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Department of Digestive Pediatric Surgery, The University
of Tokushima School of Medicine, Tokushima, Japan
Abstract: Introduction:Despite various treatment trials
for unresectable pancreatic carcinoma with liver metastases,
the outcome has not been satisfactory. This paper reports
a case of pancreatic carcinoma with multiple liver metastases
that responded well to arterial infusion chemotherapy. Case
report:A 65-year-old male was diagnosed with multiple liver
tumors, and needle biopsy revealed adenocarcinoma. With
endoscopic ultrasonography, a tumor in the pancreatic head
was detected, and pancreatic carcinoma with multiple liver
metastases was diagnosed. He received arterial infusion
chemotherapy : cisplatin at a dose of 10mg/body/day and
500mg/body/day of 5-fluorouracil. After 14days administration,
liver metastases had decreased in number and size, but thereafter,
because of hepatic arterial occlusion, the same dose of
drugs was administered intravenously. The patient was discharged
from the hospital and was given chemotherapy 3 days a week
on an outpatient basis. Although the chemotherapy was effective,
it was stopped because of severe general fatigue5 months
after discharge. His general status continued to gradually
worsen, and he died 12 months after diagnosis. Conclusions
: Prognosis of pancreatic carcinoma with liver metastases
is poor ; however, transarterial infusion chemotherapy may
be effective to improve the prognosis and quality of life
of the patients. J. Med. Invest. 50:199-202, 2003
Keywords:pancreatic carcinoma, arterial infusion chemotherapy,
liver metastases
INTRODUCTION
Previous clinical trials for the detection and treatment
of small pancreatic carcinoma have shown the possibility
of improved prognosis;however, at the time of diagnosis,
only 10-11.6% of the patients can be given a resection (1,
2). Moreover, in many cases, despite the smallness of the
primary lesion, liver metastases were detected. Though the
outcome of a patient with liver metastases has not been
satisfactory, some recent studies have reported the possibility
of improved prognosis by modified chemotherapy. Among them,
arterial infusion chemotherapy has been reported to be effective
for the treatment of liver metastases(3-5). This study reports
a case of pancreatic carcin-oma with multiple liver metastases
that responded well to transarterial infusion chemotherapy.
CASE REPORT
A 65-years-old male, diagnosed with multiple liver tumors,
visited our hospital. He was symptom-free, and physical
examination revealed no abdominal tumor or signs of jaundice.
Laboratory examinations showed a slight elevation of liver
function tests : asparate ami-notransferase (AST);43IU/L
(normal range;10-35IU/L), alanine aminotransferase (ALT)
; 50IU/L (normal range ; 15-40IU/L), alkaline phosphatase
(ALP) ;420IU/L (normal range ; 81-231IU/L) and gamma-glutamyl
transpeptidase (gamma-GTP) ; 241 (normal range ; <60IU/L).
There were no elevations of tumor markers : alpha fetoprotein
(AFP), carbohydrate antigen (CA) 19-9 and carcinoembryonic
antigen (CEA).
Diagnostic images
An abdominal ultrasonography detected multiple liver tumors,
the largest being 8×8 cm in diameter. A contrast
enhanced computed tomography (CE-CT) showed multiple low-density
tumors in the liver (Fig. 1a), and a low-density mass 2
cm in diameter, in the pancreatic head (Fig. 1b). Endoscopic
retrograde cholangiopancreatography (ERCP) showed obstruction
of the main pancreatic duct at the head of pancreas (Fig.
2a). Endoscopic ultrasonography detcted a hy-poechoic mass
3×2 cm in diameter in the pancreatic head (Fig.
2b). Celiac angiography showed multiple hypervascular tumors
in the liver (Fig. 3).
US guided fine needle aspiration biopsy of the liver tumor
revealed adenocarcinoma, and then pancreatic carcinoma with
multiple liver metastases was diagnosed.
Therapeutic regimen
A catheter was placed in the common hepatic artery for arterial
infusion chemotherapy via the right fem-oral artery, and
then the gastroduodenal artery and right gastric artery
were embolized with the microcoils. The catheter was connected
to the port implanted in the subcutaneous space of the right
lower abdomen. The patient received 5-fluorouracil (5 -
FU) and cisplatin (CDDP) combination chemotherapy for 14
days (5-FU at a dose of 500mg/day and CDDP of 10mg/day.
Total dose:5-FU;3500mg, CDDP;140mg). After 14days administration,
because of hepatic arterial occlusion, the same dose of
CDDP and 5-FU were administered intravenously for 14days
until his discharge (Total dose:5-FU;3500mg, CDDP;140mg).
At the same time, the tumor in the pancreatic head was irradiated
with total 50 Grays (2Grays/fraction per day).
Images after arterial infusion
After 14 days administration, CE-CT revealed a decrease
of liver metastases in number and size (Fig. 4a), and a
reduction in the size of the pancreatic tumor (Fig. 4b).
Clinical course after discharge
The patient was discharged from the hospital and given chemotherapy
intravenously 3 days a week on an outpatient basis. Although
the chemotherapy was effective, it was stopped because of
severe general fatigue 5 months after discharge. CE-CT showed
no sign of progression of liver and pancreatic tumors, but
ascites had appeared. His general status continued to gradually
worsen ; however, he could remain at home. The patient died
12 months after diagnosis because of peritonitis carcinomatosa.
DISCUSSION
The prognosis and outcome of patients with pancreatic carcinoma
still remain poor, despite various trials. One of the major
reasons for these unsatisfactory results is its tendency
to cause liver metastases. The incidence of liver metastases
from pancreatic carcin-oma was 27.4% at diagnosis (2), and
63% to 78% at autopsy(6). Moreover, in 50 - 62% of the patients
after operations or chemotherapies, liver metastasis was
the reason for therapeutic failure(2).
Recently, hepatic arterial infusion chemotherapy was reported
as an effective treatment for liver meta-stases. Furuse
et al. (4) treated liver metastases from pancreatic carcinoma
using hepatic arterial infusion with 5-FU, and reported
higher response rates than venous infusion, but no improvement
of survival (the median survival time ; 15.9 weeks). Also,
Suzuki et al.(5) reported a case of percutaneous isolated
hepatic perfusion after local resection;however, despite
a distinct regression of liver metastases, the patient died
9 months after diagnosis. On the other hand, Homma et al.
(3) administered 5 - FU and CDDP via a catheter placed in
the splenic and common hepatic artery after hemodynamic
change, and then the mean survival period was improved (16.25±8.35
months). In our patient, although the primary pancreatic
carcin-oma was small in size and there was no evidence of
local invasion, metastatic liver tumors were very large
and multiple. Then, liver metastases were regarded as a
prognostic factor, and hepatic arterial infusion chemotherapy
with radiation was selected for the primary pancreatic carcinoma.
Liver tumors decreased in number and size, and no progression
was observed throughout the follow-up period even after
occlusion of the hepatic artery. Although Furuse et al.
(4) pointed out that hepatic arterial occlusion during arterial
chemotherapy would be responsible for the rapid progression
of liver metastases, systemic chemotherapy after arterial
occlusion may contribute to the improvement of the prognosis.
After discharge, the patient received systemic chem-otherapy
on an outpatient basis, and he could remain at home without
severe side effects. In conclusion, transarterial infusion
chemotherapy and subsequent systemic chemotherapy may be
effective for the treatment of patients with pancreatic
carcinoma with liver metastases, and moreover, may improve
the quality of life of the patient.
REFFERENCES
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