When an intraductal papillary mucinous neoplasm (IPMN) is observed as mildly atypical adenoma, it is considered a cystic tumor with good prognosis. Generally close follow-up is conducted; whereas, if it becomes malignant, surgery is the only approach because it has an equally poor prognosis as pancreatic cancer. However, during the preoperative diagnosis, proper evaluation as to whether it is benign or malignant is difficult. A concise procedure for diagnosis is required. Hence, we statistically graded preoperative clinicopathological factors and evaluated malignant grade as follows: score=a×1+b×2 (a: 1) presence of symptoms, 2) cystic tumor greater than 30mm in diameter, 3) presence of cystic mass with a thick wall, 4) type classification of IPMN: main pancreatic duct type or miscellaneous type), (b: 5) main pancreatic duct more than 6mm in diameter, 6) presence of mural nodules, 7) presence of dilated Vater's ampulla). With the cut-off at five, an excellent result with 86% accuracy is produced. It is difficult for general practitioners, but not specialists, to evaluate the malignant grade of IPMN. Therefore, the scoring tool we advocate will aid preoperative malignancy evaluation and be added as criteria for the indication of surgery.

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A 39-year-old man was referred to our hospital for further examination of pancreas tumor. CT scan and MRI revealed a slightly enhanced mass in the pancreas tail. FDG-PET revealed a high uptake tumor with maximum index of 3.8 in early phase and 4.8 in late phase. Therefore, EUS-FNA was performed to distinguish from pancreatic cancer. This tumor was diagnosed as SPN histologically. Laparoscopic spleen preserving distal pancreatectomy was performed. A small sized SPN was often reported to have a high uptake of FDG-PET. So, preoperative diagnosis was very difficult. In our case, EUS-FNA was useful for differential diagnosis of pancreas tumor and contributes to select appropriate surgery.

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A 79-year-old man who had underwent a distal pancreatectomy for anaplastic carcinoma (pleomorphic type) in December 2005. Adjuvant chemotherapy with gemcitabine and subsequent UFT was administered. He had been followed recurrence-free for 6 years. In May 2012, CA19-9 and SPAN-1 were increased and enhanced abdominal computed tomography revealed a tumor 20mm in diameter with a contrasting margin in the residual pancreas head. FDG PET-CT showed an integrated SUV_max of 4.6. We diagnosed metachronous pancreas cancer and performed a total residual pancreatectomy. The tumor was diagnosed as adenosquamous carcinoma at the postoperative pathology examination. There are no reports of metachronous pancreatic adenosquamous carcinoma developing in the remnant pancreas after surgery for pancreatic anaplastic carcinoma. Recently, a risk of developing invasive ductal carcinoma in intraductal papillary mucinous neoplasm (IPMN) branch type was reported. The first pancreatic anaplastic carcinoma coexisted in IPMN, so this is an invaluable case for considering the development of pancreatic cancer.

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A 68-year-old man was admitted to our hospital with a chief complaint of epigastric pain. Laboratory data showed elevated serum levels of amylase, abdominal US and CT scan showed a mass in the pancreatic head 3cm in diameter and cystic mass in the pancreatic tail 2.5cm in diameter. On FDG/PET-CT scan, each mass showed high SUV. The pancreatic head mass was diagnosed by needle biopsy as adenocarcinoma. During surgery, we suspected the pancreatic head cancer of infiltrating into the portal vein associated with pancreatic tail cancer and infiltrating into the surrounding organs and tissue. We performed a total pancreatectomy with splenectomy, the concomitant resection of the portal vein and the left adrenal gland, and a partial resection of the transverse colon. Histological examination revealed poorly differentiated adenocarcinoma in the pancreatic head. In the pancreatic tail, there was a cystic mass containing purulent fluid and severe inflammatory change around the mass, but a malignant lesion was not found. We diagnosed it as pancreatic tail abscess accompanied with pancreatic head cancer.

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A 48 year-old man was pointed out to have jaundice and was introduced to our hospital. Abdominal computed tomography (CT) revealed bile duct dilatation and a 30mm mass in diameter in the head of pancreas. Cholangiography revealed lower biliary obstruction. We urgently performed ENBD to reduce obstructive jaundice. PET-CT revealed accumulation of the pancreatic head tumor. The patient underwent a pancreaticoduodenectomy under the diagnosis of pancreatic head cancer. The pathological diagnosis was inflammatory pseudotumor of pancreas. There were 10 reports of inflammatory pseudotumor of the pancreas diagnosed histologically, including our case. Our case was the first to have had undergone surgery with jaundice. Herein, we report the case with reference to the recent literature.

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Anaplastic ductal carcinoma is a relatively rare type of cancer among pancreatic carcinomas with poor prognosis. We herein report a case of pleomorphic cell type anaplastic ductal carcinoma presented rapidly growth after resection. The case was a 77-year-old female with no symptoms and mild anemia. A mass measuring 3cm in diameter in the body of the pancreas and a cystic lesion measuring 6cm in the tail of the tumor were detected on abdominal computed tomography. We performed distal pancreatectomy with splenectomy, total gastrectomy, partial transverse colectomy, and left adrenal resection. The resected specimen showed a nodular mass measuring 7.5×7cm with extensive internal hemorrhagic necrosis. The lesion was histopathologically diagnosed as pleomorphic cell type anaplastic ductal carcinoma with squamous cell carcinoma. Peritoneal dissemination occurred 1 month after surgery, and the patient died of cancer 72 days after resection. The prognosis for this type of cancer is very poor even if resected.

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Various imaging studies showed dilation of the main pancreatic duct in a male patient in his 80s. We deployed an endoscopic nasal pancreatic drainage (ENPD) tube. The fifth pancreatic juice cytological diagnosis showed that it was doubtful that adenocarcinoma cells were present. We performed surgery and obtained a diagnosis of pancreatic head cancer of TS1 (14mm). These findings suggest that the repeated cytology of pancreatic juice using an ENPD tube is effective for a diagnosis of small pancreatic cancer.

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