A Rare Case Report: Carcinoma Pancreas with Hepatocellular Carcinoma
The present case report is about a 64-year-old diabetic, non-alcoholic male patient who visited our hospital with the chief complaint of anorexia, malaise and icterus since 2 months for which he was evaluated outside with routine blood investigations showing raised serum bilirubin (6.5 mg/dl) and ultrasound reporting of hypo echoic mass (28.7 mm × 33 mm) in the head of pancreas.\nThere was no remarkable family history. On admission, patient was in good general health and vital signs were within the normal limits. On physical examination, the sclera was icterus. The abdomen was soft, but tender in the right upper quadrant. Routine blood examination showed the following: White blood cell, 10,200 cells/uL; hemoglobin, 12.1 g/dl; platelet, 218,000/mm3; blood glucose, 209 mg/dl; total bilirubin, 10.2 mg/dl; direct bilirubin, 6.2 mg/dl; alkaline phosphatize, 271 IU/l; serum glutamic-pyruvic transaminase, 101 IU/l; serum glutamic-oxaloacetic transaminase, 67 IU/l; and gamma-glutamyl transpeptidase, 343 IU/l. Viral markers were negative. Tumor marker assays showed raised alpha-fetoprotein 51.99 ng/ml (normal 0-8.5), carcinoembryonic antigen was 4.2 ng/ml (normal 0-5) and carbohydrate antigen 19-9 (CA 19-9) was markedly raised 65,919 U/ml (normal 0-37).\nA triple phase contrast enhanced computed tomography (CT) scan of the abdomen revealed 3.5 cm × 3.2 cm × 4.0 cm hypo-enhancing mass in the pancreatic head with upstream extrahepatic and bilobar intrahepatic biliary radicles dilatation [], multiple small peripancreatic and mesenteric nodes. Liver showed multiple nodular lesions (metastasis) of varying sizes with differential characteristics [], one of the large relatively defined mass in segment 7 of the liver is showing subtle arterial phase enhancement [] and washout in portal venous phase [] likely HCC. Upper gastrointestinal endoscopy was normal.\nThus, the provision diagnosis was carcinoma head of pancreas with multiple liver metastases synchronous with HCC? Ultrasonography guided fine-needle aspiration was taken from pancreatic mass, non-enhancing and enhancing liver SOL for confirmation.\nSmears from the enhancing liver lesion was hypercellular, comprise thickened trabeculae and groups lined by atypical hepatocytes with transgressing blood vessels and partial entrapment by endothelial cells at the periphery. There were few stripped nuclei seen in the background. The atypical hepatocytes show enlarged, hyperchromatic, markedly pleomorphic nuclei with irregular distribution of nuclear chromatin, prominent eosinophilic nucleoli, focal nuclear vacuolization and abundant granular eosinophilic cytoplasm with cholestasis [Figure –]. On immunohistochemistry-Tumor cells was positive for glypican 3 and hepatocyte specific antigen []. Histochemistry-trabeculare are reticulin poor. Above features are diagnostic of HCC Smears from the non-enhancing Liver lesion showed few small groups and acini of atypical epithelial cells, admixed with sheets and clusters of benign hepatocytes. These atypical epithelial cells show enlarged, hyperchromatic, markedly pleomorphic nuclei with high N:C ratio, irregular nuclear membrane, coarse chromatin and scanty cytoplasm suggestive of metastatic adenocarcinoma []. Smears from the pancreatic lesion showed few small groups and acini of atypical epithelial cells. These atypical epithelial cells show enlarged, hyperchromatic, markedly pleomorphic nuclei with high N:C ratio, irregular nuclear membrane, coarse chromatin and a fair amount of vacuolated cytoplasm suggestive of adenocarcinoma [].\nPatient was diagnosed as carcinoma pancreas with multiple liver metastases synchronous with solitary HCC. The conclusive stage of the pancreatic cancer was TNM stage IV {T2, N1, M1} whereas that of the HCC was Barcelona Clinic Liver Cancer (BCLC) stage A and TNM stage I {T2, N0, M0} according to Union for International Cancer Control classification. Percutaneous transhepatic biliary drainage followed by metallic stenting was done and planned for single agent gemcitabine based palliative chemotherapy once total serum bilirubin came down below 3 mg/dl.