On hospital day six the patient underwent a CT scan which confirmed the presence of a 10 cm × 10 cm multilobulated mass within the lumen of the stomach which was abutting the tail of the pancreas (Fig 2). Foci of central necrosis were observed on one side of the lesion but there was no evidence of obvious metastatic disease. The next morning, he was taken to the operating room for exploration. Intraoperatively, a large mass involving the posterior wall of the stomach and the lesser sac was identified. There were multiple areas of profuse hemorrhage along the surface of the tumor. Surgery was initially attempted laparoscopically, but had to be converted to a laparotomy in order to safely separate the mass from the anterior surface of the pancreas and adjacent retroperitoneum. This separation was performed bluntly in order to gain control of the ongoing hemorrhage. Since the lesion extended superiorly towards the gastroesophageal junction, a thoracoabdominal incision was made to obtain a sufficient proximal margin. Ultimately, the patient underwent a total gastrectomy, roux-en-Y esophagojejunostomy and feeding jejunostomy tube placement. A total of 2.5 liters of blood was lost intraoperatively and the patient was given six units of packed red blood cells and four units of fresh frozen plasma during surgery. Frozen section diagnosis was consistent with invasive adenosquamous cell carcinoma. Upon final pathological examination, the tumor was conclusively determined to be of pancreatic origin. Extensive sampling and permanent sections of the tumor revealed predominantly high grade adenosquamous cell carcinoma with marked nuclear atypia and necrosis and focal malignant glandular elements, consistent with adenosquamous carcinoma (Fig 3). Two of 13 perigastric lymph nodes were positive for metastatic disease, composed of only the squamous component.

Widely disseminated disease is commonly present at the time of initial presentation. Although diffuse disease usually prevents resection, palliative surgery may still be indicated in cases of hemorrhage, perforation or obstruction.

Even when potentially curative surgical resection is performed, prognosis is generally regarded as extremely poor. In 2008, Okabayashi et al reviewed 39 cases of ASC treated with pancreatic resection (pancreaticodudenectomy, distal pancreatectomy or total pancreatectomy) spanning 1980 through 2007 (7). In this review, the 1-year and 3-year survival rates following pancreatic resection were 25% and 14%. Nevertheless, some reports have demonstrated a survival benefit for patients undergoing an R0 resection (8). Similarly, Voong et al showed a survival benefit for patients treated with adjuvant chemoradiation therapy (4).

While direct invasion of adjacent organs has been reported for ASC (5), it usually does not lead to erosion through the wall of hollow viscera. When present, this presents an obvious challenge to the surgeon, but should not be interpreted as a contraindication to surgical resection. Gastrointestinal bleeding has been associated with tumors of multiple abdominal organs, but rarely so with primary lesions of the pancreas. Several treatment strategies for malignancy-related GI bleeding are commonly employed, including endoscopic techniques, angiographic embolization and surgical therapy (9). All modalities are useful in the appropriate setting, but treatment must be individualized for each case.