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4. Maisonnette F, Abita T, Pichon N, et al. Development of colonic stenosis following severe acute pancreatitis. HPB (Oxford). 2003;5:183Y185. 5. Nam JK, Kim BS, Kim KS, et al. Clinical analysis of stercoral perforation of the colon [in Korean]. Korean J Gastroenterol. 2010;55:46Y51. 6. Aldridge MC, Francis ND, Glazer G, et al. Colonic complications of severe acute pancreatitis. Br J Surg. 1989;76:362Y367. 7. Van Minnen LP, Besselink MG, Bosscha K, et al. Colonic involvement in acute pancreatitis. A retrospective study of 16 patients. Dig Surg. 2004;21:33Y38. 8. Aghenta AA, Kim HJ. An unusual case of colon perforation complicating acute pancreatitis. Case Rep Gastroenterol. 2009;3:207Y213. 9. Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitisV2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62:102Y111. 10. Hungness ES, Robb BW, Seeskin C, et al. Early debridement for necrotizing pancreatitis: is it worthwhile? J Am Coll Surg. 2002;194: 740Y744, discussion 744Y745.

Pancreatic Intraductal Papillary Mucinous Neoplasm Invading the Duodenum A Case Report and a Review of the Literature To the Editor: n 80-year-old male came to our observation for the evaluation of a suspected main duct intraductal papillary mucinous neoplasm (IPMN), previously identified with a transabdominal ultrasound examination, which the patient had undergone for the persistence of postprandial fullness. Laboratory data were normal; particularly, carbohydrate antigen 19.9 and carcinoembryonic antigen levels were negative. First, the patient underwent an endoscopy that showed multiple solid portions within the duodenal lumen, which obscured the major duodenal papilla; the histological analysis demonstrated the presence of an invasive adenocarcinoma. Then, the patient underwent a magnetic resonance, performed with a 1.5 T system (Magnetom Aera; Siemens AG, Erlangen, Germany), before and after the administration of gadolinium chelates (MultiHance; Bracco, Milan, Italy); magnetic resonance confirmed the presence of multiple solid ‘‘frond-like’’ papillary projections, hypointense on both precontrast T1-weighted and T2-weighted images within a dilated main pancreatic

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duct that were protruding through the papilla and were recognizable also within the lumen of the second, the third, and the fourth duodenal portions and showed homogeneous enhancement (Fig. 1). The patient underwent surgery, but the lesion was strongly adherent to the posterior retroperitoneum, so the surgical procedure was considered technically not feasible. IPMNs can present an extremely expansive growth that can result in penetration into adjacent organs,1Y5 an evenience reported in 6.6% of cases6; this behavior is more common, but not unique, in malignant IPMNs.4,5 The most common reported sites of penetration are the duodenum (59%Y64%), the common bile duct (51%Y57%), and the stomach (17%),6,7 but in 39% of patients, multiple penetrations can be identified.6 Fistulization can occur through 2 mechanisms, direct invasion of the surrounding tissues (60% of cases, the so-called invasive type lesions) or mechanical pressure from the pancreatic duct caused by the increase in tumor size; the latter mechanism is mainly reported for benign lesions, in which mucus produced by tumor cells is compressed and exerts pressure, inducing ischemia, atrophy, and penetration by the IPMN in the organ’s walls (‘‘automatic type’’ lesions).5,6,8 Yamada et al9 reported another hypothetical mechanism for fistula formationsVthe denudation of the dilated pancreatic duct epithelium by high-pressure

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stress caused by mucinous materials may cause dissolution of the ductal walls and pancreatic parenchyma by enzyme-rich fluid and thus the extension of mucinous materials. Subsequently, the perforation of the dilated duct into peripancreatic fat is possible, with inflammatory changes within this latter; then, adhesion between perforated pancreatic duct and other organs through the dissolution of the walls by enzyme-rich fluid and extension of the mucinous material is possible, with fistula formation. Furthermore, they stated that, as a consequence, an intraductal hemorrhage caused by epithelial denudation can be present, and it seems to be predictive of perforations and fistula formation. The prognosis of these ‘‘extensively invasive’’ IPMNs is poorer compared with that in the more common forms, with 5-year survival rates ranging from 28%10 to 43% in patients that underwent surgery.5 Shimizu et al5 reported that a biopsy specimen should be taken from the fistula endoscopically whenever possible to assess whether the tumor has invaded an adjacent organ, enabling determination of the indication for an operation, operative procedure, and prognosis; some authors, in fact, reported that these forms should be considered unresectable a priori6; despite this, we believe that, even if endoscopy and imaging show features of a malignant and extensively infiltrating main duct IPMN, surgery should be at least tried.

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FIGURE 1. AYD, axial and paracoronal T2 half-Fourier acquisition single-shot turbo spinecho images (A and B) demonstrate the presence of multiple frond-like, hypointense papillary projections extending through the major duodenal papilla inside the duodenal lumen until its fourth portion. Magnetic resonance cholangiopancreatography image (C) shows a dilated main pancreatic duct, with endoluminal hypointense solid portions. After contrast medium administration (D), these solid portions show enhancement. * 2014 Lippincott Williams & Wilkins

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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The authors declare no conflict of interest.

Mirko D’Onofrio, MD Department of Radiology G.B. Rossi Hospital University of Verona Verona, Italy [email protected]

Paolo Tinazzi Martini, MD Department of Radiology Casa di Cura Pederzoli Peschiera del Garda Verona, Italy

Riccardo De Robertis, MD Department of Radiology G.B. Rossi Hospital University of Verona Verona, Italy

Massimo Pregarz, MD Department of Radiology Casa di Cura Pederzoli Peschiera del Garda Verona, Italy

Roberto Girelli, MD Paolo Pederzoli, MD Department of Surgery Casa di Cura Pederzoli Peschiera del Garda Verona, Italy

* 2014 Lippincott Williams & Wilkins

Letters to the Editor

Roberto Pozzi Mucelli, MD Department of Radiology G.B. Rossi Hospital University of Verona Verona, Italy

REFERENCES 1. Kurihara K, Nagai H, Kasahara K, et al. Biliopancreatic fistula associated with intraductal papillary-mucinous pancreatic cancer: institutional experience and review of the literature. Hepatogastroenterology. 2000;47(34):1164Y1167. 2. Kim JY, Kang DH, Kim GH, et al. Malignant intraductal papillary mucinous neoplasm of the pancreas with multiple pancreatogastric fistulas: a report of 2 cases with different features. Gastrointest Endosc. 2007;66:854Y857. 3. Inoue M, Ikeda Y, Kikui M, et al. Mucin-producing tumor of the pancreas associated with pyothorax: report of a case. Surg Today. 2001;31(6):538Y541. 4. Jausset F, Delvaux M, Dumitriu D, et al. Benign intraductal papillary-mucinous neoplasm of the pancreas associated with spontaneous pancreaticogastric and pancreaticoduodenal fistulas. Digestion. 2010;82:42Y46. 5. Shimizu M, Kawaguchi A, Nagao S, et al. A case of intraductal papillary mucinous

neoplasm of the pancreas rupturing both the stomach and duodenum. Gastrointest Endosc. 2010;71(2):406Y412. 6. Kobayashi G, Fujita N, Noda Y, et al. Intraductal papillary mucinous neoplasms of the pancreas showing fistula formation into other organs. J Gastroenterol. 2010;45:1080Y1089. 7. Koizumi M, Sata N, Yoshizawa K, et al. Post-ERCP pancreatogastric fistula associated with an intraductal papillary-mucinous neoplasm of the pancreasVa case report and literature review. World J Surg Oncol. 2005;3:70. 8. Lee SE, Jang JY, Yang SH, et al. Intraductal papillary mucinous carcinoma with atypical manifestations: report of two cases. World J Gastroenterol. 2007;13:1622Y1625. 9. Yamada Y, Mori H, Hijiya N, et al. Intraductal papillary mucinous neoplasms of the pancreas complicated with intraductal hemorrhage, perforation, and fistula formation: CT and MR imaging findings with pathologic correlation. Abdom Imaging. 2012;37:100Y109. 10. Kimura W, Sasahira N, Yoshikawa T, et al. Ductectatic type of mucin producing tumor of the pancreasVnew concept of pancreatic neoplasia. Hepatogastroenterology. 1996;43:692Y709.

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Pancreatic intraductal papillary mucinous neoplasm invading the duodenum: a case report and a review of the literature.

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