Introduction
Recently an increase of the incidence of multiple primary cancers has been observed, and cases of two or more malignant primary tumors have appeared with a high frequency in the literature. The incidence of multiple primary malignant tumors is expected to increase with age.[1] We report a case of gastric adenocarcinoma associated with pancreatic ductal adenocarcinoma.
Case report
A 73-year-old woman was referred to the Department of Surgery of our hospital for persistent vomiting and weight loss during hospitalization at the Department of Diabetology for uncontrolled hyperglycemia.
Laboratory tests on admission showed evidence of anemia (HB 10.8 g/dl), PCR 1.4 mg/dl, and abnormal tumor markers levels: CEA 9.58 ng/ml (normal range 0.00-3.00), CA125 39.70 IU/ml (normal range 0.00-35.00), CA19-9 165.80 IU/ml (normal range 0.00-37.00), TPA 108 U/L (normal range 2.00-75.00).
Esophagogastroduodenoscopy demonstrated a large antral ulcerative lesion extending circumferentially in the gastric antrum and causing pyloric stenosis. Histological examination revealed an adenocarcinoma.
Abdominal CT showed thickening of the gastric wall to the antral and pyloric portion of the stomach (around 40 mm), and a solid lesion in the uncinate portion of the pancreas (around 25¡Á12 mm), with vanishing limits, necrotic areas, and no evidence of distant metastases (Fig. 1).
MRI showed a pancreas of reduced volume and confirmed alterations at the uncinate portion due to the presence of a nodular mass of around 3¡Á1.7 cm, with a fluid component in its context (Fig. 2). The formation was characterized by vanishing profiles and adhesions to the anterior wall of the third duodenal portion. A strict adhesion was suggested to the superior mesenteric vein.
The biopsy taken during the esophagogastroduodenoscopy revealed an adenocarcinoma.
The patient was transferred to the Department of Surgery for pancreaticoduodenectomy according to Whipple with regional Fortner type ¢ñ extension (SMV resection).
Final histology demonstrated a ductal adenocarcinoma of the pancreas (G3) with a mucinous type colloidal component (40% of the neoplasm) and an intraductal cystic papillary mucinous component (Figs. 3, 4). The neoplasm infiltrated the duodenum wall, peripancreatic tissue, and the segment of mesenteric vein. One of the seven peripancreatic lymph nodes sampled was positive for neoplasm (pT3, pN1, pMx, G3 V1 R0).
The gastric neoplasm was a moderately differentiated gastric adenocarcinoma (G2) with gastric mural invasion up to the subserous fat (Pt2B), and it was of Lauren intestinal type. The vascular invasion of the tumor was histologically confirmed (V1) (pT2b, pN0, pMx, G2 V1)(Figs. 5, 6). None of the 24 lymph nodes has shown a center of metastases. The patient did not receive any adjuvant treatment.
Discussion
Cases of double synchronous cancers involving the stomach and pancreas are relatively rare.[2, 3] In patients with gastric carcinoma, the prevalence of second tumors varies from 2.8% to 6.8%.[4] The incidence of gastric carcinoma associated with pancreatic carcinoma accounts for 3.8% in all cases of gastric carcinoma associated with carcinoma of other organs.[2, 5]
In the present case, gastric neoplasm was diagnosed by esophagogastroduodenoscopy. The symptoms of the patient included weight loss and recurrent vomiting due to the neoplasm causing stenosis of the pilorus and hindering the progression of the food bolus. A characteristic symptom was also anemia caused by the ulcerated mass.
CT scan performed during preoperative evaluation revealed the presence of a synchronous neoplasm of the pancreas. Abdominal MRI subsequently showed changes in the uncinate portion of the pancreas and the presence of a nodular mass of around 3¡Á1.7 cm was confirmed. This lesion was strictly adherent to the anterior wall of the third duodenal portion and to the superior mesenteric vein.
Pancreatoduodenectomy combined with resection of the superior mesenteric vein was performed according to the Fortner type ¢ñ regional pancreatectomy. The vein was repaired by end-to-end vascular anastomosis.[6-8]
After the intervention, the patient was maintained on parenteral nutrition for 9 days and subsequently a liquid diet was given. An elementary diet was started on the 14th postoperative day.
In conclusion, this is an unusual case of synchronous gastric adenocarcinoma and pancreatic ductal adenocarcinoma. Surgical resection remains the only potentially curative treatment for adenocarcinoma of the stomach and pancreas. Long survival is rare in patients with pancreatic cancer. Despite the advanced age of the patient and the synchronous cancer of the pancreas, we consider surgical intervention is a chance for the patient to prolong her life and improve its life quality by feeding again.
Funding: None.
Ethical approval: Not needed.
Contributors: MM wrote the first draft of this commentary. All authors contributed to the intellectual context and approved the final version. MM is the guarantor.
Competing interest: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
References
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Received January 13, 2009
Accepted after revision August 12, 2009
