Combined modality therapy including cytoreductive surgery and heated intraperitoneal chemotherapy for synchronous low volume peritoneal carcinomatosis from adenocarcinoma of the tail of pancreas in a BRCA-2 carrier resulting in long-term disease-free survival: A case report

Richard A Hoefer; Chukwuemeka Obiora; Basem Azab; Elizabeth A Harden; John F Kessler

doi:10.1016/j.ijscr.2021.106047

Combined modality therapy including cytoreductive surgery and heated intraperitoneal chemotherapy for synchronous low volume peritoneal carcinomatosis from adenocarcinoma of the tail of pancreas in a BRCA-2 carrier resulting in long-term disease-free survival: A case report

Int J Surg Case Rep. 2021 Jun:83:106047. doi: 10.1016/j.ijscr.2021.106047. Epub 2021 May 29.

Authors

Richard A Hoefer¹, Chukwuemeka Obiora², Basem Azab³, Elizabeth A Harden⁴, John F Kessler⁴

Affiliations

¹ Sentara Cancer Network, Norfolk, VA, United States of America. Electronic address: rahoefer@sentara.com.
² Department of Surgical Oncology, New Hanover Regional Medical Center, Wilmington, NC, United States of America.
³ Department of Surgical Oncology, Staten Island University Hospital, New York, NY, United States of America.
⁴ Department of Medical Oncology, Sentara Careplex Hospital, Hampton, VA, United States of America; Virginia Oncology Associates, Hampton, VA, United States of America.

Abstract

Introduction: A BRCA-2 mutation carrier with a metachronous pancreatic adenocarcinoma (PC) and established peritoneal metastases is presented. Combined modality therapy including Cytoreductive Surgery (CS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) was associated with long-term disease-free survival.

Case presentation: A 62-yr. old female underwent successful treatment for stage IIIa carcinoma of the right breast at age 48. 11 years later a cystic adenocarcinoma of the tail of the pancreas with peritoneal metastases was diagnosed. Platin based neoadjuvant chemotherapy followed by definitive resection of the pancreatic mass with cytoreductive surgery (CS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) with mitomycin C was performed. Postoperatively, a retro-gastric fluid collection developed from a pancreatic duct leak, successfully managed non-operatively. Maintenance poly ADP ribose polymerase (PARP) inhibitor therapy was initiated after recovery from surgery. The patient experienced a 30-month disease free survival and was subsequently found to have oligometastases to the brain.

Discussion: CR and HIPEC have not been reported to be efficacious in patients with pancreatic carcinomatosis. However, PC arising in BRCA-2 carriers has a DNA repair defect, which is sensitive to platin based chemotherapy and mitomycin C. HIPEC has more severe postoperative complications following distal pancreatectomy. Isolated brain metastases from PC are rare. BRCA-2 mutation carriers are at significantly increased risk for PC.

Conclusion: Leveraging the DNA Repair defect in BRCA-2 pancreatic adenocarcinoma, including CS and HIPEC, led to long-term disease-free survival and good locoregional control in this patient. Complications from HIPEC are more severe. BRCA-2 carriers should undergo annual pancreatic cancer screening.

Keywords: Breast cancer gene-2 (BRCA-2); Cytoreductive surgery (CS); Hyperthermic Intraperitoneal Chemotherapy (HIPEC); Pancreatic cancer (PC); Poly ADP ribose polymerase (PARP).