Osteosarcoma metastatic to the pancreas in young patients

Metastasis of Osteosarcoma to the Abdomen: A Report of Two Cases and a Review of the Literature

Two cases of primary distal femur osteosarcoma with subsequent metastasis to the abdomen are presented. In both cases, the development of abdominal metastasis was quickly followed by patient decline and death. A review of the literature was performed, assessing the presentation and survival of patients with osteosarcoma metastasized to the abdomen. As illustrated by the current cases and the literature review, abdominal metastasis in osteosarcoma is often a late manifestation and terminal prognostic indicator. Nonetheless, early detection and prompt intervention of this less common site of disease metastasis may improve patient care and palliative therapy.

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 involvement in neuroblastoma with radiologic-pathologic correlation: a single-institution experience

OBJECTIVE

Pancreatic involvement in neuroblastoma is extremely rare, with few cases reported in the literature. We present imaging findings of pancreatic involvement in neuroblastoma with clinical and pathologic correlation in the largest documented series to date.

SUBJECTS AND METHODS

We prospectively reported pancreatic involvement evident on multimodality imaging in neuroblastoma patients presenting to our institution from 1997 to 2011. Lesions were classified according to location within the pancreas, and imaging features were correlated with cytogenetic and surgicopathologic findings.

RESULTS

Neuroblastoma involving the pancreas was evident on imaging of seven of 1031 patients (mean age, 6.6 years). One patient had pancreatic involvement at presentation, and six developed pancreatic disease at relapse or disease progression. Pancreatic lesions were most frequently initially identified on concurrent CT and (123)I-metaiodobenzylguanidine scintigraphy, and additional lesions initially were found on MRI and ultrasound. Five of seven patients had focal lesions, one had diffuse pancreatic involvement, and one had pancreatic extension from contiguous disease. The distribution of lesions favored the pancreatic body and tail. All patients had International Neuroblastoma Staging System stage 3 or 4 disease, Children's Oncology Group intermediate- or high-risk disease, and unfavorable histology at initial diagnosis. For the five patients with surgical correlation, pancreatic surgical specimens revealed neuroblastoma in three cases and ganglioneuroblastoma in two cases.

CONCLUSION

Although rare, pancreatic involvement in neuroblastoma occurs. Its variable imaging appearance should be considered when evaluating the retroperitoneum in patients with known or suspected neuroblastoma, particularly because increased patient survival holds the potential for uncommon patterns of recurrence.

Pancreatic metastasis from osteosarcoma and Ewing sarcoma: literature review

OBJECTIVES

Pancreatic metastasis from osteosarcoma and Ewing sarcoma is extremely rare. Differential diagnosis with primary pancreatic carcinoma is crucial before any treatment, but may be very difficult.

MATERIAL AND METHODS

We searched for and reviewed the cases reported in the English literature.

RESULTS

Twelve cases were identified, including nine osteosarcoma patients and three Ewing sarcoma cases. The median time between the sarcoma diagnosis and that of pancreatic metastasis was 3 years. In most of the cases, the pancreatic relapse followed or was associated with relapse(s) in one or more sites. Two out of eight patients with available follow-up were alive without disease 6+ and 11+ months after complete surgical removal, whereas five patients died from disease. Histological diagnosis was obtained before surgery in only five cases using percutaneous Tru-Cut biopsy in three cases and endoscopic ultrasound-guided fine needle aspiration biopsy (EUS-FNAB) in the two most recent ones.

CONCLUSIONS

Osteosarcoma or Ewing sarcoma metastasis should be included in the differential diagnosis of pancreatic solid lesion, particularly in patients with a primary tumor. In this context, EUS and EUS-FNAB are reliable methods for the pre-operative diagnosis and should thus be discussed before any therapeutic decision.

Pancreatic and peripancreatic diseases mimicking primary pancreatic neoplasia

A variety of anatomic variants and pathologic conditions in and around the pancreas may simulate primary pancreatic neoplasia at routine abdominal cross-sectional imaging. An ambiguous lesion whose appearance suggests a pancreatic origin requires a broad differential diagnosis that can subsequently be narrowed on the basis of both clinical history and features at optimal computed tomography (CT) and magnetic resonance (MR) imaging. Pancreas-specific multidetector CT and MR imaging techniques with thin collimation, multiplanar and multiphasic scans, and newly introduced curved planar reformation may help avoid potential diagnostic pitfalls. These techniques can help identify and characterize a mass in multiple viewing planes, thereby helping distinguish a true pancreatic neoplasm from peripancreatic adenopathy or from a tumor of the adjacent duodenum or small bowel. They can also help determine the cause of a tumor. It is important that the radiologist be familiar with the wide spectrum of anatomic variants and disease entities that can mimic primary pancreatic neoplasia in order to initiate the appropriate lesion-specific work-up and treatment and avoid unnecessary tests or procedures, including surgery.

Diagnosis of nonprimary pancreatic neoplasms by endoscopic ultrasound-guided fine-needle aspiration

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a proven modality for the diagnosis of primary pancreatic neoplasms. We describe our experience in diagnosing nonprimary pancreatic tumors by EUS-FNA. Cytology files were searched for all EUS-FNA of the pancreas for the period 2000-2002. All cases diagnosed as neoplasms were selected and those diagnosed as nonprimary pancreatic tumors were reviewed and analyzed. One hundred ninety-one of 468 cases were diagnosed as neoplasms. Eleven of these cases were diagnosed as nonprimary pancreatic tumors (2.4% of all diagnoses and 5.7% of all neoplasms). The diagnoses were supported by clinical history (n = 7), cytological findings (n = 11), cell block histology (n = 11), cell block immunohistochemistry (n = 6), and flow cytometry (n = 1). EUS-FNA is a safe and minimally invasive method for the diagnosis of nonprimary pancreatic neoplasms. Evaluation of clinical history, cytomorphology, and ancillary techniques, especially those applied to cell block material, are essential for accurate diagnoses.

Late relapse of osteosarcoma: implications for follow-up and screening

Long-term disease-free survival in patients with localised osteosarcoma treated in large multicentre randomised trials is over 50%. Most relapses occur early, usually within 2-3 years. Relapse after 5 years is uncommon and has been infrequently described. Eight patients with osteosarcoma treated at The London Bone and Soft Tissue Tumour Service since 1986 developed recurrence of disease after 5 years, the latest 14 years after the initial diagnosis. Five patients developed pulmonary metastases, two patients isolated bone metastases and one patient intra-abdominal metastases. Although a second complete remission was achieved in six patients, four patients relapsed again, all with pulmonary metastases. Two patients had co-existent brain metastases. One of those with a second recurrence has achieved a further complete remission and remains well 50 months after the most recent treatment. A second patient is disease-free 24 months after complete excision of an isolated pulmonary metastasis and one further patient is disease-free 6 months after chemotherapy and pneumonectomy for pleural and pulmonary metastases. Five patients have died of disease with a median survival from the date of relapse of 17 months (2-68 months). Current data looking at long-term outcome of patients with osteosarcoma is limited. Reports of late relapse are rare as numbers are small, thus long-term surveillance of patients is essential. It is possible that sites of relapse are more unusual, and more extensive staging may be necessary when late relapse occurs.

Diagnosis, treatment and outcome of pancreatoblastoma

BACKGROUND

Pancreatoblastoma is a rare tumour mainly presenting in childhood but also in adults.

OBJECTIVES

The aim was to determine the clinical course of pancreatoblastoma by an analysis of reported cases.

METHODS

Patients with pancreatoblastoma were identified from Medline and combined with patients identified from the Royal Liverpool University Hospital.

RESULTS

There were 153 patients with a median (range) age at presentation of 5 (0-68) years and a male:female ratio of 1.14:1. The most frequent site was the head of pancreas (48/123, 39%). The median and 5-year (95% CI) survival rates were 48 months and 50% (37-62%) respectively. At presentation there were 17 (17%) out of 101 patients with metastases, the liver being the commonest site (15/17, 88%). On univariate analysis, factors associated with a worse prognosis were synchronous (p = 0.05) or metachronous metastases (p < 0.001), non-resectable disease at presentation (p < 0.001) and age > 16 years at time of presentation (p = 0.02). On multivariate analysis, resection (p = 0.006) and metastases post-resection (p = 0.001) but not local recurrence influenced survival.

CONCLUSIONS

Pancreatoblastoma is one of the pancreatic tumours with a relatively good prognosis. The treatment of choice is complete resection with long-term follow-up aiming to treat any early local recurrence or metastasis.

Imaging findings of extrapulmonary metastases of osteosarcoma

PURPOSE

To review imaging findings of extrapulmonary metastasis from osteosarcoma and to evaluate them for any consistent pattern and correlation between imaging findings.

MATERIALS AND METHODS

This study was retrospectively conducted in 13 patients with extrapulmonary metastasis of pathologically confirmed osteosarcoma. We evaluated the radioisotope (RI) scans (n=16), ultrasonography (USG) (n=4), computed tomography (CT) scans (n=10), MRIs (n=6), clinical records, and pathological reports for assessment of imaging findings and correlation between radiologic findings and RI uptake of the lesions. Points evaluated were the following: uptake on RI scans, presence of mineralization on CT, and MRI, size, enhancement pattern, attenuation on CT, signal intensity (SI) on MRI, and echogenicity on USG.

RESULTS

Extrapulmonary metastatic sites were diverse, including another bone other than the primary site (n=6), lymph node (n=4), pleura (n=2), liver (n=2), pancreas (n=1), kidney (n=1), peritoneum (n=1), muscle (n=1), and subcutaneous fat layer (n=1). One patient had tumor growth within the pulmonary artery and jejunum. Among 21 metastatic sites in 13 patients, bone scan was performed in 16 cases and RI uptake was detected in 10 lesions. Calcification was detected in eight lesions on radiologic imaging, including plain radiography, USG, CT, and MRI. Two lesions showed RI uptake without definite calcification or ossification on MRI and plain radiography, respectively. We analyzed the enhancement pattern and mass size in 18 metastatic sites and these factors had poor correlation with uptake on RI scans.

CONCLUSION

The sites and imaging findings of extrapulmonary metastasis of osteosarcoma were variable. All the lesions with mineralization were detectable on RI scans prior to radiologic imaging. RI scan has a limited role in the evaluation of metastatic lesions without mineralization.

Secondary tumors of the pancreas: an analysis of a surgical and autopsy database and review of the literature

The vast majority of pancreatic carcinomas are primary, and, among these, more than 90% are of ductal origin. However, a variety of extrapancreatic tumors may involve the pancreas secondarily and may manifest different clinicopathological characteristics and outcomes. In this study, pathology material from 973 surgical specimens and 4955 adult autopsy cases was reviewed to identify the tumors metastatic to or secondarily involving the pancreas. Biliary and periampullary neoplasms and tumors confined to peripancreatic soft tissue were excluded. In the autopsy series, the pancreas was involved by tumor in 190 cases, and 81 of these were secondary tumors. These were predominantly of epithelial origin, most commonly from lung (34), followed by GI tract (20), kidney (4), breast (3), liver (2), ovary (1), and urinary bladder (1). In addition, there were six tumors of hematopoietic origin, two melanomas, two sarcomas, and two mesotheliomas. Among the 973 surgical specimens, 38 cases contained metastatic tumors to the pancreas. Of these, 11 were lymphomas, and the others were carcinomas of stomach (7), kidney (6), lung (2), liver, prostate, ovary, uterus (1 case of each), and a Merkel cell carcinoma. In addition, there were three malignant gastrointestinal stromal tumors and one retroperitoneal leiomyosarcoma. In conclusion, lung cancer is the most common source of metastasis to pancreas, followed by gastrointestinal carcinomas and lymphomas. These tumors are usually seen in patients with disseminated disease and are detected mainly in autopsies. Secondary tumors constitute about 4% of pancreatic specimens in the authors' surgical database. Approximately one-third of them are clinically mistaken as primary tumors of the pancreas. These are predominantly hematopoietic malignancies or carcinomas of renal or gastric origin. Secondary tumors should be entertained in both the clinical and pathological differential diagnosis of pancreatic neoplasia.

Lace-like enhancement pattern of osteosarcoma of rib and liver metastasis in CT scans

The rib is an uncommon site of osteosarcoma. With the use of adjuvant chemotherapy and aggressive surgical resection of the metastatic pulmonary lesions, extrapulmonary metastases are becoming more clinically evident. Primary rib osteosarcoma with extrapulmonary metastasis is exceedingly rare. A case is reported, showing that the pattern of metastasis of rib osteosarcoma is similar to that of primary bone osteosarcoma. The liver metastasis occurred after resection of the metastatic pulmonary lesions. A CT scan of the primary rib lesion and liver metastasis both showed a lace-like enhancement pattern, its histological appearance corresponding with neoplastic osteoid. With the increasing use of CT abdomen for localization of extrapulmonary metastases, lace-like enhancement may be seen more readily in the future.

Intra-abdominal metastases in musculoskeletal sarcomas

This study examined the incidence, histological type, clinical symptoms, and prognosis in patients with intra-abdominal metastases of musculoskeletal sarcomas. The medical records of 505 patients with musculoskeletal sarcomas were reviewed for examples of intra-abdominal metastases. The incidence of intra-abdominal metastases (excluding lung) was: 4% in the liver (20 patients), 1.2% in gastrointestine (6 patients), 0.8% in pancreas (4 patients), and 0.8% on the peritoneal surface (4 patients). Patients with a previous hisory of lung metastases and those with high-grade liposarcoma tended to show metastasis in the intra-abdominal organs. Most patients with liver metastasis had no symptoms. Patients with gastrointestinal metastasis had abdominal pain, anemia, and melena. Patients with pancreatic metastasis had diabetes and jaundice. Six patients underwent surgical treatment, and two of them survived for more than 2 years. Metastases within the abdomen must be considered as a possible site for dissemination of musculoskeletal sarcomas, especially in patients with advanced disease and those with liposarcoma.

Surgical treatment for pancreatic metastasis from soft-tissue sarcoma: report of two cases

We present two cases in which a soft-tissue sarcoma metastasized to the pancreas, but both patients survived as a result of repetitive surgical treatment during a 6- to 10-year period. The first case was a 29-year-old man who had a history of removal of mesenchymal chondrosarcoma in the left thigh in 1986 and who underwent distal pancreatectomy and the enucleation of a tumor in the head of the pancreas because of the development of three metastatic lesions in 1989. Afterward, although metastases were found in other organs, they were resected each time (for a total of five times) and the patient has survived over 10 years. The second case was a 40-year-old woman who had a history of the removal of synovial sarcoma in the right thigh and had 6 surgical resections of local or pulmonary recurrent tumors. She underwent pylorus-preserving pancreaticoduodenectomy in 1993 because of the development of a solitary metastatic lesion in the pancreas and survived more than 6 years after the pancreatectomy. Our report suggests, in selected cases, that long-term survival from pancreatic metastasis of soft-tissue sarcoma is expected as a result of curative resection. However, because pancreatic metastasis has a potential to recur in other organs, it is necessary to take aggressive surgical procedures repeatedly for the treatment of recurrences to improve prognosis after pancreatectomy.

Metastatic osteosarcoma presenting as a small-bowel polyp. A case report and review of the literature

Gastrointestinal metastases of osteosarcoma are an extraordinarily rare event and, as far as we can determine, have been reported previously only 5 times; these cases represent an unusual pattern of progression. We describe a 21-year-old man with an osteosarcoma of the right tibia that was removed 4 years previously. Two years later, the patient showed lung metastases. At his most recent presentation, he complained of abdominal pain, nausea, vomiting, and anorexia. Radiologic examination revealed an abdominal mass close to the jejunum and 3 nodules in the liver. One metastasis was an ulcerated and pedunculated polypoid mass located in the mucosa of the bowel, and the other involved the entire thickness of the jejunum. This unusual phenomenon represents an alteration in the natural history of osteosarcoma as a result of increased long-term survival.