Successful Laparoscopic RAMPS for PDAC Combined with a Single Peritoneal Dissemination Associated with EUS-FNA: A Case Report

Abstract

Background: The indication for staging laparoscopy (SL) for pancreatic ductal adenocarcinoma (PDAC) is unclear. The incidence of peritoneal dissemination from PDAC, related to endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was reported at 2.2%. Case Presentation: A 68-year-old woman presented with poor glycemic control. Abdominal ultrasonography revealed a low-density lesion (22 mm diameter) in the pancreatic body. EUS-FNA was performed to diagnose PDAC. However, no distant metastasis or local infiltration was observed in CECT. Due to high carbohydrate antigen 19-9 (CA19-9) level (663.7 U/mL), SL was performed. A single peritoneal dissemination was found and resected from the lesser sac, although lavage cytology (LC) was negative. The patient was administered GEM + nabPTX (GnP) as potential unresectable PDAC. After four courses of GnP, CA19-9 level returned to normal and FDG PET-CT showed a negative uptake; therefore, curative resection was proposed. The second SL revealed negative LC of the lesser sac, and liver lesions through indocyanine green fluorescence imaging were not diagnosed as pathological metastases. And consecutive total laparoscopic radical antegrade modular pancreatosplenectomy (RAMPS) was successfully done, resulting in a 300-mL blood loss in 450-min. The pathological diagnosis was ypT1cN0M1 stage IV with negative surgical margins. Adjuvant chemotherapy using S-1 was introduced and a 3-month recurrence-free survival has been achieved so far. Discussion: Needle-tract seeding is a rare complication of EUS-FNA for PDAC and therapeutic strategy is discussable. Recently, neoadjuvant chemotherapy was recommended for resectable PDAC requiring pathological diagnosis in Japan. It is suggesting the significance of SL and LC after EUS-FNA in PDAC.