3D Printing for Preoperative Planning in Pancreatic Resection for Rare Metastasis from Ovarian Cancer: a case report

3D Printing for Preoperative Planning in Pancreatic Resection for Rare Metastasis from Ovarian Cancer: a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report 3D Printing for Preoperative Planning in Pancreatic Resection for Rare Metastasis from Ovarian Cancer: a case report Stefan Arsenkov, Svetozar Antovic, Ognen Plavevski, Emilija Arsenkov, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4199271/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Secondary pancreatic malignancies are a rarely reported entity, limited to sporadic case reports in the medical literature. Most oftenly these secondary malignancies are of renal origin, followed by gastrointestinal tumors and lung cancer as the primary tumor sites. Metastatic tumors from ovarian origin are few and far between. In our understanding this is the first time 3D printing has been used in the preoperative planning of one such case. Case presentation We present the case of a 63 year old patient with a history for bilateral ovariectomy for ovarian tumor 5 years prior, with a 3D printed model of the patient’s anatomy used for preoperative planning as a novel approach. During regular check-ups, an elevated CA19-9 level prompted a CT scan showing a distal pancreatic mass entering the splenic hilum, and a PET scan showed FDG avid lesion considered malignant and no other lesions were detected. The location of the metastasis warranted a distal pancreatectomy with splenectomy. To aid in the preoperative planning a 1:1 replica of the patient’s anatomy was constructed based on the CT scan, and it was manufactured using 3D printing. After extirpation of the tumor, the histological analysis showed a pancreatic pseudocyst with an intraluminal neoplastic proliferation, and further immunohistochemistry analysis determined the immunophenotype suitable of an ovarian cystadenocarcinoma metastasizing to the pancreas. Conclusions The surgical team was unanimous in the impression that the 3D printed model facilitated a swift surgery without any complications. Not only the model helped the planning phase, it is useful as a tool for patient education and further education of students and residents. 3d printing pancreatic surgery abdominal surgery preoperative planning 3d models Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Pancreatic malignancies are the seventh cancer-related cause of death in the world. [1]Even though they have a relatively high incidence, they are most commonly primary in origin. Secondary pancreatic tumors, which stem from metastases originating in other sites, represent a relatively rare occurrence constituting less than 5% of pancreatic malignancies[2], and in some series the incidence of pancreatic metastases is as low as 0.4% [3]. Due to the uncommon nature of secondary pancreatic tumors, their reporting is often limited to case series or individual case reports within medical literature. In these reported cases, the most frequently cited primary tumors giving rise to pancreatic metastases are renal cell carcinoma, gastrointestinal neoplasms, and lung cancers. [2,3,4,5]. Ovarian cancer as the primary tumor and source for metastasis is cited exceedingly rarely, with only a couple reported by Adsay et al [2], one reported by Anderloni et al [6] and one by Pingpank et al [7]. The fact that both the studies done by Adsay and Pingpank were studies spanning decades [2,7] and involving hundreds of specimens, further strengthens the notion that primary ovarian tumors with metastases to the pancreas is something rarely seen. Case Presentation We present the case of a 63-y.o. Caucasian female patient presenting to our hospital with a distal pancreatic mass, found on a CT scan of the abdomen. The patient’s medical history reveals a hysterectomy and bilateral adnexectomy, with appendectomy due to an ovarian mass, approximately 5 years prior to the consultation in our clinic. Before the hysterectomy, her CA19-9 levels were elevated at 376 U/ml. After the initial surgery, she underwent chemotherapy with carboplatin 480mg, with regular follow-ups. For 3 years she didn’t have any symptoms or abnormal results, until her CA 125 was increased at 82.9 U/ml. This prompted an MRI and CT scans which showed a thickening of the wall of the stomach. A gastroscopy with a biopsy was done, and a histology consistent with a B-cell Lymphoma was obtained. She was treated by a hematologist, and remained symptom free ever since, although her CA125 levels remained slightly elevated, ranging between 51 and 86 U/ml. Approximately 4.5 years after the surgery, her CA19-9 levels were detected to be elevated at 54.39 U/ml, even though they have been normal ever since the first surgery. This was the reason to obtain another CT scan, which showed a distal pancreatic mass ( Fig. 1 ) . A PET scan was ordered in order to differentiate the lesion and detect any additional lesions. The result of the PET scan showed a metabolically active lesion in the distal pancreas and in the splenic hilum. (Fig. 2 ) Given the above results, an extirpation of the tumor was indicated. Considering its location within the splenic hilum, the procedure of choice was determined to be a distal pancreatectomy with splenectomy. To enhance the precision of the surgical approach, a decision was made to construct a 1:1 replica of the patient’s organs to be used for preoperative planning. Using an open-source software the 3D model was generated from the CT scan data, which was obtained with a slice thickness of 1.25mm during the arterial contrast phase. Previous research shows that models generated through such methods offer an exceptionally accurate representation of the anatomical structures, with a margin of error measuring less than 1% [8]. The model of the patient’s anatomy was printed using a Fused Deposition Modeling (FDM) printer, with Thermoplastic Polyurethane (TPU) selected as the material of choice. (Fig. 3 ) The files were printed with 2 wall thickness, as only one would tear, with lightning infill which allowed the majority of the organ to be empty, but still have sufficient support for the structure to not collapse on it self. TPU was chosen because of its flexibility which enabled us to systematically deconstruct the model into its constituent components. This deconstruction facilitated a comprehensive examination of each element in isolation, and we were able to subsequently assemble the model to precisely replicate the in situ anatomical configuration of the patient. The surgical team was given ample time to analyze the 3D printed model and to devise an operative plan. Once the surgery has been completed, the specimen shown in the image below (Fig. 4 ) was obtained and a side-to-side comparison of the printed model and the obtained specimen was made, further strengthening the notion that the 3D printed model was an accurate representation of the patient’s anatomy. The operation was done in 90 minutes, which is a relatively short time for a distal pancreatectomy with splenectomy [9]. The 3D printed model continued to serve as an invaluable visual reference intraoperatively, offering real-time guidance and enhancing the surgical team's spatial awareness.The surgical team was under the impression that being able to prepare and plan the operation using the 3D printed model was of immense help. The patient’s recovery after the procedure went as expected, no SSI were noted, the abdominal drain was removed on postoperative day 5 and she was discharged on postoperative day 9. The histological analysis of the specimen showed a coagulative necrosis of the splenic tissue (Fig. 5 a). The analysis of the lesion showed pancreatic tissue bordering a pseudocystic formation encased in a pseudocapsule of connective tissue with an intraluminal neoplastic proliferation of epithelial cells which have a cubic-polygonal shape and pleomorphism. The nuclei are round to oval with a varying degree of eosinophilic cytoplasm, with some mythoses visible. The cells are arranged in cystic and papilliform fashion. The following phenotype was performed: CA125+, WT1, ER+, Pax8 +, PR -, CA19/9 - (Fig. 5 b) The discovered findings exhibit distinctive characteristics that align with a rare pancreatic neoplasm, manifesting indications suggestive of papillary serous pancreatic cystadenocarcinoma. However, the diagnostic approach is further nuanced by considerations of the immunophenotype, raising the plausible inference that these manifestations may represent a distant metastasis stemming from the patient's prior ovarian cystadenocarcinoma. The differential diagnosis, informed by both histological features and immunohistochemical markers, underscores the complexity in accurately categorizing the nature of the pancreatic lesion. Discussion and Conclusion Secondary pancreatic tumors are a rare entity, and they deserve a careful approach both in the planning phase and postoperatively, during the follow-up. This particular case serves as a poignant example underscoring the critical importance of regular and vigilant follow-ups, coupled with maintaining a heightened clinical suspicion for potential disease relapses. Additionally, due to the high variability in the anatomical structures of the upper abdomen [(10), it was crucial to be able to develop an adequate preoperative plan of action. Such attempts have been previously attempted [(11), and Song et al. showed that the use of 3D printed models offers the most benefit to those with the least amount of experience. Being such rare entities, secondary pancreatic malignancies deserve every tool in our armamentarium to be able to provide the best possible care to the patients. Such an uncommon challenge posed a need for a unique approach. When it comes to treating rare entities such as metastasis of ovarian cystadenocarcinoma to the pancreas, it is crucial to be as prepared as possible. The complex anatomy of the peripancreatic region has been making surgeons’ lives difficult since the very beginning of modern surgical practice. That’s probably why Teodor Billroth was credited with saying “God put the pancreas in the back because he did not want surgeons messing with it” [(12). It is our firm belief that the approach we undertook with 3D printing a replica of the patient’s anatomy and then carefully planning the operative approach facilitated a swift surgery and it can be theorized that it enhanced the patient’s recovery. The careful preoperative planning was instrumental in avoiding complications and performing the surgery safely. Beyond its immediate clinical applications, the generation and utilization of a 3D printed model offer long-term benefits in the fact that it can be repeatedly used for student and resident education [(13). The 3D printed model becomes an enduring asset in medical education, serving as a hands-on, three-dimensional resource for students and residents to grasp complex anatomical structures and surgical procedures. Moreover, it serves as a powerful visual aid in doctor-patient communication, fostering a clearer understanding of the treatment plan and procedures. This not only promotes transparency but also strengthens the bond of trust between healthcare providers and patients, which is inherently valuable. The enduring utility of the 3D printed model in education and communication aligns with a broader commitment to advancing medical knowledge, enhancing the training of future medical professionals, and ultimately elevating the standards of patient care. Declarations Consent for publication A written consent to publish was obtained from the patient. Availability of data and materials Data sharing is not applicable to this article as no datasets were generated or analysed during the current study. Competing interests The authors declare that they have no competing interests Funding No funding of any kind was needed for this article Authors' contributions SA - Was the primary physician and surgeon of this patient. Also produced the 3D model based on the CT scan, as well as the bulk of this manuscript SA - Oversaw the treatment of the patient and the preparation of the manuscript OP - Provided consultations regarding 3D printing, and used 3D printing to manufacture the model EA - Obtained and provided analysis of the laboratory works done and manuscript preparation GS - Obtained the PET images and provided consultation on the preparation of the manuscript VVN - Provided consultations regarding the CT images during the generation of the 3D model and provided consultations on the manuscript preparation GP - Provided the pathology specimen images and the analysis of the histology report GS - Provided assistance in the treatment of the patient and manuscript preparation References Rawla P, Sunkara T, Gaduputi V. Epidemiology of Pancreatic Cancer: Global Trends, Etiology and Risk Factors. World J Oncol. 2019 Feb;10(1):10-27. doi: 10.14740/wjon1166. Epub 2019 Feb 26. PMID: 30834048; PMCID: PMC6396775. Adsay, N. V., Andea, A., Basturk, O., Kilinc, N., Nassar, H., & Cheng, J. (2004). Secondary tumors of the pancreas: an analysis of a surgical and autopsy database and review of the literature. Virchows Archiv, 444(6). doi:10.1007/s00428-004-0987-3 Minni, F., Casadei, R., Perenze, B., Greco, V. M., Marrano, N., Margiotta, A., & Marrano, D. (2004). Pancreatic metastases: Observations of three cases and review of the literature. Pancreatology, 4(6), 509–520. doi:10.1159/000080248 Sperti C, Pasquali C, Liessi G, Pinciroli L, Decet G, Pedrazzoli S. Pancreatic resection for metastatic tumors to the pancreas. J Surg Oncol. 2003 Jul;83(3):161-6; discussion 166. doi: 10.1002/jso.10262. PMID: 12827684. Secondary Tumors of the Pancreas: A Case Series, BEIQING PAN, YOOMI LEE, TERESA RODRIGUEZ, JAMES LEE, MUHAMMAD WASIF SAIF,Anticancer Research Apr 2012, 32 (4) 1449-1452; Metachronous pancreatic metastasis of an ovarian serous papillary adenocarcinoma after 8 years; Andrea Anderloni1, Marco Ballarè1, Michela Pagliarulo1, Marco Orsello1, Antonio Ramponi2, Mario Del Piano1, doi: 10.3978/j.issn.2078-6891.2013.020 Pingpank JF Jr, Hoffman JP, Sigurdson ER, Ross E, Sasson AR, Eisenberg BL. Pancreatic resection for locally advanced primary and metastatic nonpancreatic neoplasms. Am Surg. 2002 Apr;68(4):337-40; discussion 340-1. PMID: 11952243. Ravi P, Chepelev LL, Stichweh GV, Jones BS, Rybicki FJ. Medical 3D Printing Dimensional Accuracy for Multi-pathological Anatomical Models 3D Printed Using Material Extrusion. J Digit Imaging. 2022 Jun;35(3):613-622. doi: 10.1007/s10278-022-00614-x. Epub 2022 Mar 2. PMID: 35237891; PMCID: PMC9156585. Hutchins RR, Hart RS, Pacifico M, Bradley NJ, Williamson RCN. Long-term results of distal Pancreatectomy for chronic pancreatitis in 90 patients. Ann Surg 2002;236:612–8. Pinal-Garcia DF, Nuno-Guzman CM, Gonzalez-Gonzalez ME, Ibarra-Hurtado TR. The Celiac Trunk and Its Anatomical Variations: A Cadaveric Study. J Clin Med Res. 2018 Apr;10(4):321-329. doi: 10.14740/jocmr3356w. Epub 2018 Feb 18. PMID: 29511421; PMCID: PMC5827917. Song, C., Min, J.H., Jeong, W.K. et al. Use of individualized 3D-printed models of pancreatic cancer to improve surgeons’ anatomic understanding and surgical planning. Eur Radiol 33, 7646–7655 (2023). https://doi.org/10.1007/s00330-023-09756-0. Schein M. Aphorisms & quotations for the surgeon. Shrewsbury (UK): TFM Publishing; 2004. 276 p. Yuen J. What Is the Role of 3D Printing in Undergraduate Anatomy Education? A Scoping Review of Current Literature and Recommendations. Med Sci Educ. 2020 Jun 3;30(3):1321-1329. doi: 10.1007/s40670-020-00990-5. PMID: 34457795; PMCID: PMC8368521. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4199271","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":286071078,"identity":"471cbd04-fd7b-467f-9ed6-b6745814ae7e","order_by":0,"name":"Stefan 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Ohridski","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Gjorgji","middleName":"","lastName":"Stavridis","suffix":""}],"badges":[],"createdAt":"2024-04-01 08:29:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4199271/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4199271/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":53963701,"identity":"0f99d3bd-0ad1-4e0e-a007-2246e194f37d","added_by":"auto","created_at":"2024-04-02 18:51:53","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":257137,"visible":true,"origin":"","legend":"\u003cp\u003eA CT scan showing the mass located in the distal pancreas and splenic hilum\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4199271/v1/4c25b5b860ef625a5f8a3325.png"},{"id":53963700,"identity":"1ca11041-d1ed-4362-a439-f024fdee86d7","added_by":"auto","created_at":"2024-04-02 18:51:53","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":162613,"visible":true,"origin":"","legend":"\u003cp\u003ePET scan showing a metabolically active lesion in the tail of the pancreas and the splenic hilum\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4199271/v1/fbfac49307b8a68ec42ac47f.png"},{"id":53963702,"identity":"6a3dcfa8-80b1-4b40-a952-e406ca5d9aa3","added_by":"auto","created_at":"2024-04-02 18:51:54","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":446131,"visible":true,"origin":"","legend":"\u003cp\u003eThe 3D printed model of the patient’s anatomy, showing the mass in the splenic hilum as well as the displacement of the tail of the pancreas\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4199271/v1/54a0a14a579b27da342f0477.png"},{"id":53963703,"identity":"92f8fbdc-1e0f-4662-a429-4f33c7f74e8b","added_by":"auto","created_at":"2024-04-02 18:51:54","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":982050,"visible":true,"origin":"","legend":"\u003cp\u003eThe specimen next to the 3D printed model\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-4199271/v1/d27de139d8fc68fc8dbccdd9.png"},{"id":53963704,"identity":"660b4740-629d-4c74-9f03-f5455d5bb53e","added_by":"auto","created_at":"2024-04-02 18:51:54","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":920273,"visible":true,"origin":"","legend":"\u003cp\u003ea) Splenic tissue specimen b) Histological image of the tumor in the splenic hilum\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-4199271/v1/d0aa74431a009fcf57ac775a.png"},{"id":54637072,"identity":"7b7139f6-2232-496f-a906-a4bda5cad774","added_by":"auto","created_at":"2024-04-14 03:52:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2708984,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4199271/v1/5fa9f759-60b8-40b3-9f9f-702a59949457.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"3D Printing for Preoperative Planning in Pancreatic Resection for Rare Metastasis from Ovarian Cancer: a case report","fulltext":[{"header":"Background","content":"\u003cp\u003ePancreatic malignancies are the seventh cancer-related cause of death in the world. [1]Even though they have a relatively high incidence, they are most commonly primary in origin. Secondary pancreatic tumors, which stem from metastases originating in other sites, represent a relatively rare occurrence constituting less than 5% of pancreatic malignancies[2], and in some series the incidence of pancreatic metastases is as low as 0.4% [3]. Due to the uncommon nature of secondary pancreatic tumors, their reporting is often limited to case series or individual case reports within medical literature. In these reported cases, the most frequently cited primary tumors giving rise to pancreatic metastases are renal cell carcinoma, gastrointestinal neoplasms, and lung cancers. [2,3,4,5]. Ovarian cancer as the primary tumor and source for metastasis is cited exceedingly rarely, with only a couple reported by Adsay et al [2], one reported by Anderloni et al [6] and one by Pingpank et al [7]. The fact that both the studies done by Adsay and Pingpank were studies spanning decades [2,7] and involving hundreds of specimens, further strengthens the notion that primary ovarian tumors with metastases to the pancreas is something rarely seen.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eWe present the case of a 63-y.o. Caucasian female patient presenting to our hospital with a distal pancreatic mass, found on a CT scan of the abdomen. The patient\u0026rsquo;s medical history reveals a hysterectomy and bilateral adnexectomy, with appendectomy due to an ovarian mass, approximately 5 years prior to the consultation in our clinic. Before the hysterectomy, her CA19-9 levels were elevated at 376 U/ml. After the initial surgery, she underwent chemotherapy with carboplatin 480mg, with regular follow-ups. For 3 years she didn\u0026rsquo;t have any symptoms or abnormal results, until her CA 125 was increased at 82.9 U/ml. This prompted an MRI and CT scans which showed a thickening of the wall of the stomach. A gastroscopy with a biopsy was done, and a histology consistent with a B-cell Lymphoma was obtained. She was treated by a hematologist, and remained symptom free ever since, although her CA125 levels remained slightly elevated, ranging between 51 and 86 U/ml. Approximately 4.5 years after the surgery, her CA19-9 levels were detected to be elevated at 54.39 U/ml, even though they have been normal ever since the first surgery. This was the reason to obtain another CT scan, which showed a distal pancreatic mass \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eA PET scan was ordered in order to differentiate the lesion and detect any additional lesions. The result of the PET scan showed a metabolically active lesion in the distal pancreas and in the splenic hilum. (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eGiven the above results, an extirpation of the tumor was indicated. Considering its location within the splenic hilum, the procedure of choice was determined to be a distal pancreatectomy with splenectomy. To enhance the precision of the surgical approach, a decision was made to construct a 1:1 replica of the patient\u0026rsquo;s organs to be used for preoperative planning. Using an open-source software the 3D model was generated from the CT scan data, which was obtained with a slice thickness of 1.25mm during the arterial contrast phase. Previous research shows that models generated through such methods offer an exceptionally accurate representation of the anatomical structures, with a margin of error measuring less than 1% [8].\u003c/p\u003e \u003cp\u003eThe model of the patient\u0026rsquo;s anatomy was printed using a Fused Deposition Modeling (FDM) printer, with Thermoplastic Polyurethane (TPU) selected as the material of choice. (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) The files were printed with 2 wall thickness, as only one would tear, with lightning infill which allowed the majority of the organ to be empty, but still have sufficient support for the structure to not collapse on it self. TPU was chosen because of its flexibility which enabled us to systematically deconstruct the model into its constituent components. This deconstruction facilitated a comprehensive examination of each element in isolation, and we were able to subsequently assemble the model to precisely replicate the in situ anatomical configuration of the patient.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe surgical team was given ample time to analyze the 3D printed model and to devise an operative plan. Once the surgery has been completed, the specimen shown in the image below (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) was obtained and a side-to-side comparison of the printed model and the obtained specimen was made, further strengthening the notion that the 3D printed model was an accurate representation of the patient\u0026rsquo;s anatomy. The operation was done in 90 minutes, which is a relatively short time for a distal pancreatectomy with splenectomy [9]. The 3D printed model continued to serve as an invaluable visual reference intraoperatively, offering real-time guidance and enhancing the surgical team's spatial awareness.The surgical team was under the impression that being able to prepare and plan the operation using the 3D printed model was of immense help.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe patient\u0026rsquo;s recovery after the procedure went as expected, no SSI were noted, the abdominal drain was removed on postoperative day 5 and she was discharged on postoperative day 9.\u003c/p\u003e \u003cp\u003eThe histological analysis of the specimen showed a coagulative necrosis of the splenic tissue (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003ea).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe analysis of the lesion showed pancreatic tissue bordering a pseudocystic formation encased in a pseudocapsule of connective tissue with an intraluminal neoplastic proliferation of epithelial cells which have a cubic-polygonal shape and pleomorphism. The nuclei are round to oval with a varying degree of eosinophilic cytoplasm, with some mythoses visible. The cells are arranged in cystic and papilliform fashion. The following phenotype was performed: CA125+, WT1, ER+, Pax8 +, PR -, CA19/9 - (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eb)\u003c/p\u003e \u003cp\u003eThe discovered findings exhibit distinctive characteristics that align with a rare pancreatic neoplasm, manifesting indications suggestive of papillary serous pancreatic cystadenocarcinoma. However, the diagnostic approach is further nuanced by considerations of the immunophenotype, raising the plausible inference that these manifestations may represent a distant metastasis stemming from the patient's prior ovarian cystadenocarcinoma. The differential diagnosis, informed by both histological features and immunohistochemical markers, underscores the complexity in accurately categorizing the nature of the pancreatic lesion.\u003c/p\u003e"},{"header":"Discussion and Conclusion","content":"\u003cp\u003eSecondary pancreatic tumors are a rare entity, and they deserve a careful approach both in the planning phase and postoperatively, during the follow-up. This particular case serves as a poignant example underscoring the critical importance of regular and vigilant follow-ups, coupled with maintaining a heightened clinical suspicion for potential disease relapses.\u003c/p\u003e \u003cp\u003eAdditionally, due to the high variability in the anatomical structures of the upper abdomen [(10), it was crucial to be able to develop an adequate preoperative plan of action. Such attempts have been previously attempted [(11), and Song et al. showed that the use of 3D printed models offers the most benefit to those with the least amount of experience. Being such rare entities, secondary pancreatic malignancies deserve every tool in our armamentarium to be able to provide the best possible care to the patients. Such an uncommon challenge posed a need for a unique approach.\u003c/p\u003e \u003cp\u003eWhen it comes to treating rare entities such as metastasis of ovarian cystadenocarcinoma to the pancreas, it is crucial to be as prepared as possible. The complex anatomy of the peripancreatic region has been making surgeons\u0026rsquo; lives difficult since the very beginning of modern surgical practice. That\u0026rsquo;s probably why Teodor Billroth was credited with saying \u0026ldquo;God put the pancreas in the back because he did not want surgeons messing with it\u0026rdquo; [(12). It is our firm belief that the approach we undertook with 3D printing a replica of the patient\u0026rsquo;s anatomy and then carefully planning the operative approach facilitated a swift surgery and it can be theorized that it enhanced the patient\u0026rsquo;s recovery. The careful preoperative planning was instrumental in avoiding complications and performing the surgery safely.\u003c/p\u003e \u003cp\u003eBeyond its immediate clinical applications, the generation and utilization of a 3D printed model offer long-term benefits in the fact that it can be repeatedly used for student and resident education [(13). The 3D printed model becomes an enduring asset in medical education, serving as a hands-on, three-dimensional resource for students and residents to grasp complex anatomical structures and surgical procedures. Moreover, it serves as a powerful visual aid in doctor-patient communication, fostering a clearer understanding of the treatment plan and procedures. This not only promotes transparency but also strengthens the bond of trust between healthcare providers and patients, which is inherently valuable. The enduring utility of the 3D printed model in education and communication aligns with a broader commitment to advancing medical knowledge, enhancing the training of future medical professionals, and ultimately elevating the standards of patient care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA written consent to publish was obtained from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData sharing is not applicable to this article as no datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding of any kind was needed for this article\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSA -\u0026nbsp;\u003c/strong\u003eWas the primary physician and surgeon of this patient. Also produced the 3D model based on the CT scan, as well as the bulk of this manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSA -\u0026nbsp;\u003c/strong\u003eOversaw the treatment of the patient and the preparation of the manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOP -\u0026nbsp;\u003c/strong\u003eProvided consultations regarding 3D printing, and used 3D printing to manufacture the model\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEA -\u0026nbsp;\u003c/strong\u003eObtained and provided analysis of the laboratory works done and manuscript preparation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGS -\u0026nbsp;\u003c/strong\u003eObtained the PET images and provided consultation on the preparation of the manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVVN -\u0026nbsp;\u003c/strong\u003eProvided consultations regarding the CT images during the generation of the 3D model and provided consultations on the manuscript preparation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGP -\u003c/strong\u003e Provided the pathology specimen images and the analysis of the histology report\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGS -\u0026nbsp;\u003c/strong\u003eProvided assistance in the treatment of the patient and manuscript preparation\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRawla P, Sunkara T, Gaduputi V. Epidemiology of Pancreatic Cancer: Global Trends, Etiology and Risk Factors. World J Oncol. 2019 Feb;10(1):10-27. doi: 10.14740/wjon1166. Epub 2019 Feb 26. PMID: 30834048; PMCID: PMC6396775.\u003c/li\u003e\n\u003cli\u003eAdsay, N. V., Andea, A., Basturk, O., Kilinc, N., Nassar, H., \u0026amp; Cheng, J. (2004). Secondary tumors of the pancreas: an analysis of a surgical and autopsy database and review of the literature. Virchows Archiv, 444(6). doi:10.1007/s00428-004-0987-3 \u003c/li\u003e\n\u003cli\u003eMinni, F., Casadei, R., Perenze, B., Greco, V. M., Marrano, N., Margiotta, A., \u0026amp; Marrano, D. (2004). Pancreatic metastases: Observations of three cases and review of the literature. Pancreatology, 4(6), 509\u0026ndash;520. doi:10.1159/000080248\u003c/li\u003e\n\u003cli\u003eSperti C, Pasquali C, Liessi G, Pinciroli L, Decet G, Pedrazzoli S. Pancreatic resection for metastatic tumors to the pancreas. J Surg Oncol. 2003 Jul;83(3):161-6; discussion 166. doi: 10.1002/jso.10262. PMID: 12827684.\u003c/li\u003e\n\u003cli\u003eSecondary Tumors of the Pancreas: A Case Series, BEIQING PAN, YOOMI LEE, TERESA RODRIGUEZ, JAMES LEE, MUHAMMAD WASIF SAIF,Anticancer Research Apr 2012, 32 (4) 1449-1452;\u003c/li\u003e\n\u003cli\u003eMetachronous pancreatic metastasis of an ovarian serous papillary adenocarcinoma after 8 years; Andrea Anderloni1, Marco Ballar\u0026egrave;1, Michela Pagliarulo1, Marco Orsello1, Antonio Ramponi2, Mario Del Piano1, doi: 10.3978/j.issn.2078-6891.2013.020\u003c/li\u003e\n\u003cli\u003ePingpank JF Jr, Hoffman JP, Sigurdson ER, Ross E, Sasson AR, Eisenberg BL. Pancreatic resection for locally advanced primary and metastatic nonpancreatic neoplasms. Am Surg. 2002 Apr;68(4):337-40; discussion 340-1. PMID: 11952243.\u003c/li\u003e\n\u003cli\u003eRavi P, Chepelev LL, Stichweh GV, Jones BS, Rybicki FJ. Medical 3D Printing Dimensional Accuracy for Multi-pathological Anatomical Models 3D Printed Using Material Extrusion. J Digit Imaging. 2022 Jun;35(3):613-622. doi: 10.1007/s10278-022-00614-x. Epub 2022 Mar 2. PMID: 35237891; PMCID: PMC9156585.\u003c/li\u003e\n\u003cli\u003eHutchins RR, Hart RS, Pacifico M, Bradley NJ, Williamson RCN. Long-term results of distal Pancreatectomy for chronic pancreatitis in 90 patients. Ann Surg 2002;236:612\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003ePinal-Garcia DF, Nuno-Guzman CM, Gonzalez-Gonzalez ME, Ibarra-Hurtado TR. The Celiac Trunk and Its Anatomical Variations: A Cadaveric Study. J Clin Med Res. 2018 Apr;10(4):321-329. doi: 10.14740/jocmr3356w. Epub 2018 Feb 18. PMID: 29511421; PMCID: PMC5827917.\u003c/li\u003e\n\u003cli\u003eSong, C., Min, J.H., Jeong, W.K. et al. Use of individualized 3D-printed models of pancreatic cancer to improve surgeons\u0026rsquo; anatomic understanding and surgical planning. Eur Radiol 33, 7646\u0026ndash;7655 (2023). https://doi.org/10.1007/s00330-023-09756-0.\u003c/li\u003e\n\u003cli\u003eSchein M. Aphorisms \u0026amp; quotations for the surgeon. Shrewsbury (UK): TFM Publishing; 2004. 276 p.\u003c/li\u003e\n\u003cli\u003eYuen J. What Is the Role of 3D Printing in Undergraduate Anatomy Education? A Scoping Review of Current Literature and Recommendations. Med Sci Educ. 2020 Jun 3;30(3):1321-1329. doi: 10.1007/s40670-020-00990-5. PMID: 34457795; PMCID: PMC8368521.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"3d printing, pancreatic surgery, abdominal surgery, preoperative planning, 3d models","lastPublishedDoi":"10.21203/rs.3.rs-4199271/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4199271/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSecondary pancreatic malignancies are a rarely reported entity, limited to sporadic case reports in the medical literature. Most oftenly these secondary malignancies are of renal origin, followed by gastrointestinal tumors and lung cancer as the primary tumor sites. Metastatic tumors from ovarian origin are few and far between. In our understanding this is the first time 3D printing has been used in the preoperative planning of one such case.\u003c/p\u003e\u003ch2\u003eCase presentation\u003c/h2\u003e \u003cp\u003eWe present the case of a 63 year old patient with a history for bilateral ovariectomy for ovarian tumor 5 years prior, with a 3D printed model of the patient\u0026rsquo;s anatomy used for preoperative planning as a novel approach. During regular check-ups, an elevated CA19-9 level prompted a CT scan showing a distal pancreatic mass entering the splenic hilum, and a PET scan showed FDG avid lesion considered malignant and no other lesions were detected. The location of the metastasis warranted a distal pancreatectomy with splenectomy. To aid in the preoperative planning a 1:1 replica of the patient\u0026rsquo;s anatomy was constructed based on the CT scan, and it was manufactured using 3D printing. After extirpation of the tumor, the histological analysis showed a pancreatic pseudocyst with an intraluminal neoplastic proliferation, and further immunohistochemistry analysis determined the immunophenotype suitable of an ovarian cystadenocarcinoma metastasizing to the pancreas.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe surgical team was unanimous in the impression that the 3D printed model facilitated a swift surgery without any complications. Not only the model helped the planning phase, it is useful as a tool for patient education and further education of students and residents.\u003c/p\u003e","manuscriptTitle":"3D Printing for Preoperative Planning in Pancreatic Resection for Rare Metastasis from Ovarian Cancer: a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-02 18:51:49","doi":"10.21203/rs.3.rs-4199271/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6af3e731-caac-4477-8256-53d13a44e7c5","owner":[],"postedDate":"April 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-04-14T03:44:27+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-02 18:51:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4199271","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4199271","identity":"rs-4199271","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}