A Rare Case of Sarcomatoid Carcinoma of the Pancreas Associated with Pancreatolithiasis

Pancreatolithiasis is a risk factor for developing pancreatic cancer. We report here a rare case of sarcomatoid carcinoma of the pancreas in a 55-year old diabetic male associated with pancreatolithiasis. CT scan of abdomen revealed a large operable mass occupying the distal body and tail of the pancreas. Per-operative survey revealed a small metastatic nodule in the surface of hepatic segment IVa. Histopathology of the distal pancreatic lesion revealed sarcomatoid carcinoma. Hepatic nodule was a metastatic adenocarcinoma. Distal pancreatectomy and splenectomy was done en-mass, along with non-anatomical resection of the hepatic metastatic nodule. Combined with six cycles of chemotherapy, the patient survived a total of another fourteen months. Ibrahim Med. Coll. J. 2013; 7(1): 12-15 Key word: Sarcomatoid carcinoma of pancreas, Anaplastic carcinoma of pancreas, Pancreatolithiasis showed a fairly large mass (6.5 X 5.0 X 5.0 cm) occupying the distal pancreas (Fig1b). CA 19-9 level was 183 u/L (n= <37 u/L). CT guided fine needle aspiration cytology (FNAC) was done and it was positive for malignant cells. Our impression was pancreatolithiasis with a malignant lesion in the distal pancreas. Plan of management was to perform distal pancreatectomy and splenectomy enmass along with pancreatolithotomy and Roux-en-Y pancreatojejunostomy. Patient was prepared accordingly and was vaccinated against Streptococcus pneumoniae, Haemophilus influenzae and Neisseria meningitides as per schedule. Laparotomy was done by midline incision with combined thoracic epidural and general aneaesthesia. There was no ascites and peritoneal cavity appeared to be healthy. Large stones could be felt in the pancreatic duct and there was a tumor in the distal body and tail of the pancreas, free from surrounding structures. There was no enlarged regional lymph node, but there was a metastatic nodule (1.0 X 1.25 cm) found in the hepatic segment IVa. Operative ultrasound revealed no other metastasis in any other part of the liver. Repeat survey in the abdomen revealed no other detectable metastatic lesion in any part of the peritoneal cavity or any abdominal organ. The spleen, tumor and the distal pancreas were mobilized and removed enmass as shown in Fig 2a and 2b. Hepatic nodule was removed by non-anatomical hepatic resection. (Fig.2c) Histopathology of the specimen revealed sarcomatoid carcinoma characterized by plenty of spindle cells along with glandular structures and areas of clear-cut glandular differentiation in the distal pancreatic lesion (Fig.2d). Resection margin was free of tumor invasion. Hepatic nodule was a metastatic adenocarcinoma with hepatic margin free of tumor invasion. Postoperatively, the patient developed deep vein thrombosis (DVT) on the 12th post operative day (POD) and was managed conservatively. Good glycaemic control was maintained. Patient was discharged on 18th POD with advice for oncological consultation. First follow up was after one month and subsequently the patient was followed up for next one year. During this period he received six cycles of chemotherapy and was under the care of an oncologist. After one year, there was recurrence of the tumor in the operative bed. With consultation of the oncologist, chemotherapy Fig. 1a: Plain X-ray of