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1、-最新资料推荐最新资料推荐-Lung adenocarcinoma presenting asLung adenocarcinoma presenting asobstructive jaundice a case report and review ofobstructive jaundice a case report and review ofliteratureliterature W orld Journal of Surgical Oncology Bio M e d Central ReviewO p en Access Lung adenocarcino ma presenti
2、ng as obstructivejaundice: a case report and review of literature StephanosPericleous 1 , Samrat Mukherjee 2 and Robert R Hutchins* 2Address: 1 Department of HPB Surgery, Imperial College, Hammersmith Hospital campus, Du Cane Road, London, UK and 2DepartmentofHPBSurgery,RoyalLondonHospital,Whitechap
3、el,London,UKEmail:StephanosPericleous-s.pericleousimperial.ac.uk;SamratMukherjee-samrat.mukherjeerwh-tr.nhs.uk;RobertRHutchins*-robert.hutchinsbartsandthelondon.nhs.uk*Correspondingauthor Published: 11 November 2008 Received: 19 April 2008Accepted: 11 November 2008 World Journal of Surgical Oncology
4、2008,6:120doi:10.1186/1477-7819-6-120Thisarticleisavailable from: /content/6/1/1202008 Pericleous et al;licensee BioMed Central Ltd. This is an Open Access articledistributedunderthetermsoftheCreativeCommonsAttributionLicense(mons.org/licenses/by/2.0),which1 1 / 2121permits unrestricted use, distrib
5、ution, and reproduction inany medium, provided the original work is properly cited.Abstract Background: Lung cancer is known to metastasizeto the pancreas with several case reports found in theliterature, however, most patients are at an advancedstage and receive palliative treatment. Case presentat
6、ion:We describe the case of a 56 year old male patient whopresentedwithapictureofobstructivejaundice.Investigationsrevealedanobstructinglesioninthepancreas anda further lesion inthe lung with benignappearances. The patient underwent a pancreatectomy and,unexpectedly,thehistologyoftheresectedspecimen
7、demonstratedmetastaticadenocarcinomaofbronchogenicorigin. He was referred to a cardiothoracic team whoproceeded to resect the patients thoracic lesion beforeadministration of adjuvant chemotherapy.The patient wasreviewed 18 months post operatively and remains symptom freewith no clinical or radiolog
8、ical evidence of recurrence. Wewere unable to identify any previous case reports (of lungadenocarcinoma)withsuchapresentationwhichwereultimatelytreatedwithresectionofbothlesions.Conclusion: Similar situations are bound to arise again-最新资料推荐最新资料推荐-in the future and we believe that this report couldde
9、monstratethatthereisacaseforaggressivesurgicalmanagementinahighlyselectedgroupofpatients:thosewithNSCLCandasynchronoussolitarypancreatic deposit. Background biliary stent insertion. Inthe few cases where operative intervention is considered,it is usually limited to a biliary bypass torelieve thejaun
10、dice. That a variety of malignant tu mours can metastasiseto the pancreasiswelldocu mented.Severalcasereportshave reported patientswith lungcancer whoseclinical presen- tation was that of obstructive jaundice1. W e describe an unusual presentation where an adenocar-cino ma of the lung with a synchro
11、nous solitary metastaticdepositin thepancreas(notvisible onCT)wastreated with operativeresectionof both lesions.Theuniqueness of this case is enhanced by the fact that bothlesionswereidentifiedpreoperativelyalthoughtheirnature was not. M ost patients presenting in thismannerareatan advancedstage wit
12、hwidespreaddisease,andare usually managed symptomatically.Thisgenerallyinvolves pallia- tivechemotherapyand/or3 3 / 2121radiotherapy coupled with other measures to relievethe biliary obstruction such as Page 1 of 6 (p numb r n tr ci t t i n purp s s) age e o fo a o o e World Journal ofSurgicalOncolo
13、gy2008,6:120/content/6/1/120Casepresentation A 56 year old male lawyer presented to hislocal hospital co mplaining of a recent change in hisurine colour (to bright orange) and general malaise. Thepatient suffered from moderate bronchiectasis and asthmafor which he took inhalers (fluticasone propiona
14、te,salmeterol and ipratropium bromide). He was also knownto be hyper- tensive (controlled on diltiazem) and sufferedfrom severe eczema. He had never been a smoker but hisdaily con- sumption of alcohol amounted to 1.5 bottles ofwine. Initial workuprevealed derangedliver functiontests and relevant tum
15、our markers were raised (Ca 19-9181 kU/l, CEA 25.8 ?g/l). A subsequent abdo minalultrasound showed biliary dilatationto the level of thepancreas. This was confirmed on an MRCP. However CT (64slicefine cutspiral pancreasprotocolCT)and MRIexaminations failed to reveal any pancreatic mass (figure1). An
16、ERCP whichfollowed confirmedthelower CBDstricturewith features of external compressionand a-最新资料推荐最新资料推荐-plastic biliary stent was inserted. CTFiguscanre 2chest C Tscan chest. Lesion in the right lung. The patient was thenreferred to our unit for further treat- ment. The workingdiagnosis at this sta
17、ge was a pancreatic tumour and thepatient underwentstaging with a view to apancreaticresection. Unusually, as part of the initial workup,the patient had had a CT of his thorax, showing a right lunglesion, thought to be benign, on a background of known chronicrespiratorydisease (figure2). AFDG-CTFigu
18、scanre1abdomen C T scan abdom en.Stent visible in bile duct.FDGFigurPETe 3 scan F D G PET scan. Lesion in the right lung.Page 2 of 6(page number not for citation purposes) WorldJournal of Surgical Oncology 2008, 6:120 /content/6/1/120PETscan was performed to delineate the lung lesion fur- ther(figur
19、e 3). This scan was reported as positive, thusraising the possibility of: A lung primary with pancreaticmetastasisSynchronouspancreatic and lung primariesApancreatic primary with lung metastasis CT guided biopsyof the lung lesion was performed, the histology of whichshowed reactive changes but no ev
20、i- dence of malignancy.Assuchandinviewofthepatientsbackgroundof5 5 / 2121respiratory disease thePET scan was inter-preted asdemonstrating reactive changes. Given the pres- entation,tumourmarkers,imagingappearancesand biopsyresultstheworkingdiagnosisremainedthatofapancreatic cancer with no evidence o
21、f metastatic disease.High(Fimigmurumagnificationeno5histochemviewicalsoftainlesioning wireseHigh magnification view of lesionresected fro m the pancreas (imm unohistoche mical stainingwith TTF- 1). The patient proceeded to a pylorus preservingpancreati- coduodenectomy (PPPD). There was no evidence o
22、fintra- abdo minalspreadat laparotomy.Theheadofthe pan- creas contained a palpable mass. This was resectedin rou- tine fashion. The histology of the resected specimenwasasinglepoorlydifferentiatedadenocarcinoma(figure 4) (11 m m in maximu m dimension) staining stronglyposi- tive to TTF-1 and CK7 (fi
23、gure 5), and negative stainingfor CK20 and PSA. The tumour did not approach any of theresection margins or surfaces. Also, none of the surround- ing16 lymph nodeshad any evidenceof disease. bronchialorigin rather than as a primary pancreatic lesion.As a result the patient was referred to a thoracic
24、sur- geonfor consideration of rem oval of the lung lesion. Six-最新资料推荐最新资料推荐-weeks later the patient underwent a mini thoracotomywhere a 2 3 cm lesion was identified in the medial seg-ment of the upper lobe of the right lung. The segment wasremoved along with hilar and mediastinal lymph nodes forstag
25、ing. Histology of this specimen reported a lungadenocarcinoma with complete excision and no lymph nodeinvolvement.Inviewofthereportedimmunohistochemicalprofile,coupledwiththeidentificationofalunglesion,the tumour wasinterpreted as metastatic adenocarcino ma of Three weeksafter his lung resection the
26、 patient was started on adjuvantche motherapy with gemcitabine and carbo- platin. Thisregime was continued for 6 months. The patient wasseen eighteen months from presentation. Clinically heremained sympto m free and a follow-up CT of his chest andabdo men revealed no evidence of recur- rence. Discus
27、sionPancreaticcanceris oneofthe leadingcausesofcancer deaths ranking 4th in the US and 6th in Europe 2. How-ever, little attention is devoted to secondary depositsof other tumours to the pancreas. Retrospective studieson pancreatectomy procedures have reported that metastatic7 7 / 2121disease repres
28、ents merely 3% or so of resected malignantpancreatic masses 3,4. As such they are often mistaken aspancreaticprimariesandonly recognisedforwhattheytrulyareinretrospectonhistologicalexamination5. So me98%ofpatientswithamalignant process who present with obstructive jaundicewill do so as a result of a
29、 primary pancreatic cancer6. On the other hand, autopsy statistics suggestthatthepancreasisaandmorefre-HighF(hiageumrmagnificationeato4xylinvieweosinof)lesion resected from the pancreas High magnification view oflesion resected fro m the pancreas (hae matoxylin and eosin).Page 3 of 6(page number not
30、 for citation purposes) WorldJournal of Surgical Oncology 2008, 6:120 /content/6/1/120quentsite for metastatic disease, albeit on a subclinicalscale. The incidence of secondary pancreatic tumours is up to16% of autopsy studies 7, with a wide variation of pri- marycancersresponsible.Patientswhopresen
31、twithaclinical picture which relates directly to disease in the pan-creas at presentation will tend to do so with the symptoms ofobstructive jaundice or pancreatitis 8. More oftenthan not these patients prove to have advanced disease-最新资料推荐最新资料推荐-which is only amenable to palliative treatment. Table
32、 1: Sum mary of world literature on pancreatic metastases fro m lungcancer Lung cancer histology subtype Small Cell Lung Cancer(22) Adenocarcinoma 1 (4) Large Cell (2) Squamous Cell (2)Anaplastic bronchial (1) Lung Cancer 2 (4)Presenting sym pto ms Obstructive Jaundice 1 (15) Acute Pancreatitis (13)
33、No Symptoms 3 (5) Gastrointestinal bleed (1) Not Available(1) Lungcancermetastasizestomanysites,butmost fre- quently to bone, the liver and the adrenalglands 9,10. Approximatelyonethirdofpatientswill present with sympto ms relating to extra thoracicspread10. The pan- creasis consideredto beaninfrequ
34、ent target to which lung cancer will metastasizeto. Figures are reported in the range of 012% 11-13. Themajority of those which do are of SCLC histological subtype14. Rarer still, at pres- entation, is for lung cancerto presentwith a clinicalpic- Treat ment Received 4Palliative Chemotherapy (13) Bil
35、iary stent (8) PalliativeOperation (4) Best Supportive Care (7) Pancreatic Resection(6) Adjuvant Chemotherapy (2) Exploratory laparotomy (1)Includes our case. 2 No further information from authors 39 9 / 2121Includes patients who were identified on surveillance. 4 Somepatientsreceivedtureofjaundiced
36、uetosynchronousmetastatic adenocarcinoma 1. Inthose cases where itdoes, this is m ore likely to be due to widespread hepaticdisease than to extrahepatic biliaryobstruction 15. Alarger subgroup of patients with lung cancer will develop ametachronous pancreatic metastasis, which will usually beidentif
37、iedon follow-upinvestigations.Onerecentcase report pub- lished in March 2008 reports the firstcase of lung adeno- carcino ma with a metachronous isolateddeposit in the pancreas and no evidence of other disease.This case was treated with biliary stenting and palliativechemotherapy 16. more than one t
38、reatment. papers reviewed:6,8,16,17,19-38,47 cino mas. In a series of twelve patientswith a variety of dif- ferent metastatictumours to thepancreas, Le Borgne et al 38, suggest that a moreaggressivesurgicalapproach shouldbeconsidered,especiallyin patientswithmeta- chronousampullaryand pancreatic dep
39、osits from renal cell carcino m as,sarcomasandcarcinoidtumours.Theyreported35%survival rate at 2 years and 17 % at 4 years. Of secondarydeposits discovered in the pancreas, lung cancer makes-最新资料推荐最新资料推荐-up (along with renal cell carcinoma,breast and gastriccancer) a high percentage (table 1) 7,17-3
40、6. Indicativepublished figures are 14.2% (49 of 311 second- ary tumours)7, 17.0% (18 of 108)18 and 18.2% (4 of 22) 17. The largemajority of cancer patients with meta- static disease tothepancreasaretreatedwithpalliative intent aspatients usually present with widespreaddisease. W heresurgery is conte
41、mplated, it is usually limited tobypass procedures in patients with obstructive jaundice.There have been reports where patients with this presenta- tionhave undergone more major procedures such as pan- creaticresection37, but this has tended to be inignorance of the fact that the aetiology of the ob
42、structionwas of metastatic origin, as was in our case. There are sev-eral publicationsadvocatingtheconsiderationof apan- creatic resection in selected cases. One ofthese is a literature review by Minni et al, where 333cases with sec- ondary depositsin the pancreaswerereviewed. Of these, 234 had trea
43、tment information ofwhich150(64.1%) underwent pancreaticresections 3.More than 25 differ- ent histologic types are reported1111 / 212145.0% of which were renal cell, 14.7% lung, 7.5% breastand 6.6%colonic car- StageIV NSCLChasapoorprognosis.Median survival with best supportive care isreported as 3.6
44、 m onths (range, 2.4 to 4.9 months) whilstplatinu m based chemotherapy regimes increase this statisticto 6.5 months (range, 4.7 to 8.5 months). This patientisaliveanddiseasefree18 m onthsfollowingpresentation.Itisacceptedpracticetodaytoconsider selectedpatients withsolitary intracra- nialdeposits fo
45、r resection 39-41. Also it has been sug-gested repeatedly that a survival benefit may be achievedbysurgicaltreatmentofsolitaryextracranialspread of NSCLC 42-46. The experience and informationavaila- ble forthesurgical treatmentofmetastaticdisease from the lung exclusively to the pancreas is verylimi
46、tedandfewguidelinesareavailableontheappropriate management of such cases. M ost series describetreatment which, from the outset had a palliative intent.Hiotis et al 47, how- ever, report three cases ofpatientswithmetachronous (information frompersonalcorrespondence with author) NSCLC metastatic dise
47、ase to thepancreas who underwent Page 4 of 6(page number not for citation-最新资料推荐最新资料推荐-purposes) World Journal of Surgical Oncology 2008, 6:120/content/6/1/120pancreatectomies with curative intent. Allpatients devel- oped recurrence. 5. 6. Doring C, Lindlar F:Clinically a primary lung carcino madur-
48、 ingautopsymetastasisofapancreaticcancer. MedWelt 1969,8:407-411. Zgraggen K, Fernandez-del CC, Rattner D W, SigalaH, W arshaw AL: M etastases to the pancreas and their surgicalextirpation. Arch Surg 1998, 133:413-417. Conclusion In themajority of cancers, synchronous presentation gen- erallycarries
49、 a worse prognosis than a metachronous one. O ur caseis an example of a synchronous metastatic depositresected (albeit) inadvertently. However, resec- tionof both lesions has led to long-term disease-free sur-vival.Thereforewebelievethatthisreportdemonstrates that in selected cases consideration sho
50、uldbe given not just to palliation but to potentiallycurativesurgery whetherit be synchronousor morelikelymetachronouspresentationofmetastaticlungcancer to the pancreas. This is very different from whathas been described previ- ously where very few operationswith curative intent have been carried ou
51、t, in particular on1313 / 2121patientswith NSCLC. 7. 8. Cubilla AlFPJ: Tumors of theExocrine Pancreas 1980, 137:. Kim KH, Kim CD, Lee SJ, Lee G,Jeen YT, Lee HS, Chun HJ, Song C W, U m SH, Lee S W, Choi JH,Ryu HS, Hyun JH: Metastasis-induced acute pancreatitis inapatient with small cell carcino ma of
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59、 creatic metastasis andobstructive jaundice in sm all cell lung carcino ma. Korean1515 / 2121J Intern Med 2006, 21:132-135. Liratzopoulos N, EfremidouEI, Papageorgiou MS, Romanidis K, Minopoulos GJ, ManolasKJ:Extrahepaticbiliaryobstructionduetoasolitarypancreatic metastasis of squa mous cell lung ca
60、r- cino ma. Casereport. J Gastrointestin Liver Dis 2006, 15:73-75. ChowhanNM,MadajewiczS:Manage mentofm etastases-induced acute pancreatitis in small cell carcino maofthelung.Cancer1990,65:1445-1448.Listofabbreviations CT: ComputedTomography;MRCP: MagneticResonance Cholangiopancreatography; ERCP: En
61、doscopicRetro- grade Cholangiopancreatography; CBD: Co m m onBile Duct; FDG-PET: Fluorodeoxyglucose Positron emissiontomography; NSCLC: Non-small cell lung carcino ma;TTF-1: Thyroid Transcription Factor-1; PSA: Prostate Spe-cific Antigen; CK7, CK20: Cytokeratin 7, Cytokeratin 20. 17.Consent Written
62、consent was sought and obtainedfrom the patient prior to publication of this article. 18.19. Co m peting interests The authors declare that they haveno competing interests. Author s contributions 20. 21. SPoperated on the patient, conducted the collection ofthe data and the literature and conceived
63、the case report.S Mwas involvedincollection ofliteratureand-最新资料推荐最新资料推荐-drafting the article. RRH was the principal investigator,operated onthepatientcollecteddataandwasinvolved in the drafting of the article. 22. 23. All theauthors have read and approved the final manu- script.EvansAT:Necrotisingp
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80、. Ann Surg Oncol2019, 9:675-679. 47. Publish with Bio M e dCentral and everyscientist can read your work free of charge Bio Med Central willbe the most significant developm ent for disseminating theresults of biomedical research in our lifetime. Sir Paul Nurse,Cancer Research UK Your research papers
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