Pancreatic adenocarcinoma on the dorsal part of the pancreas divisum presenting as acute recurrent pancreatitis

Small pancreatic cancer with pancreas divisum preoperatively diagnosed by pancreatic juice cytology

We present a case of small pancreatic head cancer with pancreas divisum preoperatively diagnosed by pancreatic juice cytology. A 60-year-old woman was referred to our hospital for evaluation of a dilated main pancreatic duct (MPD). A small and poorly reproducible low-echoic lesion in the pancreas was suspected by ultrasonography (US) and endoscopic ultrasonography (EUS). Magnetic resonance cholangiopancreatography (MRCP) failed to visualize the ventral pancreatic duct, and the upstream dorsal pancreatic duct was dilated. Endoscopic retrograde cholangiopancreatography (ERCP) was indicative of pancreas divisum, and complete obstruction of the MPD in the pancreatic head was seen. Cytology of pancreatic juice obtained from the dorsal pancreas after minor papilla sphincterotomy revealed the presence of adenocarcinoma cells. Pancreatoduodenectomy was performed under the diagnosis of pancreatic head cancer with pancreas divisum. Histological examination revealed moderately-differentiated tubular adenocarcinoma 20 mm in diameter, located in the pancreatic head. Dilatation of the dorsal pancreatic duct is sometimes observed in cases with pancreas divisum without the presence of tumors. When pancreatic duct stenosis also exists in such cases, even if a tumor is not clearly visualized by diagnostic imaging, vigorous examinations such as pancreatic juice cytology are recommended to establish an accurate diagnosis.

Expression of integrins in tumour tissue of a patient with cancer of the Vater's ampulla complicated by pancreas divisum

We present herein a rare case where cancer of the Vater's ampulla was complicated with pancreas divisum. Endoscopic retrograde cholangiopancreatography demonstrated the pancreas divisum and stenosis of the common channel due to the tumorous lesion of the Vater's ampulla. Magnetic resonance cholangiopancreatography demonstrated that the Wirsung duct and Santorini duct were unconnected. The biopsy specimen at the upper gastrointestinal endoscopy revealed moderately differentiated tubular adenocarcinoma. The patient was diagnosed with cancer of the Vater's ampulla complicated with pancreas divisum, and underwent a pylorus-preserving pancreaticoduodenectomy. Immunohistochemical examination showed that the p53 protein and the alpha5beta1-integrin were expressed in tumour cells, and the proliferating cell nuclear antigen test was positive. Furthermore, the alpha5beta1-integrin was expressed in chronic pancreatitis tissue. We demonstrate that there is a risk that pancreas divisum will co-exist with malignant disease in the pancreaticobiliary area, causing a potential risk of complicating malignant diseases in the pancreas.

Carcinoma of the head of the pancreas versus chronic pancreatitis: diagnostic dilemma with significant consequences

Although carcinoma of the head of the pancreas and chronic pancreatitis are usually easy to distinguish on clinical presentation and subsequent investigation, there can be enough overlap in the presenting features and on imaging studies that differentiation is sometimes extremely difficult. As this confusion may lead to either major pancreatic resection for benign disease, or rejection of surgery for a potentially curable lesion, all attempts to arrive at a correct diagnosis should be pursued. This article provides an update of investigative techniques in pancreatic disease, and offers an algorithm for the clinical approach to the patient who appears to present with this diagnostic and therapeutic dilemma.