A Woman with Remotely Treated Pancreas Cancer and New Abdominal Pain: A Discussion of Evaluation and Management

Abstract

Case HistoryDr. Epstein (New York): A 70-year-old woman with a remotely treated exocrine pancreas cancer presented with right upper quadrant abdominal pain. A CT scan of the abdomen and pelvis revealed multiple bilobar liver lesions of various sizes from 1.3 to 4.9 cm in diameter, new since a scan performed a few years previously (Fig. 1). The patient's pancreas cancer, diagnosed as adenocarcinoma at that time, was resected 25 years ago at Memorial Sloan-Kettering Cancer Center (MSKCC), treated with adjuvant chemoradiation post-operatively, and then followed regularly without evidence of disease thereafter. In light of the new CT findings, a CT-guided liver biopsy was performed at an outside institution, demonstrating poorly differentiated carcinoma. Immunohistochemical staining revealed strongly positive CK7, MOC-31, and CK/18; hepar-1 was focally positive; TTF-1, CK20, and GCDFP-15 were negative.Dr. Lowery (New York): Is it possible that this represents a late recurrence of the patient's pancreas cancer, or is this more likely a second primary tumor?Dr. O'Reilly (New York): A recurrence of exocrine pancreas cancer more than two decades after its original multimodality treatment would be highly unusual, as the majority of recurrences occur within the first 2 years after treatment. A small number of adenocarcinomas of the pancreas do have late recurrences in the lung and may follow a somewhat more indolent disease course than is typically experienced. The fact that the patient has enjoyed such a long disease-free survival after treatment of a usually highly lethal malignancy is surprising in and of itself. We were therefore eager to have the liver pathology reviewed at our institution, and comparison made to the patient's original pancreas cancer specimen. Case History (Continued):Dr. Epstein (New York): The liver specimens were interpreted at MSKCC as consistent with poorly differentiated hepatocellular carcinoma (HCC; Fig. 2). These slides were compared to the patient's pancreas cancer specimen and morphologically were deemed to be distinct in appearance (Fig. 3), further making the case for this as a new primary. Notably, the original pancreas specimen was further characterized as medullary phenotype pancreas cancer, an entity not described at the time of the patient's original diagnosis.Dr. Al-Olayan (Riyadh): Would our pathology colleagues at MSKCC please expound upon the entity of medullar1y phenotype pancreas cancer?Dr. Shia (New York): As mentioned, this is a relatively newly described entity (first reported in