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Year : 2013  |  Volume : 9  |  Issue : 4  |  Page : 733-735

Intractable nausea in a patient with synchronous pancreatic cancer and a fourth-ventricular ependymoma


1 Department of Radiation Oncology, SUNY Upstate Medical University, Syracuse NY, USA
2 Department of Neurosurgery, SUNY Upstate Medical University, Syracuse NY, USA

Date of Web Publication11-Feb-2014

Correspondence Address:
Varun K Chowdhry
Department of Radiation Oncology, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.126474

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 > Abstract 

Symptoms of nausea and vomiting can present a diagnostic challenge for physicians. In this article, we report a patient who was found to have synchronous presentation of an ependymoma and pancreatic cancer. This case illustrates some of the diagnostic challenges in patients with constitutional symptoms. Furthermore, it illustrates the importance of surgical intervention as both a diagnostic as well as a therapeutic measure when managing patients with presumed metastatic disease to the brain.

Keywords: Ependymoma, nausea and vomiting, pancreatic cancer


How to cite this article:
Chowdhry VK, Carter DA, Shapiro A. Intractable nausea in a patient with synchronous pancreatic cancer and a fourth-ventricular ependymoma. J Can Res Ther 2013;9:733-5

How to cite this URL:
Chowdhry VK, Carter DA, Shapiro A. Intractable nausea in a patient with synchronous pancreatic cancer and a fourth-ventricular ependymoma. J Can Res Ther [serial online] 2013 [cited 2019 Nov 11];9:733-5. Available from: http://www.cancerjournal.net/text.asp?2013/9/4/733/126474


 > Introduction Top


Constitutional symptoms such as nausea and vomiting can present a diagnostic dilemma to physicians, such symptoms can be a result of a variety of clinical conditions. The diagnosis can be especially difficult when the original hypothesis leads the physicians down a particular diagnostic and treatment path. In this case, we report our experience with a patient who presented with nausea, and was incidentally found to have pancreatic cancer on the basis of suspicious findings on computed tomography (CT) scan [Figure 1]. However, following definitive treatment for his pancreatic cancer his nausea persisted, magnetic resonance imaging (MRI) of the brain [Figure 2] revealed a fourth ventricular tumor, which was ultimately determined to be ependymoma. To our knowledge, the synchronous presentation of an intracranial ependymoma and pancreatic cancer has not been reported in the literature. It was not until surgical resection of the lesion in the brain that the patient's symptoms resolved. This case illustrates the importance of understanding the natural history of pancreatic cancer, and the importance of keeping a wide differential diagnosis of intracranial lesions in patients with a pre-existing diagnosis of cancer. While metastatic disease is always part of the differential diagnosis, a new primary lesion must be considered.
Figure 1: Intital CT scan of abdomen and pelvis performed on patient with the indication of nausea and vomiting resulted in the diagnosis of pancreatic cancer

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Figure 2: T1 coronal and sagittal images with gadolinium contrast enhancement showing tumor in fourth ventricle

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 > Case Report Top


The patient is a 64-year-old male who presented initially because of an 11 month history of nausea and vomiting. As a result, the patient was referred to the GI Clinic and a CT scan of the abdomen and pelvis revealed a pancreatic cyst. The patient subsequently had an endoscopic ultrasound and then subsequently fine-needle aspiration, which revealed a mucinous epithelial neoplasm, and the determination was made to seek definitive surgical intervention. The patient had a distal pancreatectomy and splenectomy performed in the pancreatic body and tail. Following the surgery the patient was referred to medical and radiation oncology and given the fact that the patient had positive microscopic margin the determination was made to provide concurrent chemotherapy and radiation therapy in the adjuvant setting. The patient was treated on a regimen based on RTOG 9704 [1] protocol, in which initial therapy with gemcitabine was alone followed by concurrent chemoradiation therapy with infusional 5-FU, followed by additional gemcitabine.

The patient tolerated adjuvant therapy well, however, he was noted to continue to have nausea during the course of radiotherapy, although this was attributed to the radiotherapy itself. The patient required antiemetic therapy to be able to lie flat to tolerate radiotherapy. However, even 4 months after the completion of radiotherapy, the patient continued to have nausea. The patient also began to note symptoms of vertigo. The patient presented to the hospital and a CT scan, followed by an MRI performed revealed a tumor in the fourth ventricle. While the initial determination was to consider surgical resection, there was concern that the patient had metastatic disease, and overall poor prognosis associated with metastatic pancreatic cancer. Therefore, radiation-oncology was consulted to consider palliative radiotherapy to the brain.

It was noted at that time that the location of the disease would not be typical for metastases, that it would be rare for pancreatic cancer to spread to the brain. Additionally, it was felt that surgical intervention would not only provide histological diagnosis which would best guide adjuvant therapy, but also provide better local control and overall survival even if the histological findings were consistent with metastatic disease. At that time, the patient underwent additional metastatic workup, including endoscopic ultrasound, and positron emission tomography (PET) scan, which did reveal any evidence of recurrent disease. As a result, the patient underwent suboccipital craniotomy, C1 bilateral laminectomies, and debulking of the fourth ventricular tumor > 95%. Scant amounts of tumor were adherent to the fourth ventricular floor precluding their safe removal. Final pathology revealed an ependymoma, world health organization (WHO) Grade II [Figure 3]. The cells were noted to be positive for glial fibrillary acidic protein (GFAP) and S-100. Postoperative MRI revealed good resection with no clear radiological evidence for residua [Figure 4]. One month postoperatively, the patient's nausea was noted to have essentially resolved. The patient was subsequently treated with radiation therapy to the posterior fossa to a total dose of 5040 cGy in 180 cGy daily fractions using intensity modulated radiation therapy. The patient's nausea has improved and he is enjoying a good quality of life.
Figure 3: Pathological specimen following resection of fourth ventricular tumor revealing ependymoma WHO Grade II

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Figure 4: Postoperative T1 contrast enhanced MRI scan showing gross total resection of ependymoma

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 > Discussion Top


This case illustrates two distinct diagnostic challenges. The first was the differential diagnosis regarding patient's initial presenting symptoms of nausea. The differential diagnosis of nausea includes gastrointestinal, infectious, neurological, toxic, and psychiatric causes. [2] The initial assumption was that the nausea was related to his abdominal symptoms. The patient was initially referred to the GI clinic, and abdominal workup was undertaken to determine the cause of nausea, which lead to the diagnosis of pancreatic cancer. The patient was found to have some changes in the pancreas, which ultimately led to the diagnosis of pancreatic cancer. Since a positive finding was discovered it was assumed that this was the cause of the patient's nausea. The patient's symptoms persisted during the course of radiotherapy, but this was attributed to nausea that can be expected in patients receiving radiotherapy to the abdomen. When the patient continued to have nausea following radiotherapy, an alternative cause of nausea needed to be established. Given the vertiginous symptoms that developed at the same time, the determination was made to obtain an MRI of the brain.

The second diagnostic challenge was apparent when the patient was found to have a lesion in the fourth ventricle. An understanding of the natural history of the disease helped consider alternatives in diagnosis in this particular patient. It would be rare to have brain metastases from a pancreatic primary, although cases have been reported in the literature. [3],[4] Spinal ependymomas have been associated with multiple endocrine neoplasia type 1, and abnormalities and genetic abnormalities have been noted on mutations on chromosome 11q13. [5],[6] One report of a patient from Italy with multiple endocrine neoplasia type 1 (MEN-1) syndrome developed an intracranial ependymoma. [7] However, to our knowledge there are no reports of the simultaneous occurrence of these two malignancies. Patchell reported that 11% of patients that were thought to have brain metastases on the basis of clinical history and radiographic findings were found to have another cause of the lesion in the brain. [8] Additionally, the same trial demonstrated a survival benefit in patients who had surgical resection followed by whole brain radiation therapy compared with whole brain radiation therapy alone. Therefore, surgical resection would not only provide a histological diagnosis to help direct adjuvant therapy, but also may lead to a survival benefit if this did indeed turn out to be metastatic disease. The most common site of brain metastases is considered to be the gray-white matter junction, making a fourth ventricular lesion more suspicious for a primary brain tumor rather than a metastatic lesion. [9] Furthermore, the unusual location for a brain metastases as well as the low-clinical index of suspicion for metastases for the patient's particular tumor were strong arguments to establish the diagnosis.

The patient tolerated surgical resection well, which resulted in resolution of his nausea. He subsequently completed a course of adjuvant radiotherapy for the ependymoma. Following the completion of surgery radiotherapy for his epdenymoma, his nausea has resolved, and the patient is enjoying a good quality of life.

 
 > References Top

1.Regine WF, Winter KA, Abrams RA. Fluorouracil vs gemcitabine chemotherapy before and after fluorouracil-based chemoradiation following resection of pancreatic adenocarcinoma: A randomized controlled trial. JAMA 2008;299:1019-26.  Back to cited text no. 1
    
2.Metz A, Hebbard G. Nausea and vomiting in adults-A diagnostic approach. Aust Fam Physician 2007;36:688-92.  Back to cited text no. 2
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3.Kuratsu J, Murakami M, Uemura S, Ushio Y. Brain and skull metastases of hepatic or pancreatic cancer-report of six cases. Neurol Med Chir (Tokyo) 1990;30:476-82.  Back to cited text no. 3
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4.Yamada K, Miura M, Miyayama H, Sakashita N, Kochi M, Ushio Y. Brain metastases from asymptomatic adenocarcinoma of the pancreas: An autopsy case report. Surg Neurol 2002;58:332-6.  Back to cited text no. 4
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5.Kato H, Uchimura I, Morohoshi M, Fujisawa K, Kobayashi Y, Numano F, et al. Multiple endocrine neoplasia type 1 associated with spinal ependymoma. Intern Med 1996;35:285-9.  Back to cited text no. 5
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6.Giraud S, Choplin H, Teh BT, Lespinasse J, Jouvet A, Labat-Moleur F, et al. A large multiple endocrine neoplasia type 1 family with clinical expression suggestive of anticipation. J Clin Endocrinol Metab 1997;82:3487-92.  Back to cited text no. 6
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7.Al-Salameh A, François P, Giraud S, CalenderA, Bergemer-Fouquet AM, de Calan L, et al. Intracranialependymoma associated with multiple endocrine neoplasia type 1. J Endocrinol Invest 2010;33:353-6.  Back to cited text no. 7
    
8.Patchell RA, Tibbs PA, Walsh JW, Dempsey RJ, Maruyama Y, Kryscio RJ, et al. A randomized trial of surgery in the treatment of single metastases to the brain. N Engl J Med 1990;322:494-500.  Back to cited text no. 8
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9.Hwang TL, Close TP, Grego JM, Brannon WL, Gonzales F. Predilection of brain metastasis in gray and white matter junction and vascular border zones. Cancer 1996;77:1551-5.  Back to cited text no. 9
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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