Total pancreatectomy for recurrent intraductal papillary mucinous carcinoma in remnant pancreas of pancreaticoduodenectomy for intraductal papillary mucinous adenocarcinoma

Abstract

A 62-year-old man underwent pancreaticoduodenectomy (PD) for intraductal papillary mucinous carcinoma (IPMC) in 2006. No signs of adenocarcinoma at the resection margin were found by intraoperative pathological examination of frozen sections. The postoperative pathological diagnosis was invasive carcinoma derived from IPMC and moderately differentiated tubular adenocarcinoma. A blood analysis in 2011 showed serum (CA19-9) to be increased since the initial resection. Imaging test showed a recurrent tumour at the site of the pancreaticogastrostomy (PG) in the remnant pancreas. We conducted total remnant pancreatectomy for recurrent IPMC and partial gastrectomy. Because both lesions had a histopathological resemblance, the pathological diagnosis was recurrent invasive IPMC. Based on this experience, it is important to facilitate early detection by annual check-up. And also, we recommend PG as a reconstructive intervention in patients at high risk of IPMC recurrence in the remnant pancreas following PD as it is grossly visible on upper gastrointestinal endoscopy.

Figure 1

Contrast-enhanced CT showed a high-density area in the head of the pancreas and dilation of the main pancreatic duct (9 mm).

Figure 2

Histological examination showed invasive carcinoma derived from intraductal papillary carcinoma in the pancreatic head (T2, ly1, v0, ne0, mpd-, s0, rp-, ch-, du0, pv0, a0, pw-, bdw-, ew-, N0, M0).

Figure 3

Positron emission tomography (PET) lead to an abnormal accumulation of fluorodeoxyglucose in the remnant pancreas (SUV max 3.5→3.8).

Figure 4

Contrast-enhanced CT showed a 22-mm high-density area in the remnant pancreas.

Figure 5

Upper gastrointestinal endoscopy showed redness and an easily bleeding elevation lesion at the anastomosis site of pancreaticogastrostomy (PG).

Figure 6

Total pancreatectomy of the remnant pancreas and partial gastrectomy was performed.

Figure 7

Histological examination showed invasive intraductal papillary mucinous carcinoma in the remnant pancreas (T2, ly0, v0, ne0, mpd+, s0, rp1, a0, pl-, ew-, N0, M0). The main pancreatic duct became dilated, and immunochemistry was performed (MUC1(+), MUC2(–), MUC5AC(–), MUC6(+)).