Adaptive Surgical Decision-Making for Synchronous Metastatic Pancreatic Cancer and Early Breast Cancer with a BRCA1 Pathogenic Variant - A Case Report

Sep 23, 2026

Synchronous pancreatic and breast cancers linked to a germline BRCA1 pathogenic variant present a rare clinical problem, especially when one malignancy is stage IV and determines overall prognosis. A woman in her 60s developed stage IV pancreatic tail cancer with multiple liver metastases and stage I left breast cancer, achieving sustained partial response to SOXIRI. After BRCA1-pathogenic testing, maintenance olaparib enabled durable stabilization, then breast-conserving surgery occurred 28 months after treatment initiation, with long-term survival and no progression.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages6

Reading Time15 min

AccessFree to download

Abstract

Introduction

Case Presentation

Conclusions

Key Clinical Data

SURGICAL CASE REPORTS Surg Case Rep 2026; 12: 26-0257 Case Report Adaptive Surgical Decision-Making for Synchronous Metastatic Pancreatic Cancer and Early Breast Cancer with a BRCA1 Pathogenic Variant: A Case Report Takahiro Akahori ,1 Tomoyo Yokotani,1 Akihiko Yoshizawa,2 Tomoko Uchiyama,2 Ryo Yamaguchi,2 and Masayuki Sho1 ABSTRACT INTRODUCTION: Synchronous pancreatic and breast cancers associated with a breast cancer susceptibility gene (BRCA)1 pathogenic variant are extremely rare. When 1 malignancy presents as stage IV disease, determining the optimal timing and extent of surgical intervention for a second primary cancer represents a major clinical challenge. CASE PRESENTATION: A woman in her 60s was diagnosed with synchronous stage IV pancreatic tail cancer with multiple liver metastases and stage I left breast cancer. S-1/oxaliplatin/irinotecan (SOXIRI) was initiated for metastatic pancreatic cancer, achieving a sustained partial response. Germline testing revealed a BRCA1 pathogenic variant. Maintenance olaparib was subsequently introduced, resulting in durable disease stabilization and normalization of tumor markers. While the pancreatic cancer remained controlled, the breast cancer progressed with axillary lymph node involvement. After confirming long-term systemic stability and preserved performance status, breast-conserving surgery with level II axillary lymph node dissection was performed 28 months after treatment initiation. At 77 months, the patient remains alive without breast cancer recurrence or pancreatic cancer progression. CONCLUSIONS: Adaptive surgical decision-making for a concurrent operable malignancy, supported by durable systemic control of a dominant stage IV cancer, may help prevent the malignancy from becoming an additional threat to long-term prognosis. Dynamic reassessment of oncologic priority is essential in the era of molecularly targeted therapy. KEYWORDS: breast neoplasms, pancreatic neoplasms, BRCA1 protein, neoplasms, multiple primary, poly(ADP-ribose) polymerase inhibitors Abbreviations BRCA breast cancer susceptibility gene CA19-9 carbohydrate antigen 19-9 1Department of Surgery, Nara Medical University, Kashihara, Nara, Japan 2Department of Diagnostic Pathology, Nara Medical University, Kashihara, Nara, Japan Corresponding author: Takahiro Akahori. Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan E-mail: [akahorin@naramed-u.ac.jp](akahorin@naramed-u.ac.jp) Received: April 2, 2026; Accepted: July 23, 2026 DOI: 10.70352/scrj.cr.26-0257 CEA carcinoembryonic antigen ER estrogen receptor HRD homologous recombination deficiency IRIS irinotecan and S-1 PARP poly (ADP-ribose) polymerase SEER Surveillance, Epidemiology, and End Results SOXIRI S-1/oxaliplatin/irinotecan INTRODUCTION Hereditary breast and ovarian cancer syndrome caused by germline pathogenic variants in breast cancer susceptibility genes BRCA1 or BRCA2 increases the lifetime risk of breast, ovarian, and pancreatic cancers.1,2) Platinum-based © 2026 The Author(s) . Published by Japan Surgical Society This article is licensed under a Creative Commons Attribution 4.0 International License. Akahori T. et al. Fig. 1 CT images. (A) Abdominal contrast-enhanced CT revealed a low-density mass occupying the entire pancreatic tail (white arrow) and multiple low-density masses in the liver (white arrows) . (B) A 1. 5-cm contrast-enhancing mass was identified in the lower inner quadrant of the left breast (white arrowhead) . chemotherapy and PARP inhibitors have improved outcomes in selected patients with BRCA-associated metastatic pancreatic cancer.3,4) Olaparib has also demonstrated efficacy in germline BRCA-mutated metastatic breast cancer.5) However, when synchronous BRCAassociated malignancies include stage IV disease, there are no established guidelines for treatment prioritization, optimal timing of surgical intervention for the c

FAQs

Why is optimal timing of surgery challenging in this case?

Because synchronous malignancies include a dominant stage IV pancreatic cancer, requiring adaptive reassessment of oncologic priority to coordinate treatment without compromising long-term prognosis.

What treatment sequence was used before breast surgery?

The patient received SOXIRI for metastatic pancreatic cancer, followed by maintenance olaparib after identifying a BRCA1 pathogenic variant, resulting in durable systemic control.

When was breast-conserving surgery performed, and what was the outcome?

Breast-conserving surgery with level II axillary lymph node dissection was performed 28 months after treatment initiation, and at 77 months the patient remained alive without breast cancer recurrence or pancreatic progression.

Sep 23, 2026

Uploaded by PakDamar76