A 51-year-old woman was suspected to have a pancreatic tumor by abdominal ultra sonography without any symptom. Endoscopic ultrasonography and intraductal ultrasonography revealed a solid mass 10mm in diameter in the neck of the pancreas with a cystic component 5mm in diameter. Multidetector computed tomography revealed only the cyst. These studies suggested an endocrine tumor or solid-pseudopapillary neoplasm rather than invasive ductal adenocarcinoma (IDAC). Middle pancreatectomy was done first and the specimen was diagnosed as IDAC by frozen section. Subtotal stomach preserving pancreaticoduodenectomy with lymphadenectomy was performed. Pathological diagnosis was Stage I IDAC. The cystic component was caused by ductal adenocarcinoma with cystic features. As a preoperative diagnosis is difficult in the case of small pancreatic mass with cystic component, it should be considered in the differential diagnosis of IDAC.

View full abstract

The patient is a 75-year-old woman, who underwent a right nephrectomy for right renal cell carcinoma in 2002. Since then, a partial left nephrectomy and subtotal thyroidectomy were performed for metastases from renal cell carcinoma. In 2008, she was diagnosed with multiple pancreatic metastases and referred to our hospital. Abdominal CT revealed multiple metastases measuring 5-45mm in diameter throughout the whole pancreas, and showed no other metastatic sites. Therefore, a total pancreatectomy was performed. Macroscopically, a total of seventeen lesions were found in the resected specimen, and histopathological examination confirmed the entire lesion to be pancreatic metastases from renal cell carcinoma. Fourteen months after total pancreatectomy, a total thyroidectomy was performed for recurrence at the residual thyroid, and she remains alive without recurrence twenty-four months after total pancreatectomy. Long-term survival can be achieved by performing complete resection of pancreatic metastases from renal cell carcinoma, but pancreatic metastases are often multiple, and small metastatic lesions are difficult to detect preoperatively. Therefore, postoperative follow-up of the remnant pancreas is important, and total pancreatectomy is an useful option to accomplish complete resection for multiple metastatic lesions.

View full abstract

A 63-year-old woman was diagnosed with an intestinal obstruction due to pancreatic cancer in the pancreas tail with peritoneal dissemination. She underwent a partial resection of the ileum that was causing the obstruction and was then treated with S-1+Gemcitabine chemotherapy for 13 cycles. Meanwhile the main tumor shrank. Serum CA19-9 level decreased from 2973 to 225U/ml after 6 cycles, however, after 10 cycles it started to increased up to 402U/ml at the 13^th cycle. We performed a distal pacreatectomy with partial resection of stomach and transverse colon that were directly invaded. There were no peritoneal dissemination and malignant cells in lavage ascites. We could perform an R0 resection. One year and ten months after the second operation, she is alive, but unfortunately with recurrence on retroperitoneal area. We propose that we have to deliberate the possibility of operation for unresectable case of pancreatic cancer during the treatment of chemotherapy for prolonged prognosis.

View full abstract

The patient was a 69-year-old man, diagnosed as having pancreatic head cancer. On CT, no major artery invasion was recognized, but small nodular shadows were detected in both lung bases. Because the possibility of pulmonary metastasis could not be denied, the pancreatic cancer was considered unresectable. Then, chemotherapy using gemcitabine was started. After 11 courses of chemotherapy, the pulmonary lesions showed no change, and were consequently regarded as benign. In contrast, neither major artery invasion nor metastatic lesions were detected. Therefore the pancreatic lesion was considered resectable, and pancreaticoduodenectomy was performed. Pathological examination of the resected specimen revealed fibrous tissue in the main part of the tumor, and neoplastic tissue only in a minor part. We think that the fibrous tissue lesion was an invasive carcinoma before chemotherapy, and this may reflect an excellent pathological effect of gemcitabine.

View full abstract

A 35-year-old woman was admitted to our Department of Obstetrics and Gynecology because of threatened premature labor. The patient suddenly developed general fatigue and upper abdominal pain at 35 weeks and 6 days of her pregnancy, and presented with signs of acute liver failure and DIC. Abdominal ultrasound did not show a bright liver, but, with a diagnosis of acute fatty liver of pregnancy, an emergency Caesarean section was performed on the same day. However, the next day, the left upper abdominal pain increased in intensity, and the serum amylase level rose sharply. Abdominal CT revealed diffuse enlargement of the pancreas with the extent of inflammation reaching to the surrounding tissues. Three of the prognostic factors fulfilled the diagnostic criteria for severe acute pancreatitis. Her clinical course after conservative treatment was uneventful, and she was relieved of her symptoms and discharged 18 days after the diagnosis of pancreatitis.
In this patient, marked hyperlipidemia as a possible cause of acute gestational pancreatitis was not present. Acute fatty liver of pregnancy is believed to be due to vasospasm of the celiac artery. We speculate that the acute pancreatitis complicating acute fatty liver of pregnancy in this patient was caused by pancreatic ischemia due to vasospasm of the arteries supplying the pancreas.

View full abstract

A 61-year-old male, who was a heavy alcohol drinker and has a long history of chronic pancreatitis, presented with severe upper abdominal pain. Abdominal contrast-enhanced CT showed diffuse calculus with dilation of the main pancreatic duct in the pancreas and a splenic pseudoaneurysm in the pancreatic body.
A ruptured pseudoaneurysm into a pseudocyst was suspected, therefore, an emergency diagnostic angiography and interventional therapy (IVR) were carried out to avoid further bleeding into the abdominal cavity. The pseudoaneurysm was successfully treated with coil embolization of the splenic artery. Subsequently, duodenum-preserving resection of the pancreatic head combined with longitudinal pancreaticojejunostomy of the body and tail of the pancreas (Frey's procedure) was performed under stable conditions 17 days after the IVR. The further course was uneventful with complete recovery.
Bleeding of pancreatic pseudoaneurysms is a rare complication of chronic pancreatitis with a severe prognosis and high mortality.
Elective surgical intervention after splenic arterial embolization for pancreatic pseudoaneurysm is a safe treatment strategy which enables preoperative work-up and stabilizes patient condition.

View full abstract

An 80-year-old woman was admitted to our hospital because abdominal ultrasonography taken at a nearby medical clinic revealed a cystic lesion in the pancreatic tail. Further examination showed a multilocular cystic lesion with a diameter of 50mm in the pancreatic tail and a solid mass with a diameter of 20mm in the pancreatic parenchyma adjacent to the cystic lesion. Either invasive mucinous cystadenocarcinoma (MCC) or intraductal papillary mucinous carcinoma (IPMC) was considered. Distal pancreatectomy, splenectomy, and partial transverse colectomy were carried out in September 2010. The resected specimen contained a multilocular cystic lesion in the pancreatic tail and a whitish solid mass in the cystic lesion adjacent to the pancreatic parenchyma. Histological examination revealed moderately differentiated adenocarcinoma of the solid mass, while the cyst wall was composed of thick fibrous partition and all of the epithelial cells were covered with atypical cells. In addition, partial ossification was confirmed, while neither typical ovarian-like stroma nor evidence of communication with the main pancreatic duct was found. The following diagnoses were considered: (1) invasive mucinous cystadenocarcinoma (MCC); (2) intraductal papillary mucinous carcinoma (IPMC); and (3) invasive ductal carcinoma of the pancreas with retention cyst. This case was suspected invasive mucinous cystadenocarcinoma, but findings for a definitive diagnosis could not be established.

View full abstract

A 60-year-old man presented to our department with epigastric pain. He had a past history of acute pancreatitis two years and six months previously, and initial examinations after pancreatitis showed a dilated MPD of 3mm, and US, CT, and MRI revealed an increase in MPD dilatation (4-5mm).
EUS showed a low echoic mass, 12mm in diameter, in the MPD of the pancreatic body.
ERP demonstrated intraductal mucus and irregular stenosis in the MPD of the body.
IDUS of the stenotic MPD showed a low echoic mass with a papillary surface, which filled the dilated MPD and branched pancreatic duct.
Distal pancreatectomy was performed under a diagnosis of mixed type IPMN.
The mass histologically consisted of adenoma with moderate to severe atypia.
Reviewing the initial EUS images, a low echoic mass, 4.5mm in diameter, in the MPD was detected. The tumor volume doubling time of the mass was 212 days.

View full abstract

A 34-year-old man visited a hospital because of the abdominal pain. Abdominal ultrasonography and abdominal CT showed multiple liver tumors and a mass, 4cm in diameter, at the uncus of the pancreas. Probe laparotomy was performed at the hospital. Intraoperative diagnosis was pancreatic tumor and multiple liver metastases. Intraoperative biopsy of the liver tumor was diagnosed histologically as well-differentiated neuroendocrine carcinoma. After discharge from the hospital, he was admitted to our hospital. Serum levels of insulin, gastrin and glucagon were within normal range. Non-functional pancreatic neuroendocrine carcinoma with multiple liver metastases was diagnosed. Chemotherapy with etoposide (ETP) and cisplatin (CDDP) was commenced. Chemotherapy induced stable disease and then pyrolus-preserving pancreatoduodenectomy (PPPD) with partial colectomy and partial resection of the liver was performed. Histological diagnosis was well differentiated neuroendocrine carcinoma. He has been well for 14 months since the operation although recurrence has been observed in the liver.

View full abstract