ductal carcinoma is the most common exocrine tumor of the pancreas and is subdivided into adenocarcinoma and squamous cell carcinoma .
adenocarcinoma , the most common subtype , comprises 80% of all malignant tumors of the pancreas,1,2 while primary squamous cell carcinoma is an extremely rare subtype of ductal carcinoma in the pancreas because the cell line does not exist in a normal pancreas.3,4 consequently , if the presence of squamous cell carcinoma is confirmed in a biopsy , the possibility of metastatic disease must be considered first , and an extensive search for the primary lesion should be undertaken.5,6 recently , we confirmed a case of synchronous esophageal cancer with pancreatic metastasis and hepatocellular carcinoma ( hcc ) .
a 58-year - old male with a 1-month history of abdominal bloating and indigestion visited our hospital for esophagogastroduodenoscopy .
this detected a 34-cm erythematous lesion with an irregular nodular surface extending between 38 and 41 cm from the incisors in the 9 to 1 o , clock position ( fig .
it was shown as an iodine - void area with a well - defined boundary .
a biopsy revealed squamous cell carcinoma , and he was admitted for further evaluation and management of this esophageal cancer .
he was an alcoholic who had been drinking one bottle of soju daily for the past 30 years and had a 30-pack - year smoking history .
he was a hepatitis b carrier without regular follow - up . at admission , the patient 's vitals were stable and he was alert mentally .
the peripheral blood tests were normal , with hemoglobin 13.6 g / dl , white blood cell count 7,330/mm , platelets 238,000/mm , as were the blood chemistry and electrolytes .
additional studies for hepatitis b showed hepatitis b e antigen ( - ) and anti - hepatitis b e antibody ( + ) , and no virus was detected with hepatitis b virus real - time polymerase chain reaction .
the results for tumor markers were as follows : carcinoembryonic antigen 2.39 ng / ml ( reference range , < 4.1 ) , ca19 - 9 2 u / ml ( reference range , < 37 ) , and alpha - fetoprotein ( afp ) 8.58 ng / ml ( reference range , < 4.0 ) . abdominal computed tomography ( ct ) showed a poorly demarcated and poorly enhancing mass at the pancreatic tail ( fig .
magnetic resonance imaging ( mri ) showed that the pancreatic mass appeared poorly demarcated and hyperintense on t2-weighted image and hypointense on t1-weighted image .
so we were highly suspicious that the pancreatic mass was a primary adenocarcinoma rather than metastasis , because of tumor character and extremely low incidence of pancreatic metastasis from esophageal cancer .
ct and mri showed 1.2 cm - sized single nodule in the liver ( fig .
mri showed that the hepatic mass was hypointense on t1-weighted image and hyperintense on t2-weighted image , and poorly enhanced on dynamic enhancing study .
however , serum afp was elevated ( 8.52 ng / ml ) and we had to undergo ultrasound - guided liver biopsy .
the hepatic mass was confirmed as a primary hcc based on the loss of ductular reaction and cd34 positivity ( fig .
the patient underwent surgery for the esophagus and pancreas lesions and radiofrequency ablation for the hepatic cancer .
histologically , the partial esophagectomy and distal pancreatectomy specimens showed squamous cell carcinoma and local lymph node invasion and the patient was diagnosed with stage iv esophageal cancer with pancreatic metastasis ( fig .
the tumor invaded to submucosal layer with lymphatic invasion and metastasis to 3 of 31 regional lymph nodes . in the pancreas ,
the size was 54.54 cm with clean resection margins but there was lymphatic invasion involving 2 of 20 regional lymph nodes .
the patient had received 5-fluorouracil / cisplatin combination therapy six times for 4 months after the surgery .
he has been followed up without any evidence of recurrence on abdomen ct and gastroscopy until this month .
epithelial tumors of the pancreas are divided into exocrine tumors , which are derived from ductal and acinar cells , and endocrine tumors , which are derived from islet cells.1,2 most malignant tumors in the pancreas are primary , and approximately 80% are adenocarcinomas .
the rest include metastatic lesions , squamous cell carcinoma , small cell carcinoma , and acinar cell carcinoma.7 primary squamous cell carcinoma of the pancreas is extremely rare , accounting for only 0.7% of 1,300 pancreatic cancer in a 1992 report from japan because the normal pancreas does not contain squamous epithelium.8 typically , primary squamous cell carcinoma of the pancreas is confirmed only after other primary sources have been excluded using diagnostic tests like ct of the head and chest , gastrointestinal endoscopy , a pelvic exam with a pap smear , and a thorough examination of the skin .
once there is no evidence of a primary lesion elsewhere , the diagnosis of primary pancreatic cancer can be made.5,6 isolated pancreatic metastases from nonpancreatic primary tumors are also very rare , accounting for about 2% of all pancreatic tumors .
autopsy studies of cancer patients with pancreatic metastasis have shown that the lungs and liver are the most common sites of primary lesions , followed by the colon and kidney .
primary esophageal cancer compromises only 0% to 4.8% of pancreatic metastasis , and there has been no reported case in south korea.8 - 10 generally , it is difficult to distinguish a solitary pancreatic metastasis from a primary cancer and a double or triple primary pancreatic cancer is difficult to diagnose in almost all cases .
a tissue diagnosis can be made before surgery with a fine needle aspiration biopsy , guided by ultrasonography , ct , or another modality . in the case of a pancreatic mass ,
resectability should be considered ahead of a preoperative biopsy . in our case , both primary pancreatic cancer and pancreatic metastasis from the esophageal cancer or hcc were possible .
so we decided surgical resection because the tumors were thought to be triple primary cancer arising from liver , esophagus , and pancreas .
after the operation , the pancreatic mass was unexpectedly confirmed as metastasis from the esophageal cancer . in the treatment of cancer patients with an isolated distant organ metastasis and
no widespread disease , resection of the metastasis is beneficial for some types of tumor .
hiotis et al.11 reported that the resection of pancreatic metastatic lesions in 16 patients with different primary tumors led to a longer disease - free interval and improved overall survival .
in addition , the surgical resection of solitary metastatic lesions from colorectal cancer to the pancreas increases patient survival.10 furthermore , the resection of isolated extrahepatic recurrences of hcc prolonged the survival in selected patients.12 a review of the surgical outcomes of reported cases , including our patient , indicated that the surgical mortality rate in pancreatic surgery is less than 5%.13 in our case , surgical resection was reasonable for treatment and obtaining a definite diagnosis , as well as for improving patient survival , although there are few guidelines for managing cases such as ours .
however , these previous reports are based on metastatic lesions that developed after the diagnosis of well - controlled primary tumors .
there are some limitations to applying these reported cases to our case , in which a primary lesion and an isolated metastatic lesion were found simultaneously and the metastatic lesion was considered as primary tumor on imaging studies .
further observations of the prognosis are required in cases diagnosed with synchronous double primary cancer with an isolated metastatic lesion .
we reported this case because isolated pancreatic metastasis of esophageal cancer is rare , and careful treatment decisions are required .
moreover , established guidelines for treating double primary cancer with an isolated metastatic lesion are needed .
 solitary pancreatic metastasis of esophageal cancer is extremely rare . 
 we report the case of a 58-year - old male admitted with esophageal cancer . 
 additional asymptomatic solitary hepatic and pancreatic masses were observed in the staging work - up for esophageal cancer . 
 the hepatic mass was confirmed as a primary hepatocellular carcinoma with an ultrasound - guided needle biopsy . 
 an esophagectomy with a distal pancreatectomy and radiofrequency ablation for hepatocellular carcinoma were performed . 
 histologically , the pancreatic mass was confirmed to be a metastasis from the esophageal cancer . 
 the patient has been followed up with chemotherapy . 
INTRODUCTION
CASE REPORT
DISCUSSION