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Synchronous multiple pancreatic cancers developed long after severe postendoscopic retrograde cholangiopancreatography pancreatitis


1 Department of Gastroenterology and Hepatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
2 Division of Endoscopy, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
3 Department of Surgical Pathology, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
4 Gastroenterological Surgery II, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan

Date of Submission25-Jun-2018
Date of Acceptance10-Dec-2018
Date of Web Publication12-Mar-2019

Correspondence Address:
Masaki Kuwatani,
Division of Endoscopy, Hokkaido University Hospital, North 14, West 5, Kita-ku, Sapporo, Hokkaido 060-8648
Japan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/eus.eus_67_18

PMID: 30880725



How to cite this URL:
Sugiura R, Kuwatani M, Hirata K, Kato S, Kawamoto Y, Kawakubo K, Mitsuhashi T, Asano T, Hirano S, Sakamoto N. Synchronous multiple pancreatic cancers developed long after severe postendoscopic retrograde cholangiopancreatography pancreatitis. Endosc Ultrasound [Epub ahead of print] [cited 2019 Mar 23]. Available from: http://www.eusjournal.com/preprintarticle.asp?id=254012



A 69-year-old female was referred to our hospital for workup of two pancreatic masses. The patient had no history of alcohol consumption or smoking. One of her brothers had had pancreatic cancer (PC). Six years before consultation, she had undergone endoscopic treatment of choledocholithiasis and had developed severe postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) without a mass in the pancreas [Figure 1]a. Although PEP had improved, a pancreatic mass appeared in the pancreatic body (Pb) 2 months after PEP [Figure 1]b. As the mass remained unchanged for 2 years on computed tomography (CT) images, she was diagnosed with an inflammatory mass based on the clinical course without a pathological examination. Six years after PEP, her serum level of hemoglobin A1c was elevated, and she had left hypochondralgia. CT images revealed two hypodense pancreatic masses: one (35 mm × 27 mm) was in the Pb as described above and the other (23 mm × 18 mm) was in the pancreatic tail [Figure 1]c without lymphadenopathy and metastatic lesions. EUS showed two hypoechoic solid masses and atrophic pancreatic parenchyma between the two masses [Figure 2]a. EUS-guided fine-needle aspiration biopsies of both the masses with two needles (22- and 25-gauge needles, respectively) [Figure 2]b and [Figure 2]c revealed similar cell nests consisting of adenocarcinomatous cells with hyperchromatic enlarged eccentric nuclei varying in size and amphophilic mucinous cytoplasm [Figure 2]d and [Figure 2]e. We made a definitive diagnosis of synchronous multiple PCs. Since liver metastases appeared waiting for surgery, she underwent palliative chemotherapy.
Figure 1: Contrast-enhanced computed tomography showing the pancreas just after severe postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) (a), the hypodense mass in the pancreatic body 2 months after severe PEP (b), and the two separated pancreatic masses in the pancreatic body and tail, respectively, 6 years after severe PEP (c)

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Figure 2: EUS showing two solid masses (arrows) separated by atrophic pancreatic parenchyma (arrowhead) (a), EUS-guided fine-needle aspiration biopsies of the mass in the pancreatic body using a 22-gauge needle (b) and pancreatic tail using a 25-gauge needle, (c) histologic images with hematoxylin and eosin staining showing similar cell nests consisting of adenocarcinomatous cells with hyperchromatic enlarged eccentric nuclei varying in size and amphophilic mucinous cytoplasm in the masses both in the pancreatic body (d) and pancreatic tail (e), respectively (×400)

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Synchronous multiple PCs are extremely rare.[1],[2] There are some possibilities regarding multiple PCs: (1) multifocal cancers; (2) a metastatic PC from another primary one;[3] and (3) a unique-shaped dumbbell-like PC as a whole. Based on the images and pathological findings, we made a definitive diagnosis of synchronous multiple PCs.

Progression from acute to chronic pancreatitis is associated with a high risk of PC.[4] The risk is the highest in the first 2 years following acute pancreatitis, although it remains high throughout the follow-up period.[5] Thus, PEP might cause PC. However, it is a limitation of this case that it was difficult to prove the hypothesis based on the specimens from EUS-guided fine-needle biopsies alone.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Izumi S, Nakamura S, Mano S, et al. Resection of four synchronous invasive ductal carcinomas in the pancreas head and body associated with pancreatic intraepithelial neoplasia: Report of a case. Surg Today 2009;39:1091-7.  Back to cited text no. 1
    
2.
Goong HJ, Moon JH, Choi HJ, et al. Synchronous pancreatic ductal adenocarcinomas diagnosed by endoscopic ultrasound-guided fine needle biopsy. Gut Liver 2015;9:685-8.  Back to cited text no. 2
    
3.
Ogawa M, Kawaguchi Y, Uchida T, et al. A case of small pancreatic cancer with intra-pancreatic metastasis diagnosed by endoscopic ultrasound. Tokai J Exp Clin Med 2011;36:75-8.  Back to cited text no. 3
    
4.
Rijkers AP, Bakker OJ, Ahmed Ali U, et al. Risk of pancreatic cancer after a primary episode of acute pancreatitis. Pancreas 2017;46:1018-22.  Back to cited text no. 4
    
5.
Kirkegård J, Cronin-Fenton D, Heide-Jørgensen U, et al. Acute pancreatitis and pancreatic cancer risk: A nationwide matched-cohort study in Denmark. Gastroenterology 2018;154:1729-36.  Back to cited text no. 5
    


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