A 70-year-old man with esophageal cancer underwent subtotal esophagectomy with combined right thoracotomy and laparotomy including lymph node dissection and retrosternal gastric tube reconstruction. There was no recurrence of cancer postoperatively but he had been diagnosed with branch-type IPMN in the pancreatic head 2 years before. During follow-up, dilatation of the main pancreatic duct progressed and pointed outward with thickened enhanced cyst walls. Mural nodules were present in the branch and main pancreatic ducts. The patient was diagnosed with mixed-type IPMN (high-risk stigmata). PPPD was performed while preserving the gastroduodenal artery, right gastroepiploic artery, and right gastric artery and vein. Histopathological diagnosis revealed a mixed-type IPMN with intermediate dysplasia. The patient was discharged on postoperative day 12 without any complications. Pancreatoduodenectomy is rarely performed after radical surgery for esophageal cancer, and only 28 cases have been reported as of 2018. It is necessary to consider blood flow preservation after gastric tube reconstruction, and 3D-CTA is useful to confirm the vascular morphology and arterial anatomy. In patients after gastric tube reconstruction, right gastroepiploic artery/venous preservation is typical, but preservation and revascularization of the right gastric artery/vein should be considered when resecting.

We describe a patient with a pancreatic hamartoma. The patient is a 65-year-old woman followed for a hepatic cyst. She was asymptomatic, but a pancreatic tumor was incidentally found and she was referred for further evaluation. Serum tumor markers and hormone levels were within normal limits. Dynamic computed tomography scan showed a well-demarcated tumor in the head of the pancreas measuring 1.5cm in maximum diameter. An arterial phase image shows a relatively well-circumscribed nodule with enhancement in the portal venous phase. Endoscopic ultrasonography-fine needle aspiration was non-diagnostic. The patient underwent pylorus-preserving pancreatoduodenectomy with a preoperative diagnosis of a pancreatic neuroendocrine tumor. A well-demarcated solid nodule was found in the head of the pancreas. Microscopically, the lesion consisted of disarranged ductal and acinar cells embedded in fibroinflammatory stroma but lacked concentric elastic fibers in the duct walls, peripheral nerves, and islets of Langerhans. The histological diagnosis was pancreatic hamartoma. Pancreatic hamartoma is a rare tumor and it is very difficult to obtain a preoperative histological diagnosis. We report a patient with a pancreatic hamartoma resembling a non-functional pancreatic neuroendocrine tumor.

A 78-year-old female underwent distal pancreatectomy for cancer of the pancreatic body and tail diagnosed by trans-gastric endoscopic-guided fine needle aspiration (EUS-FNA). Pathological findings showed invasive ductal carcinoma T2N0M0 (JPS7^th). The patient received S-1 therapy as postoperative chemotherapy for 6 months. Four and a half years after resection, a positron emission tomography computed tomography scan showed strong uptake in the proximal posterior gastric body wall (SUV max=6.9), and esophagogastroduodenoscopy (EGD) revealed a submucosal tumor (SMT) near the puncture site from the previous EUS-FNA. Biopsy of of the SMT showed tubular adenocarcinoma resembling the resected pancreatic cancer. A partial gastrectomy was performed for suspected needle tract seeing in the gastric wall. Comparing immunostaining of the primary pancreatic cancer and the gastric wall SMT, we diagnosed needle tract seeding caused by EUS-FNA. Needle tract seeding caused by EUS-FNA must be considered, and we suggest EGD as regular follow-up for the early diagnosis of needle tract seeding.

Thrombotic microangiopathy is a rare adverse effect associated with gemcitabine therapy which can be life-threatening and severely affect renal function. We report two patients with thrombotic microangiopathy who were diagnosed early and improved without specific treatment. Two patients with locally advanced pancreatic cancer (a 40-year-old with heavy iron radiotherapy and a 70-year-old) started Gemcitabine monotherapy. Both patients developed mild renal dysfunction and were diagnosed with thrombotic microangiopathy by pathologic findings, and required no specific treatment other than withdrawal from Gemcitabine monotherapy.

A 64-year-old man was referred because of a mass detected by ultrasonography in the body of the pancreas. Although preoperative histopathological diagnosis was not obtained, neuroendocrine neoplasm was suspected based on imaging studies. Due to a family history of pancreatic cancer, we recommended surgical resection. Laparoscopic distal pancreatectomy was successfully performed, and histopathological evaluation revealed the tumor to be a retroperitoneal schwannoma. Generally, it is difficult to diagnose this disease preoperatively. However, it is important to take this entity into consideration when contrast-enhanced computed tomography scan reveals a tumor with delayed enhancement near the pancreas.

Patient 1: A 29-year-old man was suspected to have pancreatic cancer and underwent SSPPD-IIA-1, right hemicolectomy, and partial resection of the SMV. He was diagnosed with pancreatic acinar cell carcinoma (PACC) (T3N1aM0 Stage IIB) and received adjuvant chemotherapy with S-1. A local recurrence appeared and was treated with nab-PTX+GEM therapy, but the lesion enlarged. He was then treated with modified FOLFIRINOX therapy. The recurrent lesion disappeared after 12 courses, and he was alive 44 months after surgery.

Patient 2: A 69-year-old man was suspected to have a pancreatic neuroendocrine tumor or PACC and underwent distal pancreatectomy, The lesion was PACC (T3N0M0 Stage IIA). He received adjuvant chemotherapy with S-1, but multiple liver metastases and an elevated AFP developed. He was then treated with nab-PTX+GEM therapy, but the liver metastases enlarged and the AFP level increased. He underwent modified FOLFIRINOX as the next treatment, the liver metastases resolved and AFP decreased to within normal limits after 12 courses. He was alive at 19 months after surgery.

Conclusion: FOLFIRINOX therapy may enable long-term survival for patients with postoperative recurrence of PACC.

An 86-year-old woman presented with loss of consciousness and had Whipple's triad. Enhanced abdominal computed tomography scan showed a pancreatic tumor and multiple liver tumors with hypervascularity. The patient was diagnosed with malignant insulinoma, with secretion from both lobes of the liver based on results of a 48-hour fasting test, and selective arterial secretagogue injection test. Somatostatin receptor scintigraphy was positive in the pancreatic tumor and multiple liver metastases. Surgical treatment was considered to be ineffective, and the patient was treated with somatostatin analog and diazoxide. Symptoms of hypoglycemia were diminished with this treatment. This approach can improve the quality of life for elderly patients with unresectable malignant insulinoma.

A 70-year-old man was diagnosed with carcinoma of the pancreatic head because of worsening diabetes, and pancreatoduodenectomy was performed. The tumor was 9mm in diameter (TS1 in JPS classification), and histopathological examination revealed an osteoclast-like giant cell-type anaplastic pancreatic carcinoma. Twenty-nine months after surgery, abdominal CT scan revealed a 22-mm mass in the residual pancreatic body with a dilated pancreatic duct, indicating another tumor. Residual pancreatectomy (total pancreatectomy) was then performed. Histopathologically, a spindle cell-type anaplastic carcinoma was found that was different from the subtype of the initial anaplastic carcinoma. We regarded this as a new lesion, not a recurrence of the initial one. This is the first report in Japan of metachronous anaplastic pancreatic carcinomas with different subtypes. Anaplastic pancreatic carcinoma is very rare and is associated with a poor prognosis. The current patient achieved long-term survival with multimodal therapy including two pancreatic resections. Aggressive surgical treatment can contribute to the prognosis of patients with this disease.

The patient is a 46-year-old woman admitted with epigastric pain and nausea. She was found to have elevated pancreatic enzymes and treated for acute pancreatitis. Imaging findings showed uneven contrast enhancement of the pancreatic body to tail and enlargement of the caudal pancreatic duct. A pancreatic tumor was suspected. Although no definitive histologic diagnosis was obtained using endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA), the possibility of pancreatic body cancer could not be ruled out, and resection was performed. The resected specimen showed characteristic histologic findings, leading to a diagnosis of type 2 autoimmune pancreatitis.

A 64-year-old man underwent distal pancreatectomy for moderately differentiated tubular adenocarcinoma. Adjuvant chemotherapy with S-1 was administered for 1 year. He was followed and recurrence-free for over 6 years. Seventy-five months after resection, CA19-9 became elevated and enhanced abdominal computed tomography scan revealed a 30mm tumor in the remnant pancreas. Anaplastic carcinoma was diagnosed by biopsy of the tumor using endoscopic ultrasound-guided fine needle aspiration, and total remnant pancreatectomy performed. The histological diagnosis was anaplastic carcinoma (osteoclast-like giant cell type). There are few reports of carcinoma in the remnant pancreas associated with anaplastic carcinoma, and to the best of our knowledge, this is the first report of metachronous anaplastic carcinoma in the remnant pancreas.