A 30-year-old woman was found to have a pancreatic tumor. Abdominal ultrasonography showed a solid tumor without cystic component lesion in the head of pancreas that was 2cm in the diameter. Dynamic computed tomography showed that the tumor was a low density lesion and slightly enhanced in the portal phase. Positron emission computed tomography showed a high uptake tumor with a maximum index of 8.0. Endoscopic retrograde pancreatography showed no communication between the ventral and dorsal pancreatic ducts, indicating that pancreas divisum was present. The patient underwent a pancreaticoduodenectomy. Immunohistochemical analysis demonstrated that the tumor cells were positive for synaptophysin and CD10 but negative for chromogranin A and CD56. The tumor was diagnosed as a solid pseudopapillary tumor of the pancreas. A search of PubMed turned up only one report of concomitant solid pseudopapillary tumor and pancreas divisum. Solid pseudopapillary tumors of the pancreas with pancreas divisum are extremely rare.

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A 58-year-old woman was referred to another hospital due to the presence of severe fever and general malaise. Laboratory data showed marked leucocytosis. Computed tomography showed pancreatic head cancer involving major vessels. At first the patient was suspected to have acute pancreatitis accompanied with pancreatic cancer. However, leucocytosis persisted irrespective of administration of antibiotic agents. The serum G-CSF concentration was elevated to 194pg/ml . Immunohistochemical examination of endoscopic ultrasound-fine needle aspiration revealed tumor cells were stained by anti G-CSF antibody. Chemotherapy by oral S-1 with gemcitabine was administered, together with steroidal therapy. The patient once appeared to respond to the therapy, and could be discharged from the hospital. However, 3 cycles after chemotherapy, her general condition worsened, and died 66 days after the first therapy. We suggest that the serum G-CSF should be examined in the case of cancer with non-suppurative leucocytosis.

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A 72-year-old man visited a nearby hospital because of diarrhea. An abdominal tumor was detected, and he was referred to our hospital. An abdominal CT showed a tumor extending from the uncus of the pancreas around to the superior mesenteric artery. Such tumor markers as CA19-9 and DUPAN-2 were within normal limits. A tumor biopsy was performed under laparotomy for a definite diagnosis, and histological findings revealed anaplastic ductal carcinoma of the pancreas. Based on the diagnosis, we started chemotherapy using S-1. However, his condition was complicated with obstructive jaundice, and we therefore performed percutaneous transhepatic biliary drainage (PTBD). Despite a reduction of jaundice, the tumor progressed rapidly, and he died. With progress of the carcinoma, peripheral leukocyte count increased to 93400/μl and serum G-CSF concentration increased to 312pg/ml. Immunohistochemical staining of the autopsied specimen showed the presence of G-CSF in tumor cells, and a diagnosis of anaplastic ductal carcinoma of the pancreas producing G-CSF was made.

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An 80-year-old man was noted to have a 20-mm hypoechoic mass in the pancreatic body on abdominal ultrasonography. Serum glucagon level was elevated to 610pg/ml. An abdominal CT revealed a 20-mm tumor in the pancreatic body that showed poor enhancement in the arterial phase and slight enhancement in the portal venous phase. FDG-PET-CT showed a low SUV of 3.3. These findings suggested an endocrine tumor, but did not establish the diagnosis; therefore, EUS-FNAB was performed. On histological examination, tumor cells were observed to proliferate in solid nests, suggesting an endocrine tumor. On immunostaining, tumor cells were positive for glucagon. We performed a laparoscope-assisted resection of the pancreatic body and tail with splenectomy for asymptomatic glucagonoma. Histopathological and immunohistochemical examination showed glucagonoma. Lymph node metastasis around the splenic artery was also observed. Based on these findings, a well-differentiated endocrine carcinoma (malignant glucagonoma) was diagnosed. Currently, 3 years after surgery, the patient is well and free of recurrence.

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