Long-term survival with repeat resection for lung oligometastasis from pancreatic ductal adenocarcinoma: a case report
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Long-term survival after resection of metastases from pancreatic ductal adenocarcinoma is rare.
A 54-year-old man underwent pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) with UICC staging pT3N1M0 followed by adjuvant chemotherapy with gemcitabine (GEM). Three years after radical resection of the primary tumor, a tiny nodule was found in the lower lobe of the left lung. Despite treatment with GEM, it increased gradually, but no other metastases were found. Eighteen months after the first indication of the nodule, wedge resection was performed. Pathological examination of the nodule indicated a metastatic tumor from PDAC. Pulmonary metastasectomy was again performed for lung oligometastases at 77 and 101 months after PD. The patient has been asymptomatic without tumor recurrence for 4 years since the last pulmonary resection.
In PDAC, the treatment strategy for oligometastasis is controversial. However, a few cases of long-term survival after pulmonary metastasectomy for oligometastasis of PDAC have been reported. More such cases need to be studied to address this issue effectively.
KeywordsPancreatic ductal adenocarcinoma Oligometastasis Pulmonary metastasectomy
Fluorodeoxyglucose-positron emission tomography
Pancreatic ductal adenocarcinoma
Surgical resection for metastases or recurrences of pancreatic ductal adenocarcinoma (PDAC) is not widely accepted because of frequent relapses with unlimited and aggressive growth. Systemic chemotherapy is commonly used for metastases or recurrences of PDAC. Recently, single cases and small series of surgical resection for oligometastasis from PDAC have been reported [1, 2, 3, 4]. A case of long-term survival after three pulmonary metastasectomies for oligometastasis of PDAC is reported.
Percutaneous lung biopsy showed atypical cells in granulation tissue. Differentiation between a primary and metastatic tumor was difficult on preoperative imaging studies and the percutaneous lung biopsy specimen. Furthermore, no other tumors were found on imaging examinations. Therefore, wedge resection of the left lower lobe of the lung was performed in October 2008.
This was a rare case that underwent pulmonary metastasectomy for recurrence of PDAC three times and achieved long-term relapse-free survival. Surgical resection of metastatic tumors or recurrent tumors of PDAC has not become an established therapy because of frequent relapses with unlimited growth and rapid progression. Recently, a few cases that showed the effectiveness of metastasectomy for oligometastasis of PDAC have been reported [1, 2, 3, 4].
In our case, peripancreatic infiltration was found but vascular invasion was not found.
Pulmonary metastasectomy has evolved for other cancers with synchronous or metachronous metastatic disease, such as colorectal adenocarcinoma, with a demonstrated survival benefit [12, 13, 14, 15]. In PDAC, Arnaoutakis et al. reported that, in patients with isolated PM from PDAC, median cumulative survival was significantly improved in the pulmonary metastasectomy group compared with the chemotherapy group (51 vs 23 months); they considered that a relatively long interval between the initial PDAC resection and tumor relapse, with isolated and stable disease over time, and a favorable response to systemic chemotherapy indicated “good biology” . Thomas et al. reported a survival benefit in patients who had disease-free survival prior to recurrence > 20 months, and the greatest benefit was seen in patients with isolated pulmonary metastases . The previously reported small series showed that the median interval between the initial resection and pulmonary metastasectomy was 29.3–48 months and the overall survival after pulmonary metastasectomy was 18.6–38 months respectively [4, 17, 18]. However, to the best of our knowledge, no cases in which pulmonary metastasectomy was performed three times have been reported in the English literature.
In this case, adjuvant chemotherapy using GEM was performed after PM according to the primary resection. The benefit of adjuvant chemotherapy cannot be determined in this case because of the re-recurrence of lung metastases after chemotherapy, with no other recurrence being found. In PDAC, the treatment strategy for oligometastasis has not been established. A few cases of long-term survival after pulmonary metastasectomy for oligometastasis of PDAC have been reported. It is controversial whether or not performing repeat metastasectomy from PDAC is of oncological benefit. As in this case, repeat metastasectomy may achieve long-term survival after primary resection of the PDAC; the present case is considered to have relatively “good biology” and be a potentially good candidate for metastasectomy of recurrence. Studies of more such cases are needed to address this issue.
In PDAC, the treatment strategy for oligometastasis is controversial. However, a few cases of long-term survival after pulmonary metastasectomy for oligometastasis of PDAC have been reported. Metastasectomy may achieved long-term survival after primary resection of the PDAC Studies of more such cases are needed to address this issue.
RM and MS drafted the manuscript. RM wrote the paper, including the first draft, and RM decided to publish the paper. HT and HK performed the pulmonary metastasectomy. MF and JS diagnosed the pathological findings. JF performed the chemotherapy and follow-up after metastasectomy. All authors have read and approved the final manuscript.
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The authors declare that they have no competing interests.
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