Metastatic tumors of the pancreas (MTP) occur exceptionally rarely, accounting for only 2-3% of all pancreatic malignancies [1,2]. Compared to the results of the series of autopsies conducted, secondary lesions had a significantly higher percentage (11-40%) [3]. MTP most commonly originate from renal cell carcinoma (RCC, 55-70%), colorectal cancer (CRC, 6-9%), lung cancer (7-8%), melanoma (9-10%), and breast cancer (6-7%) [1,4,5]. There is still no consensus on treating patients with metastatic pancreatic lesions. Performing pancreatic resection hides its risks, but the results are optimistic when patients meet the criteria for resectability. Due to the urgent intervention, we did not have time for a more detailed preoperative evaluation of the patient. The pancreatic lesion was assumed to be primarily about the data from a previous MRI.

We present the case of a 73-year-old male patient admitted to the gastroenterology clinic as an emergency with evidence of gastrointestinal bleeding. As comorbidities, we noted a history of pulmonary embolism (2014), stroke (2017), arterial hypertension, and Type II Diabetes Mellitus. His disease was diagnosed in November 2019 when he committed laparoscopic anterior resection of the rectum for metastatic adenocarcinoma of the rectosigmoid (pT3N2bM1aG2, KRAS – mutant type) with synchronous liver lesions present. He underwent eight chemo- and targeted therapy courses according to CAPOX/Avastin regimen. Restaged by PET/CT and CT with hepatic volumetry showed a reduction in liver lesions' size. Amid the response to adjuvant therapy, laparoscopic right hepatectomy with metastasectomy of a segment IV liver lesion was performed in October 2020. He underwent four more courses of the CAPOX regimen. Follow-up CT scans performed three and six months after liver resection showed no evidence of disease (Figure 1).

Figure 1: C? performed ten months before emergency surgery - no evidence of pancreatic lesion.

Both operations were performed by the same surgical team in our department. In December 2021, he was hospitalized for jaundice in a gastroenterology clinic at our institution. ERCP was performed with placement of SEMS prosthesis due to evidence of malignant distal bile duct stenosis. MRI revealed a lesion in the head of the pancreas, which was interpreted as a primary tumor (Figure 2).

Figure 2: MRI shows a lesion in the head of the pancreas (yellow arrow), dilatated common bile duct (green arrow), duodenum (orange arrow), superior mesenteric vein (blue arrow), and superior mesenteric artery (red arrow).

A month after hospital discharge (January 2022), he presented with complaints of rectorrhagia and astheno-adynamia. Bleeding from the biliary tract was not able to manage endoscopically. No result was achieved from the conservative treatment conducted with blood-sparing medications and bioproducts. Therefore a decision was made to carry out emergency surgery. The operation was performed through a conventional abdominal approach via a Gable incision. Intraluminal hemorrhage was found in the common bile duct due to a tumor formation in the head of the pancreas. Emergency pancreaticoduodenal resection was performed. The histological diagnosis showed a low-grade differentiating secondary lesion of colorectal origin. (Figure 3) The postoperative period was uneventful and without complications, with the patient discharged on 11-postoperative day. After a multidisciplinary oncology committee discussion, a decision was made to continue chemotherapy.

Figure 3: Histological examination (?. HE 10x - colorectal metastasis in the pancreas; B. CK7 10x - negative in the metastatic tumor; positive in pancreatic ducts).

Metastatic tumors of the pancreas represent about 2-3% of all malignant processes [1,4]. The most common lesions originate from RCC (55-70%). The incidence of colorectal metastases is about 8-9% of all MTP [1,6]. Other malignant diseases can also metastasize to the pancreas, most commonly lung cancer, breast cancer, malignant melanoma, and sarcomas [1,4-6]. Some of these patients are suitable for surgery when meeting the criteria for pancreatic resectability. According to one of the most extensive series of pancreatic resections due to secondary lesions, the most common clinical presentations are epigastric tenderness, jaundice, weight loss, bleeding, vomiting, and astheno-adynamic syndrome [1]. Only two originated from colorectal cancer in their study of 98 pancreatic resections for MTP. The time of metastases in the pancreas after a radical operative intervention of the primary tumor is different. Patients with secondary lesions originating from the RCC are between 65.9 and 122.4 months after the operation [1,6,7]. There are cases of secondary lesions in the pancreas by RCC 27 years after nephrectomy. According to the literature review, secondary lesions other than the RCC occur earlier after the primary tumor resection [6]. In our case, a secondary lesion in the pancreas appears 25 months after the first operation, under the background of ongoing chemotherapy. A case of pancreatic metastasis 11 years after colonic resection has been described [8]. In other cases, synchronous colorectal and pancreatic resection has been performed, but patients indicated for this volume of surgical intervention must meet strict criteria [9,10].

MTP is a rare cause and indication for resection, and there is not yet enough data and specific criteria to definitively conclude what approach should be performed. Recent series have provided optimistic results for survival and a disease-free period after this type of surgery [4,6,11]. For diagnosis of MTP, it is appropriate to carry out CT in symptomatic patients and, where possible, PET/CT, although imaging studies cannot definitively establish the origin of the lesion. On CT scan, secondary lesions other than RCC are visualized as hypervascular tumors, also characteristic of pancreatic carcinoma [1]. Therefore, we may think of MTP when conducting PET/CT in patients with evidence of malignancy and an established lesion within the pancreas [12]. Another method of diagnosing secondary lesions is by biopsy under ultrasonographic guidance control [7]. The feasibility of surgical intervention is determined according to the CT findings and whether the lesion infiltrates adjacent vascular structures. The criteria for pancreatic resection do not differ from those for primary disease. In case of dissemination to adjacent organs and the possibility of radical removal of secondary lesions, synchronous resection can be performed under strict criteria.  

Survival in patients undergoing surgical intervention for MTP varies according to the type of primary malignant process [4,7,13]. In patients with pancreatic metastases from RCC, the mean survival after resection was 4.8 years compared to the other MTP-2 years [1,4,5]. However, there are still lacking studies on the survival of patients undergoing sequential resection and chemotherapy compared to chemotherapy and resection separately. Our literary review found no similar case of emergency pancreaticoduodenal resection performed for metastatic CRC manifested by jaundice and biliary bleeding.  

Metastatic lesions of the pancreas are an uncommon reason for performing resection. In patients with previous surgery for malignancy and evidence of tumor in the pancreas, the metastatic lesion may be suspected. In properly selected patients in high-volume centers, pancreatic resections can be performed with a high success and a low complication rate, even in emergencies. More studies are needed to reach a consensus on the management of these cases.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

The authors declare that they have no conflict of interest.

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