due to the aid of modern radiologic diagnostic tools , mass screening , increasing patient age and improving survival rates for patients with neoplastic disease , there has been an increase in the rate of detection of multiple synchronous and metachronous primary cancers . synchronous double primary malignant tumor of pancreas and liver has never been reported in review literature . here is a case with synchronous pancreatic head carcinoma and hepatocellular carcinoma ( hcc ) . the present case report is about a 64-year - old diabetic , non - alcoholic male patient who visited our hospital with the chief complaint of anorexia , malaise and icterus since 2 months for which he was evaluated outside with routine blood investigations showing raised serum bilirubin ( 6.5 mg / dl ) and ultrasound reporting of hypo echoic mass ( 28.7 mm  33 mm ) in the head of pancreas . patient was in good general health and vital signs were within the normal limits . on physical examination , the sclera was icterus . routine blood examination showed the following : white blood cell , 10,200 cells / ul ; hemoglobin , 12.1 g / dl ; platelet , 218,000/mm ; blood glucose , 209 mg / dl ; total bilirubin , 10.2 mg / dl ; direct bilirubin , 6.2 mg / dl ; alkaline phosphatize , 271 iu / l ; serum glutamic - pyruvic transaminase , 101 iu / l ; serum glutamic - oxaloacetic transaminase , 67 tumor marker assays showed raised alpha - fetoprotein 51.99 ng / ml ( normal 0 - 8.5 ) , carcinoembryonic antigen was 4.2 ng / ml ( normal 0 - 5 ) and carbohydrate antigen 19 - 9 ( ca 19 - 9 ) was markedly raised 65,919 u / ml ( normal 0 - 37 ) . a triple phase contrast enhanced computed tomography ( ct ) scan of the abdomen revealed 3.5 cm  3.2 cm  4.0 cm hypo - enhancing mass in the pancreatic head with upstream extrahepatic and bilobar intrahepatic biliary radicles dilatation [ figure 1a ] , multiple small peripancreatic and mesenteric nodes . liver showed multiple nodular lesions ( metastasis ) of varying sizes with differential characteristics [ figure 1b ] , one of the large relatively defined mass in segment 7 of the liver is showing subtle arterial phase enhancement [ figure 1c ] and washout in portal venous phase [ figure 1d ] likely hcc . heterogenous ill - defined soft - tissue attenuation mass involving the pancreatic head and uncinate process ( a ) with multiple liver metastases ( b ) incidentally noted one of the large relatively defined mass in segment 7 of the liver is showing subtle arterial phase enhancement ( c ) and washout in portal venous phase ( d ) likely hepatocellular carcinoma thus , the provision diagnosis was carcinoma head of pancreas with multiple liver metastases synchronous with hcc ? ultrasonography guided fine - needle aspiration was taken from pancreatic mass , non - enhancing and enhancing liver sol for confirmation . smears from the enhancing liver lesion was hypercellular , comprise thickened trabeculae and groups lined by atypical hepatocytes with transgressing blood vessels and partial entrapment by endothelial cells at the periphery . the atypical hepatocytes show enlarged , hyperchromatic , markedly pleomorphic nuclei with irregular distribution of nuclear chromatin , prominent eosinophilic nucleoli , focal nuclear vacuolization and abundant granular eosinophilic cytoplasm with cholestasis [ figure 2a  c ] . on immunohistochemistry - tumor cells was positive for glypican 3 and hepatocyte specific antigen [ figure 2d ] . are diagnostic of hcc 
 figure 2fine - needle aspiration from the enhancing liver lesion . ( a ) cellular smear with thickened trabeculae ( geimsa stain , 100 ) ( b ) thickened trabeculae with vascular transgression , partial endothelial wrapping , bile stasis and malignant nuclear features of hepatocytes ( h and e , 200 ) ( c ) cell block preparation showing malignant hepatocytes with bile stasis ( h and e , 200 ) ( d ) cell block preparation with glypican 3 positivity ( 200 ) 
 smears from the non - enhancing liver lesion showed few small groups and acini of atypical epithelial cells , admixed with sheets and clusters of benign hepatocytes . these atypical epithelial cells show enlarged , hyperchromatic , markedly pleomorphic nuclei with high n : c ratio , irregular nuclear membrane , coarse chromatin and scanty cytoplasm suggestive of metastatic adenocarcinoma [ figure 3a ] . figure 3(a ) fine - needle aspiration from other liver lesion showing metastatic adenocarcinoma ( large arrow ) closely admixed with benign hepatocytes ( small arrow ) ( geimsa stain , 200 ) ( b ) fna from pancreatic head mass showing adenocarcinoma ( geimsa stain , 200 ) 
 smears from the pancreatic lesion showed few small groups and acini of atypical epithelial cells . these atypical epithelial cells show enlarged , hyperchromatic , markedly pleomorphic nuclei with high n : c ratio , irregular nuclear membrane , coarse chromatin and a fair amount of vacuolated cytoplasm suggestive of adenocarcinoma [ figure 3b ] . smears from the enhancing liver lesion was hypercellular , comprise thickened trabeculae and groups lined by atypical hepatocytes with transgressing blood vessels and partial entrapment by endothelial cells at the periphery . the atypical hepatocytes show enlarged , hyperchromatic , markedly pleomorphic nuclei with irregular distribution of nuclear chromatin , prominent eosinophilic nucleoli , focal nuclear vacuolization and abundant granular eosinophilic cytoplasm with cholestasis [ figure 2a  c ] . on immunohistochemistry - tumor cells above features are diagnostic of hcc 
 figure 2fine - needle aspiration from the enhancing liver lesion . ( a ) cellular smear with thickened trabeculae ( geimsa stain , 100 ) ( b ) thickened trabeculae with vascular transgression , partial endothelial wrapping , bile stasis and malignant nuclear features of hepatocytes ( h and e , 200 ) ( c ) cell block preparation showing malignant hepatocytes with bile stasis ( h and e , 200 ) ( d ) cell block preparation with glypican 3 positivity ( 200 ) 
  fine - needle aspiration from the enhancing liver lesion . ( a ) cellular smear with thickened trabeculae ( geimsa stain , 100 ) ( b ) thickened trabeculae with vascular transgression , partial endothelial wrapping , bile stasis and malignant nuclear features of hepatocytes ( h and e , 200 ) ( c ) cell block preparation showing malignant hepatocytes with bile stasis ( h and e , 200 ) ( d ) cell block preparation with glypican 3 positivity ( 200 ) smears from the non - enhancing liver lesion showed few small groups and acini of atypical epithelial cells , admixed with sheets and clusters of benign hepatocytes . these atypical epithelial cells show enlarged , hyperchromatic , markedly pleomorphic nuclei with high n : c ratio , irregular nuclear membrane , coarse chromatin and scanty cytoplasm suggestive of metastatic adenocarcinoma [ figure 3a ] . figure 3(a ) fine - needle aspiration from other liver lesion showing metastatic adenocarcinoma ( large arrow ) closely admixed with benign hepatocytes ( small arrow ) ( geimsa stain , 200 ) ( b ) fna from pancreatic head mass showing adenocarcinoma ( geimsa stain , 200 ) 
  ( a ) fine - needle aspiration from other liver lesion showing metastatic adenocarcinoma ( large arrow ) closely admixed with benign hepatocytes ( small arrow ) ( geimsa stain , 200 ) ( b ) fna from pancreatic head mass showing adenocarcinoma ( geimsa stain , 200 ) smears from the pancreatic lesion showed few small groups and acini of atypical epithelial cells . these atypical epithelial cells show enlarged , hyperchromatic , markedly pleomorphic nuclei with high n : c ratio , irregular nuclear membrane , coarse chromatin and a fair amount of vacuolated cytoplasm suggestive of adenocarcinoma [ figure 3b ] . the conclusive stage of the pancreatic cancer was tnm stage iv { t2 , n1 , m1 } whereas that of the hcc was barcelona clinic liver cancer ( bclc ) stage a and tnm stage i { t2 , n0 , m0 } according to union for international cancer control classification . percutaneous transhepatic biliary drainage followed by metallic stenting was done and planned for single agent gemcitabine based palliative chemotherapy once total serum bilirubin came down below 3 mg / dl . smears from the enhancing liver lesion was hypercellular , comprise thickened trabeculae and groups lined by atypical hepatocytes with transgressing blood vessels and partial entrapment by endothelial cells at the periphery . the atypical hepatocytes show enlarged , hyperchromatic , markedly pleomorphic nuclei with irregular distribution of nuclear chromatin , prominent eosinophilic nucleoli , focal nuclear vacuolization and abundant granular eosinophilic cytoplasm with cholestasis [ figure 2a  c ] . on immunohistochemistry - tumor cells was positive for glypican 3 and hepatocyte specific antigen [ figure 2d ] . histochemistry - trabeculare are reticulin poor . above features are diagnostic of hcc 
 figure 2fine - needle aspiration from the enhancing liver lesion . ( a ) cellular smear with thickened trabeculae ( geimsa stain , 100 ) ( b ) thickened trabeculae with vascular transgression , partial endothelial wrapping , bile stasis and malignant nuclear features of hepatocytes ( h and e , 200 ) ( c ) cell block preparation showing malignant hepatocytes with bile stasis ( h and e , 200 ) ( d ) cell block preparation with glypican 3 positivity ( 200 ) 
 smears from the non - enhancing liver lesion showed few small groups and acini of atypical epithelial cells , admixed with sheets and clusters of benign hepatocytes . these atypical epithelial cells show enlarged , hyperchromatic , markedly pleomorphic nuclei with high n : c ratio , irregular nuclear membrane , coarse chromatin and scanty cytoplasm suggestive of metastatic adenocarcinoma [ figure 3a ] . figure 3(a ) fine - needle aspiration from other liver lesion showing metastatic adenocarcinoma ( large arrow ) closely admixed with benign hepatocytes ( small arrow ) ( geimsa stain , 200 ) ( b ) fna from pancreatic head mass showing adenocarcinoma ( geimsa stain , 200 ) 
 smears from the pancreatic lesion showed few small groups and acini of atypical epithelial cells . these atypical epithelial cells show enlarged , hyperchromatic , markedly pleomorphic nuclei with high n : c ratio , irregular nuclear membrane , coarse chromatin and a fair amount of vacuolated cytoplasm suggestive of adenocarcinoma [ figure 3b ] . smears from the enhancing liver lesion was hypercellular , comprise thickened trabeculae and groups lined by atypical hepatocytes with transgressing blood vessels and partial entrapment by endothelial cells at the periphery . the atypical hepatocytes show enlarged , hyperchromatic , markedly pleomorphic nuclei with irregular distribution of nuclear chromatin , prominent eosinophilic nucleoli , focal nuclear vacuolization and abundant granular eosinophilic cytoplasm with cholestasis [ figure 2a  c ] . on immunohistochemistry - tumor cells histochemistry - trabeculare are reticulin poor . above features are diagnostic of hcc 
 figure 2fine - needle aspiration from the enhancing liver lesion . ( a ) cellular smear with thickened trabeculae ( geimsa stain , 100 ) ( b ) thickened trabeculae with vascular transgression , partial endothelial wrapping , bile stasis and malignant nuclear features of hepatocytes ( h and e , 200 ) ( c ) cell block preparation showing malignant hepatocytes with bile stasis ( h and e , 200 ) ( d ) cell block preparation with glypican 3 positivity ( 200 ) 
  fine - needle aspiration from the enhancing liver lesion . ( a ) cellular smear with thickened trabeculae ( geimsa stain , 100 ) ( b ) thickened trabeculae with vascular transgression , partial endothelial wrapping , bile stasis and malignant nuclear features of hepatocytes ( h and e , 200 ) ( c ) cell block preparation showing malignant hepatocytes with bile stasis ( h and e , 200 ) ( d ) cell block preparation with glypican 3 positivity ( 200 ) smears from the non - enhancing liver lesion showed few small groups and acini of atypical epithelial cells , admixed with sheets and clusters of benign hepatocytes . n : c ratio , irregular nuclear membrane , coarse chromatin and scanty cytoplasm suggestive of metastatic adenocarcinoma [ figure 3a ] . figure 3(a ) fine - needle aspiration from other liver lesion showing metastatic adenocarcinoma ( large arrow ) closely admixed with benign hepatocytes ( small arrow ) ( geimsa stain , 200 ) ( b ) fna from pancreatic head mass showing adenocarcinoma ( geimsa stain , 200 ) 
  ( a ) fine - needle aspiration from other liver lesion showing metastatic adenocarcinoma ( large arrow ) closely admixed with benign hepatocytes ( small arrow ) ( geimsa stain , 200 ) ( b ) fna from pancreatic head mass showing adenocarcinoma ( geimsa stain , 200 ) smears from the pancreatic lesion showed few small groups and acini of atypical epithelial cells . n : c ratio , irregular nuclear membrane , coarse chromatin and a fair amount of vacuolated cytoplasm suggestive of adenocarcinoma [ figure 3b ] . the conclusive stage of the pancreatic cancer was tnm stage iv { t2 , n1 , m1 } whereas that of the hcc was barcelona clinic liver cancer ( bclc ) stage a and tnm stage i { t2 , n0 , m0 } according to union for international cancer control classification . percutaneous transhepatic biliary drainage followed by metallic stenting was done and planned for single agent gemcitabine based palliative chemotherapy once total serum bilirubin came down below 3 mg / dl . in reviews of the literature the overall frequency of multiple primary malignancies is between 0.73% and 11.7% respectively . there are several proposed contributing factors toward multiple malignancies i.e. heredity , constitution , environmental , immunological , carcinogenic viruses , radiological and chemical treatments factors but still exact mechanism is not clear . incidence of pancreatic cancer associated with other organ malignancies is 1.2 - 20.0% , with malignancies predominately of the stomach , colon , thyroid and genitourinary tract . pancreatic carcinoma is one of the most aggressive malignancies with overall 5 year survival below 5% . mainstay curative treatment for pancreatic carcinoma is surgery which is possible in less than 20% of patients . nearly 80% of pancreatic carcinoma present with either locally advanced unresectable or with distant metastasis and managed with palliative chemotherapy with or without radiotherapy . treatment strategy is tailored on the basis of the extent of tumor burden and underlying liver reserve . curative treatment options for hcc are resection , transplantation and percutaneous ablation and are reserved to selected patients bearing an early or very early hcc . only 30 - 40% of patients with a newly diagnosed hcc can undergo curative treatments in the west . liver transplantation is the only definitive treatment for both hcc and the underlying liver disease with 5 year survival rates exceeding 70% with milan criteria . surgical resection is reserved to single lesion with preserved liver function and without portal hypertension with survival of more than 70% at 5 years . hcc patients who are not suitable for curative treatment the survival is very poor . the prognosis of patients with multiple primary malignant malignancies should be determined independently by the stage of each malignancy . for treatment purpose the prognosis of patient in our case will depend on the behavior of pancreatic carcinoma . in our case , only single lesion ( size less than 3 cm ) of hcc was detected on imaging and staged as bclc stage a. as per bclc guidelines treatment for small solitary hcc lesions ( bclc stage o and a ) is hepatic resection or radiofrequency ablation or liver transplant with a median 5 year survival of nearly 70% . carcinoma pancreas is more advanced with multiple liver metastases in our case and has a poor prognosis with average survival of 6 months . in such situation , it is not advisable to treat hcc with a radical approach . until date only sorafinib is approved for palliate treatment in an advanced stage ( bclc stage c ) . gemcitabine is a standard drug for metastatic pancreatic carcinoma and also have some advantage in hcc in phase ii trials . no literature available on the combination of sorafinib with gemcitabine and also theoretically it will be a very toxic regimen and hence single agent gemcitable is planned in our case .
synchronous double malignancies involving different organs are relatively rare and uncommon finding . 
 we report an interesting case of double malignancy in which a patient exhibited synchronous two separate carcinomas , pancreatic and hepatocellular carcinoma ( hcc ) . 
 patient was a 64-year - old male who presented primarily with symptoms pertaining to the biliary obstruction and ultrasound of abdomen revealing pancreatic head mass . 
 hcc was detected incidentally during the investigations for carcinoma pancreas .