Korean J Hepatobiliary Pancreat Surg.  2014 Feb;18(1):33-37. 10.14701/kjhbps.2014.18.1.33.

AFP-producing acinar cell carcinoma treated by pancreaticoduodenectomy in a patient with a previous radical subtotal gastrectomy by gastric cancer

• Kim CY
• Lee SH
• Jeon HM
• Kim HK
• Kang CM
• Lee WJ

• KMID: 1890079
• DOI: http://doi.org/10.14701/kjhbps.2014.18.1.33

Abstract

We report a case of alpha-fetoprotein (AFP)-producing acinar cell carcinoma (ACC) of the pancreas. The tumor was diagnosed in a 72 yearold female after radical subtotal gastrectomy (Billroth I) due to early gastric cancer six months before. The initial serum AFP levels were increased to 2,254.1 IU/ml and preoperative imaging studies showed a mass with approximately 2.5 cm in diameter near the neck of the pancreas. A pancreaticoduodenectomy was performed. The pathologic examination revealed an ill-defined lobulating tumor confined to the pancreas (T1 stage). Immunohistochemical study showed that the tumor cells expressed AFP. The Adenosine triphosphate-based chemotherapy response assay (ATP-CRA) suggested that cisplatin would be more desirable than gemcitabine in AFP-producing ACC of the pancreas as an adjuvant chemotherapy. However, the adjuvant chemotherapy was not performed due to the early pathological stage. The patient died from carcinomatosis and pneumonia. Even if the tumor was on a relatively early stage, an adjuvant treatment should be considered ACC.

Keyword

Alpha-fetoprotein; Acinar cell carcinoma; Pancreatectomy; Gastric cancer

MeSH Terms

Acinar Cells*
Adenosine
alpha-Fetoproteins
Carcinoma
Carcinoma, Acinar Cell*
Chemotherapy, Adjuvant
Cisplatin
Drug Therapy
Female
Gastrectomy*
Humans
Neck
Pancreas
Pancreatectomy
Pancreaticoduodenectomy*
Pneumonia
Stomach Neoplasms*
Adenosine
Cisplatin
alpha-Fetoproteins

Figure

• 

  Fig. 1 Preoperative image study findings. CT scan showed about a 2.5 cm-sized mass near the pancreatic neck portion without evidences of distant metastasis (A). No definitive hypermetabolic signal intensity was shown in FDG-PET scan (B). Filling defect and dilatation of the distal pancreatic duct was shown on magnetic resonance cholangiopancreatography (C).

• 

  Fig. 2 Intraoperative findings. Severe adhesions were noted, especially around the common hepatic artery and the celiac axis. The pancreatic neck portion needed first to be dissected for the anatomic landmark identification. The round mass at the posterior aspect of the pancreatic neck portion (long, thick arrow) should be noted (A), an operative finding after pancreatoduodenectomy. The stump of the gastroduodenal artery is noted (short, thin arrow) (B). SMV, superior mesenteric vein; SV, splenic vein; PV, portal vein; S, remnant stomach; P, remnant pancreas; BD, common hepatic duct.

• 

  Fig. 3 Surgical pathology and postoperative course. An about 1.9 cm-sized pancreas-confining lobulated tumor was noted on the neck of the pancreas (A). The tumor cells are arranged in irregular solid sheets and acinar pattern (B, ×100), The AFP immunohistochemical staining was diffuse positive in tumor cells (C, ×100). The patient got no adjuvant chemotherapy in follow up. The serial follow up of serum AFP showed re-elevation after declining near the normal level following operation (D). H&E, hematoxylin-eosin.

Reference

1. Wisnoski NC, Townsend CM Jr, Nealon WH, et al. 672 patients with acinar cell carcinoma of the pancreas: a population-based comparison to pancreatic adenocarcinoma. Surgery. 2008; 144:141–148. PMID: 18656619.

2. Chen J, Baithun SI. Morphological study of 391 cases of exocrine pancreatic tumours with special reference to the classification of exocrine pancreatic carcinoma. J Pathol. 1985; 146:17–29. PMID: 2989468.

3. Ishizaki A, Koito K, Namieno T, et al. Acinar cell carcinoma of the pancreas: a rare case of an alpha-fetoprotein-producing cystic tumor. Eur J Radiol. 1995; 21:58–60. PMID: 8654461.

4. Seregni E, Botti C, Bombardieri E. Biochemical characteristics and clinical applications of alpha-fetoprotein isoforms. Anticancer Res. 1995; 15:1491–1499. PMID: 7544570.

5. Cingolani N, Shaco-Levy R, Farruggio A, et al. Alpha-fetoprotein production by pancreatic tumors exhibiting acinar cell differentiation: study of five cases, one arising in a mediastinal teratoma. Hum Pathol. 2000; 31:938–944. PMID: 10987254.

6. Kolb-van Harten P, Rosien U, Klöppel G, et al. Pancreatic acinar cell carcinoma with excessive alpha-fetoprotein expression. Pancreatology. 2007; 7:370–372. PMID: 17703084.

7. Benassai G, Mastrorilli M, Quarto G, et al. Survival after pancreaticoduodenectomy for ductal adenocarcinoma of the head of the pancreas. Chir Ital. 2000; 52:263–270. PMID: 10932371.

8. Lee JH, Lee KG, Park HK, et al. Acinar cell carcinoma of the pancreas in Korea--clinicopathologic analysis of 27 patients from korean literature and 2 cases from our hospital--. Korean J Gastroenterol. 2010; 55:245–251. PMID: 20389178.

9. Kawamoto S, Hiraoka T, Kanemitsu K, et al. Alpha-fetoprotein-producing pancreatic cancer--a case report and review of 28 cases. Hepatogastroenterology. 1992; 39:282–286. PMID: 1380476.

10. Burris HA 3rd, Moore MJ, Andersen J, et al. Improvements in survival and clinical benefit with gemcitabine as first-line therapy for patients with advanced pancreas cancer: a randomized trial. J Clin Oncol. 1997; 15:2403–2413. PMID: 9196156.

11. Kawamura H, Ikeda K, Takiyama I, et al. The usefulness of the ATP assay with serum-free culture for chemosensitivity testing of gastrointestinal cancer. Eur J Cancer. 1997; 33:960–966. PMID: 9291821.

12. Kim HA, Yom CK, Moon BI, et al. The use of an in vitro adenosine triphosphate-based chemotherapy response assay to predict chemotherapeutic response in breast cancer. Breast. 2008; 17:19–26. PMID: 17659874.

13. Ng TY, Ngan HY, Cheng DK, et al. Clinical applicability of the ATP cell viability assay as a predictor of chemoresponse in platinum-resistant epithelial ovarian cancer using nonsurgical tumor cell samples. Gynecol Oncol. 2000; 76:405–408. PMID: 10684718.

14. Kim HU, Ryu JK, Choi SB, et al. The clinical characteristics of acinar cell carcinoma in the Pancreas. Korean J Hepatobiliary Pancreat Surg. 2009; 13:54–59.