Synchronous adenocarcinoma of the sigmoid colon and multifocal intraductal papillary mucinous neoplasm of the pancreas in an elderly patient

Intraductal papillary mucinous neoplasms are a well-recognized pathologic entity of the pancreas that is being reported with increasing frequency. These tumours carry a relatively favourable prognosis and are frequently associated with extrapancreatic malignancies. The combination of advanced age and co-existence of two neoplasms challenges the planning of the best treatment option. A 78-year-old man presented with rectal bleeding which led to the diagnosis of a stenosing adenocarcinoma of the sigmoid colon. No metastatic lesions were present but a 30 mm intraductal papillary mucinous neoplasm with mural nodules was detected in the uncinate process of the pancreas. Small diffused dilations of the side branches were present in the body and tail of the gland. A two-stage procedure was planned: an R0 sigmoid resection was undertaken first with an uneventful postoperative course. Forty-five days later a pancreaticoduodenectomy was performed and the postoperative course was again uneventful apart from delayed gastric emptying. Histology showed a combined-type intraductal papillary mucinous neoplasm with foci of non-invasive carcinoma. The patient is still alive without evidence of cancer recurrence 33 month after the pancreatico-duodenectomy. The co-existence of a potentially malignant pancreatic tumour with an extra-pancreatic overt malignancy in elderly patients poses difficulties in the attempt to cure the patient with minimal morbidity. In the present case we considered a staged surgical procedure with the aim of reducing the perioperative risk, since the excision of the pancreatic neoplasm required a pancreaticoduodenectomy in an elderly patient.