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Invited Commentary
April 1998

Metastases to the Pancreas and Their Surgical Extirpation—Invited Commentary

Arch Surg. 1998;133(4):418. doi:10.1001/archsurg.133.4.418

The report by Z'graggen et al describes a 5-year experience with 10 patients whose clinical presentations were those of primary pancreatic malignant neoplasms. Fine-needle sampling revealed that tumors in 3 were obviously metastatic, but those in the other 7 were presumed to be pancreatic in origin. The outcomes demonstrated that, regardless of whether primary or secondary neoplasia is responsible, best palliation and even possible cure can be obtained by managing these lesions as if none is metastatic. When not resectable, the appropriate bypass operation should be performed to improve quality of life for the patient's remaining days. Another pancreatic mass can also mimic a primary malignant neoplasm, and that is a desmoplastic infectious process. Personal experience with 2 patients with distal common bile duct obstruction produced by a coccidioidomycotic granuloma immediately comes to mind. Cytologic study of a fine-needle aspirant was diagnostic of 1 tumor, but the other was not appreciated until permanent histologic sections of a lymph node from the porta hepatis were reviewed postoperatively. Each patient did well on follow-up after a protracted course of fluconazole. Accordingly, the message conveyed in this article should not just be heeded, but ever kept in mind when treating patients with an otherwise clear-cut picture of pancreatic cancer.