A healthy 50-year-old man complained of acute abdominal pain after heavy drinking. An abdominal enhanced CT scan demonstrated an enlarged heterogeneous pancreas with fluid collection. The patient was diagnosed with severe acute pancreatitis (SAP) and treated with continuous arterial infusion of nafamostat mesilate, antibiotics, continuous hemodiafiltration and artificial ventilation. Pancreatic necrosectomy and ileostomy were performed because of a giant peripancreatic and retroperitoneal abscess and sepsis. Despite surgical treatment, complications ensued from perforations to the colon and stomach, and intra-abdominal bleeding. He died on the 70th day after his admission. Autopsy results revealed that he had SAP accompanied with a systemic cytomegalovirus (CMV) infection, characterized with a high presence of CMV inclusion bodies in the lung, esophagus, stomach, colon and pancreas. It is necessary to consider the possibility of complications from CMV infection when treating patients with SAP.

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A 40-year-old man was introduced to our hospital for further investigation of a cystic tumor in the pancreatic tail. Abdominal ultrasonography and endoscopic ultrasonography revealed a low echoic cystic mass lesion with a solid portion in the pancreatic tail. Abdominal computed tomography showed some enhanced parts of a low density mass in the pancreatic tail, which was recognized as low- and high-intensity mass on T1- and T2-WI magnetic resonance images, respectively. Endoscopic retrograde pancreatography revealed no dilated main pancreatic duct and cystic mass lesion communicated with the main pancreatic duct. We did not see mucin in the duodenal papilla. Pancreatic juice cytology was negative. Under the diagnosis of intraductal papillary-mucinous carcinoma, distal pancreatectomy with splenectomy was performed. Histopathological diagnosis of the resected specimen showed a mucinous carcinoma derived from a branch duct type intraductal papillary mucinous neoplasm.

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An 80-year-old woman was referred to our hospital for further examination of a tumor in the pancreas head. Laboratory data demonstrated elevated CA19-9 serum levels. Ultrasonography and computed tomography showed a solid tumor measuring 2cm in diameter in the pancreatic head that directly invaded the portal vein. According to these findings, the patient was diagnosed with unresectable locally advanced pancreatic cancer. She was treated by chemotherapy with S-1 at a dose of 100mg/day that had to be stopped after 1 course because of anorexia. Combination therapy with S-1 (50mg/day) and radiation (50.4Gy) reduced tumor size. After chemo-radiotherapy, S-1 was continued at a dose of 50mg/day; however, a peripheral blood examination revealed anemia. Results of a bone marrow aspiration showed myelodysplastic syndrome (MDS), and is likely that combination therapy might have been the cause of secondary MDS.

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Anaplastic carcinoma of the pancreas is a relatively rare type of invasive ductal carcinoma. When detected, patients usually have huge tumors showing rapid growth and thus have a very poor prognosis. Intraductal papillary-mucinous neoplasm of the pancreas is sometimes accompanied by invasive ductal carcinoma. We herein report a case of anaplastic carcinoma of the pancreas coexisting with intraductal papillary-mucinous carcinoma (IPMC). A 78-year-old woman with acute heart failure and aortic stenosis was admitted to our hospital. Computed tomography accidentally revealed a tumor of the head of the pancreas. She first underwent aortic valve replacement for aortic stenosis, and computed tomography two months later inadvertently revealed a rapidly expanding tumor in the head of the pancreas. We performed subtotal stomach-preserving pancreaticoduodenectomy following diagnosis of the pancreatic carcinoma. The pathological diagnosis was anaplastic carcinoma of the pancreas coexisting with IPMC.

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We report a rare case of pancreatic cancer, islet cell carcinoma with an acinar and ductal cell carcinoma component whose clinical and pathological features are little known. A 68-year-old woman was admitted to our hospital because of upper abdominal pain. Abdominal enhanced-CT showed a clearly demarcated 30mm tumor in the tail of pancreas and it was a more clearly delineated solid mass. ERP showed a smooth stenosis in the main pancreatic duct. With a diagnosis of acinal cell carcinoma, a distal pancreatectomy was performed. Histologic and immunohistochemical examinations revealed the tumor to consist of duct, acinar and islet cells components. By these findings, the tumor was diagnosed as islet cell carcinoma with an acinar and ductal cell carcinoma component that was mainly composed of endocrine cell carcinoma.

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A 49-year-old male visited at our hospital with a major complaint of epigastric pain. After close examination, cancer of the pancreatic body with infiltration into the celiac artery and the portal vein was revealed. One month later, transcatheter arterial embolization of the common hepatic artery was performed prior to surgery, and 1 week later, DP-CAR, the concomitant resection of the portal vein, and a partial transverse colectomy were performed. The pathological examination showed Stage IVa. Approximately 1 month after surgery, peritonitis due to gastric perforation occurred, and closure of the perforation via sutures and a drainage procedure were performed. After recovery, postoperative adjuvant chemotherapy was initiated using gemcitabine, and the patient was then discharged. Subsequently, no local recurrence was observed, but hepatic metastases occurred at S5 and S6, so radiofrequency ablation was performed. Combination therapy was performed thereafter, however, the patient died 25 months after the surgery. Until then, no cancer-related pain or refractory diarrhea was observed, and the patient worked and spent most of his time at home until 1 month before his death. DP-CAR is a newly designed extended surgical procedure, so it can be a choice of treatment for locally advanced pancreatic cancer.

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We report a case of resected remnant pancreatic cancer from a 58-year-old man who underwent pylorus preserving pancreaticoduodenectomy (PPPD) for cancer of the papilla of Vater. The pancreatic surgical margin was free of cancer cells. Four years after PPPD, a follow-up abdominal CT showed a pancreatic tumor with invasion into the splenic artery. With the diagnosis of remnant pancreatic cancer, he underwent completion pancreatectomy with splenectomy, partial resection of the stomach and left adrenal gland. Histopathological diagnosis was moderately differentiated tubular adenocarcinoma originated from the pancreas. He received liver perfusion chemotherapy with 5-fluorouracil and systemic gemcitabine chemotherapy after completion pancreatectomy. He is alive without recurrence 4 years 3 months after the second surgery. It is extremely rare that metachronous double cancer of the papilla of Vater and the remnant pancreas were curatively resected, and we consider that aggressive surgery and chemotherapy are useful for remnant pancreatic cancer after PPPD.

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