Pleomorphic carcinoma of the pancreas: reappraisal of surgical resection

Prognostic indicators for undifferentiated carcinoma with/without osteoclast-like giant cells of the pancreas

BACKGROUND

Undifferentiated carcinoma of the pancreas (UPC) is a rare malignancy. There are no standardized guidelines for treatment. Current management has been extrapolated from smaller reviews.

METHODS

858 patients with UPC were identified in the 2004-2017 NCDB. Kaplan-Meier method followed by Cox proportional-hazards regression examined independent prognostic factors associated with overall survival (OS). Logistic regression analyses were performed to determine independent predictors of surgical intervention and the status of surgical resection by histologic subtype.

RESULTS

Patients with osteoclast-like giant cells (OCLGC) had a longer median OS compared to those without (aHR 0.52: 95% CI 0.41-0.67). Of the non-OCLGC subtypes, pleomorphic large cell demonstrated the shortest median OS (2.4 months). Surgical resection was associated with improved survival in all histologies except for pleomorphic cell carcinoma. R0 resection and negative lymph nodes were independently associated with an improved OS.

CONCLUSION

This is the largest database review published to date on UCP. OCLGC histology is associated with an improved survival compared to those without OCLGC. Of the non-OCLGC subtypes, pleomorphic large cell is associated with the shortest overall survival. Surgical resection is associated with a significant survival advantage for all histologies except for pleomorphic cell carcinoma.

An Autopsy Case of Anaplastic Carcinoma of the Pancreas in a 39-Year-Old Woman that Developed from Hereditary Pancreatitis

Patient: Female, 39-year-old

Final Diagnosis: Anaplastic carcinoma of the pancreas • pancreatic cancer

Symptoms: Epigastralgia • jaundice

Medication: —

Clinical Procedure: —

Specialty: Gastroenterology and Hepatology • Oncology

Clinical Characteristics and Overall Survival in Patients with Anaplastic Pancreatic Cancer

Anaplastic pancreatic cancer (APC) is a rare undifferentiated variant of pancreatic ductal adenocarcinoma with poor overall survival (OS). The aim of this study was to evaluate the clinical outcomes of APC compared with differentiated pancreatic ductal adenocarcinoma. We conducted a retrospective review of all patients treated at the Mayo Clinic with pathologically confirmed APC from 1987 to 2011. After matching with control subjects with pancreatic ductal adenocarcinoma, OS was evaluated using Kaplan-Meier estimates and log-rank test. Sixteen patients were identified with APC (56.3% male, median age 57 years). Ten patients underwent exploration of whom eight underwent pancreatectomy. Perioperative morbidity was 60 per cent with no mortality. The median OS was 12.8 months. However, patients with APC who underwent resection had longer OS compared with those who were not resected, 34.1 versus 3.3 months ( P = 0.001). After matching age, sex, tumor stage, and year of operation, the median OS was similar between patients with APC and those with ductal adenocarcinoma treated with pancreatic resection, 44.1 versus 39.9 months, ( P = 0.763). Overall survival for APC is poor; however, when resected, survival is similar to differentiated pancreatic ductal adenocarcinoma.

A Comparison of the Pathological Types of Undifferentiated Carcinoma of the Pancreas

OBJECTIVES

This study aimed to identify the detailed clinicopathological features of undifferentiated carcinoma of the pancreas (UCP).

METHODS

We investigated clinical, imaging features and the prognoses of 261 patients; 8 were our patients, and the remainder were identified by searching English-language articles in PubMed.

RESULTS

We classified patients with UCP into 3 types based on pathological findings: osteoclast-like giant cell-associated carcinoma, pleomorphic cell carcinoma (PLC), and spindle cell carcinoma. There were no remarkable differences in clinical, radiological features between these 3 types. However, PLCs were significantly more likely to be unresectable than were the other 2 types (P < 0.001). Patients with osteoclast-like giant cell-associated carcinoma achieved the best overall survival (OS) rates (P < 0.001), whereas those with spindle cell carcinoma had significantly longer OS rates than did those with PLC (P = 0.004). These OS patterns were maintained when considering only those patients who underwent resection. Patients with PLC had both lower curative resection and high lymph node metastasis rates (P = 0.029, P = 0.023). Patients who underwent resection had more favorable prognoses than did those who did not.

CONCLUSIONS

Surgery is the first choice for resectable UCP. Pleomorphic cell carcinoma is particularly malignant; postoperative treatment should be introduced immediately.

Expression of Epithelial-Mesenchymal Transition Proteins in Pancreatic Anaplastic (Undifferentiated) Carcinoma

OBJECTIVES

The aim of this study was to identify an association of pancreatic anaplastic carcinoma (APC) with the epithelial-mesenchymal transition (EMT).

METHODS

Resected APCs (n = 24) were examined to assess components of APCs, including carcinomatous, transitional, and sarcomatous regions. Analysis was performed based on the immunoreactivity of E-cadherin and 3 EMT-related proteins: Slug (zinc finger protein SNAI2), Twist (Twist-related protein 1), and Zeb1 (zinc finger E-box-binding homeobox 1). Expression score was determined based on staining intensity and stained area of the target cells. Finally, we performed a hierarchical clustering based on the expression pattern of E-cadherin and EMT-related proteins of the sarcomatous component.

RESULTS

The expression score of E-cadherin decreased in the order of sarcomatous > transitional > carcinomatous components (P < 0.01). Although there were significant differences in the immunohistochemical scores of Slug, Twist, and Zeb1 between carcinomatous and transitional components (P < 0.01), the significant difference in immunohistochemical score of Zeb1 between transitional and sarcomatous components was found (P < 0.05). Furthermore, APCs were divided into 2 subgroups based on the expression patterns of E-cadherin and EMT-related proteins (hierarchical clustering analysis). Consequently, these subgroups were distinguished by Twist expression.

CONCLUSIONS

Epithelial-mesenchymal transition plays an essential role in the pathogenesis of APC.

Anaplastic pancreatic cancer diagnosed with endoscopic ultrasound guided fine needle aspiration showing hypervascular tumor: A case report

RATIONALE

Pancreatic ductal carcinoma is a hypovascular tumor, and characteristic findings are observed on imaging modalities, such as computed tomography (CT) and magnetic resonance imaging (MRI), in most cases.

PATIENT CONCERNS

Here we report a case of anaplastic carcinoma of the pancreas (ACP) with characteristics of hypervascular tumor diagnosed by endoscopic ultrasound guided fine needle aspiration (EUS-FNA). A 70-year-old woman was admitted to hospital because of exacerbation of diabetes. Contrast-enhanced CT revealed a hypervascular tumor at the head of the pancreas.

DIAGNOSIS

EUS-FNA was performed. Osteoclast-like giant cells and tumor cells with polymorphic nuclei were found on pathological examination and she was diagnosed with ACP.

INTERVENTIONS

Although it was a surgical indication at the time of diagnosis, the tumor rapidly worsened. Oral administration of TS-1 (tegafur/gimeracil/oteracil) was initiated. Chemotherapy was discontinued after the end of 2 courses because the tumor had increased prominently on CT.

OUTCOMES

She died approximately a year since the onset of the illness.

LESSONS

ACP occasionally exhibits the characteristics of a hypervascular tumor and may require differentiation from other pancreatic tumors, such as neuroendocrine tumor. Therefore, pathological diagnosis by EUS-FNA at an early stage is important to determine treatment strategies.

Rare Tumors and Lesions of the Pancreas

There are a few entities that account for most solid and cystic masses of the pancreas. The pancreas harbors a wide array of diseases, including adenocarcinoma, and its variants, such as anaplastic and adenosquamous carcinoma. Other neoplasms include acinar cell carcinoma, solid pseudopapillary tumor, and sarcomas. Benign lesions include hamartomas, hemangiomas, lymphangioma, and plasmacytoma. Isolated metastases include renal cell carcinoma, melanoma, and other carcinomas. Benign inflammatory conditions, such as autoimmune pancreatitis and groove pancreatitis can also mimic solid neoplasms of the pancreas.

A case of long-term 24-month survival in pancreatic anaplastic carcinoma (giant cell type) after S1 postoperative adjuvant chemotherapy

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The prognosis for patients with anaplastic carcinoma of the pancreas is reported much poorer even if resected.

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S-1 is more effective for anaplastic carcinoma of the pancreas.

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Adjuvant chemotherapy with S-1 in patients with resected anaplastic carcinoma of the pancreas is recommended.

We herein describe the case of a 70-year-old female patient diagnosed with pancreatic carcinoma. An abdominal enhanced computed tomography scan revealed a poorly enhanced mass (17 mm × 15 mm in size) in the pancreatic head. Magnetic resonance cholangiopancreatography revealed stenosis of the main pancreatic and common bile ducts caused by a mass-neighboring cyst. Based on these findings, we performed subtotal stomach-preserving pancreaticoduodenectomy. The patient demonstrated a good postoperative course, and was discharged from our hospital in remission 49 days after the surgery. Pathological findings confirmed that it was anaplastic pancreas carcinoma (giant cell type). After the surgery, we performed S-1 adjuvant chemotherapy 100 mg/day for four weeks, repeated similarly every six weeks for a total of four courses.

We have followed this case for over 2 years so far with adjuvant chemotherapy, and no recurrence or metastasis has been revealed. Adjuvant chemotherapy with S-1 in patients with resected anaplastic carcinoma of the pancreas is also recommended as a result of Japan Adjuvant Study Group of Pancreatic Cancer 01(JASPAC-01) like the ordinary pancreatic ductal carcinomas. There is a possibility to achieve long-term survival in cases in which multidisciplinary treatment such as a curative resection and adjuvant chemotherapy are performed.

Establishment and characterization of new cell lines of anaplastic pancreatic cancer, which is a rare malignancy: OCUP-A1 and OCUP-A2

BACKGROUND

Anaplastic pancreatic cancer (APC) cell lines have been scarcely established.

METHODS

The morphology, gene expressions, karyotyping and epithelial-mesenchymal transition markers of newly established APC cell lines OCUP-A1 and OCUP-A2 were analyzed. Their abilities of proliferation under normoxia and hypoxia, migration and invasion were compared to 4 commercially available pancreatic ductal adenocarcinoma (PDA) cell lines. Their induction of angiogenesis, stem-like cell population and subcutaneous tumor growth in nude mice were estimated, comparing 2 PDA cell lines examined here.

RESULTS

OCUP-A1 and OCUP-A2 cells continuously grew with spindle and polygonal shapes, respectively. Gene analysis revealed 9 gene mutations including KRAS and TP53. Karyotyping clarified numerical structural abnormalities in both cells. Loss of E-cadherin and expression of vimentin in both cell lines were observed. The doubling time of both cell lines was approximately 20 h. Proliferation, migration and invasion abilities were not notable compared to other PDA cell lines. However stem-like cell population of both cell lines was superior to a part of PDA cell lines. Moreover OCUP-A1 showed stronger hypoxia tolerance and induction of angiogenesis than other PDA cell lines. The tumorigenicity in vivo of OCUP-A2 was stronger than conventional PDA cell lines.

CONCLUSIONS

The OCUP-A1 and OCUP-A2 cell lines of rare malignancies might be useful for investigating the biology of pancreatic cancer.

Huge undifferentiated carcinoma of the pancreas with osteoclast-like giant cells

Undifferentiated carcinoma of the pancreas with osteoclast-like giant cells (OGCs) is very rare, less than 1% of all pancreatic malignancies, and shows worse prognosis than that of invasive ductal adenocarcinoma of the pancreas. We present a case of en bloc resection for a huge undifferentiated carcinoma with OGCs that invaded the stomach and transverse mesocolon. A 67-year female was admitted for left upper quadrant pain and computed tomography demonstrated a mass occupying the lesser sac and abutting the stomach and pancreas. There were no distant metastases and the patient underwent subtotal pancreatectomy with splenectomy, total gastrectomy, and segmental resection of the transverse colon. Histopathological examination confirmed an 11 cm-sized undifferentiated carcinoma of the pancreas with OGCs. Immunohistochemical staining revealed reactivity with pan-cytokeratin in adenocarcinoma component, with vimentin in neoplastic multi-nucleated cells, with CD45/CD68 in OGCs, and with p53 in tumor cells, respectively. The patient had suffered from multiple bone metastases and survived 9 mo after surgery. This case supports the ductal epithelial origin of undifferentiated carcinoma with OGCs and early diagnosis could result in favorable surgical outcomes. Investigations on the surgical role and prognostic factors need to be warranted in this tumor.

Anaplastic carcinoma of the pancreas mimicking submucosal gastric tumor: a case report of a rare tumor

Anaplastic carcinoma of the pancreas (ACP) is a rare neoplasm of the pancreas. ACPs are aggressive neoplasms with a poorer prognosis than poorly differentiated ductal adenocarcinomas of the pancreas. The 3-year survival rate of patients with ACP is less than 3%, with a life expectancy of 10 to 20 months. We describe here a 64-year-old man with ACP mimicking a submucosal gastric tumor. The patient was found to have a giant mass mimicking a submucosal tumor. Total gastrectomy with splenectomy and partial resection of the tail of the pancreas were performed. The pathological diagnosis was ACP, with immunohistological findings showing pleomorphic-type ACP. Because the surgery was noncurative, the patient received adjuvant chemotherapy with paclitaxel but died of peritoneal dissemination and multiple liver metastases 4 months after surgery.

Clinical outcomes for anaplastic pancreatic cancer: a population-based study

BACKGROUND

Anaplastic pancreatic cancer (APC) is a rare subtype of pancreatic ductal adenocarcinoma (PDA) that can carry a worse overall survival (OS) when compared with other variants. However, the presence of osteoclast-like giant cells (OCGCs) in APC specimens can predict improved OS. The aim of this study was to evaluate the OS of patients with APC (with and without OCGCs) compared with patients with other subtypes of PDA using a population-based registry.

STUDY DESIGN

We identified all patients in the Surveillance, Epidemiology and End Results (SEER) database with pathologically confirmed APC and PDA diagnosed between 1988 and 2008. Overall survival was evaluated using Kaplan-Meier and Cox proportional hazard regression.

RESULTS

The study cohort included 5,859 (94.3%) patients with PDA and 353 (5.7%) with APC. Overall survival for all patients with APC was significantly worse than for patients with PDA (hazard ratio [HR] = 1.9; 95% CI, 1.7-2.1; p < 0.001); however, in the subgroup of resected patients, APC (n = 81) had similar OS to PDA (n = 3,517) (HR = 0.9; 95% CI, 0.7-1.2; p = 0.37). Patients with APC tumors with OCGCs (n = 11) demonstrated improved OS when compared with all other APC variants without OCGCs (n = 342) (HR = 0.3; 95% CI, 0.1-0.7; p = 0.004), but this survival difference was not observed in the subgroup of resected patients (HR = 0.5; 95% CI, 0.2-1.4; p = 0.18).

CONCLUSIONS

Anaplastic pancreatic cancer is a rare malignancy with poor OS. The diagnosis of APC with OCGCs is predictive of improved OS compared with other patients with APC. This survival benefit, however, is not observed in patients with resected disease.

Complete response of anaplastic pancreatic carcinoma to paclitaxel treatment selected by chemosensitivity testing

A 58-year-old woman was admitted to our institute in June 2007 because of obstructive jaundice. A mass in the pancreatic head and multiple swollen lymph nodes surrounding the common hepatic artery were identified using computed tomography (CT). Subsequently, endoscopic ultrasonography-guided fine-needle aspiration biopsy (EUS-FNA) was done. Histopathologic results revealed anaplastic carcinoma of the pancreas. Using specimens obtained with EUS-FNA, chemosensitivity testing with adenosine triphosphate assay was performed. Testing indicated high chemosensitivity to paclitaxel (PTX). According to this result, chemotherapy using PTX was performed, and the primary lesion and lymph node metastases disappeared completely on CT. The patient has been doing well with no recurrence for 1 year and 11 months since initial chemotherapy.

Endoscopic ultrasound-guided fine-needle aspiration for the diagnosis of anaplastic pancreatic carcinoma: a single-center experience

OBJECTIVES

Anaplastic carcinoma of the pancreas (ACP) is an aggressive variant of ductal adenocarcinoma. The aim of this study was to describe a single-center experience with the use of endoscopic ultrasound (EUS) with or without fine-needle aspiration (FNA) for the diagnosis of ACP.

METHODS

The cytology and surgical pathology databases were searched for a diagnosis of ACP between 1992 and 2008. Demographic, clinical,surgical, radiographic, pathological, and EUS data were abstracted.

RESULTS

Thirteen patients with ACP were identified, which represented 0.8% of all pancreatic cancers diagnosed during the study period. Six of 13 patients had EUS. Features of these 6 tumors: median diameter of 42 mm (range, 20-100 mm), hypoechoic (n = 6), solid (n = 3) or mixed solid and cystic (n = 3), heterogeneous (n = 5) or homogeneous (n = 1),and well defined (n = 2) or poorly defined (n = 4) borders. Five underwent EUS-FNA of a pancreatic mass, and cytology demonstrated ACP in 4 and ductal adenocarcinoma in 1. The diagnosis of ACP was confirmed after surgical resection in 2 of these 5, including one in whom cytology demonstrated only adenocarcinoma. The sixth patient had EUS without FNA, and surgical pathology after distal pancreatectomy found ACP.

CONCLUSIONS

Anaplastic carcinoma of the pancreas has variable endosonographic features. Endoscopic ultrasound-FNA may assist in the cytological diagnosis of these tumors.

A case of anaplastic carcinoma of the pancreas producing granulocyte-colony stimulating factor

We report a case of anaplastic carcinoma of the pancreas with production of granulocyte-colony stimulating factor (G-CSF) in a 59-year-old male. He was referred to our hospital with a chief complaint of epigastralgia and suffered from leukocytosis. Differential diagnosis included pancreatic tumors and submucosal tumor of the stomach, but definite preoperative diagnosis could not be made. He underwent distal pancreactomy, total gastrectomy with Roux-en-Y reconstruction and splenectomy. He recovered uneventfully postoperatively and was discharged from hospital on the 14th postoperative day. Histological examination showed anaplastic carcinoma of the pancreas. Since the peripheral leukocyte count was sharply decreased after the operation, we suspected the tumor would be producing G-CSF. Then immunohistochemistry showed a positive stain in the tumor. Therefore, we diagnosed the tumor as anaplastic carcinoma of the pancreas producing G-CSF. Three months after the resection, local recurrence was detected by abdominal computed tomography. The patient died of hemorrhagic shock due to tumor invasion of the intestine 8 months after the operation.