Synchronous Distal Cholangiocarcinoma and Pre-Operative Unacknowledged Pancreatic Ductal Adenocarcinoma: An Extremely Rare Finding!

Background: the presence of a synchronous biliary tract and pancreatic cancers is extremely rare and has been described in few cases only. Herein, a case of a man who underwent pylorus-preserving pancreaticoduodenectomy for a distal cholangiocarcinoma is reported. However, on top of the cholangiocarcinoma a diagnosis of synchronous pancreatic ductal adenocarcinoma was made at pathological examination of the operative specimen. Case: an 82-years-old man with history of multiple abdominal surgery, presented at the emergency room with jaundice. Abdominal ultrasound detected a bile duct dilatation, and contrast-enhanced abdominal-CT showed a suspicious 21mm enhanced lesion of the pancreatic head. No secondary lesions were detected. Endoscopic US described a hypoechoic lesion of 26,9x10,5mm of the distal bile duct suspicious for distal cholangiocarcinoma and an early chronic pancreatitis. No other lesions were found after a MRCP and restaging CT, and a pylorus-preserving pancreaticoduodenectomy was performed. The post-operative course was regular. However, on the pancreatic margin of the operative specimen a second neoplasia was found. This prompted the diagnosis of extrahepatic cholangiocarcinoma with synchronous pancreatic ductal adenocarcinoma, with 4/23 metastatic lymphnodes from adenocarcinoma-NOS. After referral to a specialized Center, considering comorbidities and personal medical history as well as the previous oncological treatment, no adjuvant chemotherapy was decided, and only a clinical-instrumental follow-up was established. After 18 months, the patient is still in good conditions with no signs of recurrence. Conclusion: we report an extremely rare case of distal cholangiocarcinoma in an elderly patient with a synchronous pancreatic ductal adenocarcinoma with a surprisingly clinical surgical outcome.