Metachronous Breast, Ovary and Pancreatic Cancer: A Decade-Long Survivorship Journey
Authors: Sanjidur Rahman, S M Rahid Sarwar, Md Ashraful Alam
Institution: Department of Medical Oncology, Combined Military Hospital (CMH), Dhaka, Bangladesh
Introduction
Breast cancer survivors carry an increased lifetime risk of second primary malignancies. Breast, ovarian and pancreatic cancers form the core of the hereditary breast and ovarian cancer (HBOC) spectrum, most often linked to germline BRCA2 and PALB2 variants. International guidelines recommend germline testing for every patient with epithelial ovarian or pancreatic cancer, yet testing remains underused in Bangladesh. We report a woman who developed three metachronous primary cancers at these sites over ten years, treated successfully with surgery and adjuvant chemotherapy.
Methods
We retrospectively reviewed the patient’s clinical notes, imaging, histopathology, immunohistochemistry and treatment records from 2015 to 2026 at CMH Dhaka. Tumours were staged by AJCC 8th edition and FIGO 2014 criteria. Multiple primary malignancy was defined by the Warren and Gates criteria. Written informed consent for publication was obtained from the patient.
Results
In July 2015, a 53-year-old woman with no comorbidities was diagnosed with carcinoma of the right breast and underwent right simple mastectomy with axillary clearance. Histopathology showed invasive ductal carcinoma, grade III (pT1 N0 (0/8) M0, stage IA). Immunohistochemistry revealed hormone receptor-negative, HER2-positive disease. She received adjuvant chemotherapy with AC ×4 followed by paclitaxel ×4, then completed 1 year of trastuzumab in January 2017. Follow-up imaging in September 2018 revealed a left ovarian mass, and she underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy and excision of a sigmoid mesocolon deposit. Frozen section was malignant, and final histology showed high-grade serous carcinoma (pT2b Nx, FIGO IIB). She completed six cycles of paclitaxel-carboplatin in February 2019. Surveillance from 2019 to 2024 showed normal CA 15-3, CA-125 and CA 19-9, with imaging showing only a stable hepatic cyst and benign breast changes. In February 2025, MRCP performed for obstructive jaundice revealed a 9 × 7 mm periampullary growth. Duodenoscopic biopsy showed chronic duodenitis. Following a multidisciplinary tumour board decision, Whipple’s pancreaticoduodenectomy was performed in March 2025 and revealed adenocarcinoma of the head of the pancreas, grade II, 3.5 cm, with perineural invasion and clear resection margins (pT2 N0 (0/11), stage IB). Adjuvant gemcitabine plus capecitabine was started in April 2025, and six cycles were completed in August 2025. Follow-up imaging in May 2026 showed no recurrence, and tumour markers in June 2026 were within normal limits.
Conclusion
The sequential development of breast, ovarian and pancreatic cancers in one patient raises strong suspicion of a hereditary predisposition such as a BRCA2- or PALB2-associated syndrome. A germline result would guide eligibility for PARP inhibitors, intensity of surveillance and cascade testing of first-degree relatives. Breast cancer survivors who develop a second primary at a hereditary-spectrum site should be offered germline evaluation regardless of tumour phenotype or family history, and they need long-term multidisciplinary surveillance.