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The patient, a 56-year-old woman, was found during routine checkup to have a disorder of hepatic function. Abdominal ultrasonography showed an ill-defined hypoechoic mass in the head and body of the pancreas; however, no blood-flow signal was observed within the tumor on Doppler ultrasonography. Abdominal computed tomography showed a low-density area in the arterial and portal venous phases. The lesion was visualized as an area of low signal intensity on both T1- and T2-weighted magnetic resonance images, whereas fluorodeoxyglucose positron emission tomography showed fluorodeoxyglucose accumulation in the tumor. Although a preoperative diagnosis was difficult to make, a rapid cytologic examination revealed evidence of a pancreatic endocrine tumor, and subtotal stomachpreserving pancreaticoduodenectomy with portal vein resection was performed. Histopathological examination showed tumor cell nests scattered in abundant fibrotic tissue; the tumor cells had proliferated in a cord-like fashion and showed immunostaining for chromogranin A. Staining for fibroblast activation protein a was seen in the fibroblastic cells contained within the fibrous stroma surrounding the tumor cell nests, whereas both the fibroblastic cells in the tumor and those in the stroma showed a high rate of staining for thrombospondin. We presume that tumor-associated fibroblasts were involved in the fibrosis of the tumor stroma. [ABSTRACT FROM AUTHOR]

Purpose: We investigated the clinicopathological features of borderline resectable invasive carcinomas (BRICs) derived from intraductal papillary mucinous neoplasms (IPMNs) and examined the significance of the aggressive "surgery first" approach compared with the treatment of conventional borderline resectable pancreatic ductal adenocarcinomas (BRPDAs). Patients and Methods: We retrospectively studied 7 patients with BRICs derived from IPMNs and 14 patients with conventional BRPDAs. Several factors were reviewed: initial symptoms, preoperative imaging, serum level of CA19-9, perioperative factors, pathological findings, adjuvant chemotherapy, and outcome. Results: All BRICs derived from IPMN were huge tumors (more than 3 cm in diameter) suspected to involve <180° of the circumference of the vessel. Five patients (71%) underwent a modified Whipple procedure, and 2 (29%) underwent distal pancreatectomy. Only 3 patients (43%) required vascular resection. Curative resection was achieved in all 7 patients, who are alive with no evidence of recurrence. There were no severe postoperative complications. With regards to the pathological IPMN subtype, 2 tumors (29%) were gastric and 5 (71%) were intestinal. Only 2 patients (29%) had lymph node metastasis. The final stage was II in 4 (57%) cases and IVa in 3 cases (43%). The 3-year survival rate was 100%. Tumors of BRICs derived from IPMNs were larger than those of conventional BRPDAs (p<0.05). The BRICs derived from IPMN less frequently metastasized to lymph nodes (p<0.05) and were of an earlier stage (p<0.05) than were conventional BRPDAs. The 3-year survival rate was significantly higher for BRICs derived from IPMNs (100%) than for conventional BRPDAs (19%, p<0.001). Conclusion: The BRICs derived from an intestinal or gastric IPMN are less aggressive than conventional BRPDAs and have a more favorable prognosis. In addition, aggressive "surgery first" approach may contribute to this better prognosis. [ABSTRACT FROM AUTHOR]

Abstract  A 46-year-old woman was readmitted to our hospital in August 2005 because of severe abdominal pain and nausea. Computed tomography demonstrated a huge cystic lesion in the retroperitoneal space behind the hepatoduodenal ligament and lesser peritoneal cavity. Endoscopic retrograde pancreatography revealed communication between the dilated main pancreatic duct and a pseudocyst. The condition was preoperatively diagnosed as chronic pancreatitis associated with a pseudocyst or an intraductal papillary mucinous neoplasm without mucin hypersecretion. The patient underwent a distal pancreatectomy with splenectomy. The pathologic diagnosis was multicentric pancreatic intraepithelial neoplasia (PanIN), and histological examination revealed a positive surgical margin around the remnant pancreas. Four months after the surgery, the patient underwent a total pancreatectomy. Macroscopic observation revealed diffuse fibrosis of the pancreatic parenchyma compatible with chronic pancreatitis. Histological examination revealed a constellation of noninvasive intraductal neoplasias with high-grade atypia, diffusely distributed in the small pancreatic ducts of the resected pancreas. Localized fibrosis and cystic dilation of the small ducts were detected in a lobule of exocrine glands draining into a ductule involved by PanIN lesions in the head of the pancreas. In summary, multicentric PanIN lesions are associated with lobular atrophy of the pancreatic parenchyma and chronic pancreatitis-like changes that follow. Total pancreatectomy may be recommended for patients with multicentric precursor lesions throughout the entire pancreas. [ABSTRACT FROM AUTHOR]

Background: Characteristics of a cancer-positive margin around a resected uncinate process of the pancreas (MUP) due to a pancreticoduodenectomy are difficult to understand by standardized evaluation because of its complex anatomy. The purposes of this study were to subclassify the MUP with tissue marking dyes of different colors and to identify the characteristics of sites that showed positivity for cancer cells in patients with pancreatic head carcinoma who underwent circumferential superior mesenteric arterial nerve plexuspreserving pancreaticoduodenectomy. Results of this evaluation were used to review operation procedures and perioperative methods. Method: We divided the MUP into 4 sections and stained each section with a different color. These sections were the pancreatic head nerve plexus margin (Area A), portal vein groove margin (Area B), superior mesenteric artery margin (Area C), and left of the superior mesenteric artery margin (Area D). The subjects evaluated were 45 patients who had carcinoma of the pancreatic head and were treated with circumferential superior mesenteric arterial nerve plexus-preserving pancreaticoduodenectomy. Results: Of the 45 patients, nine cases (90%) of incomplete resection showed cancer-positivity in the MUP. Among the 4 sections of the MUP, the most cases of positive results [MUP(+)] were found in Area B, with Area A(+), 0 case; Area B(+), 6 cases; Area C(+), 2 cases; and Area D(+), 3 cases (total, 11 sites in 9 patients). Relapse occurred in 7 of the 9 patients with MUP(+). Local recurrence was observed as initial relapse in all 3 patients with Area D(+). In contrast, the most common site of recurrence other than that in patients with Area D(+) was the liver. Conclusion: By subclassifying the MUP with tissue marking dyes of different colors, we could confirm regional characteristics of MUP(+). As a result, circumferential superior mesenteric arterial nerve plexuspreserving pancreticoduodenectomy was able to be performed in R0 operations in selected patients while a better postoperative quality of life was maintained. Furthermore, Area D(+) represents an extension beyond the limit of the local disease and may indicate the need for early aggressive adjuvant chemotherapy. [ABSTRACT FROM AUTHOR]

Background: Pancreatic body and tail cancer easily invades retroperitoneal tissue, including the transverse mesocolon. It is difficult to ensure a dissected peripancreatic margin with standard distal pancreatectomy for advanced pancreatic body and tail cancer. Thus, we developed a novel surgical procedure to ensure dissection of the peripancreatic margin. This involved performing dissection deeper than the fusion fascia of Toldt and further extensive en bloc resection of the root of the transverse mesocolon. We performed distal pancreatectomy with transverse mesocolon resection (DP-TCR) using a mesenteric approach and achieved good outcomes. Methods: There are two main considerations for surgical procedures using a mesenteric approach: 1) dissection deeper than the fusion fascia of Toldt (securing the vertical margin) and 2) modular resection of the pancreatic body and tail, with the root of the transverse mesocolon and adjacent organs in a horizontal direction (ensuring the caudal margin). Results: From 2017 to 2019, we performed DP-TCR using a mesenteric approach for six patients with advanced pancreatic body and tail cancer. Histopathological radical surgery was possible in all patients who underwent DP-TCR. No Clavien-Dindo grade IIIa or worse perioperative complications were observed in any patient. Conclusions: We believe that DP-TCR is useful as a radical surgery for advanced pancreatic body and tail cancer with extrapancreatic invasion. [ABSTRACT FROM AUTHOR]