A 62-year-old female presented with a chief complaint of recurrent epigastric discomfort and progressively worsening vomiting for two weeks. The patient had experienced anorexia and weight loss for several months, but had no significant past medical history. The patient’s family history was significant for pancreatic cancer from her mother, but no other malignancies were present in her other immediate family members. On admission, the patient’s vital signs were stable and a mass of approximately 10 cm was palpated in the upper quadrant area of the abdomen. The remainder of the examination was unremarkable.
The complete blood count identified a white cell count of 6,900 cells/mm3 (73.4% neutrophils), hemoglobin count of 135 g/dl and a platelet count of 181,000 platelets/mm3. The blood chemistry examination revealed 23.0 μmol/l total bilirubin, 9.6 μmol/l direct bilirubin, 74 U/l aspartate transaminase (AST) and 102 U/l alanine aminotransferase (ALT). The carbohydrate antigen 19-9 (CA19-9) was slightly elevated to 78.4 U/l (normal range, 0–37 U/l), while carcinoembryonic antigen (CEA), α-fetoprotein (AFP), carbohydrate antigen 24-2 (CA24-2), blood glucose, calcium and amylase levels were within normal ranges.
Computed tomography (CT) revealed a discrete mass measuring 8×7 cm with notable enhancement in the body of stomach (). It also revealed a 4×3-cm lesion with an unclear boundary and mild enhancement in the uncinate process of pancreas and close to the horizontal part of the duodenum (). Ultrasonography of the liver, pancreas, spleen and gallbladder revealed no abnormality.
Abdominal CT scan revealing a tumor in the body of stomach (arrow). CT, computed tomography.
Abdominal CT scan revealing a tumor in the uncinate process of pancreas with an unclear boundary, which had horizontally infiltrated part of the duodenum and closely adhered to the inferior vena cava (arrow). CT, computed tomography.
The initial impression from the CT scan was emphasized on the gastric mass as the lesion in the uncinate process of the pancreas was not well-defined. The gastric mass was suspected to be a GIST (), and the symptoms of bowel obstruction were suggested to be caused by the presumed GIST in the patient’s stomach. However, an upper gastrointestinal series with meglumine diatrizoate was consistent with a partial bowel obstruction at the level of the third portion of duodenum. Therefore, the case was discussed at the multi-disciplinary team (MDT) conference, and it was recommended to intraoperatively explore the pancreas in addition to the resection of the gastric mass.
Intraoperatively, no liver metastasis or peritoneal dissemination was identified. A solid, partially capsulated mass, measuring approximately 8×7×7 cm, was identified in the body of the stomach near the lesser curvature. Another solid mass was also revealed in the uncinate process of the pancreas, which had horizontally infiltrated part of duodenum and closely adhered to the inferior vena cava for ~4 cm (). A fine needle aspiration biopsy was conducted in the uncinate process of the pancreas and revealed the adenocarcinoma. Therefore, a pancreaticoduodenectomy (PD) was conducted, which included resection of the gastric mass and partial resection of the inferior vena cava.
The pathological specimen was composed of the head of the pancreas, distal portion of the stomach, common bile duct, duodenum and gallbladder. Microscopically, the gastric tumor tissue was comprised of spindle cells with coagulative necrosis and a mitotic rate of ≤5/50 within a high power field (HPF; ). The tumor cells were immunoreactive for CD117 (), supporting the diagnosis of GIST. The Union for International Cancer Control tumor-node-metastasis (UICC TNM) pathological staging of this GIST was pT3 (stage IB), and its National Institute of Health (NIH) risk stratification was intermediate. The pancreatic tumor was comprised of poorly differentiated cells with vascular and perineural invasion and infiltrating submucosa of duodenum (). The tumor cells in the pancreas were immunoreactive for cytokeratin 5/6 (CK5/6), p63 and CAM5.2, supporting the diagnosis of ASC (). None of the nine peripancreatic lymph nodes were involved. Ultimately, the pathological TNM staging was pT3N0M0.
Figure 3. (A) Medium-power review of the gastric biopsy specimen identifiying a soft tissue mass consisting of a spindle cell neoplasm. (B) Positive immunohistochemistry staining for c-kit (CD117) was consistent with the diagnosis of GIST (magnification, x20). (more ...)
Figure 4. (A) Microphotograph of CUPP identifiying the intercellular bridge (the feature of squamous carcimoma) and mucus (magnification, x40). Subsequent images show positive immunohistochemistry staining for (B) CK5/6, (C) P63 and (D) CAM5.2, consistent with (more ...)
The postoperative course was uneventful. The patient declined any further adjuvant therapy, and 6 months following therapy the patient remains healthy and has experienced no tumor recurrence.