Maulana Azad Medical College Pittsburgh, PA, United States
Rahul Karna, MD1, Alfonzo Halfin Guerrero, MD1, Tavankit Singh, MD2, Suzanne Morrissey, MD1 1Allegheny Health Network, Pittsburgh, PA; 2Allegheny General Hospital, Pittsburgh, PA
Introduction: Synchronous triple primary tumors are rarely described in the literature. Here, we present a case of synchronous triple primary tumors consisting of pancreatic neuroendocrine tumor (PNET), sessile serrated adenoma (SSA) and mucosal schwann cell hamartoma (MSCH) of the colon incidentally discovered in an asymptomatic female.
Case Description/Methods: We evaluated a 66-year-old Caucasian female with an incidental finding of a 15 mm solid heterogeneous pancreatic tail lesion seen on US, performed for evaluation of asymptomatic transaminitis. Her LFTs revealed AST 56 U/L, ALT 69 U/L, total bilirubin 0.5 mg/dl, ALP 68 U/L. She had a history of osteoarthritis and had recently started taking etodolac. Her transaminitis resolved with discontinuation of etodolac. CECT scan confirmed the lesion in pancreatic body. EUS and FNB revealed a well-differentiated, Grade 1, neuroendocrine tumor with immunohistochemistry staining positive for CAM5.2, synaptophysin, chromogranin, and Islet 1 and Ki67 < 1%. Serum chromogranin A level was normal at 31 ng/ml. Gallium-68 PET scan showed moderate Ga uptake in pancreatic body mass and ruled out any distant metastases. Subsequently, screening colonoscopy showed a 2 mm polyp in the ascending colon, which turned out to be SSA. Another, 2 mm polyp in the sigmoid colon was MSCH, positive for S-100 but negative for desmin and EMA on IHC. She was evaluated by genetic counselor. Genetic testing to identify single-gene hereditary predisposition to tumors was negative for mutations in 86 genes. We conservatively managed her with surveillance imaging over six months for neuroendocrine tumor with plans of eventual resection based on patient preference and repeat colonoscopy in a year.
Discussion: The incidence of multiple primary GI tumors is increasing, likely due to aggressive screening, improved treatment modalities and surveillance techniques, approaches which have also increased overall life expectancy. Our patient presented with an incidental finding of PNET and was found to have MSCH and SSA on screening colonoscopy. MSCH is a rare benign tumor of schwann cells with 38 cases reported in literature to date, 12 of which were associated with colonic adenomas. To our knowledge, this is the first reported case of MSCH in association with SSA and PNET. There was no identifiable mutation/syndrome to explain the association in the patient. We expect more such cases to be reported in the future, which will help guide appropriate work up and management of multiple primary tumors.
Figure: A) EUS showing a round hypoechoic mass measuring 1.3 X 1.5 cm in pancreatic body. B) Axial PET-CT showing a focal area of Ga-68 uptake in the body of pancreas. C) Colonoscopy showing 2 mm polyp in ascending colon D) Touch preparation from pancreatic body lesion shows tumor cells with uniform nuclei, small nucleoli and lack of nuclear atypia or necrosis. E) 40X H & E of sigmoid polyp shows bland spindle cell lesion located inside lamina propria with elongated nuclei and eosinophilic cytoplasm. F) Ascending colon polyp shows dilation and serration of colonic epithelium without dysplasia
Rahul Karna indicated no relevant financial relationships.
Alfonzo Halfin Guerrero indicated no relevant financial relationships.
Tavankit Singh indicated no relevant financial relationships.
Suzanne Morrissey indicated no relevant financial relationships.
Rahul Karna, MD1, Alfonzo Halfin Guerrero, MD1, Tavankit Singh, MD2, Suzanne Morrissey, MD1. P0197 - Synchronous Triple Primary Tumors: Pancreatic Neuroendocrine Tumor, Sessile Serrated Adenoma and Mucosal Schwann Cell Hamartoma of the Colon, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.