Japanese Journal of Clinical Oncology, 2015, 45(2) 232 doi: 10.1093/jjco/hyu217 Advance Access Publication Date: 14 January 2015
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A case of pancreaticobiliary ﬁstula associated with an intraductal papillary mucinous neoplasm of the pancreas Kisyo Mihara1, Yusuke Yamamoto1,*, Keiko Sasaki2, and Katsuhiko Uesaka1 1
Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, and 2Division of Pathology, Shizuoka Cancer Center Hospital, Shizuoka, Japan
A 77-year-old male complaining of fever and epigastralgia was referred to our hospital. Obstructive jaundice and cholangitis were diagnosed based on the ﬁndings of liver biochemistry and abdominal ultrasonography. In addition, computed tomography showed dilatation of the bile duct and main pancreatic duct with multiple cystic masses in the pancreatic head, and a ﬁstula between the cystic lesion and common bile duct was clearly visualized (Fig. 1, arrow). Subsequent endoscopic retrograde cholangiography revealed amorphous ﬁlling defects, presumably mucin products, in the distal bile duct (Fig. 2, arrowheads) and a communication with the pancreatic duct. A pancreatogram obtained via cholangiography showed diffuse dilatation of the main and branched ducts with intraductal projections. We therefore diagnosed the patient as having an intraductal papillary mucinous neoplasm (IPMN) of the pancreas with a pancreaticobiliary ﬁstula.
We subsequently performed pancreatoduodenectomy to achieve radical excision of the tumor. Macroscopically, thick mucus was impacted in the duct of Wirsung and protruded into the common bile duct from the pancreas through the pancreaticobiliary ﬁstula. A histological examination disclosed invasive intraductal papillary mucinous carcinoma of the pancreas with mucin hypersecretion, partly composed of signet ring cells (Fig. 3). The invasive component of IPMN was located only in the uncinate process. The ﬁstula was surrounded by IPMN without stromal invasion, and the bile duct mucosa within 10 mm of the oriﬁce of the ﬁstula was replaced by IPMN (Fig. 4). These ﬁndings suggested that the ﬁstula may have been caused by the effects of continuous mechanical pressure of the IPMN, not cancerous invasion. After ﬁstula formation, tumor cells may spread into and become embedded in the bile duct mucosa.
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*For reprints and all correspondence: Yusuke Yammoto, Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, 1007 Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka 411-8777, Japan. E-mail: [email protected]