Mixed acinar-endocrine carcinoma of pancreas: A case report and brief review of the literature

Figures & data

Figure 1 Abdominal enhanced magnetic resonance imaging with T1 findings.

Notes: (A) An 8×6 cm mass in the head of the pancreas (white arrow). (B) Liver metastasis from mixed acinar-endocrine carcinoma of the pancreas (red arrow).

Figure 2 Histopathology of the pancreas tumor.

Notes: (A) (a) Hematoxylin–eosin image of the pancreas tumor (HEX200). (b) Immunohistochemistry of trypsin (×400, Abcam). (c) Immunohistochemistry of chymotrypsin (×400, Abcam). (d) Immunohistochemistry of Ki-67 (×400, Abcam [Cambridge, MA, USA]). (B) (a) Immunohistochemistry of chromogranin A(×400, Abcam) (b) Immunohistochemistry of synaptophysin (×400, Abcam). (c) Immunohistochemistry of CD56 (×400, Abcam). (d) Immunohistochemistry of neuron-specific enolase (NSE) (×400, Abcam).

Figure 3 Histopathology of the liver metastasis.

Notes: (A) (a) Hematoxylin–eosin image of the liver metastasis (HEX100). Left is adjacent cancerous tissue and right is the liver metastasis. (b) Immunohistochemistry of hepatocyte paraffin 1 (Hep Par 1) (×100, Dako). Adjacent cancerous tissue was positive for immunohistochemistry of Hep Par 1 and the liver metastasis was negative for the same. (c) The liver metastasis was negative for immunohistochemistry of Hep Par 1 (×400, Dako Denmark A/S, Glostrup, Denmark). (d) Immunohistochemistry of CD56 (×400, Abcam). (B) (a) Immunohistochemistry of trypsin (×400, Abcam), indicating that the tissue had an acinar component. (b) Immunohistochemistry of chromogranin A(×400, Abcam). (c) Immunohistochemistry of synaptophysin (×400, Abcam). (d) Immunohistochemistry of neuron-specific enolase (NSE) (×400, Abcam). Chromogranin A, synaptophysin, and NSEwere weakly positive for immunohistochemistry, suggesting that the tissue of the liver metastasis had endocrine component.

Figure S1 Survival curve for the patients after surgery.

Table S1 Reported cases of mixed acinar-endocrine carcinoma in pancreas

Case	Authors	Sex	Age (years)	Presentation	Location	Sizea (cm)	Metastasis anteriorb	Acinar marker	Endocrine markers	Morphology	Ki-67	Treatment	Postoperative course	Metastasis posteriorc	Yeard
1	Current study	F	65	Jaundice, epigastric pain, diarrhea	Head	8	Liver	Trypsin, chymotrypsin	CGA, SYN, NSE	Predominately solid and partly acinar	10%	PD	12 months without recurrence	N/A	2015
2	Yu et al^Citation5	M	80	Abdominal pain, early satiety	Head	14	Right kidney	Trypsin, chymotrypsin	CGA, SYN	Predominately solid and partly acinar	53%	Splenectomy and debulking of the pancreatic mass and continued Sandostatin LAR and chemotherapy	Recurrence and metastasis; still alive at 3 years	Liver and right kidney	2013
3	Yu et al^Citation5	M	89	Melena	Head	3.9	No	Chymotrypsin	CGA, SYN	Predominately acinar and partly solid	65%	Whipple procedure	Dead (2.5 months) after surgery due to complications	N/A	2013
4	Yu et al^Citation5	M	60	Abdominal pain	Head	16	No	Trypsin, chymotrypsin	CGA, SYN	Partly acinar and partly solid/trabecular	65%	Subtotal colectomy, partial gastrectomy, and 70% pancreatectomy and chemotherapy	Recurrence and metastasis; dead (6 months)	Liver	2013
5	Yu et al^Citation5	M	74	Abdominal pain	Body	10	No	Trypsin, chymotrypsin	CGA, SYN	Predominately acinar	10%	Neoadjuvant chemotherapy then underwent distal pancreatectomy and splenectomy and chemotherapy	Metastasis; still alive at 17 months	Wide metastasis	2013
6	Yu et al^Citation5	M	59	Fatigue, anorexia, jaundice	Head	7.5	No	Trypsin, chymotrypsin	CGA, SYN	Predominately solid	30%–80%	Whipple procedure and adjuvant chemotherapy	Recurrence and 4 months metastasis; still alive at 7 months	Liver	2013
7	Ogbonna et al^Citation7	F	57	Epigastric pain	Body	2.5	No	Trypsin, chymotrypsin PAS+cytokeratin	CGA, SYN	Predominately solid	40%–45%	Distal pancreatectomy and splenectomy and adjuvant chemotherapy	N/A	N/A	2013
8	Sullivan et al^Citation18	M	75	Liver transplant, multiple masses	Genu	0.6	Liver	Trypsin, chymotrypsin	CGA, SYN	Half acinar component and half solid component	40%	Chemotherapy	N/A	N/A	2013
9	Sullivan et al^Citation18	M	51	Acute pancreatitis	Body	1.6	No	Trypsin, chymotrypsin	CGA, SYN	Predominately solid and partly acinar	7%–11%	Distal pancreatectomy	N/A	N/A	2013
10	Lee et al^Citation6	M	66	Vague midepigastric discomfort	Head	3.1	Liver	Trypsin, cytokeratin CAM 5.2	CGA, SYN	Half acinar component and half solid component	35%	Chemotherapy	Dead (21 months)	N/A	2013
11	Soubra et al^Citation21	M	52	Epigastric pain, fatigue and jaundice	Head	1.5	No	Trypsin, chymotrypsin	CGA, SYN	Predominately solid and partly acinar	N/A	PD and chemotherapy	After 12 months recurrence, still alive 30 months	Liver	2011
12	Kobayashi et al^Citation13	M	75	Asymptomatic	Tail	7	No	Trypsin, PAS+	CGA, SYN	Predominately acinar and partly solid	N/A	Distal pancreatectomy with lymph node dissection	6 months without recurrence	N/A	2010
13	Chung et al^Citation22	F	59	Watery diarrhea	Tail	8	No	Trypsin, PAS+	SYN	Half acinar component and half solid component	N/A	A partial pancreatectomy along with a splenectomy	N/A	N/A	2010
14	Kyriazi et al^Citation2	M	74	Asymptomatic	Head	12	No	Trypsin, C56, CK7	CGA, SYN	Predominately acinar and partly solid	80%	A modified Whipple procedure	Dead (21 months)	N/A	2009
15	Imaoka et al^Citation10	M	80	Generalized swollen lymph nodes	Head	4	No	Trypsin, chymotrypsin, lipase	CGA, SYN	Predominately acinar and partly solid	N/A	Systemic chemotherapy and Whipple procedure	N/A	N/A	2008
16	Ohike et al^Citation4	M:F 2:4	58.4	N/A	N/A	8.2 (n=2)	N/A	N/A	N/A	N/A	N/A	Surgery resection	N/A	N/A	2004
17	Mizuno et al^Citation12	F	67	Zollinger–Ellison syndrome	Body	N/A	SMV	α-1-antitrypsin	CGA, SYN gastrin insulin	N/A	N/A	Chemotherapy	Dead (8 years)	Wide metastasis	2001
18	Skacel et al^Citation23	M	75	N/A	Tail	5.5	No	Chymotrypsin α-1-antitrypsin	SYN	N/A	N/A	Surgery resection	10 months without recurrence	N/A	2000
19	Skacel et al^Citation23	M	69	N/A	Head	10	No	Chymotrypsin α-1-antitrypsin	SYN	N/A	N/A	Surgery resection	Dead (20 months)	N/A	2000
20	Ogawa et al^Citation24	M	50	Asymptomatic regular medical checkup	Head	3	No	PAS+ α-1-antichymotrypsin	CGA	Half acinar component and half solid component	N/A	A pylorus-preserving PD	18 months without recurrence	N/A	2000
21	Frank et al^Citation25	M	61	Abdominal pain, diarrhea,	Head and body	4.9	Liver	PAS+ Trypsinogen	NSE, CGA	Half acinar component and half solid component	N/A	PD, left hepatectomy, chemotherapy	Metastasis at 3 months; dead (2 years and 9 months)	Liver	1998
22	Shimoike et al^Citation26	M	28	Convulsions	Tail	3	Liver	Trypsinα-1-antichymotrypsin	NSE, CGA	N/A	N/A	Biopsy and TAE, chemotherapy	Dead (10 months)	N/A	1997
23	Cho et al^Citation27	F	52	Jaundice	Head	6	SMV	PAS+ amylase	NSE, CGA somatostatin and gastrin	Predominately solid and partly acinar	N/A	PD	Alive (1 year)	N/A	1996
24	Klimstra et al^Citation11	M	81	Nausea, abdominal pain	Tail	3	No	Trypsin, chymotrypsin, lipase	CGA gastrin	Predominately acinar and partly solid	N/A	Surgery resection	Alive (3 months)	N/A	1994
25	Klimstra et al^Citation11	M	70	Backaches, incidental mass	Multicentric	10	Lung, liver	Trypsin, chymotrypsin	CGA, CEA	Predominately solid and partly acinar	N/A	Surgery resection	Dead (3 months)	N/A	1994
26	Klimstra et al^Citation11	F	64	Hematemesis	Head	10	No	Trypsin, lipase	CGA, SYN, somatostatin	Predominately solid and partly acinar	N/A	Biopsy and bypass	Dead (1 year and 6 months)	N/A	1994
27	Klimstra et al^Citation11	F	48	Incidental mass	Tail	11	No	Trypsin, chymotrypsin, lipase	CGA, SYN, CEA	Predominately solid and partly acinar	N/A	Surgery resection	Alive with recurrence (12 months)	Liver	1994
28	Klimstra et al^Citation11	F	79	Abdominal pain	Head	10	No	Trypsin, chymotrypsin, lipase	CGA, SYN	Predominately solid and partly acinar	N/A	Biopsy and bypass, chemotherapy, radiation	Alive (12 months)	N/A	1994
29	Ichijima et al^Citation28	F	6	Abdominal mass	Tail	8	No	PAS+	Tryptophan immunoperoxidase	N/A	N/A	Surgery resection	Alive (13 years)	N/A	1985
30	Ulich et al^Citation29	F	30	Epigastric pain	Head	9.3	No	PAS+ lipase	Immunoperoxidase	Half acinar component and half solid component	N/A	PD	Alive (4 months)	N/A	1982

Notes:

a Tumor size.

b Treatment of anterior.

c Treatment of posterior.

d Year of publication.

Abbreviations: CEA, carcinoembryonic antigen; CGA, chromogranin A; F, female; M, male; N/A, not available; NSE, neuron-specific enolase; PAS, periodic acid–Schiff; PD, pancreaticoduodenectomy; SMV, superior mesenteric artery; SYN, synaptophysin; TAE, transcatheter arterial embolization.

Table S2 Life table showing survival time after surgery (months)a

Interval start time	Number entering interval	Number withdrawing during interval	Number exposed to risk	Number of terminal events	Proportion terminating	Proportion surviving	Proportion surviving at end of interval	Standard error of cumulative proportion surviving at end of interval	Probability density	Standard error of probability density	Hazard ratio	Standard error of hazard rate
0	21	0	21.000	0	0.00	1.00	1.00	0.00	0.000	0.000	0.00	0.00
1	21	0	21.000	0	0.00	1.00	1.00	0.00	0.000	0.000	0.00	0.00
2	21	0	21.000	0	0.00	1.00	1.00	0.00	0.000	0.000	0.00	0.00
3	21	0	21.000	1	0.05	0.95	0.95	0.05	0.048	0.046	0.05	0.05
4	20	2	19.000	1	0.05	0.95	0.90	0.07	0.050	0.049	0.05	0.05
5	17	1	16.500	0	0.00	1.00	0.90	0.07	0.000	0.000	0.00	0.00
6	16	0	16.000	1	0.06	0.94	0.85	0.08	0.056	0.055	0.06	0.06
7	15	2	14.000	0	0.00	1.00	0.85	0.08	0.000	0.000	0.00	0.00
8	13	0	13.000	0	0.00	1.00	0.85	0.08	0.000	0.000	0.00	0.00
9	13	0	13.000	0	0.00	1.00	0.85	0.08	0.000	0.000	0.00	0.00
10	13	1	12.500	0	0.00	1.00	0.85	0.08	0.000	0.000	0.00	0.00
11	12	0	12.000	0	0.00	1.00	0.85	0.08	0.000	0.000	0.00	0.00
12	12	12	6.000	0	0.00	1.00	0.85	0.08	0.000	0.000	0.00	0.00

Note:

a The median survival time is 12.00.

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