are described. The frequency of intrapancreatic metastases in autopsy studies and surgical resection studies will be discussed. Further emphasis is placed on endoscopic ultrasound-guided sampling to confirm the diagnosis.

Metastatic Renal Cell Carcinoma to Pancreas: Case Series and Review of the Literature

Metastasis to the pancreas represents a small proportion of all pancreatic malignancies. Among primary tumors that metastasize to the pancreas, renal cell carcinoma (RCC) is one of the most common causes of metastatic pancreatic lesions. We herein report a case series of three patients with pancreatic metastasis from RCC. The first is a 54-year-old male with a history of left nephrectomy for RCC, in whom an isthmic pancreatic mass suggestive of a neuroendocrine lesion was found during oncological follow-up. Endoscopic ultrasound (EUS)-guided fine needle biopsy (FNB) identified pancreatic metastasis of RCC and the patient was referred for surgery. The second case is a 61-year-old male, hypertensive, diabetic, with left nephrectomy for RCC six years previously, who complained of weight loss and was found with a hyperenhancing mass in the head of the pancreas and a lesion with a similar pattern in the gallbladder. EUS-FNB from the pancreas proved to be a metastatic pancreatic lesion. Cholecystectomy and treatment with tyrosine kinase inhibitors were recommended. The third case is a 68-year-old dialysis patient referred for evaluation of a pancreatic mass, also confirmed by EUS-FNB, who was started on sunitinib treatment. We report a literature summary on epidemiology and clinical features, diagnosis and differential diagnosis and treatment and outcomes in pancreatic metastasis of RCC.

Metastatic Renal Cell Carcinoma to Pancreas: Case Series and Review of the Literature

Metastasis to the pancreas represents a small proportion of all pancreatic malignancies. Among primary tumors that metastasize to the pancreas, renal cell carcinoma (RCC) is one of the most common causes of metastatic pancreatic lesions. We herein report a case series of three patients with pancreatic metastasis from RCC. The first is a 54-year-old male with a history of left nephrectomy for RCC, in whom an isthmic pancreatic mass suggestive of a neuroendocrine lesion was found during oncological follow-up. Endoscopic ultrasound (EUS)-guided fine needle biopsy (FNB) identified pancreatic metastasis of RCC and the patient was referred for surgery. The second case is a 61-year-old male, hypertensive, diabetic, with left nephrectomy for RCC six years previously, who complained of weight loss and was found with a hyperenhancing mass in the head of the pancreas and a lesion with a similar pattern in the gallbladder. EUS-FNB from the pancreas proved to be a metastatic pancreatic lesion. Cholecystectomy and treatment with tyrosine kinase inhibitors were recommended. The third case is a 68-year-old dialysis patient referred for evaluation of a pancreatic mass, also confirmed by EUS-FNB, who was started on sunitinib treatment. We report a literature summary on epidemiology and clinical features, diagnosis and differential diagnosis and treatment and outcomes in pancreatic metastasis of RCC.

Survival impact of pancreatic resection for metastases in the pancreas: A retrospective multi-center study

BACKGROUND

Pancreatic metastases from other primary malignancies are rare. There is no clear evidence for a treatment strategy for this condition. The purpose of this study was to assess the clinical outcomes, including prognostic factors for pancreatic resection of metastatic tumors in the pancreas, through a retrospective review.

METHODS

Data of 35 patients who underwent pancreatic resection for pancreatic metastasis between 2005 and 2020 in eight Japanese institutions were included in this study. Survival analyses were performed using the Kaplan-Meier method, and comparisons were made using the Cox proportional hazards model.

RESULTS

The median follow-up period was 35 months (range, 5-102 months). Median duration from resection for primary tumor to resection for metastatic pancreatic tumor was 10.6 years (range, 0.6-29.2 years). The 3- and 5-year survival rates after resection for metastatic tumors in the pancreas were 89% and 69%, respectively. In contrast, the 3- and 5-year disease-free survival rates after resection for metastatic tumors in the pancreas were 48% and 21%, respectively. Performance status ≥1 at the time of resection for metastatic tumors in the pancreas (HR: 7.56, p = 0.036) and pancreatic metastasis tumor diameter >42 mm (HR: 6.39, p = 0.02) were significant poor prognostic factors only in the overall survival.

CONCLUSIONS

The prognosis of pancreatic resection for metastatic tumors in the pancreas is relatively good for selected patients. However, because it is prone to recurrence after radical surgery, it should only be considered in patients with good PS.

Early progression of a pancreatic metastasis of synovial sarcoma after pancreatectomy

BACKGROUND

Synovial sarcoma is a malignant tumor that constitutes up to 10% of all soft-tissue sarcomas. The most frequent metastatic sites of synovial sarcoma are the lungs, lymph nodes, and bone, whereas pancreatic metastasis is extremely rare. Here, we report a case of pancreatic metastasis of synovial sarcoma.

CASE PRESENTATION

Nine years before presentation, a 31-year-old woman underwent extensive resection of the primary tumor after chemotherapy for left upper extremity synovial sarcoma. Six months before presentation, interscapulothoracic amputation was performed for an enlarged mass in the left upper extremity; the patient was treated with pazopanib. Three months before presentation, chest computed tomography showed multiple lung metastases; during subsequent follow-up, abdominal computed tomography revealed a pancreatic metastasis of synovial sarcoma. The doubling time of the pancreatic tumor was 14 days, and it grew rapidly. Furthermore, treatment-resistant pancreatitis symptoms were detected; thus, we performed distal pancreatectomy and administered one course of a 70% dose of trabectedin. However, the patient died of rapid progression of lung metastasis and respiratory failure within 2 months after surgery.

CONCLUSIONS

Pancreatectomy may be carefully performed in cases of isolated pancreatic metastasis. However, the presence of other distant extrapancreatic metastases (e.g., uncontrolled lung metastases) may rule out pancreatectomy treatment.

A nomogram diagnostic prediction model of pancreatic metastases of small cell lung carcinoma based on clinical characteristics, radiological features and biomarkers

Objective

To investigate clinical characteristics, radiological features and biomarkers of pancreatic metastases of small cell lung carcinoma (PM-SCLC), and establish a convenient nomogram diagnostic predictive model to differentiate PM-SCLC from pancreatic ductal adenocarcinomas (PDAC) preoperatively.

Methods

A total of 299 patients with meeting the criteria (PM-SCLC n=93; PDAC n=206) from January 2016 to March 2022 were retrospectively analyzed, including 249 patients from hospital 1 (training/internal validation cohort) and 50 patients from hospital 2 (external validation cohort). We searched for meaningful clinical characteristics, radiological features and biomarkers and determined the predictors through multivariable logistic regression analysis. Three models: clinical model, CT imaging model, and combined model, were developed for the diagnosis and prediction of PM-SCLC. Nomogram was constructed based on independent predictors. The receiver operating curve was undertaken to estimate the discrimination.

Results

Six independent predictors for PM-SCLC diagnosis in multivariate logistic regression analysis, including clinical symptoms, CA199, tumor size, parenchymal atrophy, vascular involvement and enhancement type. The nomogram diagnostic predictive model based on these six independent predictors showed the best performance, achieved the AUCs of the training cohort (n = 174), internal validation cohort (n = 75) and external validation cohort (n = 50) were 0.950 (95%CI, 0.917-0.976), 0.928 (95%CI, 0.873-0.971) and 0.976 (95%CI, 0.944-1.00) respectively. The model achieved 94.50% sensitivity, 83.20% specificity, 86.80% accuracy in the training cohort and 100.00% sensitivity, 80.40% specificity, 86.70% accuracy in the internal validation cohort and 100.00% sensitivity, 88.90% specificity, 87.50% accuracy in the external validation cohort.

Conclusion

We proposed a noninvasive and convenient nomogram diagnostic predictive model based on clinical characteristics, radiological features and biomarkers to preoperatively differentiate PM-SCLC from PDAC.

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.

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.

Synchronous or metachronous presentation of pancreatic neuroendocrine tumor versus secondary lesion to pancreas in patients affected by renal cell carcinoma. Systematic review

The simultaneous or metachronous occurrence of pancreatic neuroendocrine tumor (panNET) and renal cell carcinoma (RCC) may represent a rare coincidence or a manifestation of von Hippel-Lindau disease (VHL). These two malignancies share both radiological and cytopathological features, making the differential diagnosis very challenging. In this review, we collected all cases of concurrent diagnosis of localized panNET and RCC, with or without VHL, as reported in the literature to date. We aimed to provide an insight into the differential diagnosis between panNET and RCC pancreatic metastasis with a focus on the optimal therapeutic algorithm depending on the diagnosis. We performed literature research in PubMed library databases for articles about coexisting panNET and RCC published from 2001 to 2018. We selected nine articles with a total of 13 patients, including one treated at our institution. Patients' median age was 49 years and eight out of 13 patients were women. VHL was diagnosed in nine cases. Most patients underwent radical nephrectomy for RCC (9/13) and a clear cell renal carcinoma variant was identified in six cases. The diagnosis of panNET was synchronous with RCC detection in nine cases and metachronous in four cases. The diameter of the pancreatic lesion was >2 cm in six cases. In two cases the panNET was misdiagnosed as metastatic RCC by radiological tests. Somatostatin receptor scanning was performed only in our patient (Octreoscan) showing intense uptake in the pancreatic mass. Endoscopic ultrasound fine needle aspiration of the pancreatic lesion was performed in four patients: in two cases the panNET was confused with metastatic RCC by cytological analysis. Most patients underwent pancreatic surgery (10/13) without histological confirmation. Clear cell panNET was recognized in six cases, while mixed neuroendocrine non-neuroendocrine neoplasm was diagnosed in one patient. Immunohistochemistry (IHC) staining showed positivity to typical neuroendocrine markers (chromogranin A and synaptophysin) in all reported tested cases (8/8). Three patients underwent systemic treatment: two patients received sunitinib and one patient interleukin-2 (IL-2). Other neoplasms were observed in seven patients, of whom six were affected by VHL syndrome. When neoplastic lesions are recognized in both the kidney and pancreas, panNET and RCC pancreatic metastasis are often misdiagnosed due to similar radiological and cytopathological features. An accurate differential diagnosis is crucial and IHC plays a central role in distinguishing the two entities. The therapeutic algorithm may change depending on the diagnosis: while pancreatic RCC metastases benefit from resection, in panNETs and VHL the indication for surgery must be carefully evaluated.

Early Application of Next-Generation Sequencing Identifies Pancreatic Mass as Metastasis From an EGFR-Mutated Lung Adenocarcinoma

Pancreatic metastasis of primary lung adenocarcinoma is a rare occurrence, accounting for <0.3% of all pancreatic malignancies. Given that the prognosis and treatment options for primary pancreatic cancer differ greatly from pancreatic metastases from a primary site, an accurate diagnosis is critical. This report presents a unique case of a 65-year-old man who was admitted with significant unintentional weight loss, fatigue, abdominal pain, and jaundice, and found to have a pancreatic mass initially thought to be primary pancreatic adenocarcinoma and subsequently diagnosed as an EGFR-mutated lung adenocarcinoma with metastases to the pancreas via early application of next-generation sequencing (NGS). The use of NGS early in the patient's clinical course not only changed the treatment strategy but also drastically altered the prognosis. Although metastatic pancreatic adenocarcinoma has a poor prognosis and survival rate, treatment of EGFR-mutated non-small cell lung cancer with EGFR tyrosine kinase inhibitors is associated with high response rates. Importantly, our case demonstrates that timely application of NGS very early in the disease course is paramount to the diagnosis, management, and prognosis of solid malignancies.

A Rare Case of Single Gallbladder and Multiple Pancreatic Metastases of Renal Cell Carcinoma

Renal cell carcinoma (RCC) is the most common tumor to metastasize to uncommon sites. Synchronous metastases in the gall bladder and pancreas are rare entities. In this report, we present the case of a 43-year-old male with a complaint of hematuria presenting with a left renal mass. Contrast-enhanced CT revealed an arterially enhancing mass in the left kidney, a synchronous tiny polyp in the gall bladder, and multiple focal lesions in the pancreas. The patient underwent surgery and the tumor was histopathologically labeled as a clear cell RCC with metastases to the pancreas and gall bladder. Post-surgery, the patient has been followed up.

Literature review of imaging, pathological diagnosis, and outcomes of metachronous lung and pancreatic metastasis of cecal cancer

Background

Pancreatic metastasis from colorectal cancer is extremely rare. Here, we report a case of colorectal cancer with lung and pancreatic metastasis and analyze the histopathology, immunohistochemistry, and next-generation sequencing (NGS) to generate a differential diagnosis and treatment of metastatic colon cancer.

Case presentation

AC1

A 78-year-old man was admitted because of a recently elevated carcinoembryonic antigen. This patient had undergone laparoscopic right hemicolectomy for cecal cancer IIA (T3N0M0) 5 years before admission, and thoracoscopic left upper lung wedge resection for primary colon cancer lung metastasis 2 years before admission. At that time, the patient was thought to have pancreatic metastasis from colon cancer. He underwent laparoscopic distal pancreatectomy (combined with splenectomy). Postoperative pathology revealed colon cancer metastasis. We performed NGS on tumor samples at three loci and found colon cancer's most common oncogenic driver genes (KRAS, APC, and TP53). One month after surgery, the patient was given capecitabine for six cycles of chemotherapy. At present, no high adverse reactions have been reported.

Discussion

For patients with pancreatic space-occupying, such as a previous history of colorectal cancer, and recent carcinoembryonic antigen elevation, we should highly suspect pancreatic metastatic colorectal cancer. NGS is an essential auxiliary for identifying metastatic tumors. Surgery combined with postoperative chemotherapy is an effective treatment.

Misdiagnosis of pancreatic metastasis from renal cell carcinoma: A case report

BACKGROUND

Pancreatic metastases account for only a small proportion of all pancreatic malignancies. Isolated pancreatic metastasis from renal cell cancer (isPM-RCC) is extremely rare and may be difficult to differentiate from more common primary neoplasms. A history of nephrectomy is crucial for the diagnosis.

CASE SUMMARY

We report the case of a 64-year-old Asian man who was diagnosed with a mass in the pancreatic head using computed tomography. He had no related symptoms, and his medical history was unremarkable, except for unilateral nephrectomy performed to remove a “benign” tumor 19 years ago. All preoperative imaging findings suggested a diagnosis of pancreatic neuroendocrine tumor. However, ultrasound-guided biopsy revealed features of clear cell renal cell carcinoma (ccRCC). Re-examination of the specimen resected 19 years ago confirmed that he had a ccRCC. The pancreatic mass was resected and pathological examination confirmed isPM-RCC.

CONCLUSION

Misdiagnosis of isPM-RCC is common because of its rarity and the long interval from resection of the primary tumor and manifestation of the metastasis. The history of the previous surgery may be the only clue.

Pancreatic metastases after surgery for renal cell carcinoma: survival and pathways of progression

PURPOSE

Metastatic ccRCC has peculiar tropism in the pancreas. We describe the characteristics and pathways of progression of patients with PM in a large multi-institutional consortium and compare them to patients with metastases from ccRCC at other sites.

METHODS

Detailed clinical and histopathological data were collected. To account for differences in baseline characteristics between the two groups, IPTW was used to compare the two groups in terms of PFS and OS.

RESULTS

Of the 182 patients, 33 (18%) had pancreatic, 94 (52%) pulmonary, 30 (16%) bone, 13 (7%) hepatic, and 12 (7%) brain metastases. Patients with PM had less aggressive ccRCC at baseline compared to those with progression at other sites in terms of tumour stage and grade. Median time from ccRCC surgery to PM was 8 (95%CI 5-10) vs. 1 year (95%CI 1-2) for progression to other sites (p < 0.001). Median IPTW-weighted time to second progression was 4.3 years (95%CI 2.4-not reached) for patients with PM vs 1.1 year (95%CI 0.8-2.3) for those with progression in other sites (p < 0.001). The most frequent second progression sites were pancreas (24%) and liver (15%) in patients with PM, while progression to the pancreas was rare (4%) in those with a different first progression site. Surgery alone (55%) or in combination with medical therapy (30%) was more frequent in the PM group than in other sites (p < 0.001). Median IPTW-OS time was longer for patients with PM [8.8 years (95%CI 6.5-not reached)] compared to those with first progression in other sites [2.8 years (95%CI 1.9-4.3), p < 0.001].

CONCLUSION

Pancreatic tropism is typical of ccRCC tumours with more indolent behaviour than those progressing to other sites. A long follow-up period is necessary to distinguish PM from ccRCC.

MRI-guided Radiotherapy (MRgRT) for treatment of Oligometastases: Review of clinical applications and challenges

PURPOSE

Early clinical results on the application of magnetic resonance imaging (MRI) coupled with a linear accelerator to deliver MR-guided radiation therapy (MRgRT) have demonstrated feasibility for safe delivery of stereotactic body radiotherapy (SBRT) in treatment of oligometastatic disease. Here we set out to review the clinical evidence and challenges associated with MRgRT in this setting.

METHODS AND MATERIALS

We performed a systematic review of the literature pertaining to clinical experiences and trials on the use of MRgRT primarily for the treatment of oligometastatic cancers. We reviewed the opportunities and challenges associated with the use of MRgRT.

RESULTS

Benefits of MRgRT pertaining to superior soft-tissue contrast, real-time imaging and gating, and online adaptive radiotherapy facilitate safe and effective dose escalation to oligometastatic tumors while simultaneously sparing surrounding healthy tissues. Challenges concerning further need for clinical evidence and technical considerations related to planning, delivery, quality assurance (QA) of hypofractionated doses, and safety in the MRI environment must be considered.

CONCLUSIONS

The promising early indications of safety and effectiveness of MRgRT for SBRT-based treatment of oligometastatic disease in multiple treatment locations should lead to further clinical evidence to demonstrate the benefit of this technology.

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.

Malignant biliary obstruction due to metastatic non-hepato-pancreato-biliary cancer

Malignant biliary obstruction generally results from primary malignancies of the pancreatic head, bile duct, gallbladder, liver, and ampulla of Vater. Metastatic lesions from other primaries to these organs or nearby lymph nodes are rarer causes of biliary obstruction. The most common primaries include renal cancer, lung cancer, gastric cancer, colorectal cancer, breast cancer, lymphoma, and melanoma. They may be difficult to differentiate from primary hepato-pancreato-biliary cancer based on imaging studies, or even on biopsy. There is also no consensus on the optimal method of treatment, including the feasibility and effectiveness of endoscopic intervention or surgery. A thorough review of the literature on pancreato-biliary metastases and malignant biliary obstruction due to metastatic non-hepato-pancreato-biliary cancer is presented. The diagnostic modality and clinical characteristics may differ significantly depending on the type of primary cancer. Different primaries also cause malignant biliary obstruction in different ways, including direct invasion, pancreatic or biliary metastasis, hilar lymph node metastasis, liver metastasis, and peritoneal carcinomatosis. Metastasectomy may hold promise for some types of pancreato-biliary metastases. This review aims to elucidate the current knowledge in this area, which has received sparse attention in the past. The aging population, advances in diagnostic imaging, and improved treatment options may lead to an increase in these rare occurrences going forward.

Metastatic tumors to the pancreas, a 12-year single institution review

BACKGROUND

Tumors of the pancreas are often primary in nature, but are occasionally proven to be secondary. We report a 12-year review of all pancreatic tumors shown to be metastatic at the University of Colorado.

METHOD

The electronic pathology database was searched between 2008 and 2020, for all pancreatic fine-needle aspiration cases at the University of Colorado to identify and review metastatic tumors to the pancreas. Additional data points to include age, sex, radiographic features, and clinical management were analyzed.

RESULTS

Our data retrieval identified 39 metastatic tumors to the pancreas comprised of 12 (31%) renal cell carcinomas, 6 (15%) lung carcinomas, and 5 (13%) melanomas with the remainder of tumors originating from a variety of other sites. The most common location of these metastases within the pancreas was the pancreatic head (49%) followed by the body (20%). Eighty-five percentage of cases presented with a single radiographically identified mass.

CONCLUSION

While the majority of pancreatic tumors represent primary processes, metastatic tumors to the pancreas represent a possible pitfall. The most common tumors to metastasize to the pancreas in this series were renal cell carcinoma, lung carcinoma, and melanoma. General awareness of the most frequent tumors to metastasize to the pancreas is practical when faced with a pancreatic lesion that could represent a metastasis, or in the absence of clinical history.

Endoscopic Ultrasound-Guided Radiofrequency Ablation as an Future Alternative to Pancreatectomy for Pancreatic Metastases from Renal Cell Carcinoma: A Prospective Study

Simple Summary

Glandular metastases and more precisely pancreatic metastases (PM) from renal cell carcinoma (mRCC) are associated with a long survival. Focal treatment in order to control oligo-metastatic disease and avoid systemic therapy is a standard in RCC. However, pancreatic radiofrequency ablation remains a marginal and under evaluated technic. Standard treatment remains pancreatectomy with hazardous outcomes. We report here the largest series of endoscopic radiofrequency ablation (EUS-RFA) on PM for patient treated at Institut Paoli-Calmettes for a mRCC. Patients with progressive PM was treated under general anesthesia with an ultrasound guided endoscopic radiofrequency ablation procedure then followed by CT-scan. We prospectively included 12 patients, median age was 70.5 years old and median size and number of PM at inclusion was 17 mm and 1 respectively. All 26 procedures performed went as planned and no immediate complications were experienced. After 27.7 months of follow-up, the 6- and 12-month focal control rates were 84% and 73% respectively. Two severe complications occurred after EUS-RFA but were totally resolved after specific treatment. In total, EUS-RFA is feasible and displayed an excellent focal control and should be integrated in the arsenal to treat PM from mRCC in order to spare systemic therapy and/or pancreatic surgery.

Abstract

Background: Pancreatic metastases (PM) from renal cell carcinoma (RCC) are rare, are associated with favorable outcomes and are usually handled by surgery or VEGFR inhibitors, which both have side effects. Endoscopic Ultrasound (EUS)-guided radiofrequency ablation (RFA) is an innovative approach to treat focally deep metastases and could be a relevant technique to control PM from RCC. Methods: This monocentric, prospective study aimed to evaluate the safety and efficacy of EUS-RFA to treat PM. We included patients with confirmed and progressive PM from RCC. PM was ablated under general anesthesia with a linear EUS scope and a EUS-RFA 19-gauge needle electrode placed into the tumor. Results: Twelve patients from Paoli-Calmettes Institute were recruited between May 2017 and December 2019. Median age was 70.5 years (range 61–75), 50% were female, 100% were ECOG 0–1. At inclusion, mean PM size was 17 mm (range 3–35 mm); and all were progressive before EUS-RFA. Seven patients had EUS-RFA as the only treatment for RCC. We performed 26 EUS-RFA procedures and 21 PM was ablated. Median follow up was 27.7 months (range 6.4–57.1). For evaluable PM, the 6- and 12-month focal control rates were 84% and 73% respectively. One patient treated with TKI developed a paraduodenal abscess 2 months after EUS-RFA and another patient with biliary stent developed hepatic abscesses few days after EUS-RFA. No other severe side effects were experienced. Conclusions: in this series, which is the largest ever reported, we showed that EUS-RFA is feasible and yields an excellent local control rate for PM from mRCC. With manageable complications, it could be a valuable alternative to pancreatic surgery in well-selected patients.

A case of hemobilia caused by pancreatic metastasis of renal cell carcinoma treated with a covered metallic stent

We present the case of an 86-year-old man who had undergone left nephrectomy for renal cell carcinoma (clear cell carcinoma) 22 years ago. He visited the emergency department complaining of right hypochondrial pain and fever. He was eventually diagnosed with acute cholangitis. Abdominal contrast-enhanced computed tomography showed multiple tumors in the pancreas. The tumor in the pancreatic head obstructed the distal bile duct. Endoscopic retrograde cholangiopancreatography detected bloody bile juice flowing from the papilla of Vater. Therefore, he was diagnosed with hemobilia. Cholangiography showed extrinsic compression of the distal bile duct; a 6 Fr endoscopic nasobiliary drainage tube was placed. Endoscopic ultrasound showed that the pancreas contained multiple well-defined hypoechoic masses. Endoscopic ultrasound-guided fine-needle aspiration was performed using a 22 G needle. Pathological examination revealed clear cell carcinoma, and the final diagnosis was pancreatic metastasis of renal cell carcinoma (RCC) causing hemobilia. A partially covered metallic stent was placed in the distal bile duct. Consequently, hemobilia and cholangitis were resolved.

Renal cell carcinoma with unusual metachronous metastasis up to 22 years after nephrectomy: two case reports

Introduction

Renal cell carcinoma is the third most common malignant tumor in the urogenital tract. An estimated 25% of renal cell carcinomas are in stage IV when diagnosed. The 5-year-survival with stage IV is about 20%. Late metastases are found after an extended disease-free interval up to 20 years after primary nephrectomy.

Case presentation

Here, we present two cases with late-onset metastasis of renal cell carcinoma with different clinical presentations. The first patient, an 88-year-old Caucasian man, presented with bleeding of the upper gastrointestinal tract. Biopsies taken from the duodenal bulb showed a tumor compatible with a solitary metastasis from renal cell carcinoma 22 years ago. The second patient, a 79-year-old Caucasian man, consulted our gastroenterological department with results of an outpatient computed tomography scan with multiple suspected tumor areas in the liver, omentum, thyroid, and mediastinum. A computed tomography-guided liver biopsy was performed that showed a clear-cell tumor consistent with a metastasis of the renal cell carcinoma 17 years ago.

Conclusion

Both cases show that patients with a history of renal cell carcinoma should be followed up for a longer time than patients with other malignant tumors.

Differentiation between pancreatic metastases from renal cell carcinoma and pancreatic neuroendocrine neoplasm using endoscopic ultrasound

OBJECTIVES

Pancreatic metastases from renal cell carcinoma (PRCC) often appear many years after treatment of the primary tumor, and differentiation from pancreatic neuroendocrine neoplasm (PanNEN) can be challenging due to their hypervascularity. Here, we investigated the utility of endoscopic ultrasound (EUS) for differentiation of these conditions.

METHODS

A retrospective analysis was performed in 17 and 79 consecutive patients with pathologically proven PRCC and non-functional PanNEN who were examined by EUS. In cases examined by EUS elastography or contrast-enhanced harmonic EUS (CH-EUS), the lesions were classified as stiff or soft, or into three vascular patterns as hypoechoic, isoechoic, and hyperechoic. CH-EUS images at 20 s, 40 s, 60 s, 3 min and 5 min were used for evaluation. EUS images were independently reviewed by two readers who were blinded to all clinical information.

RESULTS

The patients with PRCC were significantly older than those with PanNEN (median, 71 (range, 45-81) vs. 58 (22-76), P = 0.001) and more often had multiple tumors (6/17 (35%) vs. 7/79 (9%), P = 0.010). In EUS findings, PRCC lesions significantly more frequently had a marginal hypoechoic zone (MHZ) (11/17 (65%) vs. 27/79 (34%), P = 0.028), being classified as soft (12/13 (92%) vs. 26/58 (45%), P = 0.002), and showed sustained hyperechoic vascular patterns at 5 min (7/8 (88%) vs. 4/59 (7%), P < 0.001) compared to PanNEN lesions.

CONCLUSIONS

The presence of a MHZ, a soft lesion, and a sustained hyperechoic vascular pattern in EUS may be useful for differentiating PRCC from PanNEN.

Practice patterns about the role of palliation in veterinary surgical oncology

Whether surgical palliative therapy is appropriate for oncologic veterinary patients is an increasing concern as pet age increases because of improved care. In this study, an online survey (available for 30 days), comprising 100 questions with structured response options, was administered to 492 diplomates of the European College of Veterinary Surgeons (ECVS). The survey queried the technical, ethical, social, medical, and financial aspects of surgical palliative therapy for oncologic veterinary patients. Responses were received from 155 ECVS diplomates (31.5%, n = 155/492). Palliative surgery was a relatively common intervention in veterinary oncology, with 50% of respondents (n = 77.5/155) indicating that 75%-100% of oncological surgeries performed were palliative. The presence of metastasis was judged as a key determinant when deciding to perform palliative oncological surgery by 41% of the respondents (n = 63.5/155). The survey revealed that the most commonly performed procedures in palliative oncological surgery were marginal resection, debulking, and amputation. In contrast to human medicine, palliative limb-sparing surgery, stent placement, and embolization were rarely used in veterinary settings, mainly because of a general lack of expertise among veterinarians, elevated costs, and recourse to euthanasia. Taken together, the survey results highlight the need for appropriate guidelines in the field of oncological surgery. To establish general guidelines and direct veterinarians towards the most appropriate judgement, understanding how and what veterinary surgeons manage palliative oncological surgery and how they perceive the main ethical, social, medical, and financial concerns are essential. Such guidelines will lead to better care for ailing animals and will facilitate the path to healing for owners.

Metachronous pulmonary and pancreatic metastases arising from sigmoid colon cancer: A case report

BACKGROUND

Metachronous pulmonary and pancreatic metastases from colorectal cancer are rare. The diagnosis of pancreatic metastases is difficult and predominantly relies on computed tomography, pathology and immunohistochemistry. Here, we describe the use of next-generation sequencing (NGS) for determination of the origin of metastasis and prognostic prediction of colorectal cancer.

CASE SUMMARY

A 59-year-old man was diagnosed with sigmoid adenocarcinoma stage IIA (T3N0M0) and underwent surgery in April 2014, followed by XELOX adjuvant chemotherapy. The patient developed pulmonary metastasis in the right upper lung and underwent surgery in May 2016 without further adjuvant chemotherapy. In May 2018, pancreatic metastasis was found and he underwent pancreaticoduodenectomy. After surgery, he was treated with adjuvant S-1 chemotherapy from June 2018 to March 2019. Histopathological review of the specimens from all three lesions indicated consistent patterns characteristic of colon cancer. Concordant gene mutation profiles were observed across the three lesions that included oncogenic driver mutations most frequently seen in colon cancer (e.g., APC, TP53, KRAS and FBXW7). Blood circulating tumor (ct)DNA before adjuvant chemotherapy was undetectable with NGS, suggesting a favorable response to chemotherapy. The patient was alive and well at the latest follow-up visit, achieving a disease-free survival of 17 mo.

CONCLUSION

The genetic profiles of primary tumor, metastases and ctDNA may have clinical value in auxiliary diagnosis, prognosis and therapeutic decision-making.

Acute exudative polymorphous paraneoplastic vitelliform maculopathy (AEPPVM) associated with choroidal melanoma

Background

To report a case of acute exudative polymorphous paraneoplastic vitelliform maculopathy in a patient with a history of choroidal melanoma, with metastases to the pancreas, liver, and central nervous system.

Case presentation

A 63-year-old patient, with a history of enucleation of the right eye due to choroidal melanoma, complained of progressive visual loss during a follow-up visit. Fundoscopic examination revealed multiple small areas of serous retinal detachment scattered throughout the posterior pole and ancillary tests confirmed the diagnosis of acute exudative polymorphous paraneoplastic vitelliform maculopathy (AEPPVM). Screening for systemic metastases showed pancreatic, hepatic, and central nervous system involvement.

Conclusions

We describe a rare case of acute exudative polymorphous paraneoplastic vitelliform maculopathy, which should be considered in patients with or without a history of melanoma, who have vitelliform retinal detachments. Nevertheless, no previous reviews of literature have shown a correlation between AEPPVM and pancreatic metastasis.

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.

Pancreatic Metastasis of Renal Cell Carcinoma: A Surgical Indication for a Disseminated Disease

Pancreatic metastasis (PM) of renal cancer is a rare condition. It is characterized by a long period after initial nephrectomy and a favorable prognosis compared to other pancreatic malignancies. Its diagnosis may confuse clinicians if the medical history is not known. In the era of targeted therapies for metastatic renal carcinoma, surgery stands as the best treatment option for PM of renal cancer. We report the case of a woman who underwent successfully left splenopancreatectomy for corporeal PM of renal cancer treated seven years ago. This case underlines the necessity of long-term follow-up of patients treated for kidney cancer.

Pancreatic Metastasis from Malignant Melanoma: Not All That Glitters Is Gold

Pancreatic adenocarcinoma is the most common malignancy of the pancreas; on rare occasions, metastatic tumors are present. Differentiating a primary neoplasm from a metastatic one is important for ensuring adequate treatment for the patient. We present a case of metastatic melanoma to the pancreas. A 60-year-old man presented with a history of weight loss, vague abdominal pain, jaundice, and pruritus. Laboratory tests showed increased total bilirubin, with a direct fraction predominance, as well as increased alkaline phosphatase and gamma glutamyl transferase. Imaging studies revealed a mass in the head of the pancreas. Endoscopic ultrasound (EUS)-guided fine needle biopsy was performed, and histologic examination confirmed the diagnosis of metastatic melanoma. This case report illustrates the invaluable use of EUS-guided tissue acquisition in the study of pancreatic solid lesions to obtain an accurate diagnosis. Melanomas should always be part of a differential diagnosis when evaluating patients with pancreatic masses.

A case of hypervascular tumors in the liver and pancreas: synchronous hepatocellular carcinoma and pancreatic metastasis from renal cell carcinoma 36 years after nephrectomy

It is sometimes difficult to distinguish between multiple cancers and metastases using only diagnostic imaging, particularly when multiple hypervascular tumors are found in multiple organs. We present a case in which the preoperative histological evaluation was essential to determine the management of a hypervascular pancreatic tumor and liver tumor.

[Surgical treatment of hepato-pancreatic metastases from renal cell carcinoma]

Hintergrund

Der Stellenwert der chirurgischen Therapie hepatopankreatischer Metastasen des oligometastasierten Nierenzellkarzinoms ist Gegenstand der aktuellen Diskussion.

Material und Methoden

Wir berichten über 51 Patienten, von denen 33 wegen Lebermetastasen und 19 wegen Pankreasmetastasen im Zeitraum von 1995 bis 2018 operiert wurden.

Ergebnisse

Die 5‑Jahres-Überlebensrate aller Patienten nach Leberteilresektion war statistisch signifikant geringer (38 %, mediane Überlebenszeit 34 Monate) als nach Pankreasresektion (69 %, mediane Überlebenszeit 69 Monaten; p = 0,017). 21 Patienten haben bislang die Metastasenentfernung länger als 5 Jahr überlebt, 4 Patienten länger als 10 Jahre. Bei den R0-resezierten Patienten wurden Rezidive in 13 Fällen nach Leber- und 9 Fällen nach Pankreasresektion beobachtet. Die kumulative Rezidivrate nach 5 Jahren betrug bei der Leber 38 % und beim Pankreas 57 %. Bei R0-Leberteilresektionen erwiesen sich ein Intervall von <24 Monaten zwischen Nephrektomie und Leberresektion sowie multiple Metastasen als negative Prognosefaktoren.

Diskussion

Unsere Ergebnisse gestatten eine aktive chirurgische Strategie in der Behandlung hepatopankreatischer Metastasen oligometastasierter Nierenzellkarzinome, insbesondere bei kompletter Resektion solitärer, metachroner Metastasen. Wiederholte Eingriffe bei komplett resektablen Metastasen führen zu langen tumorfreien Intervallen und tragen damit zu guten Langzeitergebnissen bei.

Metastasis to the pancreas: a rare site for secondary malignancy of breast cancer (a case report)

Breast cancer is the most frequent invasive cancer in women and the second cause of death by cancer in women after lung cancer. It causes metastases especially to bones, liver and lungs. Pancreatic metastases from a primary breast neoplasm are rare and unusual, occurring in less than 3% of the cases. There have been only 28 cases described in the literature. This paper adds one more case to the published literature. We present a case of pancreatic metastasis of the breast in a 64-year-old female and a discussion based on a review of the literature.

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.

Sarcoma metastasis to the pancreas: experience at a single institution

Background

Reports of metastatic sarcoma to the pancreas are limited. We reviewed the clinicopathologic characteristics of such cases.

Methods

We reviewed 124 cases of metastatic tumors to the pancreas diagnosed at Asan Medical Center between 2000 and 2017.

Results

Metastatic tumors to the pancreas consisted of 111 carcinomas (89.5%), 12 sarcomas (9.6%), and one melanoma (0.8%). Primary sarcoma sites were bone (n=4); brain, lung, and soft tissue (n=2 for each); and the uterus and pulmonary vein (n=1 for each). Pathologically, the 12 sarcomas comprised 2 World Health Organization grade III solitary fibrous tumors/hemangiopericytomas, and one case each of synovial sarcoma, malignant solitary fibrous tumor, undifferentiated pleomorphic sarcoma, osteosarcoma, mesenchymal chondrosarcoma, intimal sarcoma, myxofibrosarcoma, myxoid liposarcoma, rhabdomyosarcoma, subtype uncertain, and high-grade spindle-cell sarcoma of uncertain type. The median interval between primary cancer diagnosis and pancreatic metastasis was 28.5 months. One case manifested as a solitary pancreatic osteosarcoma metastasis 15 months prior to detection of osteosarcoma in the femur and was initially misdiagnosed as sarcomatoid carcinoma of the pancreas.

Conclusions

The metastatic sarcoma should remain a differential diagnosis when spindle-cell malignancy is found in the pancreas, even for solitary lesions or in patients without prior history.

Pancreatic tropism of metastatic renal cell carcinoma

Renal cell carcinoma (RCC) is characterized by a particularly broad metastatic swath, and, enigmatically, when the pancreas is a destination, the disease is associated with improved survival. Intrigued by this observation, we sought to characterize the clinical behavior, therapeutic implications, and underlying biology. While pancreatic metastases (PM) are infrequent, we identified 31 patients across 2 institutional cohorts and show that improved survival is independent of established prognostic variables, that these tumors are exquisitely sensitive to antiangiogenic agents and resistant to immune checkpoint inhibitors (ICIs), and that they are characterized by a distinctive biology. Primary tumors of patients with PM exhibited frequent PBRM1 mutations, 3p loss, and 5q amplification, along with a lower frequency of aggressive features such as BAP1 mutations and loss of 9p, 14q, and 4q. Gene expression analyses revealed constrained evolution with remarkable uniformity, reduced effector T cell gene signatures, and increased angiogenesis. Similar findings were observed histopathologically. Thus, RCC metastatic to the pancreas is characterized by indolent biology, heightened angiogenesis, and an uninflamed stroma, likely underlying its good prognosis, sensitivity to antiangiogenic therapies, and refractoriness to ICI. These data suggest that metastatic organotropism may be an indicator of a particular biology with prognostic and treatment implications for patients.

Cholestatic syndrome as initial manifestation of pancreatic metastasis of papillary thyroid carcinoma: case report and review

Most papillary thyroid carcinomas (PTC) harbor excellent prognosis. Although rare, distant metastases normally occur in lungs and/or bones. Here we describe a rare case of pancreatic metastasis presenting with rapid onset cholestatic syndrome. A literature review was also performed. A 73-year-old man with a high risk PTC was submitted to total thyroidectomy (TT) followed by radioiodine therapy. After initial therapy, he persisted with progressive rising serum thyroglobulin levels but with no evidence of structural disease. Recently, the patient presented with a rapid onset and progressive cholestatic syndrome. A 4 cm lesion in pancreas was identified, with echoendoscopy fine-needle aspiration biopsy (FNAB) confirming a pancreatic metastasis from PTC. The patient was submitted to a successful pancreaticoduodenectomy. Pancreatic metastases of PTC are rare and few long-term follow-up data are available to guide management. Fourteen cases were former reported, mean age was 65.7 years-old with mean time between PTC and pancreatic metastasis diagnosis of 7.9 years. Nine of them had another distant metastasis, nine were diagnosed by FNAB and just two received sorafenib.

Metastasis of Ewing Sarcoma to the Pancreas: Case Report and Literature Review

Ewing sarcoma (ES) is a highly aggressive malignant bone cancer. ES is part of the Ewing sarcoma family of tumors (ESFT), which express characteristic t(11;22) translocation as well as higher levels of CD99. Given that metastasis and tumor burden are significant prognostic factors in patient's response to treatment, prompt diagnosis is needed to effectively treat ESFT patients. However, the challenges in classifying and characterizing ESFT complicate effective management and treatment of ES. In this report, we present a rare case of ES metastasis to the pancreas. Upon review of the literature, we found 39 cases of ESFT involving the pancreas, but only 3 were metastatic to the pancreas while the remaining cases of ESFT primarily originated from the pancreas. Given the rarity of such metastasis, the positive outcome in our patient's case may explain the importance of prompt diagnosis in order to initiate appropriate treatment.

Curative-intent pancreas resection for pancreatic metastases: surgical and oncological results

Background

Pancreatic metastasis is a rare cause for pancreas surgery and often a sign of advanced disease no chance of curative-intent treatment. However, surgery for metastasis might be a promising approach to improve patients’ survival. The aim of this study was to analyze the surgical and oncological outcome after pancreatic resection of pancreatic metastasis.

Methods

This is a retrospective cohort analysis of a prospectively-managed database of patients undergoing pancreatic resection at the University of Freiburg Pancreatic Center from 2005 to 2017.

Results

In total, 29 of 1297 (2%) patients underwent pancreatic resection due to pancreatic metastasis. 20 (69%) patients showed metastasis of renal cell carcinoma (mRCC), followed by metastasis of melanoma (n = 5, 17%), colon cancer (n = 2, 7%), ovarian cancer (n = 1, 3%) and neuroendocrine tumor of small intestine (n = 1, 3%). Two (7%) patients died perioperatively. Median follow-up was 76.4 (range 21–132) months. 5-year and overall survival rates were 82% (mRCC 89% vs. non-mRCC 67%) and 70% (mRCC 78% vs. non-mRCC 57%), respectively. Patients with mRCC had shorter disease-free survival (14 vs. 22 months) than patients with other primary tumor entities.

Conclusion

Despite malignant disease, overall survival of patients after metastasectomy for pancreatic metastasis is acceptable. Better survival appears to be associated with the primary tumor entity. Further research should focus on molecular markers to elucidate the mechanisms of pancreatic metastasis to choose the suitable therapeutic approach for the individual patient.

Solitary Colorectal Cancer Metastasis to the Pancreas

Introduction

Secondary pancreatic metastasis from other solid organ malignancy is rare and accounts for less than 2% of all pancreatic tumors. The aim of this study is to highlight that colorectal metastatic disease in the pancreas could be in selected cases an indication for surgery rather than for palliative chemotherapy.

Case Presentation

We present a case of a 62-year-old Caucasian female with a history of rectal adenocarcinoma. Four years ago, the patient underwent low anterior resection of the rectosigmoid, post neoadjuvant chemoradiotherapy, with adjuvant chemotherapy. During her follow-up, imaging examinations revealed a lesion in the pancreatic neck with features indicating primary pancreatic cancer. Near-total distal pancreatectomy with en bloc splenectomy was performed. Histopathology revealed metastatic disease compatible with colorectal adenocarcinoma as the primary cancer. Second-line chemotherapy was decided from the institutional tumor board. The patient remains disease free one year later.

Conclusion

Pancreatic lesions in patients with a history of extrapancreatic malignancy should raise suspicions of metastatic disease. Surgical intervention is a legitimate treatment option for these pancreatic lesions, since they represent solitary disease deposits and of course in the context of multidisciplinary meeting decisions, and after proper and extensive staging investigations.

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.

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.