Curative resection after chemotherapy and chemoradiotherapy for postoperative recurrence of pancreatic tail cancer in the abdominal wall: a case report

Abstract

Background: Locoregional recurrence and metastasis to the liver, peritoneum, and lung are the most common recurrent patterns of pancreatic ductal adenocarcinoma (PDAC) after radical resection. Recurrence in the abdominal wall is extremely rare. Herein, we report our experience with a patient who had recurrent PDAC in the abdominal wall with long-term survival by means of multidisciplinary therapy.

Case presentation: A 76-year-old Japanese woman was diagnosed with resectable pancreatic tail cancer. She underwent distal pancreatectomy with regional lymphadenectomy after two cycles of gemcitabine plus S-1 as neoadjuvant therapy. She also received eight cycles of S-1 as adjuvant chemotherapy. Approximately 14 months after the initial surgery, imaging examinations identified a mass suggesting recurrence in the abdominal wall at the middle wound that involved the transverse colon. After two cycles of gemcitabine plus nab-paclitaxel, chemoradiotherapy (S-1 plus 45 Gy) and seven cycles of modified FOLFIRINOX (5-fluorouracil/leucovorin, irinotecan, and oxaliplatin) were administered. The patient did not develop any new recurrent lesions during chemotherapy and chemoradiotherapy. Therefore, the recurrent lesion in the abdominal wall and the involved transverse colon were resected. We confirmed the lack of peritoneal dissemination during surgery. Pathological examination revealed that the resected lesion was metastasis of primary PDAC, and the surgical margin was 1 mm. However, re-recurrence localized in the abdominal wall was detected 9 months later. The re-recurrent lesion was diagnosed as local recurrence of the first recurrent lesion. We performed a second resection of the abdominal wall using a femoral myocutaneous flap to achieve sufficient surgical margin. The pathological findings of the resected specimen were the same as those of the previous specimens, and the resection margin was negative. The patient's postoperative course was uneventful. Seven years after the initial surgery and 3 years and 7 months after the third surgery, the patient is alive with no signs of recurrence.

Conclusions: Long-term survival could be achieved by radical resection with sufficient surgical margins for recurrence of PDAC in the abdominal wall if new other recurrent lesions, including peritoneal dissemination, are prevented through chemotherapy.

Keywords: Abdominal wall recurrence; Femoral myocutaneous flap; Multidisciplinary therapy; Pancreatic ductal adenocarcinoma; Surgical margin.

Fig. 1

Imaging results at admission. a Contrast-enhanced abdominal computed tomography showed a 35-mm hypovascular mass in the tail of the pancreas (white arrow). b ¹⁸F-fluorodeoxyglucose-positron-emission tomography/computed tomography showed high accumulation of fluorodeoxyglucose in the tumor (yellow arrow)

Fig. 2

Imaging results 14 months after the initial surgery. a Contrast-enhanced abdominal magnetic resonance imaging showed a 30-mm low-intensity signal from the wound to the transverse colon in T1-weighted imaging that was suggestive of recurrence (white arrows). b ¹⁸F-fluorodeoxyglucose-positron-emission tomography/computed tomography showed high fluorodeoxyglucose accumulation in the tumor at the wound of the pancreatectomy

Fig. 3

Clinical course and level of serum carbohydrate antigen 19-9. GEM gemcitabine, RT radiotherapy, GnP gemcitabine plus nab-paclitaxel therapy, mFOLFIRINOX modified 5-fluorouracil/leucovorin, irinotecan, and oxaliplatin

Fig. 4

Gross and histopathological findings of the primary pancreatic cancer and abdominal wall recurrence. a The cut surface of the original resected specimen was 3.3 × 2.8 × 2.0 cm in size. The tumor was whitish and had invaded the splenic vessels (white arrows). b Microscopic findings (hematoxylin and eosin [HE] staining × 100) showed proliferation of the tumor cells, which were composed of large, atypical tubules, indicating a well-differentiated adenocarcinoma. c The cut surface of the resected first recurrent specimen was 6.0 × 4.8 × 4.5 cm in size. There were no tumor cells on the surgical margin, but it was close to the colonic mucosa (yellow arrows) and the transected plane (white arrowheads). d Microscopic findings (HE staining × 100) showed atypical ductal cells resembling primary pancreatic ductal adenocarcinoma

Fig. 5

Imaging and intraoperative and gross findings of the second abdominal wall recurrence. a Contrast-enhanced abdominal magnetic resonance imaging showed a 15-mm iso-intensity signal localized in the abdominal wall in T1-weighted imaging that was suggestive of recurrence (white arrows). b ¹⁸F-fluorodeoxyglucose-positron-emission tomography/computed tomography showed high fluorodeoxyglucose accumulation in the mass in the abdominal wall. c Intraoperative findings. The recurrent lesion was resected with a sufficient margin, and the abdominal wall was repaired using a femoral myocutaneous flap. d The cut surface of the resected specimen showed no tumor cells in the transected plane or the intra-abdominal plane