Revisiting the Whipple procedure in chondrosarcoma metastasis to the pancreas

Abstract

Introduction

Chondrosarcoma is the second most common primary bone cancer with the lungs being the primary site of metastasis. Pancreatic metastases can occur, but their rarity makes management challenging.

Presentation of case

A 27-year-old female with a past medical history of childhood chondrosarcoma of her left tibia presented with metastatic chondrosarcoma of the pancreas five years later. The patient underwent an upfront Whipple procedure with positive margins. Upon recovery, her oncology team recommended watchful waiting. One year later, she presented to the emergency department with coffee ground emesis and diffuse abdominal pain. A computed tomography scan showed a large recurrent mass at the pancreatic remnant concerning for local recurrence. Upper endoscopy found active bleeding near the gastrojejunostomy anastomosis with no ulcers as well as portal hypertensive gastropathy. After discussing these findings, the patient ultimately declined any further treatment, and she was discharged to hospice.

Discussion

This is the second reported case of a Whipple procedure for metastatic chondrosarcoma, and first with positive margins (R1). It appears that chondrosarcoma metastasis to the pancreas requiring Whipple procedure is associated with poor outcomes. This unfortunate result is further compounded by the lack of neoadjuvant or adjuvant chemotherapy or radiation in the setting of R1 resection.

Conclusion

Upfront Whipple procedure in metastatic chondrosarcoma at high risk for R1 resection should be considered with neoadjuvant radiation Adjuvant radiation can be considered if there are positive margins.