Osteoclastic giant cell tumor of the pancreas

Undifferentiated carcinoma of the pancreas with osteoclast-like giant cells, a two cases report

INTRODUCTION AND IMPORTANCE

Fine needle aspiration is the standard method for the pathological evaluation of pancreatic masses. In the following context, rare variants of such masses might present a challenge. Our goal is to describe the clinical, cytological, and histological findings of two cases of undifferentiated carcinoma with osteoclast-like giant cells (UCOCGC) a rare variant of pancreatic ductal adenocarcinoma (PDAC).

CASE PRESENTATION

Two cases were identified. Cytological findings exhibit similarities between the two cases. One patient received multiple chemotherapy regimens and a surgery and recurred within three years of diagnosis, while the other succumbed to cholangitis resulting from hepatic metastases a year after their initial surgery.

DISCUSSION

UCOCGC is a rare variant of pancreatic cancer, characterized by a unique cytological aspect. Recognizing this variant is essential considering its distinct prognosis compared to usual pancreatic adenocarcinoma.

CONCLUSION

We presented two cases of UCOCGC a rare pancreatic cancer variant, exposing diagnostic particularities and clinical evolution.

Long-term Survivor of Unresectable Pancreatic Cancer Treated with Concurrent Chemoradiotherapy

Undifferentiated carcinoma of the pancreas (UPC) is a rare, aggressive pancreatic cancer subtype. In addition, there is limited data on optimal management and patients tend to present with unresectable disease. This highlights the need to explore non-surgical treatments, such as chemotherapy and radiotherapy. In 2017, a 40-year-old male was diagnosed with UPC, presenting with a 6 cm mass in the pancreas, encasing the major arteries, indicative of a locally advanced stage. Histopathology confirmed UPC with osteoclast-like giant cells. After nine cycles of modified FOLFIRINOX chemotherapy and concurrent chemoradiotherapy, treatment was stopped in 2018 because of his declining health. Remarkably, despite the cessation of treatment, by 2023, the tumor had shrunk to 3.5 cm with no metabolic activity indicated by FDG-PET/CT. This six-year survival and response to non-surgical treatment highlight potential new avenues for managing unresectable pancreatic cancer, underscoring the need for further comprehensive studies to evaluate these therapeutic strategies.

Undifferentiated carcinoma of the pancreas with osteoclast-like giant cells: a case report

BACKGROUND

Undifferentiated carcinomas of the pancreas with osteoclast-like giant cells (UCPOGC) are rare pancreatic neoplasms that account for less than 1% of all pancreatic malignancies. This case report of a 54-year-old male with metastatic UCPOGC adds to the existing literature and further ascertains the clinical and imaging features, treatment options, and prognosis of this rare entity.

CASE PRESENTATION

We present the detailed clinical course of a 54-year-old Asian male patient with UCPOGC, with focus on the relevant clinical features and imaging findings that are characteristic of this disease entity.

CONCLUSIONS

UCPOGC is an extremely rare pancreatic tumor with a unique histopathology and clinical course. It is often difficult to distinguish UCPOGCs from other pancreatic tumors, such as traditional pancreatic ductal adenocarcinomas (PDAC), on imaging, and it therefore remains a pathological diagnosis. Surgery is generally regarded as the first-line treatment option, and the roles of chemotherapy and radiation are unclear. Due to the exceeding rarity of this tumor, large-scale clinical studies are not feasible. Therefore, it is important to share individual insights and experiences to improve our understanding and care for patients with this devastating disease.

CT Findings of Undifferentiated Pancreatic Cancer With Osteoclast-Like Giant Cells: A Case Series from a Single Center's Experience With 10 Cases

Little is known about the imaging features of undifferentiated carcinoma with osteoclast-like giant cells of the pancreas (UCOGCP) because of its extremely low incidence. To improve the diagnostic accuracy of this tumor, 10 UCOGCP cases with confirmed histopathology were collected and their clinical and image data features were analyzed. We found that the median age of our study was 61 years (50-76 years in range) and the main clinical manifestations were nonspecific abdominal pain. There were some differences in the degree of enhancement and computed tomography (CT) features between the tumor located at the head and body or tail of the pancreas. Perhaps these subtle imaging findings can provide valuable diagnostic information.

Real-Life Management of Pancreatic Cysts: Simplified Review of Current Guidelines

Pancreatic cysts are becoming a popular diagnostic tool due to the increased availability of high-quality cross-sectional imaging. Pancreatic cystic lesions constitute closed, liquid-containing cavities, which are either neoplastic or non-neoplastic. While serous lesions often follow a benign course, mucinous lesions can hide carcinoma and, therefore, require different management. Moreover, all cysts should be considered mucinous until proven otherwise, thus limiting the errors in managing these entities. Due to the need for high contrast soft tissue imaging, magnetic resonance imaging represents an elective, non-invasive diagnostic tool. Endoscopic ultrasound (EUS) has started gaining more prominence with regard to the proper diagnosis and management of pancreatic cysts, offering quality information with minimal risks. Enabling both the acquisition of endoscopic images of the papilla and the endosonographic high-quality evaluation of septae, mural nodules along with the vascular patterns of the lesion contribute to a definitive diagnosis. Moreover, the possibility of obtaining cytological or histological samples could become mandatory in the foreseeable future, allowing for more precise molecular testing. Future research should focus on detecting methods to quickly diagnose high-grade dysplasia or early cancer for patients with pancreatic cysts, thus allowing time for appropriate treatment and avoiding surgical overtreatment or over surveillance in selected cases.

EUS-guided fine needle biopsy is able to provide diagnosis in rare osteoclast-like giant cells undifferentiated carcinoma of the pancreas: Report of two cases

Undifferentiated carcinoma of the pancreas with osteoclast-like giant cells (UC-OGC) is a rare subtype of pancreatic cancer, accounting for less than 1% of all pancreatic tumors. Preoperative diagnosis is cumbersome as cross-sectional imaging is often not capable to distinguish between UCOGC and other pancreatic tumors such as pancreatic adenocarcinoma, mucinous carcinoma or neuroendocrine tumors and specific tumor markers seem to be lacking. Endoscopic ultrasound r `m(EUS) with tissue acquisition via fine-needle aspiration (FNA) or biopsy (FNB) with microscopic HE staining and immunohistochemistry allows for an accurate diagnosis, thus influencing further treatment. We present herein the cases of two patients with osteoclast-like giant cells tumors of the pancreas diagnosed by EUS-guided fine needle biopsy and perform a literature review on the role of EUS-guided biopsy for diagnosis.

Case report: Pathological and genetic features of pancreatic undifferentiated carcinoma with osteoclast-like giant cells

Objectives: Pancreatic undifferentiated carcinoma accounts for 2%-7% of pancreatic carcinomas. We aimed to investigate the pathological and genetic characteristics of pancreatic undifferentiated carcinoma with osteoclast-like giant cells and the key points of treatment. Methods: The clinical data and follow-up results of four patients diagnosed with pancreatic undifferentiated carcinoma with osteoclast-like giant cells between May 2015 and May 2020 at the First Affiliated Hospital of Xi'an Jiaotong University were retrospectively analyzed. Results: Chief complaints included "pain and discomfort in the upper abdomen" (2/4), "nausea and vomiting" (1/4) or no symptoms (1/4). Preoperative mildly elevated tumor markers included carcinoembryonic antigen (1/4) and CA19-9 (1/4). The tumors were located in the tail of the pancreas in three patients and the head and neck in one patient. Tumor metastasis was found in pancreatic adipose tissue in two patients and lymph node metastasis in one patient, with microscopic heterogeneous mononuclear cells and scattered osteoclast-like giant cells of various sizes. One patient (1/4) had a mucinous cystic tumor of the pancreas, and two patients (2/4) had adenocarcinoma of the pancreatic duct. Only one patient received postoperative gemcitabine combined with albumin-bound paclitaxel chemotherapy. Conclusion: Currently, treatment guidelines are lacking for PUC-OGC, and prognosis varies markedly. More cases must be reported to clarify its origination. The long-term follow-up of diagnosed patients and genetic mutation testing can also contribute to improving treatment and prognosis of this disease.

Metastatic Undifferentiated Osteoclast-Like Giant Cell Pancreatic Carcinoma

Undifferentiated osteoclast-like giant cell pancreatic carcinoma (UC-OGC) is a rare pancreatic carcinoma that is composed of osteoclast-like giant cells among other cells and is hardly described in literature due to its infrequent presentation. With that, a rare symptom of pancreatic cancers is upper gastrointestinal (GI) bleeding. We report a 76-year-old African American male who presented with one episode of bloody emesis associated with intermittent episodes of severe abdominal pain and a 25 lbs of unintentional weight loss secondary to metastatic UC-OGC. The patient was stabilized and referred to an oncologist for further treatment. We present this case to add to the existing literature on UC-OGC of the pancreas.

Clinical and pathological features of undifferentiated pancreatic carcinoma with osteoclastic giant cells: a rare case

INTRODUCTION

undifferentiated pancreatic carcinoma with osteoclastic giant cells (UOC) is a rare pancreatic malignancy composed of three unique cell types. Currently, the histopathologic origin of UOCs remains unclear. Some studies considered that it was differentiated from epithelial tissues, while others favored a mesenchymal derivation.

METHODS

we present the case of a 59-year-old UOC patient with a tumor (3.0 cm × 3.0 cm × 2.5 cm) in the pancreatic neck. He underwent an en bloc resection of the distal pancreas associated with the spleen.

RESULTS

light microscopic examination revealed two typical types of UOC cells, with one type absent. The immunohistochemical staining was positive for pancytokeratin, epithelial membrane antigen, vimentin and cluster of differentiation 68, which indicated different derivations for these two kinds of cells.

DISCUSSION

UOC is a rare condition with unique imaging and pathological features. Endoscopic ultrasonography and fine needle aspiration are dispensable preoperatively. Radical resection should be tried for UOC treatments. In our opinion, osteoclastic giant cells are reactive cells derived from histocytes. The case presented here will be of interest to the whole UOC cohort.

A Rare Case of Pancreatic Cancer: Undifferentiated Carcinoma of the Pancreas With Osteoclast-Like Giant Cells

Ductal adenocarcinoma of the pancreas is the most common pancreatic cancer, but undifferentiated carcinoma of the pancreas with osteoclast-like giant cells (UC-OGCs) is an exceedingly rare tumor. Microscopically, this tumor is characterized by the presence of two different cellular elements, namely, spindle or ovoid mononuclear cells and osteoclast-like giant cells (OGCs). Here, we report a rare case of UC-OGCs in a 79-year-old male with a one-month history of epigastric abdominal pain and unintentional weight loss. A blood workup revealed new-onset type 2 diabetes mellitus, and a computed tomography scan of the abdomen showed acute pancreatitis with a hypodense lesion in the head of the pancreas concerning for malignancy. He underwent an endoscopic ultrasound that also revealed a mass in the head of the pancreas, but no lymphadenopathy was observed. Biopsy was obtained and histopathology revealed UC-OGCs. We present this case to increase awareness of this rare clinical entity in patients presenting with acute-onset pancreatitis.

Undifferentiated Carcinoma of Pancreas with Osteoclast-Like Giant Cells: One Center’s Experience of 13 Cases and Characteristic Pre-Operative Images

Background

Methods

Results

Conclusion

Cephalic undifferentiated carcinoma with osteoclast-like giant cells arising from the main pancreatic duct: case report and literature review

Undifferentiated carcinoma with osteoclast-like giant cell (UCOGC) is a ductal carcinoma variant with a recently reported more protracted survival and pathognomonic histology comprising two cell populations: the mononuclear tumoral cells and nontumoral multinucleated giant cells. It usually presents as a large heterogenic tumor with mixed solid-cystic components. The tumor develops from the ductal epithelium but the sequence of epithelial changes is often not identified due to the rapid tumoral growth and associated necrotic changes. We report a case of a 76-year-old patient diagnosed with cephalic UCOGC originating in the epithelium of the main pancreatic duct with endoluminal growth and foci of other ductal neoplasms (high-grade pancreatic intraepithelial neoplasia (PanIN) and conventional ductal carcinoma). The particularity of our case consists in the identification of the columnar epithelium conversion, through high-grade PanIN, into UCOGC specific malignant features, in a large size tumor - aspect usually reported in small tumors. Alongside our case we also present a brief literature review of cephalic UCOGC case reports and case series.

Assessment and management of undifferentiated carcinoma with osteoclastic like giant cells of the pancreas: a case report and revision of literature

BACKGROUND

Undifferentiated carcinoma with osteoclast-like giant cells (UCOGCs) is a rare and aggressive non endocrine pancreatic carcinoma characterized by the presence of osteoclastic giant cells mixed with mononuclear cell. Very few cases have been reported in the literature and the histogenesis is controversial as, at the time of diagnosis, the tumor is often of advanced size and stage and it is difficult to pathologically observe its relationship with the pancreatic duct.

CASE PRESENTATION

We present a case of 65-year-old male patient presenting with abdominal pain, nausea, and weight loss, which was treated with surgical resection. Histological examination revealed an undifferentiated pancreatic carcinoma with osteoclast-like giant cells. The patient underwent to a routine pylorus preserving pancreatoduodenectomy. Actually, the patient was in good performance status and disease-free five months.

CONCLUSIONS

Based on the present case and limited previous data, further researches preferably with large cohorts are necessary to clarify the pathogenesis of the neoplasm. However, as show in this case, histopathological and immunohistochemically studies are the gold standard for the diagnosis of UCPOGC. Investigation of the genomic alterations in UPOGCs could help to explain the histologic diversity of variant tumor and could provide a genetic basis for prognosis and treatment.

Undifferentiated Pancreatic Carcinoma With Osteoclast-Like Giant Cells and Associated Ductal Adenocarcinoma With Focal Signet-Ring Features

Undifferentiated pancreatic carcinoma with osteoclast-like giant cells (UPC-OGC) is a unique and rare tumor characterized by the presence of highly atypical carcinoma cells and non-neoplastic osteoclast-like giant cells. The histogenesis of this tumor is unclear and data on its prognosis remain controversial. Some data show poor clinical outcomes in affected patients while other more recent studies report a better outcome especially for cases with pure UPC-OGC. There are currently no established reliable management guidelines for UPC-OGC partly because of its rarity and presence of conflicting data in the literature. Hence the need for continued reporting and further research on this neoplasm. We report an incidental finding of UPC-OGC with associated ductal adenocarcinoma and focal signet ring features in an elderly male patient who presented with symptoms of urinary tract infection (UTI).

A pancreatic mixed neuroendocrine-non-neuroendocrine neoplasms (MiNEN) (NET and undifferentiated carcinoma of the pancreas with osteoclast-like giant cells) with metastatic neuroendocrine component to the liver

Undifferentiated carcinoma of the pancreas with osteoclast-like giant cells (UCOGCs) is an extremely rare morphologically and clinically distinct variant of pancreatic ductal adenocarcinoma (PDAC), exhibiting a characteristic component of reactive osteoclast-like giant cells admixed with neoplastic mononuclear cells. Sommers and Meissner first described it in 1954 as an “unusual carcinoma of the pancreas”. Later it acquired many different names. In 2010, the WHO classified these tumors as a variant of PDAC under the heading of “undifferentiated carcinoma with osteoclast-like giant cells”. Here we describe the first case of pancreatic mixed neuroendocrine-non-neuroendocrine neoplasms (MiNEN) composed of UCOGC and pancreatic neuroendocrine tumor (NET), which occurred in a 78-year-old man with biliary colic and pancreatitis. The mass did not respond to the chemotherapy, and he soon developed liver metastasis from the NET component, and unfortunately, the patient passed away 10 months later. Since UCOGC is extremely rare, and its association with NET has not been reported yet, our case expands the knowledge regarding its unusual presentation and poor prognosis.

Seven-year disease-free survival in a patient with osteoclast-like giant cell-containing pancreatic undifferentiated carcinoma: a case report and literature review

BACKGROUND

Undifferentiated carcinoma with osteoclast-like giant cells (UCOGC) of the pancreas is a very rare variant of pancreatic malignant neoplasm. It is regarded as a highly aggressive tumor with a worse prognosis than conventional pancreatic ductal adenocarcinoma.

CASE PRESENTATION

A 54-year-old male patient presented with 3-month recurrent epigastric distress. Computed tomography of the abdomen showed a large cystic mass in the distal pancreas. On macroscopic examination, the lesion had numerous multiloculated cystic cavities. Microscopically, the tumor predominantly comprised a considerable number of evenly distributed non-neoplastic osteoclast-like giant cells and a few neoplastic pleomorphic cells. Although extensive histologic sampling was conducted, a classic ductal adenocarcinoma component was not identified. The patient received no further treatment after his surgery and has been doing well with no evidence of recurrence or metastasis for >7 years.

CONCLUSIONS

Our results suggest that pure UCOGC has a significantly better prognosis and supports that pure UCOGC may represent a biologically distinct variant of pancreatic carcinoma and it should be separated from other undifferentiated pancreatic carcinomas.

Morphologic and Molecular Landscape of Pancreatic Cancer Variants as the Basis of New Therapeutic Strategies for Precision Oncology

To date, pancreatic cancer is still one of the most lethal cancers in the world, mainly due to the lack of early diagnosis and personalized treatment strategies. In this context, the possibility and the opportunity of identifying genetic and molecular biomarkers are crucial to improve the feasibility of precision medicine. In 2019, the World Health Organization classified pancreatic ductal adenocarcinoma cancer (the most common pancreatic tumor type) into eight variants, according to specific histomorphological features. They are: colloid carcinoma, medullary carcinoma, adenosquamous carcinoma, undifferentiated carcinoma, including also rhabdoid carcinoma, undifferentiated carcinoma with osteoclast-like giant cells, hepatoid carcinoma, and signet-ring/poorly cohesive cells carcinoma. Interestingly, despite the very low incidence of these variants, innovative high throughput genomic/transcriptomic techniques allowed the investigation of both somatic and germline mutations in each specific variant, paving the way for their possible classification according also to specific alterations, along with the canonical mutations of pancreatic cancer (KRAS, TP53, CDKN2A, SMAD4). In this review, we aim to report the current evidence about genetic/molecular profiles of pancreatic cancer variants, highlighting their role in therapeutic and clinical impact.

Undifferentiated carcinoma with osteoclast-like giant cells of the pancreas diagnosed by endoscopic ultrasound guided biopsy

Undifferentiated pancreatic carcinoma with osteoclast-like giant cells is a rare tumour that has been published under a wide variety of names, including pleomorphic carcinoma, giant cell carcinoma, sarcomatoid carcinoma and carcinosarcoma, among others. For these reasons and its low frequency, the reports of these tumours are scarce and frequently lead to confusion with other entities which present with giant cells.

We present the case of a patient with obstructive jaundice and a mixed cystic and solid pancreatic mass, accompanied by multiple hepatic lesions.

The histological study of the material obtained by endoscopic ultrasound guided biopsy demonstrated a proliferation of atypical epithelioid cells, accompanied by a spindle cell component with marked pleomorphism and numerous osteoclast-like giant cells. The epithelioid component showed positive immunostaining with cytokeratin cocktail and cytokeratin 7. The spindle cell component showed coexpression of cytokeratins and vimentin. The osteoclast-like giant cells were positive for CD68. Protein p53 was overexpressed in both epithelial and spindle cell neoplastic components, and was negative in the giant cells. These findings permitted the diagnosis of undifferentiated carcinoma of the pancreas with osteoclast-like giant cells. This case outlines the effectiveness of endoscopic ultrasound-guided biopsy and the importance of morphological and immunohistochemical examination in the diagnosis of different types of pancreatic tumours, especially when they are in advanced stages and are not suitable for surgical treatment.

Cell-in-Cell Phenomenon and Its Relationship With Tumor Microenvironment and Tumor Progression: A Review

The term cell-in-cell, morphologically, refers to the presence of one cell within another. This phenomenon can occur in tumors but also among non-tumor cells. The cell-in-cell phenomenon was first observed 100 years ago, and it has since been found in a variety of tumor types. Recently, increasing attention has been paid to this phenomenon and the underlying mechanism has gradually been elucidated. There are three main related process: cannibalism, emperipolesis, and entosis. These processes are affected by many factors, including the tumor microenvironment, mitosis, and genetic factors. There is considerable evidence to suggest that the cell-in-cell phenomenon is associated with the prognosis of cancers, and it promotes tumor progression in most situations. Notably, in pancreatic cancer, the cell-in-cell phenomenon is associated with reduced metastasis, which is the opposite of what happens in other tumor types. Thus, it can also inhibit tumor progression. Studies show that cell-in-cell structure formation is affected by the tumor microenvironment, and that it may lead to changes in cellular characteristics. In this review, we summarize the different cell-in-cell processes and discuss their role in tumor progression and how they are regulated by different mechanisms.

A Case Report Presenting an Undifferentiated Pancreatic Carcinoma with Osteoclastic-Like Giant Cells with an Unusual Indolent Course

BACKGROUND Undifferentiated pancreatic carcinoma with osteoclast-like giant cells represents less than 1% of pancreatic cancers. Histogenesis and prognosis are still debated. Three subtypes are defined by the World Health Organization: osteoclastic, pleomorphic, and mixed. The differential diagnosis of a pancreatic tumor with giant cells varies from a benign osteoclastoma to an undifferentiated pancreatic carcinoma with osteoclastic-like cells. The specimen should be carefully examined to rule out conventional pancreatic adenocarcinoma even in the presence of the giant cells. CASE REPORT A 77-year-old male was diagnosed with a pancreatic tail tumor with osteoclastic like cells revealed by a biopsy done by echo-endoscopy; the patient was lost to follow up for 24 months before he was admitted to our institute for severe abdominal pain. A computed tomography showed the same lesion without progression. He was operated on using laparoscopic distal pancreatectomy with splenectomy. Pathology analysis revealed the presence of osteoclast-like giant cells without pleomorphic cells. Mutated KRAS on molecular study confirmed the diagnosis of undifferentiated pancreatic carcinoma with osteoclast-like giant cells. The patient was in good performance status and disease-free 19 months after surgery without any sign of progression. CONCLUSIONS Undifferentiated pancreatic carcinoma with osteoclast-like cells has a challenging pathology diagnosis. Molecular and immunostaining are essential to diagnosis. The absence of pleomorphic cells in the present case has classified it into the osteoclastic subtype. Further cases and studies are needed to confirm the heterogeneity of the malignant course between subtypes.

The Italian Rare Pancreatic Exocrine Cancer Initiative

INTRODUCTION

Exocrine pancreatic cancers include common type pancreatic ductal adenocarcinoma and cystic neoplasms, which account for 85% and 10% of cases, respectively. The remaining 5% are rare histotypes, comprising adenosquamous carcinoma, acinar cell carcinoma, signet ring cell carcinoma, medullary carcinoma, pancreatoblastoma, hepatoid carcinoma, undifferentiated carcinoma and its variant with osteoclast-like giant cells, solid pseudopapillary carcinoma, and carcinosarcoma. Due to their low incidence, little knowledge is available on their clinical and molecular features as well as on treatment choices. The national initiative presented here aims at the molecular characterization of series of rare histotypes for which therapeutic and follow-up data are available.

METHODS

A nationwide Italian Rare Pancreatic Cancer (IRaPaCa) task force whose first initiative is a multicentric retrospective study involving 21 Italian cancer centers to retrieve histologic material and clinical and treatment data of at least 100 patients with rare exocrine pancreatic cancers has been created. After histologic revision by a panel of expert pathologists, DNA and RNA from paraffin tissues will be investigated by next-generation sequencing using molecular pathway-oriented and immune-oriented mutational and expression profiling panels constructed availing of the information from the International Cancer Genome Consortium. Bioinformatic analysis of data will drive validation studies by immunohistochemistry and in situ hybridization, as well as nanostring assays.

CONCLUSIONS

We expect to gather novel data on rare pancreatic cancer types that will be useful to inform the design of therapeutic choices.

Osteoclast Giant Cell Tumor of Pancreas: A Case Report and Literature Review

We report a rare case of undifferentiated carcinoma of the pancreas with osteoclast-like giant cells (UC-OGC) in a 62-year-old female who presented with a three-month history of bilateral flank pain and significant unintentional weight loss. Computed tomography (CT) scan of the abdomen showed pancreatic tail mass, concerning for malignancy. She underwent endoscopic ultrasound (EUS) which also revealed a pancreatic mass invading into the splenic artery. CT chest and positron emission tomography (PET) scan did not reveal any metastases. The patient had a distal pancreatectomy, splenectomy, and left partial adrenalectomy. Histopathology revealed undifferentiated carcinoma of the pancreas with osteoclast-like giant cells (OGCs). The patient was recently started on adjuvant chemotherapy with capecitabine and gemcitabine and the plan is to repeat imaging to assess response. We present this case to increase clinical awareness of this rare clinical entity, and also review controversies in the management and surveillance of UC-OGC.

An osteoclast-like giant cell tumor embedded in the mural nodule of a pancreatic mucinous cystic neoplasm: A case report and literature review

RATIONALE

Mucinous cystic neoplasms (MCNs) are relatively rare lesions, accounting for 2%-5% of all exocrine pancreatic neoplasms. MCNs mainly occur in women (female:male ratio = 20:1), with a peak incidence in the 5th decade of life. Osteoclast-like giant cell tumors (OGCTs) are rare and relatively aggressive neoplasms, comprising <1% of all pancreatic carcinomas. Herein, we present a rare "combination tumor" case and discuss the impact of mural nodules in pancreatic MCNs considering malignant transformation.

PATIENT CONCERNS

A 54-year-old Mongolian man, without vomiting, nausea or jaundice, presented with abdominal distention since 3 months. He had a 7-year history of diabetes. Physical examinations indicated slight middle abdominal tenderness without rebound tenderness or rigidity. Laboratory results revealed that the level of carcinoembryonic antigen (CEA) was 1.16 ng/ml (normal: <5 ng/ml); CA-199: 30.02 U/ml (normal: <27 U/ml); hemoglobin: 143 g/L; fasting glucose: 7.71 mmol/L; and albumin: 43 g/L. Abdominal enhanced computed tomography revealed a 7 × 6 cm solid neoplasm in the pancreatic body with partial enhancement and heterogeneity. Endoscopic ultrasound revealed a solid-cystic space-occupying lesion in the pancreatic body.

DIAGNOSIS

The preoperative preliminary diagnosis was pancreatic solid-cystic tumor, possibly a solid pseudopapillary tumor. Postoperative pathological findings revealed a pancreatic borderline MCN with an OGCT embedded in a mural nodule of the capsule. Immunohistochemical results indicated a simultaneous dual origin from the epithelium and stroma.

INTERVENTIONS

The patient underwent open distal pancreatectomy and splenectomy. Postoperative blood glucose levels were closely monitored and regulated. We intravenously administered single-agent gemcitabine (1400 mg on day 1) as the first-time chemotherapy, 1 month after surgery. After the first chemotherapy, the patient refused to receive further treatment owing to personal reasons.

OUTCOMES

The patient showed uneventful recovery and was discharged 13 days after the initial surgery. Follow-up was performed 1, 3 and 6 months after surgery. At 6 months, abdominal computed tomography scan showed no signs of recurrence, regional lymphadenopathy, or other abnormalities. And laboratory tests showed a platelet count of 301 × 10/L, postprandial blood glucose of 12.9 mmol/L and CA-199 level of 20 U/ml. The patient had no obvious discomfort.

LESSONS

Although pancreatic MCNs are widely accepted as borderline tumors, malignant transformations may occur due to various risk factors (cyst size, mural nodules, septations, and tumor location). The combination tumor in this case was more likely to increase the possibility of malignant biological behavior, thereby worsening overall prognosis. Therefore, long-term follow-up must be maintained with strict monitoring.

Osteoclast-like giant cell tumor of the pancreas-an unusual presentation in a patient with large mantle cell lymphoma

Osteoclast-like giant cell tumor of the pancreas is very rare. We report a 78-year-old male who was previously treated for large mantle cell lymphoma, was found to have an increased uptake in a peri-pancreatic node from his restaging PET scan. Endoscopic ultrasound-directed fine-needle aspiration of the mass and lymph node revealed an undifferentiated carcinoma with osteoclast-like giant cells. Osteoclast-like giant cell tumors of the pancreas are frequently found to be unresectable at diagnosis due to their large size (>5 cm). In our patient, due to its small size (<3 cm) sub-total pancreatectomy was performed. Three years from the surgery, the patient is doing well without recurrence. This case report intends to increase provider awareness that in the setting of new pancreatic lesions in a patient with previous history of lymphoma, a high index of suspicion for a primary pancreatic lesion should be included in the differential diagnosis.

Undifferentiated carcinoma with osteoclast-like giant cells of pancreas: A case report with review of the computed tomography findings

RATIONALE

Undifferentiated carcinoma with osteoclast-like giant cells (UC-OGCs) of the pancreas is an extremely rare and aggressive pancreatic malignancy. To our knowledge, the computed tomography (CT) findings of this disease have rarely been analyzed.

PATIENT CONCERNS

A 65-year-old man who experienced weight loss of about 4 kg over 3 months presented to our clinic. The abdominal ultrasound (US) detected a 5.8 × 5.5 cm well-defined, cystic-solid mass in the head of the pancreas, which had been present for 1 month.

DIAGNOSIS

A benign pancreatic tumor was initially suspected on the basis of the US findings. The patient then received serum tumor markers and CT examinations for further diagnosis, including carbohydrate antigen 199 (CA199), carcinoembryonic antigen (CEA), carbohydrate antigen 125 (CA125), contrast-enhanced CT (CECT) and CT angiography (CTA). His CA199, CEA, and CA125 marker levels were normal, which supported the diagnosis of a benign tumor. CECT showed a well-defined cystic-solid mass in the head of the pancreas, with a slightly enhanced solid portion and pancreatic ductal dilatation, which led us to consider the possibility of a malignant tumor. CTA revealed that the tumor nourishing arteries emitted from the pancreaticoduodenal superior and inferior arteries into the mass. Then, the patient underwent a pancreaticoduodenectomy. Finally, postoperative pathology and immunohistochemistry confirmed UC-OGC of the pancreas.

INTERVENTIONS

The patient has been treated by a pancreaticoduodenectomy alone.

OUTCOMES

The operation had no complications, and the patient recovered well after surgery. Ten months after surgery, the patient reviewed the CECT, and no recurrence or metastasis was noted.

LESSONS

Old patients with cystic-solid lesions in the pancreas should be aware of UC-OGC. CT findings usually show a clear boundary and a slightly enhanced mass with pancreatic duct expansion.

Systemic Chemotherapy for Advanced Rare Pancreatic Histotype Tumors: A Retrospective Multicenter Analysis

OBJECTIVES

Two issues were put forth by clinicians in the management of the advanced stages of rare variants of pancreatic ductal adenocarcinoma and other exocrine histotypes with peculiar clinical and pathological features: Do chemotherapy regimens recommended in pancreatic ductal adenocarcinoma patients have a clinical activity in rare pancreatic tumors? Or should other chemotherapy combinations be considered in this subset of patients?

METHODS

We conducted a multicenter retrospective study that collected data from 2005 to 2016 at 14 Italian cancer centers with the aim to evaluate tumor response and time to progression for first- and second-line and overall survival.

RESULTS

Of approximately 4300 exocrine pancreatic cancer patients, 79 advanced cases affected by rare histological types were identified, with pancreatic acinar cell cancer (n = 23), pancreatic adenosquamous cancer (n = 16), and mucinous cystic neoplasm with an associated invasive mucinous cystadenocarcinoma (n = 15) most represented. Survival analyses for each subgroup in relation with the different chemotherapy regimens showed the lack of statistical significance correlations.

CONCLUSIONS

Because of the lack of clinical trials in patients affected by these rare pancreatic histotypes, only their molecular classification would help clinicians in future therapeutic choice.

Uncommon Solid Pancreatic Neoplasm: The Role of New Modalities of Ultrasound Endoscopy

Undifferentiated carcinoma with osteoclast-like cells is a rare pancreatic neoplasm with unique ultrasound endoscopic features. A 59-year-old female presented with a 3-month history of weight loss. Abdominal computed tomography and endoscopic ultrasound showed a large pancreatic tumor with a heterogeneous echotexture and liver metastasis. Endoscopic ultrasound fine needle aspiration was used to establish the diagnosis. In this case report, we review the endoscopic, clinical, and pathological features of this type of tumor and describe for the first time the endoscopic features of real-time elastography and contrast enhancement. Real-time elastography revealed a heterogeneous predominantly blue pattern suggestive of pancreatic malignancy, and the contrast-enhanced endosonography showed a hypervascular mass and distinctive vascular (solid) and avascular (liquid/necrotic) components of the lesion, guiding the fine needle aspiration.

Complete resection of a huge pancreatic undifferentiated carcinoma with osteoclast-like giant cells

Pancreatic undifferentiated carcinoma with osteoclast-like giant cells (PUC-OGC) is a rare neoplasm. We report a case of rapidly advancing PUC-OGC. A 54-year-old man had elevated tumor marker levels. Abdominal computed tomography showed a cystic mass in the body and tail of the pancreas, which infiltrated adjacent organs. The tumor exhibited rapid growth (doubling time: 39 days) but no metastases. We diagnosed PUC-OGC clinically and excised the pancreatic body and tail along with the spleen, left kidney, adrenal gland, and transverse colon. Pathological diagnosis showed histology consistent with PUC-OGC and a negative margin without nodal involvement despite the tumor being 28 cm in maximum diameter and having invaded the left kidney. The patient survived a year with a recurrence of liver metastasis after the initial surgery due to the partial hepatectomy and chemotherapy. Complete resection might be a good strategy to cure PUC-OGC in this case.

Undifferentiated (anaplastic) carcinoma with osteoclast-like giant cells of the pancreas: a series of 5 cases with clinicopathologic correlation and cytomorphologic characterization

INTRODUCTION

Undifferentiated carcinoma with osteoclast-like giant cells of the pancreas (UCOGCP) is a rare neoplasm involving the pancreas. Although typically diagnosed initially via endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), cytomorphologic characterization of the neoplasm has been limited to individual cases in the literature.

MATERIALS AND METHODS

Five cases were identified in a retrospective review of our institution's records from 2006 to 2015. Cytomorphologic, immunophenotypic, and corresponding clinical features of the neoplasm are examined and described.

RESULTS

UCOGCP accounted for 0.9% of all new pancreatic neoplastic diagnoses, had a median greatest dimension of 4.3 cm, were variably located within the pancreas, and had variable features by radiologic imaging. Patients were of a median age of 78 years old at diagnosis, and had a median length of survival of 10 months. Smear-based cytomorphology and histomorphology from cell block preparations show atypical/pleomorphic mononuclear carcinomatous and bland osteoclast-like giant cellular populations. The immunophenotype of the mononuclear carcinomatous component was CD68, CD99, CK7 (variably), CKAE1/AE3 (variably), and, rarely, p40-positive. The osteoclast-like giant cells positively expressed CD68 and CD99.

CONCLUSIONS

Initial diagnosis of UCOGCP is frequently made via EUS-FNA of pancreas tumors, with cytomorphologic features on smears and hematoxylin and eosin stained slides prepared from cell block material being characteristic for the diagnosis. Although the cellular constituents have a consistent immunophenotype, the diagnosis can be based on the morphologic features alone. UCOGCP is an important diagnosis as it may have a distinct clinical course from undifferentiated carcinomas of the pancreas lacking osteoclast-like giant cells.

Use of molecular studies for treatment of metastatic pleomorphic large cell pancreatic cancers-a novel strategy

Pleomorphic large cell pancreatic cancer is a rare and more aggressive variant with no proven treatment in the metastatic setting. It constitutes about 1% of the total pancreatic cancer cases. In the absence of any standard of care, we aim to increase awareness amongst clinical practitioners that molecular level testing, using immunohistochemistry, next-generation sequencing and chromogenic in-situ hybridization can help in making chemotherapeutic decisions for this variant of pancreatic cancer. We present a 50-year-old male who presented to our hospital complaining of persistent abdominal pain. CT scan revealed a pancreatic tail mass that was invading the splenic flexure causing high-grade obstruction. There was evidence of peritoneal studding. He underwent exploratory laparotomy with biopsy of the pancreatic mass and omentum which revealed metastatic undifferentiated pleomorphic large cell pancreatic cancer. Since there is no proven treatment for this particular entity, his specimen was sent for molecular testing. The molecular studies revealed positive mutations of TLE3 gene, EGFR, KRAS, PD1 gene, TP53 and TOP2A gene. The tumor was found to be sensitive to gemcitabine, paclitaxel, docetaxel, temozolamide, dacarbazine and doxorubicin. He was initiated on gemcitabine and nab-paclitaxel. The patient was treated based on these recommendations. The patient completed 5 cycles of gemcitabine and nab-paclitaxel. Treatment had to be held because of gemcitabine induced hemolytic uremic syndrome. Serial CT scans have shown stable disease and currently it has been 10 months since his diagnosis. Molecular level testing can be an important instrument in not only diagnosing but also be an important aid in deciding about the chemotherapeutic agents to be used in cases of metastatic pleomorphic large cell pancreatic cancer. Availability a knowledge of the novel tools like immunohistochemistry, next-generation sequencing and chromogenic in-situ hybridization can be prudent and treating some rare forms of pancreatic cancer as in this patient.

A case of pulmonary adenocarcinoma harboring osteoclast-like giant cells: Its evaluation by immunohistochemical and genetic analyses

Tumors harboring osteoclast-like giant cells (OGCs) at extraosseous site are extremely rare. These rare tumors have been detected most frequently in the pancreas and few pulmonary tumors harboring OGCs have been previously reported. In addition, the genetic profiles of these tumors have remained virtually unknown. Therefore, we report a case of pulmonary adenocarcinoma harboring OGCs in which k-ras mutation and immunohistochemical study of proteins associated with OGCs were examined. The case was a 70-year-old man, who demonstrated a pulmonary mass associated with unusual radiological features. Histopathologically, three different cell types, mucinous adenocarcinoma cell, OGC and mononuclear cell were detected. OGCs were immunohistochemically negative for epithelial markers and positive for histiocytic markers but mononuclear cells were immunopositive for epithelial markers. In addition, both mononuclear and adenocarcinoma cells had the same k-ras mutation profiles and mononuclear cells were immunohistochemically positive for macrophage colony-stimulating factor (M-CSF), one of the factors associated with OGC differentiation. Therefore, mononuclear cells were considered to be derived from neoplastic epithelium and OGCs could represent non-neoplastic cells. In addition, M-CSF locally produced could promote the differentiation of OGCs.

Undifferentiated carcinoma of the head of pancreas with osteoclast-like giant cells presenting as a symptomatic cystic mass, following acute pancreatitis: Case report and review of the literature

INTRODUCTION

Undifferentiated head of pancreas carcinoma with osteoclast-like giant cells (UC-OGC) is a rare neoplasm, with less than a hundred cases reported. We present such a case, in which the UC-OGC presented atypically as a cystic lesion following acute pancreatitis and led to late diagnosis.

PRESENTATION OF CASE

A 75-year-old female patient, who had suffered acute pancreatitis three years ago, was referred with a diagnosis of osteoclast-like giant cell (OGC) tumor of the head of pancreas. She had suffered acute pancreatitis three years ago. Two years ago she developed abdominal pain, steatorrhea and weight loss. Abdominal computed tomography imaging showed a cystic mass in the head of the pancreas (maximum diameter 4cm). The initial diagnosis was pancreatic pseudocyst; however as the mass gradually increased in size and the patient continued to be symptomatic, a CT-guided biopsy was performed. Histological examination revealed an OGC pancreatic tumor. In laparotomy a large (9cm) encapsulated heterogeneous mass was found with partial involvement of the common hepatic artery. Pancreaticoduodenectomy was performed and the involved part of the common hepatic artery was replaced with a homologous graft from the major saphenous vein. Post-operative course was uneventful. Histology revealed an undifferentiated pancreatic adenocarcinoma with OGCs. She survived 10 months after the operation.

DISCUSSION

Pancreatic undifferentiated carcinomas with OGCs are very rare neoplasms and can present with an atypical clinical picture.

CONCLUSIONS

A symptomatic cystic lesion of the pancreas, which is growing in size, should be investigated promptly in order to exclude the presence of malignancy.

Osteoclastic giant cell rich squamous cell carcinoma of the uterine cervix: a case report and review of the literature

Cervical carcinoma is the most common malignancy of the female genital tract and represents the second most common malignancy in women worldwide. Histologically 85 to 90% of cervical cancers are squamous cell carcinoma. Osteoclastic giant cell rich squamous cell carcinoma is an unusual histological variant of which only 4 cases have been reported. We present the case of a 49-year-old woman with a 6-month history of irregular vaginal bleeding. Examination revealed a 2.7 cm polypoid mass in the anterior lip of the uterine cervix. The patient underwent hysterectomy with bilateral salpingo-oophorectomy. Microscopically the tumor was composed of infiltrative nests of poorly differentiated nonkeratinizing squamous cell carcinoma. Interspersed in between these tumor cells were numerous osteoclastic giant cells with abundant eosinophilic cytoplasm devoid of nuclear atypia, hyperchromatism, or mitotic activity. Immunohistochemistry was performed; CK and P63 were strongly positive in the squamous component and negative in the osteoclastic giant cells, while CD68 and Vimentin were strongly positive in the giant cell population and negative in the squamous component. The patient received chemo- and radiotherapy for recurrent disease identified 3 months later on a follow-up CT scan; 7 months after the surgical procedure the patient is clinically and radiologically disease-free.