Unresectable Pancreatic Ductal Adenocarcinoma in the Remnant Pancreas Diagnosed during Every-6-Month Surveillance after Resection of Branch Duct Intraductal Papillary Mucinous Neoplasm: A Case Report
Context There are few studies regarding the surveillance period and interval of resected or observed branch duct intraductal papillary mucinous neoplasms (IPMNs) of the pancreas in terms of early detection of concomitant pancreatic ductal adenocarcinoma. Despite a strict surveillance protocol, some patients are diagnosed with metastatic distinct ductal adenocarcinoma after resection of IPMN. Case report We herein report a patient with unresectable pancreatic ductal adenocarcinoma that developed in the remnant pancreas 18 months after resection of branch duct IPMN. Although the patient was surveyed every 6 months after the operation and imaging studies at 6 and 12 months postoperatively demonstrated no evidence of recurrence, invasive ductal adenocarcinoma with liver metastasis appeared 18 months after the operation. The patient subsequently underwent chemotherapy; however, he died 9 months after the diagnosis of metachronous pancreatic ductal adenocarcinoma. Conclusions In some patients with branch duct IPMNs, 6-month surveillance seems to be insufficient to detect resectable concomitant pancreatic ductal adenocarcinoma. Therefore, identification of high-risk patients who require surveillance at shorter intervals is urgently needed.
Image: Peroral pancreatoscopy reveals a fish egg-like appearance.
Ohashi K, Murakimi Y, Maruyama M, Takekoshi T, Ohta H, Ohashi I, et al. Four cases of “mucin-producing” cancer of the pancreas on specific findings of the papilla of Vater. Prog Dig Endosc 1982; 20:348-51.
Ingkakul T, Sadakari Y, Ienaga J, Satoh N, Takahata S, Tanaka M. Predictors of the presence of concomitant invasive ductal carcinoma in intraductal papillary mucinous neoplasm of the pancreas. Ann Surg 2010; 251:70-5. [PMID: 20009749].
Yamaguchi K, Ohuchida J, Ohtsuka T, Nakano K, Tanaka M. Intraductal papillary-mucinous tumor of the pancreas concomitant with ductal carcinoma of the pancreas. Pancreatology 2002; 2:484-90. [PMID: 12378117].
Yamaguchi K, Kanemitsu S, Hatori T, Maguchi H, Shimizu Y, Tada M, et al. Pancreatic ductal adenocarcinoma derived from IPMN and pancreatic ductal adenocarcinoma concomitant with IPMN. Pancreas 2011; 40:571-80. [PMID: 21499212].
Uehara H, Nakaizumi A, Ishikawa O, Ishi H, Tatsumi K, Takakura R, et al. Development of ductal carcinoma of the pancreas during follow-up of branch duct intraductal papillary mucinous neoplasm of the pancreas. Gut 2008; 57:1561-5. [PMID: 18477671].
Ohtsuka T, Kono H, Tanabe R, Nagayoshi Y, Mori Y, Sadakari Y, et al. Follow-up study after resection of intraductal papillary mucinous neoplasm of the pancreas; special references to the multifocal lesions and development of ductal carcinoma in the remnant pancreas. Am J Surg 2012; 204:44-8. [PMID: 21996346].
Tanno S, Nakano Y, Koizumi K, Sugiyama Y, Nakamura K, Sasajima J, et al. Pancreatic ductal adenocarcinomas in long-term follow-up patients with branch duct intraductal papillary mucinous neoplasms. Pancreas 2010; 39:36-40. [PMID: 19745777].
Tanno S, Nakano Y, Sugiyama Y, Nakamura K, Sasajima J, Koizumi K, et al. Incidence of synchronous and metachronous pancreatic carcinoma in 168 patients with branch duct intraductal papillary mucinous neoplasms. Pancreatology 2010; 10:173-8. [PMID: 20484955].
Tada M, Kawabe T, Arizumi M, Togawa O, Matsubara S, Yamamoto N, et al. Pancreatic cancer in patients with pancreatic cystic lesions. A prospective study in 197 patients. Clin Gastroenterol Hepatol 2006; 4:1265-70. [PMID: 16979953].
Mori Y, Ohtsuka T, Tsutsumi K, Yasui T, Sadakari Y, Ueda J, et al. Multifocal pancreatic ductal adenocarcinomas concomitant with intraductal papillary mucinous neoplasms of the pancreas detected by intraoperative pancreatic juice cytology. A case report. JOP 2010; 11:389-92. [PMID: 20601817].
Tanaka M, Chari S, Adsay V, Fernandez-del Castillo C, Falconi M, Shimizu M, et al. International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas. Pancreatology 2006; 6:17-32. [PMID: 16327281].
Tanaka M, Fernández-del Castillo C, Adsay V, Chari S, Falconi M, Jang JY, et al. International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology 2012; 12:183-97. [PMID: 22687371].
Izawa T, Obara T, Tanno S, Mizukami Y, Yanagawa N, Kohgo Y. Clonality and field cancerization in intraductal papillary-mucinous tumors of the pancreas. Cancer 2001; 92:1807-17. [PMID: 11745253].
Biankin AV, Kench JG, Biankin SA, Lee CS, Morey AL, Dijkman FP, et al. Pancreatic intraepithelial neoplasia in association with intraductal papillary mucinous neoplasms of the pancreas: Implications for disease progression and recurrence. Am J Surg Pathol 2004; 28:1184-92. [PMID: 15316318].
Hruban RH, Takaori K, Klimstra DS, Adsay NV, Albores-Saavedra J, Biankin AV, et al. An illustrated consensus on the classification of pancreatic intraepithelial neoplasia and intraductal papillary mucinous neoplasms. Am J Surg Pathol 2004; 28:977-987. [PMID: 15252303].
Ohtsuka T, Ideno N, Aso T, Nagayoshi Y, Kono H, Mori Y, et al. Role of endoscopic retrograde pancreatography for early detection of pancreatic ductal adenocarcinoma concomitant with intraductal papillary mucinous neoplasm of the pancreas. J Hepatobiliary Pancreat Sci 2013; 20: 356-61. [PMID: 22878836].
Ideno N, Ohtsuka T, Kono H, Fujiwara K, Oda Y, Aishima S, et al. Intraductal papillary mucinous neoplasms of the pancreas with distinct pancreatic ductal adenocarcinomas are frequently of gastric subtype. Ann Surg 2013; 258:141-51. [PMID: 23532108].
Copyright (c) 2014 Koji Tamura, Takao Ohtsuka, Noboru Ideno, Teppei Aso, Hiroshi Kono, Yousuke Nagayoshi, Koji Shindo, Yasuhiro Ushijima, Junji Ueda, Shunichi Takahata, Tetsuhide Ito, Yoshinao Oda, Kazuhiro Mizumoto, Masao Tanaka
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