Preoperative gemcitabine and oxaliplatin in a patient with ovarian metastasis from pancreatic cystadenocarcinoma

Abstract

We describe a case of clinical benefit and partial response with gemcitabine and oxaliplatin (GEMOX) in a young patient with ovarian metastasis from cystadenocarcinoma of the pancreas. A young woman complained of abdominal pain and constipation. Computed tomography (CT) and magnetic resonance imaging scans disclosed two bilateral ovarian masses with pancreatic extension. She underwent bilateral ovarian and womb resection. During surgery peritoneal carcinosis, a pancreatic mass and multiple abdominal lesions were found. The final diagnosis was mucinous pancreatic cystadenocarcinoma with ovarian and peritoneal metastases. She started chemotherapy with GEMOX (gemcitabine 1,000 mg/m(2)/d1 and oxaliplatin 100 mg/m(2)/d2 every 2 weeks). After 12 cycles of chemotherapy a CT scan showed reduction of the pancreatic mass. She underwent distal pancreatic resection, regional lymphadenectomy and splenectomy. Pathologic examination documented prominent fibrous tissue and few neoplastic cells with mucin-filled cytoplasm. Chemotherapy was continued with gemcitabine as adjuvant treatment for another 3 cycles. There is currently no evidence of disease. As reported in the literature, GEMOX is associated with an improvement in progression-free survival and clinical benefit in patients with advanced pancreatic cancer. This is an interesting case in whom GEMOX transformed inoperable pancreatic cancer into a resectable tumor.

Keywords: Chemotherapy; Gemcitabine and oxaliplatin (GEMOX); Metastatic cystadenocarcinoma; Mucinous pancreatic cystadenocarcinoma; Pancreatic cancer.

Fig. 1

Left column: a Low-power appearance of the ovarian lesion, displaying cystic spaces (asterisks) alongside with glandular areas (arrows). Both are lined by mucin-filled cells (H&E, ×10). c Higher-power view of the glands depicted above showing infiltrating pattern and malignant cytology (H&E, ×20). Right column: b Post-chemotherapeutic appearance of the pancreatic lesion. On a background of prominent fibrous tissue, few neoplastic cells (arrows) are noticeable (H&E, ×20). d At higher magnification, the neoplastic cells show mucin-filled cytoplasm (H&E, ×40).

Fig. 2

CT scan after 6 cycles of chemotherapy showed stable disease. a Heterogeneously hypodense neoformation at the pancreatic body. b Complete thrombosis of the splenic vein (G4) with opening of perigastrosplenic collateral circulation. c The tumor extended posteriorly encompassing the origin of the celiac axis with artery thrombosis at splenic origin (G4). d Close relationship of continuity, with a missing adipose cleavage plane, with lateral margin of the superior mesenteric artery at origin (G1).

Fig. 3

In August 2009 a repeat CT scan showed further reduction of the pancreatic lesion (a) with partial revascularization of splenic artery origin (b, c) and the appearance of a cleavage plane with the left margin of the superior mesenteric artery (d).