[A case of primary undifferentiated carcinoma of the duodenum].

We report a case of undifferentiated carcinoma of the duodenum. A 40-year-old man was referred to our hospital as he experienced upper abdominal pain that had persisted for half a year. Gastrointestinal endoscopy revealed a semicircular tumor in the duodenum. Enhanced computed tomography( CT) revealed that the tumor had not invaded the adjacent tissues, and lymph node metastases were not detected. Biopsy indicated a diagnosis of Group V cancer. Because the tumor was diagnosed as primary duodenal cancer, pancreatoduodenectomy and lymphadenectomy were performed. Histopathological examination revealed the presence of variant cells with irregular cores; we then diagnosed the tumor as undifferentiated cancer of the duodenum. No lymph node metastasis was detected microscopically. This patient has remained well without recurrence for 17 months since the operation. Undifferentiated carcinoma of the duodenum is rare, as only 9 cases have been reported in the Japanese literature.

[A case of neuroendocrine carcinoma of the duodenal papilla].

A 75-year-old man with a complaint of right hypochondrial pain consulted our hospital, and was diagnosed as having acute cholecystitis. We performed percutaneous transhepatic gallbladder drainage (PTGBD), and the cholecystitis resolved. However, obstructive jaundice occurred 2 weeks later. Thus, we performed an in-depth investigation and detected duodenal papilla cancer (cT3N1M0, Stage III). Pancreatoduodenectomy was performed. As postoperative histological diagnosis yielded positive and strongly positive immunostaining for synaptophysin and Ki-67, respectively, we diagnosed the patient as having neuroendocrine carcinoma (NEC) of the duodenal papilla. Three months after surgery, computed tomography (CT) scan showed multiple liver metastases and lymph node metastasis. Chemotherapy with carboplatin and etoposide was administered, but severe neutropenia developed, and therefore, the chemotherapy was discontinued. Subsequently, we decided on a policy of best supportive care (BSC). The patient died 11 months after surgery. NEC of the duodenal papilla is reported to be a rare and rapidly progressing disease and is associated with a very poor prognosis. Herein, we report a case of a patient in whom NEC of the duodenal papilla was resected.

[Focal nodular hyperplasia that was difficult to differentiate from hepatocellular carcinoma].

A 59-year-old man had received medical treatment for alcoholic hepatopathy. He stopped drinking 3 years before visiting the hospital. On medical examination, the abdominal echo showed a hepatic mass lesion that was HBs-Ag (-) and HCV-Ab (-). Computed tomography (CT) revealed a tumor of more than 25 mm in diameter at S7 of the liver. Dynamic CT showed that it was stained in the early phase but washed out in the delay phase. Magnetic resonance imaging (MRI) showed high intensity staining of the tumor in both T1-and T2-weighted images, and it was also stained in the EOB Primovist MRI hepatobiliary phase. The findings from the images were not typical for hepatocellular carcinoma(HCC) or other benign tumors. We therefore performed an S7 partial hepatectomy. We diagnosed the tumor as focal nodular hyperplasia (FNH) by histology.

[A surgical case of solitary lymph node metastasis of hepatocellular carcinoma after nonsurgical treatment].

A 66-year-old man with multiple hepatocellular carcinomas(HCCs) underwent transcatheter arterial chemoembolization(TACE) twice and radiofrequency ablation(RFA) twice at another hospital in June 2009. In November 2010, abdominal computed tomography(CT) revealed a solitary lymph node metastasis( 23 mm in diameter) in the hepatoduodenal ligament, after which he was admitted to our hospital in December 2010. In February 2011, ethoxybenzyl diethylenetriamine pentaceric acid-enhanced magnetic resonance imaging (EOB-MRI) showed revealed a growing solitary lymph node metastasis(33 mm in diameter) and good control of the intrahepatic lesion. Positron emission tomography(PET)-CT confirmed the solitary lymph node metastasis without any other extrahepatic recurrence. We performed lymph node resection in March 2011 because of good control of the intrahepatic lesion and the lack of extrahepatic recurrence. He was discharged from our hospital 11 days after surgery with a good postoperative course. Histologically, the tumor was diagnosed as a lymph node metastasis of poorly differentiated HCC. Subsequent abdominal CT in January 2012 revealed multiple recurrent lesions, and he underwent TACE therapy in February 2012. Currently, the patient is alive 1 year 3 months after lymph node resection without any other extrahepatic recurrence.

[Total pancreatectomy for pancreatic head cancer accompanied with multiple lesions].

Our patient was a 67-year-old man, with a chief complaint of brown urine. He subsequently underwent medical examination in June. Because the results of his blood examination revealed liver dysfunction, he was admitted to our hospital for further careful examination. An abdominal computed tomography(CT) scan showed the presence of a pancreas tumor, with a diameter of 2 cm, at the pancreas head, as well as common biliary duct dilatation and main pancreatic duct dilation from the head to the tail of the pancreas. The patient was diagnosed with pancreatic cancer[cT3( CH+, DU+), cN0, cM0, cStage III], with obstructive jaundice. After biliary drainage, we performed laparotomy in August. During the operation, other than the tumor on the pancreas head, identified at the preoperative diagnosis, we found 2 white nodules on the pancreas surface. One nodule was located at the body of the pancreas and the other, at its tail. On intraoperative pathological examination of the nodules, they were found to be invasive ductal carcinomas. On the basis of these findings, we suspected multiple cancers or overall pancreatic cancer; therefore, we performed total pancreatectomy, not pancreaticoduodenectomy (PD). We choose pancreatectomy over PD because it was impossible to confirm the cancerous area. Pathological examination of the resected specimen did not reveal any malignant lesion. Thus, if we had not performed pancreatectomy, assuming that the pancreas body or tail had no cancer lesion, based on the pathological examination result, the cancer would have persisted. Further, careful examination involving inspection and palpation is considered to be essential before resection of the pancreas tumor.

[A case of invasive ductal carcinoma of the pancreas originating from an intraductal papillary mucinous tumor that was initially misdiagnosed as a mucinous cystic tumor].

A 57-year-old woman was discovered to have a cystic tumor, 8 cm in diameter, at the pancreas tail, during routine screening with ultrasonography. The patient did not complain of tenderness, and no abdominal mass was palpable at physical examination. Enhanced computed tomography(CT) revealed that the tumor had mural nodules in the cyst wall, and we suspected it to be a malignant tumor that had occurred in the mucinous cystic neoplasm(MCN). Therefore, surgical resection was attempted, upon which the tumor was found to be hard and the surrounding tissue adhered widely to the stomach. We separated it carefully from the stomach and then performed a distal pancreatectomy. The cut surface revealed that the posterior wall of the cystic tumor was partly thickened, and microscopic examination revealed it to be invasive ductal carcinoma. No ovarian-like stroma was involved and some degree of dysplasia(PanIN 1-3) was found in the neighboring tissues. Therefore, we re-diagnosed it to be invasive ductal carcinoma of the pancreas derived from intraductal papillary mucinous tumor(IPMT), not from MCN. The patient received adjuvant chemotherapy, although 5 months later multiple lung metastases had appeared. The international consensus guidelines for management of IPMN and MCN of the pancreas suggest that they can usually be distinguished preoperatively, if there is a complete understanding of their clinical and imaging features. However, we sometimes find it difficult to distinguish the 2, because some IPMN or MCN cases have shared preoperative features. Herein, we report the case of invasive ductal carcinoma of the pancreas derived from IPMT that was originally misdiagnosed as a MCN.