Lung adenocarcinoma presenting as obstructive jaundice: a case report and review of literature

Isolated Pancreatic Metastasis from a Lung Adenocarcinoma Primary: A Case Report and Literature Review

Isolated pancreatic metastasis is a rare occurrence and is commonly misdiagnosed as primary pancreatic malignancy. We present a case of a 65-year-old female patient with a history of stage IIIA lung adenocarcinoma, who developed significant epigastric pain 27 months after diagnosis and treatment of a primary lung adenocarcinoma. This patient was found to have a pancreatic head lesion initially suspected to be a primary pancreatic neoplasm but eventually discovered to be a metastatic lesion from the previously treated primary lung adenocarcinoma.

Painless jaundice as an initial presentation of lung adenocarcinoma

Malignant bile duct obstruction is a common entity in clinical practice and is infrequently caused by non-biliopancreatic neoplasms. We report the case of a male admitted with malignant obstruction of the biliary tract, showing after numerous studies that this obstruction was the initial presentation of a stage IV adenocarcinoma of the lung. Pulmonary neoplasms have variable behaviors being often spread at time of diagnosis, especially in the more aggressive subtypes. However, it is uncommon its manifestation as obstructive jaundice and when this happens it is usually due to liver damage and not to metastases to periampullary region that are extremely infrequent. In this case, the role of pathological anatomy and immunohistochemistry was essential in identifying the origin of the tumor and starting targeted treatment, since the clinical presentation and usual laboratory and image tests did not allow to differentiate it from a primary cholangiocarcinoma.

Solitary Skull Metastasis as the First Presentation of a Metachronous Primary Lung Cancer in a Survivor from Pancreatic Cancer

Skull metastasis from lung cancer is relatively common, yet the first presentation for this malignant disease is a rare occurrence. We herein report a case of a 54-year-old female, who had a good outcome following Whipple procedure for periampullary adenocarcinoma five years before her current presentation. During a routine follow-up, she was found to have a slowly progressive painless right parietal swelling. The systemic screening workup revealed no abdominal disease, but a solitary pulmonary nodule was identified. The presence of these two lesions raised the diagnosis of metastases from a previously treated pancreatic adenocarcinoma. The patient underwent complete excision of the skull lesion and subsequent lung biopsy, both of which proved on histopathological examination to be consistent with a primary lung cancer. This case emphasizes the importance of imaging and histopathological correlation in the diagnosis of solitary skull metastases and their effect on the subsequent management.

A presenting with obstructive jaundice in pulmonary adenocarcinoma: a case report

INTRODUCTION

Obstructive jaundice caused by metastases to the distal common bile duct or the ampulla of Vater is often observed in patients with various advanced cancers; however, metastasis of lung cancer to the ampulla of Vater with subsequent development of jaundice is rare.

CASE PRESENTATION

The patient was a 41-year-old Chinese female who presented with apparent jaundice and itching. An enlarged right supraclavicular lymph node was found during physical examination. Laboratory tests revealed significantly elevated bilirubin and aminotransferase. Imaging examinations, including ultrasonography, computed tomography (CT), and magnetic resonance cholangiopancreatography (MRCP) revealed a 3.1×2.5×2 cm mass in the distal common bile duct and the ampulla of Vater. The routine chest x-ray film revealed a 4-cm nodule in the upper lobe of the left lung and further CT scan confirmed the diagnosis of left lung cancer. A biopsy of supraclavicular lymph node was performed and the histopathology showed poorly differentiated adenocarcinoma with cytokeratin-7 (CK-7) and thyroid transcription factor-1 (TTF-1) being positive immunohistochemically. The patient underwent a pylorus preserving pancreaticoduodenectomy and the histology of the resected specimen revealed characteristic of pulmonary adenocarcinoma. Thus, the final diagnosis was periampullary metastasis from pulmonary adenocarcinoma. The patient's postoperative recovery was uneventful and the jaundice was disappeared one month later. A pulmonary lobectomy was followed by chemotherapy with combination of vinorelbine and cisplatin for six cycles.

CONCLUSION

Similar situations are bound to occur again in the future and we believe that this report could demonstrate that there is a case for aggressive surgical management in patients with periampullary metastasis from pulmonary adenocarcinoma.

Gastrointestinal bleeding due to pancreatic metastasis of non-small cell lung cancer: A report of two cases and a literature review

The current study presents two cases of gastrointestinal (GI) bleeding due to pancreatic metastasis of non-small cell lung cancer (NSCLC). The two patients had a history of lung adenocarcinoma prior to pancreatic metastasis. The first patient presented with melena, epigastric pain and weight loss, and the second patient presented with melena and weight loss. The diagnoses were confirmed by biopsy of the metastatic lesions. Immunohistochemistry is useful for managing the differential diagnosis between lung cancer and pancreatic carcinoma in patients with a history of lung cancer. Chemotherapy prolonged the survival of the second patient. However, the first patient received no chemotherapy and succumbed to NSCLC six weeks after the diagnosis of metastatic pancreatic cancer. GI bleeding as a result of pancreatic metastasis of NSCLC is extremely rare; including the present two cases, only three cases have been reported in the English literature. The current study is presented in order to increase the awareness of GI hemorrhage as a manifestation of this relatively rare condition.

Resection of oligometastatic lung cancer to the pancreas may yield a survival benefit in select patients--a systematic review

OBJECTIVES

To conduct a systematic review of the existing literature regarding surgical therapy for oligometastatic lung cancer to the pancreas.

METHODS

Data was collected on patients with singular pancreatic metastases from lung cancer from papers published between January 1970 and June 2014. This was performed following the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) guidelines. Kaplan-Meier and Cox Regression analyses were then used to determine and compare survival.

RESULTS

There were 27 papers that fulfilled the search criteria, from which data on 32 patients was collected. Non-small cell lung cancer (NSCLC) was the most prevalent type of primary lung malignancy, and metachronous presentations of metastases were most common. Lesions were most frequently located in the pancreatic head and consequently the most common curative intent metastasectomy was pancreaticoduodenectomy. There was a statistically significant survival benefit for patients whose metastasis were discovered incidentally by surveillance CT as opposed to those whose metastasis were discovered during a work up for new somatic complaints (p = 0.024). The overall median survival for patients undergoing curative intent resection was 29 months, with 2-year and 5-year survivals of 65% and 21% respectively. Palliative surgery or medical only management was associated with a median survival of 8 months and 2-year and 5-year survivals of 25% and 8% respectively.

CONCLUSIONS

Curative intent resection of isolated pancreatic metastasis from lung cancer may be beneficial in a select group of patients.

Metastatic tumors to the pancreas: The role of surgery

Pancreatic metastases from other primary malignancies are a rare entity. By far, the most common primary cancer site resulting in an isolated pancreatic metastasis is the kidney, followed by colorectal cancer, melanoma, breast cancer, lung carcinoma and sarcoma. Only few data on the surgical outcome of pancreatic resections performed for metastases from other primary tumor have been published, and there are no guidelines to address the surgical treatment for these patients. In this study, we performed a review of the published literature, focusing on the early and long-term results of surgery for the most frequent primary tumors metastasizing to the pancreas. Results for the Literature’s analysis show that in last years an increasing number of surgical resections have been performed in selected patients with limited pancreatic disease. Pancreatic resection for metastatic disease can be performed with acceptable mortality and morbidity rates. The usefulness of pancreatic resection is mainly linked to the biology of the primary tumor metastasizing to the pancreas. The benefit of metastasectomy in terms of patient survival has been observed for metastases from renal cell cancer, while for other primary tumors, such as lung and breast cancers, the role of surgery is mainly palliative.

Resection for secondary malignancy of the pancreas

OBJECTIVES

This study tried to clarify the role of pancreatic resection in the treatment of secondary malignancy with metastasis or local invasion to the pancreas in terms of surgical risk and survival benefit.

METHODS

Data of secondary malignancy of the pancreas from our 19 patients and cases reported in the English literature were pooled together for analysis.

RESULTS

There were 329 cases of resected secondary malignancy of the pancreas, including 241 cases of metastasis and 88 cases of local invasion. The most common primary tumor metastatic to the pancreas and amenable to resection was renal cell carcinoma (RCC) (73.9%). More than half (52.3%) of the primary cancers with local invasion to the pancreas were colon cancer, and nearly half (40.9%) were stomach cancer. The median metastatic interval was 84 months (7 years) for overall primary tumors and 108 months (9 years) for RCC. The 5-year survival for secondary malignancy of the pancreas after resection was 61.1% for metastasis and 58.9% for local invasion, with 72.8% for RCC metastasis, 69.0% for colon cancer, and 43.8% for stomach cancer with local invasion to the pancreas.

CONCLUSIONS

Pancreatic resection should not be precluded for secondary malignancy of the pancreas because long-term survival could be achieved with acceptable surgical risk in selected patients.

Metastatectomy for extra-cranial extra-adrenal non-small cell lung cancer solitary metastases: systematic review and analysis of reported cases

BACKGROUND

Although patients with stage IV non-small cell lung cancer (NSCLC) have a poor prognosis, a subset of patients with solitary brain or adrenal metastasis have more favorable outcome following surgical resection. Nevertheless, the outcome and predictive factors for survival following metastatectomy for patients with other metastatic sites are not well defined.

METHODS

We performed a systematic review using PUBMED database for all articles which included patients with NSCLC and solitary metastasis to sites other than the adrenal gland or the brain who had undergone resection of their metastasis and definitive treatment of the primary lung cancer. Potential prognostic factors on survival including age, sex, histology, T and N stage of the primary tumor, synchronous vs. metachronous presentation, visceral vs. non-visceral metastasis and the use of perioperative chemotherapy were analyzed using multi-variable Cox proportional hazard model.

RESULTS

62 cases were eligible for the analysis. The 5-year survival rate was 50% for the entire cohort. Mediastinal lymph node involvement was independently predictive of inferior outcome; 5-year survival rate 0% vs. 64% in favor of no involvement, p<0.001. Similarly, patients with intra-thoracic stage III disease had an inferior outcome compared to patients with stage II and stage I disease: 5-year survival rate 0% vs. 77% and 63%, respectively, p<0.001. Other factors have no effect on outcome.

CONCLUSION

Selected patients with distant metastatic NSCLC can achieve long term survival following metastatectomy and definitive treatment of the primary tumor. Mediastinal lymph node involvement is associated with poor prognosis.

Surgical treatment of oligometastatic non-small cell lung cancer

Patients with stage IV metastatic non-small cell lung cancer (NSCLC) are generally believed to have an incurable disease. Patients with oligometastatic disease represent a distinct subset of patients among those with metastatic disease. There is evidence that these patients have synchronous or metachronous satellite nodules in different pulmonary lobes or have solitary extrapulmonary metastases. In these cases, evidence has shown that surgical resection may provide patients with survival benefit. This article discusses the biology of the oligometastatic state in patients with lung cancer and the selection of patients for surgery, as well as the prognostic factors that influence survival of the patient. To properly select patients for an aggressive local treatment regime, accurate clinical staging is of prime importance. The use of FDG-PET should be considered for restaging if oligometastatic disease is suspected based on a patient's CT scan. A limitation of retrospective clinical studies for oligometastatic disease is that it is difficult to summarize and evaluate the available evidence for the effectiveness of surgical resection due to selection bias, and to a high degree of variability among different clinical studies. Nevertheless, we can certainly learn from the clinical experience acquired from retrospective case series to identify prognostic factors. Following surgical resection, the overall 5-year actuarial survival rate is about 28% for patients with satellite nodules and 21% for patients with ipsilateral nodules. Patients with resected brain metastasis achieve 5-year survival rates between 11% and 30%, and those with adrenalectomy for adrenal metastasis achieve 5-year survival rates of 26%.

Pancreatic metastases: An increasing clinical entity

Pancreatic metastases, although uncommon, have been observed with increasing frequency recently, especially by high-volume pancreatic surgery centers. They are often asymptomatic and detected incidentally or during follow-up investigations even several years after the removal of the primary tumor. Renal cell cancer represents the most common primary tumor by far, followed by colorectal cancer, melanoma, sarcoma and lung cancer. Pancreatic metastasectomy is indicated for an isolated and resectable metastasis in a patient fit to tolerate pancreatectomy. Both standard and atypical pancreatic resection can be performed: a resection strategy providing adequate resection margins and maximal tissue preservation of the pancreas should be pursued. The effectiveness of resection for pancreatic metastases is mainly dependent on the tumor biology of the primary cancer; renal cell cancer is associated with the best outcome with a 5-year survival rate greater than 70%.

Acute cholangitis due to pancreatic metastasis from squamous cell lung carcinoma: a case report and review of literature

Introduction

The pancreas is a well-documented but relatively uncommon site of non-small-cell cancer metastases. However, at the time of diagnosis the disease is usually locoregionally advanced, therefore therapeutic management is mostly palliative and symptomatic.

Case Presentation

We report the case of a 77-year-old Caucasian male patient who presented initially with a clinical picture of acute cholangitis approximately 2 years after a left lower lobectomy for a low-grade squamous lung carcinoma. CT scan imaging of the abdomen and chest revealed an abnormal growth of the pancreatic head and distention of both the intra- and extra-hepatic billiary tree, whereas osteolytic abnormalities were observed of the 5th left rib, consistent with secondary deposits. Initially an endoscopic retrograde cholangio-pancreatography (ERCP) and sphincterectomy was performed and a plastic stent was placed in the common bile duct to decompress the biliary tree. Cytological examination of the aspirate collected by FNA of the pancreatic lession under EUS guidance revealed cells consistent with a low grade squamous lung carcinoma. Two months later an open cholecystectomy along with a gastrojejunostomy was performed to relieve the patient's gastric outlet obstruction symptoms. Following remission of the patient's attack of acute cholangitis and excessive vomiting he was released from the hospital and instructed to initiate chemotherapy with vinorelbine. The patient succumbed to disseminated disease almost 5 months later.

Conclusion

Symptomatic metastatic lesions of the pancreas from squamous cell carcinoma of the lung are infrequent. Typically, the patients remain asymptomatic until their disease reaches a fairly advanced stage and therapeutic options are limited to palliative measures. A high index of suspicion is the only way of early detection and potentially effective treatment for this rare localization of metastatic squamous lung carcinoma.