Surgical treatment for secondary pancreatic tumors

• Verbovsky A.N.
• Setdikova G.R.
• Semenkov A.V.
• Gurevich L.E.
• Shikina V.E.
• Skugarev A.L.

Abstract

Background. Isolated metastases to the pancreas are an extremely rare pathology with an incidence of less than 2% of all malignant tumors of this localization. The leading primary localizations in autopsy studies are lungs, gastrointestinal tumors and hematological malignancies, and after surgical treatment metastases of kidney, lung and colon cancer were more often found. In most patients, when metastatic lesions of the pancreas are detected, there is a widespread systemic disease, so often secondary neoplasms of this localization are not subject to surgical treatment. Solitary pancreatic metastases are rare and may pose a significant clinical, radiological and/or diagnostic challenge in the differential diagnosis from advanced ductal adenocarcinoma or other primary tumor histotypes. By analogy with surgical treatment of primary pancreatic tumors, surgical treatment of solitary metastases of neoplasms from other primary locations in the pancreas is possible only in the absence of other distant metastases at the same time. In this case, the goal of surgical treatment is to achieve R0 resection, since non-radical surgery and the presence of signs of distant spread are associated with poor long-term patient survival.

Aim. Analysis of the experience of surgical treatment of 20 patients who underwent resection of the pancreas over the past decade due to metastatic disease.

Material and methods. Clinical observations of 20 patients with secondary pancreatic tumors surgically treated from 2007 to 2023 in various institutions in Moscow are presented.

Results. The leading primary localization of metastases to the pancreas was renal cell carcinoma (n=7). Metastases of breast cancer (n=3), melanoma (n=3), colorectal cancer (n=3), lung cancer (n=2) and ovarian cancer (n=2). Metachronous (n=19), synchronous (n=1). The interval from surgical removal of the primary tumor to the detection of metastases in the pancreas depended on the primary location: for renal cell carcinoma and melanoma – average 134 months; for other types of tumors – average 34 months. In most cases, no deviations were detected in the data of laboratory research methods (including tumor markers). Difficulties in diagnosing metastases in the pancreas are due to the fact that secondary tumors mimic primary neoplasia, especially metastases of renal cell carcinoma, which resemble primary pancreatic neuroendocrine tumors. In most cases there were multiple attempts at preoperative morphological verification of neoplasms (from 2 to 5 biopsies). Diagnostic efficiency was achieved in only 3 out of 20 (15%) observations. All cases of successful studies are represented by core needle biopsies. Surgical treatment included pancreatoduodenal resection (n=12), distal resection (n=6), enucleation of metastases (n=2). A macro- and microscopic description of distant metastases for each of the primary tumor sites is presented. In contrast to primary pancreatic cancer, all cases of secondary pancreatic tumors lacked perineural invasion, spread beyond the pancreas, and involvement of regional lymph nodes. In all cases, radical resection (R0) was performed. To confirm the diagnosis of metastasis to the pancreas and differential diagnosis, an immunohistochemical study was performed in all cases.

Conclusion. With metastases in the pancreas, it is necessary to carefully evaluate many factors: the type of primary cancer, its biological potential, the clinical course of the disease and the general condition of the patient, the presence of multiple primary processes and the duration of the disease-free period. With the correct selection of patients, no type of cancer is a contraindication to surgical treatment. In patients with local metastases in the pancreas and no metastases at other sites, combined treatment including pancreatic resection can be planned.

Keywords:secondary tumors of the pancreas; metastases to the pancreas; surgical treatment of metastases in the pancreas; metastases of renal cell carcinoma to the pancreas; metastases of breast cancer to the pancreas; metastases of melanoma to the pancreas; metastases of colorectal cancer to the pancreas; metastases of lung cancer to the pancreas; ovarian cancer metastases to the pancreas

References

1.     Sweeney A.D., Wu M.F., Hilsenbeck S.G., Brunicardi F.C., Fisher W.E. Value of pancreatic resection for cancer metastatic to the pancreas. J Surg Res. 2009; 156 (2): 189–98.

2.     Reddy S., Wolfgang C.L. The role of surgery in the management of isolated metastases to the pancreas. Lancet Oncol. 2009; 10 (3): 287–93.

3.     Setdikova G.R., Paklina O.V., Rotin D.L. Secondary tumors of the pancreas: case reports and literature review. Zlokachestvennye opukholi [Malignant Tumours]. 2014; (2): 11–23. DOI: https://doi.org/10.18027/2224-5057-2014-2-11-23 (in Russian)

4.     Mourra N., Arrive L., Balladur P., Flejou J.-F., Tiret E., Paye F. Isolated metastatic tumors to the pancreas: Hôpital St-Antoine experience. Pancreas. 2010; 39 (5): 577–80.

5.     Bilimoria K.Y., Talamonti M.S., Sener S.F., et al. Effect of hospital volume on margin status after pancreaticoduodenectomy for cancer. J Am Coll Surg. 2008; 207: 510–9.

6.     Winter J.M., Cameron J.L., Campbell K.A., et al. 1423 pancreaticoduodenectomies for pancreatic cancer: a single-institution experience. J Gastrointest Surg. 2006; 10: 1199–210.

7.     Sperti C., Pasquali C., Liessi G., Pinciroli L., Decet G., Pedrazzoli S. Pancreatic resection for metastatic tumors to the pancreas. J Surg Oncol. 2003; 83 (3): 161–6.

8.     Nakamura E., Shimizu M., Itoh T., Manabe T. Secondary tumors of the pancreas: clinicopathological study of 103 autopsy cases of Japanese patients. Pathol Int. 2001; 51 (9): 686–90.

9.     Sweeney A.D., Fisher W.E., Wu M.F., Hilsenbeck S.G., Brunicardi F.C. Value of pancreatic resection for cancer metastatic to the pancreas. J Surg Res. 2010; 160 (2): 268–76.

10. Yazbek T., Gayet B. The place of enucleation and enucleo-resection in the treatment of pancreatic metastasis of renal cell carcinoma. JOP. 2012; 13 (4): 433–8.

11. Dronov A.I., Zemskov S.V., Kryuchina E.A., Bakunets P.P. Resection methods for the treatment of secondary tumor lesions of the pancreas. Khirurgiya. Vostochnaya Evropa [Surgery. Eastern Europe]. 2014; 2 (10): 133–40. (in Russian)

12. Adler H., Redmond C.E., Heneghan H.M., Swan N., Maguire D., Traynor O., et al. Pancreatectomy for metastatic disease: a systematic review. Eur J Surg Oncol. 2014; 40 (4): 379–86.

13. Fragulidis G.P., Vezakis A., Chondrogiannis K., Mellou A., Melemeni A., Polydorou A. Clinical presentation and management of gastro-intestinal and pancreatic secondary metastatic tumors. J BUON. 2015; 20 (4): 1009–14.

14. Davidson M., Olsen R.J., Ewton A.A., Robbins R.J. Pancreas metastases from papillary thyroid carcinoma: a review of the literature. Endocr Pract. 2017; 23 (12): 1425–9.

15. Pronina G.M., Bystrovskaya E.V., Kovalenko D.D., Noskova K.K., Setdikova G.R. Endosonography in the diagnosis of metastatic lesion of the pancreas. Annaly khirurgicheskoy gepatologii [Annals of Surgical Hepatology]. 2019; 24 (1): 17–26. DOI: https://doi.org/10.16931/1995-5464.2019117-26 (in Russian)

16. Chikhladze S., Lederer A.K., Kühlbrey C.M., Hipp J., Sick O., Fichtner-Feigl S., et al. Curative-intent pancreas resection for pancreatic metastases: surgical and oncological results. Clin Exp Metastasis. 2020; 37 (2): 313–24.

17. Mikhet’ko A.A., Ivko O.V. Cytomorphological diagnosis of metastatic lesions to the pancreas. Prakticheskaya onkologiya [Practical Oncology]. 2020; 21 (2): 136–44. (in Russian)

18. Bassi C., Butturini G., Falconi M., Sargenti M., Mantovani W., Pederzoli P. High recurrence rate after atypical resection for pancreatic metastases from renal cell carcinoma. Br J Surg. 2003; 90 (5): 555–9.

19. Strobel O., Hackert T., Hartwig W., Bergmann F., Hinz U., Wente M.N., et al. Survival data justifies resection for pancreatic metastases. Ann Surg Oncol. 2009; 16 (12): 3340–9.

20. Sellner F., Thalhammer S., Klimpfinger M. Tumour evolution and seed and soil mechanism in pancreatic metastases of renal cell carcinoma. Cancers. 2021; 13: 1342.

All articles in our journal are distributed under the Creative Commons Attribution 4.0 International License (CC BY 4.0 license)