Acute pancreatitis revealing diffuse infiltration of the pancreas by melanoma

Nonsurgical Approach to Isolated Pancreatic Metastatic Malignant Melanoma: A Case Report and Review of the Literature

Isolated pancreatic metastases from melanoma are rare with high mortality rate and account for less than 1% of metastatic melanomas. Treatment options are limited with highest overall survival reported in those with complete surgical resection. Of cases reported in the literature with nonsurgical management, highest length of survival was reported to be 10 months. We report a case of malignant melanoma with isolated pancreatic metastasis treated with interferon therapy and immunotherapy, with evidence of progressive tumor shrinkage and survival at 38 months.

Isolated pancreatic metastasis from malignant melanoma: a case report and literature review

Isolated pancreatic metastasis from malignant melanoma is rare. Pancreatic metastasis is difficult to diagnose in patients with unknown primary malignant melanoma. Endoscopic ultrasound-guided fine-needle aspiration plays an important role in confirming the diagnosis. A 67-year-old woman was referred to our institution because of a mass in her pancreas. Computed tomography and magnetic resonance imaging revealed a 35-mm mass localized on the pancreatic tail, with low attenuation, surrounded by a high-attenuation rim. Endoscopic ultrasonography revealed a hypoechoic mass with central anechoic areas. Endoscopic ultrasound-guided fine-needle aspiration of the mass was performed, and the pathological diagnosis was malignant melanoma. Intense fluorodeoxyglucose uptake was observed in the pancreatic tail on positron emission tomography-computed tomography. No other malignant melanoma was found. Distal pancreatectomy was performed. Six months postoperatively, positron emission tomography-computed tomography revealed high uptake in the left nasal cavity, and biopsy revealed the mass to be a malignant melanoma, indicating that the primary site of the malignant melanoma was the left nasal cavity and that the pancreatic mass and peritoneal lesion were metastases. The patient had survived > 2 years after the distal pancreatectomy. Pancreatic resection of isolated pancreatic metastasis can possibly prolong survival; however, metastatic melanoma usually has poor prognosis.

Surgically resected pancreatic metastasis from nasal malignant melanoma: case report and literature review

A 13-mm mass was observed in the pancreatic head of a 70-year-old woman who had undergone melanoma resection in the nasal cavity 10 years earlier. Endoscopic ultrasonography (EUS) showed that the mass consisted of multiple hypoechoic nodules. EUS-guided fine needle aspiration and pancreatic juice cytologies revealed neoplastic cells positive for HMB45 and melan-A staining with a few melanin granules, indicating the presence of a metastatic malignant melanoma. These additional stainings were evaluated after surgery. In the surgically resected specimen, the mass had multiple nodule-like structures, some of which were brown colored. Immunocytochemistry and electronic microscopy findings confirmed the diagnosis of malignant melanoma. Microscopic findings were similar to the nasal specimen; therefore, the pancreatic lesion was considered to be a metastasis from the nasal cavity.

Metastatic primary pulmonary melanoma successfully treated with checkpoint inhibitors

Our patient is a 69-year-old man who presented to the emergency department with left-sided hemiparesis that started 4 hours prior to presentation. Brain CT showed right basal ganglia and internal capsule haemorrhagic strokes. MRI revealed multiple brain lesions suspicious for metastases. Further workup revealed a 5 cm lung mass and a 1 cm pancreatic nodule. Biopsy of both pulmonary and pancreatic lesions was consistent with melanoma and was similar histologically. The patient underwent cyberknife stereotactic radiosurgery to the brain metastases followed by immunotherapy with pembrolizumab, and then by nivolumab and ipilimumab. The patient remains free of disease progression 2 years after treatment.

Value of pancreatic resection for cancer metastatic to the pancreas

BACKGROUND

Cancer metastatic to the pancreas from other primary sites is uncommon, and it has been treated with an aggressive surgical approach in fit patients when the primary tumor is controlled and the pancreas is the only site of metastatic disease. The value of pancreatic resection in this setting is unclear. The purpose of this study was to review cases of cancer metastatic to the pancreas.

METHODS

We reviewed our experience with cancer metastatic to the pancreas and the literature regarding resection of pancreatic metastases. Patient and tumor characteristics were summarized using descriptive statistics.

RESULTS

A total of 220 patients with pancreatic metastasis were analyzed. Three patients were selected from our own experience, and 217 were selected from a literature review. In the 127 patients whose symptoms were recorded at the time of presentation, the most common presenting symptoms were jaundice (n=32, 25.2%) and abdominal pain (n=25, 19.7%). In the 189 patients for whom the location of the metastasis in the pancreas was revealed, the most common location was the head of the pancreas (n=79, 41.8%). The primary tumor site was most commonly kidney (n=155, 70.5%). Surgical resection was attempted in 177 of 220 patients; 135 patients suffering from renal cell carcinoma (RCC) metastasis also underwent pancreatic resection. In the latter group, a median survival of 70 mo was seen, as well as 78% and 65% 2- and 5 y survival rates, respectively.

CONCLUSION

Survival after resection of RCC with isolated metastasis to the pancreas is favorable. However, a more detailed analysis considering outcomes without surgery for each primary tumor site is needed before the value of this aggressive surgical approach can be completely assessed in the general occurrence of pancreatic metastasis.

Surgical treatment of metastatic tumors to the pancreas: a single center experience and review of the literature

BACKGROUND

Unlike primary pancreatic carcinoma, metastases to the pancreas are rare, and their resection may be performed as palliative treatment. The aim of this study was to review our experience with the operative management of pancreatic metastases.

MATERIALS AND METHODS

Between January 1994 and December 2004 13 patients (nine women and four men; median age: 59 years; range: 36-79 years) were admitted to our institution with metastatic lesion to the pancreas. The clinical features of the treatment and results were examined.

RESULTS

Primary tumors were renal cell carcinoma (n=5), lobular carcinoma of the breast (n=3), endometrioid carcinoma of the ovary (n=1), colonic adenocarcinoma (n=1), jejunal leiomyosarcoma (n=1), melanoma (n=1), and non-small-cell lung cancer (n=1). The median interval between primary tumor and pancreatic metastases was 36 months (range: 5-192 months). Six patients (46%) were asymptomatic, while the other seven patients presented with jaundice, pain, and duodenal obstruction. Two patients with extrapancreatic disease underwent palliative surgery, and the remaining 11 patients underwent operative procedures that included seven pancreaticoduodenectomy and four distal pancreatectomies with splenectomy. Postoperative mortality was nil, and the morbidity rate was 30%. The two patients who underwent palliative surgery died after 7 and 9 months, respectively. The median survival of the resected patients was 26 months (range: 13-95 months). Five patients died of disease, eight are alive at the time of this report.

CONCLUSION

A trend towards improved survival, even if not statistically significant, was observed in the renal carcinoma patients reported here. Surgical resection can be performed safely in selected patients with isolated metastases to the pancreas, achieving long-term survival as well as good palliation.

Pancreatic metastases: observations of three cases and review of the literature

BACKGROUND

The aim of the study is to analyze pancreatic metastases and their clinical, radiological, therapeutic and prognostic features.

METHODS

Three cases of pancreatic metastases observed and a world literature review of 333 cases were recorded.

RESULTS

Pancreatic metastases are due more frequently to renal cell carcinoma; they are usually metachronous and characterized by a long period of time between the resection of the primary tumor and their detection. The differential diagnosis with other pancreatic masses is difficult, but an accurate anamnesis, some peculiar findings of imaging techniques and percutaneous fine needle aspiration could allow preoperative diagnosis. Pancreatic resections are the treatment of choice allowing the better palliation and improving survival. 150/234 pancreatic metastases underwent pancreatic resections (resectability index = 64.1%); 88/132 patients are alive with a mean follow-up of 27.1 months; of the 44 dead patients the mean survival time was 21.3 months. Among pancreatic metastases the primary tumor with better prognosis is renal cell carcinoma.

CONCLUSION

Pancreatic metastases are rare; their preoperative diagnosis is difficult but useful and possible. Surgical resection is suggested because the patient still may have a prolonged survival.