Purpose: The purpose of this study was to investigate the short- and long-term outcomes after pancreatectomy for pancreatic ductal adenocarcinoma (PDAC) in octogenarians.

Methods: The medical records of 141 patients who underwent pancreatectomy for PDAC were retrospectively reviewed. The patients were divided into two groups: non-octogenarians (n=124) and octogenarians (n=17).

Results: The prevalence of comorbidities was significantly higher in octogenarian than non-octogenarian patients, and the performance status was significantly worse in octogenarians compared to non-octogenarians. However, 82% of octogenarians had a performance status of ≤ 1. There was no difference in the American Society of Anesthesiologists physical status (ASA-PS) between the 2 groups. The postoperative clinical courses were not different between the two groups. There were no significant differences in recurrence-free survival and overall survival between the 2 groups in univariate analysis. Age was not a significant independent factor for recurrence-free survival and overall survival in multivariate analysis.

Conclusions: Pancreatectomy for PDAC can be performed safely even in octogenarians based on an assessment of their general condition using the ASA-PS or performance status. The benefit of undergoing pancreatectomy for PDAC was the same for octogenarian and non-octogenarian patients.

We carried out routine examinations with ultrasonography, contrast CT scan, MRCP, and blood tests to diagnose pancreatic cancer early in asymptomatic subjects since August 2016. Since health insurance did not cover these examinations, all subjects underwent this evaluation at their own expense. By December 2018, 92 people had been evaluated. If an abnormality was found, the subsequent examinations such as EUS, medical treatment and observation were covered by health insurance. Reviewing the results, it was striking that 37% of subjects had a family history of pancreatic cancer as a motive for this evaluation. We found that 66% of healthy individuals had biliary or pancreatic abnormalities. Three cases of malignant tumors (pancreatic neuroendocrine tumor, gallbladder cancer, and recurrence of renal cell carcinoma) were diagnosed but there was no patient with pancreatic cancer. MRCP was generally superior for the detection of pancreatic lesions, but the detection rate of other modalities was higher depending on the individual. We hope that this study is useful for establishing a surveillance method for patients at high risk of developing pancreatic cancer.

A 74-year-old female presented for evaluation of a mass around the gallbladder. Plain abdominal CT scan revealed a round tumor anterior to the pancreatic head. The tumor showed strong enhancement in the arterial phase and washed-out on the delayed phase on abdominal dynamic CT scan. From the enhanced pattern, we suspected this to be a lymph node metastasis from a pancreaticoduodenal NET. EUS-FNA was performed and the cytological diagnosis was NET. Somatostatin receptor scintigraphy showed increased radioactive tracer suggestive of NET. Serum pancreatic hormone levels such as insulin, gastrin and glucagon were normal. All studies supported the diagnosis of a lymph node metastasis from a pancreaticoduodenal NET although no pancreaticoduodenal NET was detected. The tumor was resected and histological diagnosis showed paraganglioma. Paraganglioma usually arises from the extra-adrenal paraganglionic system. Tumor location and various imaging studies complicated establishing the diagnosis. We report a rare case of paraganglioma anterior to the pancreatic head.

Adenosquamous carcinoma (ASC) of the pancreas is believed to be associated with a poor prognosis. We report a patient with ASC who has survived for 17 years after resection without adjuvant chemotherapy. A 60-year-old man presented with left lower abdominal pain. Laboratory data showed an elevation of carbohydrate antigen 19-9 (232U/ml), and s-pancreas-1 antigen (96U/ml) without elevation of squamous cell carcinoma-related antigen. Ultrasound revealed a 4×3×3cm ellipsoid solid tumor with central cystic degeneration in the pancreatic tail. Dynamic CT scan showed a mildly enhanced solid portion of the tumor in the portal and delayed phases. MRI/MRCP showed a 2cm cystic element with a mural nodule and a dilated distal main pancreatic duct. Distal pancreatectomy (body-tail) with regional lymph node dissection was performed. Pathology showed ASC of the pancreas (T2N0M0, Stage IB). The tumor was covered with a thick pseudo-capsule and composed mostly of squamous cell carcinoma, accompanied by a cavity derived from central necrosis. Inside and adjacent to the tumor was an adenocarcinoma component, mostly in the form of carcinoma-in-situ. He has been well without recurrence for 17 years since surgery.

Tumor lysis syndrome (TLS) and disseminated intravascular coagulation (DIC) are oncologic emergencies caused by cytotoxic chemotherapy. We present a 74 year old male with metastatic pancreatic cancer to the liver who presented with TLS and DIC. Shortly after diagnosis, gemcitabine and nab-paclitaxel were administered. Three days after starting chemotherapy the patient developed clinical TLS and DIC. Despite aggressive treatment with intravenous hydration, electrolyte monitoring, Radburicase and renal replacement therapy, he died 4 days after starting treatment. This patient with metastatic pancreatic cancer had TLS and DIC caused by administration of gemcitabine and nab-paclitaxel chemotherapy.

A 68-year-old woman was diagnosed with IgG4-related dacryoadenitis and sialadenitis in 2009. Administration of prednisolone in 2011 improved her symptoms and was later discontinued. Serum IgG4 levels were elevated in July 2017. CT scan revealed a round cyst surrounded by delayed perfusion in the tail of the pancreas. T1-weighted images on MRI scan showed the inside of the cyst had low intensity and the wall of the cyst had high intensity. On T2-weighted images, however, the inside of the cyst displayed high intensity and the wall of the cyst had low intensity. There were no apparent abnormalities in the main pancreatic duct. EUS disclosed a low echoic layer between the cyst and pancreatic parenchyma. ERP showed no communication between the pancreatic cyst and the main pancreatic duct. Laparoscopic distal pancreatectomy was performed with a preoperative diagnosis of mucinous cystic neoplasm or pancreatic endocrine neoplasm. Histopathological examination revealed that the cyst was surrounded by fibrosis and infiltration of chronic inflammatory cells, most of which were IgG4-positive plasma cells. Based on these findings, a revised diagnosis of focal autoimmune pancreatitis with storiform fibrosis and obliterative phlebitis around the cyst was made.

A 42-year-old man was admitted with abdominal pain and leg pain. He had been diagnosed with severe acute pancreatitis. He also developed rhabdomyolysis and acute renal failure because of elevated serum CK and myoglobin. After multidisciplinary treatment including volume repletion and renal replacement therapy, the pancreatitis and rhabdomyolysis improved. Since severe acute pancreatitis associated with rhabdomyolysis is associated with a poor prognosis, we propose urgent and aggressive treatment.

A woman in her 70s was admitted with a cystic lesion in the pancreatic body. With no elevation of tumor markers, a CT scan incidentally demonstrated a 10mm solid lesion in the caudal part of the original cystic lesion, with delayed contrast enhancement. EUS showed a small cystic space around that lesion. Since the lesion had no findings suspicious for malignancy, it was followed for 17 months with imaging studies. During this period, no remarkable changes were seen on imaging. However, to establish the diagnosis, we performed EUS-FNA resulting in a histological diagnosis of branch duct IPMN (BD-IPMN). Due to these abnormal findings, distal pancreatectomy was performed, and the diagnosis of BD-IPMN of gastric type without malignant features was confirmed. The tumor occupied most of a cyst, consistent with the preoperative findings. However, it had a different gross appearance from typical BD-IPMN. We report a BD-IPMN with an atypical shape.

Although a unilocular cystic tumor 10mm in diameter was detected in the pancreatic tail of a woman in her 40s during routine evaluation, it was observed because there were no findings consistent with malignancy. At 24 months after identifying the lesion, the tumor increased in size and became multilocular with internal calcifications. Six months later, she was referred for further examination. Dynamic CT scan revealed a decrease in the cystic component and overall tumor size, but a solid component was seen. Based on suspicion of a non-invasive malignant tumor, she underwent laparoscopic distal pancreatectomy. The pathological findings showed low-grade dysplasia of the cystic epithelium and ovarian-type stroma and was positive for progesterone and estrogen receptors. Although the tumor was diagnosed as a mucinous cystic neoplasm, low-grade dysplasia, the absence of a common capsule and the cyst in cyst formation was an interesting feature considering the progression of a mucinous cystic neoplasm. The pathological findings also suggest communication between the tumor and the main pancreatic duct, which might have caused a decrease in the tumor size.

A 67-year-old male underwent upper gastrointestinal evaluation which revealed abnormalities. Upper gastrointestinal endoscopy identified a large tumor extending from the antrum of the stomach to the descending portion of the duodenum. Biopsy results supported the diagnosis of poorly differentiated adenocarcinoma. Contrast-enhanced computed tomography (CT) scan showed a 68mm tumor extending from the antrum of the stomach to the duodenum and the head of the pancreas. Resection was not feasible due to a portal vein tumor thrombus. The patient was treated with six cycles of S-1 and oxaliplatin combination chemotherapy. CT scan after chemotherapy showed reduction in size of the primary tumor and the portal vein tumor thrombus. Pancreatoduodenectomy with portal vein reconstruction was then performed. The inside of the tumor was diffusively positive for the immunohistological marker BCL10. Ultimately, the patient was diagnosed with pancreatic acinar cell carcinoma with duodenal invasion. Local recurrence was found four months after resection, but 13 months after starting chemotherapy, the patient is still alive. This suggests, similar to previous reports, that 5-fluorouracil-based chemotherapy is effective for patients with acinar cell carcinoma.