Back pain in a locally advanced pNET with hepatic metastases – a rare case with an unusual secondary diagnosis

Introduction:

Pancreatic neuroendocrine tumours are rare with an incidence of less than 0,01%. At the time of diagnosis, metastases of the liver often have already occurred. Hepatic metastases are one of the main prognostic factors of pNETs. Main factors for the indication of a curative therapy are grade of differentiation (G1, G2, G3) and resectability of the primary tumour.

Material and Methods:

A 51-year-old female patient was admitted to our hospital with abdominal pain, nonspecific back-pain and distinct cachexia. CT-scans showed a mass located at the tail of pancreas as well as multiple bilobular hepatic metastases. Biopsy approved the diagnosis of a primary locally advanced pNET. As a first step, we performed a left sided resection of the pancreas including splenectomy and multiple, non-anatomic left sided liver-resections as well as a resection of a thrombus of the portal vein. Further therapy included right sided portal vein embolisation to ensure a safe second step right-sided hepatectomy which we were able to perform 3 months later. Intervall MRI showed an intraspinal mass which was diagnosed as a meningioma. It was removed surgically and the back-pain finally stopped immediately. Postoperative course was uneventful, the patient received Lanreotid-therapy. Peptide-receptor-radionuclide-therapy was started after a hepatic recurrence was diagnosed. Since then the patient received PRRT 177Luteum-DOTA-DETA and Somatuline every 4 weeks. Her last follow-up showed a complete remission.

Conclusion:

Even in case of a primary inoperable pNET with liver bilateral liver metastases, surgical hepatobiliary expertise can influence patient outcome positively, especially in slow growing NET. A dedicated HPB surgeon should be mandatory in NET multidisciplinary team discussions.