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Page 2 of 6 Fontes-Sousa et al. J Cancer Metastasis Treat 2018;4:5 I http://dx.doi.org/10.20517/2394-4722.2017.70

Figure 1. Computed tomography scan at diagnosis (2013). Shown is the pancreatic mass (25.3 mm, yellow arrow), a histologically proven
pancreatic adenocarcinoma. A metal stent was placed to relieve symptoms such as jaundice

[3,4]
meeting surgical criteria - the only treatment offering the potential for a cure . Alternatively, the patients
may be candidates for systemic palliative treatment, if clinically compatible, or best supportive care. In
[4]
general, the estimated 5-year survival is 5% . More than 85% of all solid pancreatic neoplasms are ductal
[5]
[3]
adenocarcinoma . On the other hand, pancreatic neuroendocrine tumors are considered rare , although
[6]
with a reported increase in incidence in the last decades . Although little is known about the epidemiology
[7]
of metastization in this disease, the liver is the preferential site metastatic disease and treatment algorithms
[8]
are available . The authors present a case of a long-term survivor with an unresectable pancreatic
adenocarcinoma, stage III with a later diagnosis of liver metastasis of pancreatic neuroendocrine origin.
CASE REPORT
A 69-year-old male patient, who was initially evaluated at another institution, presented with new-
onset cholestatic jaundice and involuntary weight loss. He had a history of benign prostatic hyperplasia,
osteoporosis, chronic gastritis and hiatus hernia, but he was not taking any prescription medications.
The patient was diagnosed in July 2013 with a 25-mm mass at the head of the pancreas, with superior
mesenteric artery invasion and regional node metastization by computed tomography (CT) scan [Figure 1].
He underwent a biopsy and subsequently was diagnosed with unresectable pancreatic ductal
adenocarcinoma, thus considered clinically stage III (cT4N + M0), according to the 7th edition of the AJCC
cancer staging manual criteria.

A metallic biliary stent was placed to reduce jaundice [Figure 1]. The patient was referred to best supportive
care by the attending physician at that time, and he approached our institution for a second opinion. At this
point, the patient was relieved of cholestatic symptoms and was considered Eastern Cooperative Oncology
Group (ECOG) score 0; therefore, systemic treatment was proposed. The patient accepted the proposed
2
treatment and began palliative single-agent weekly Gemcitabine 1000 mg/m , for 6 months, after which a
CT scan was performed in December 2013 showing stable disease (SD). The patient’s carbohydrate antigen
(CA) of 19.9 was not considered indicative of disease as it was consistently within normal range values. The
multidisciplinary group decision was to further treat with chemoradiotherapy (CRT). The patient started
continuous infusional 5-fluorouracil and radiation therapy (RT) was performed concomitantly (50.4 Gray; 28
fractions, 5 x/week, according to Intensity Modulated RT), for 5-and-a-half weeks. The CT scan after CRT in
June 2014 showed SD. After this treatment, the patient re-started Gemcitabine until August 2014, after which
he began regular clinical and imagiological follow-up. The patient was, shortly after, admitted for cholangitis
but fully recovered after antibiotics and fluid resuscitation. The hepato-biliary group re-appreciated the case
in August 2015, but still considered it to be unresectable and the patient remained in follow-up. In February