Discussion
The Japanese guideline for pancreatic cancer recommends ERCP if there
are findings suggestive of pancreatic cancer, such as pancreatic duct
dilation or stenosis, even if imaging does not show any evidence of a
mass (5). Although no pathologic diagnosis was obtained in our patient
using pancreatic juice cytology obtained during ERCP, we were able to
make the diagnosis using specimens obtained from SPACE. Iiboshi et al
compared patients diagnosed using single pancreatic juice cytology
versus SPACE, and report that the sensitivity, specificity, and accuracy
of SPACE are 100%, 83.3%, and 95%, respectively (6). The advantage of
SPACE lies in its better sensitivity for micropancreatic cancer (4).
According to previous reports, patients with early pancreatic cancer are
rarely symptomatic but frequently demonstrate focal branch-duct
dilation, focal irregular stenosis, small cystic lesions around the area
of ductal stenosis, and distal dilation of the main pancreatic duct on
EUS and MRCP (4). In patients with PCIS, assessment with ERCP frequently
reveals irregularity, noncontinuous narrowing, granular defects, and
dilation. Kikuyama et al report that patients with stage 0 disease
demonstrate a high degree of fatty change on enhanced CT, in the
pancreatic parenchyma around the area of PCIS (7). In certain patients
with PCIS, focal pancreatitis with inflammatory cells, desmoplastic
changes, fibrosis, and fatty changes are observed in the parenchyma
around the area of PCIS (8-10). Ikeda et al classify PCIS into 3 types:
flat, low papillary, and mixed (11). Based on this classification
system, our patient’s disease would be classified as the low papillary
type, which may tend to spread intraductally. As PCIS with intraductal
spread into the main pancreatic duct and the branch duct can cause focal
pancreatitis, patients may experience stenosis and dilation of the main
pancreatic duct. We confirmed the
presence of lymphocyte infiltration in our patient, and we believe that
his stenosis was triggered by inflammation.
In Japan, the use of an oral fluoropyrimidine (S-1) is indicated for
postoperative adjuvant chemotherapy in patients with pancreatic
cancer (12). However, there is no
evidence of the need for adjuvant chemotherapy for PCIS. More case
reports are needed to determine whether adjuvant chemotherapy is indeed
indicated for patients with PCIS.
As in our case, patients with both gastric cancer and pancreatic body
cancer may require total gastrectomy with distal pancreatectomy, since
distal gastrectomy with distal pancreatectomy may leave the patient with
venous stasis and insufficient arterial perfusion to the remnant
stomach. On the other hand, spleen preserving distal pancreatectomy with
conservation of the splenic artery and vein for a pancreatic benign or
low grade malignant tumor has accepted (13). Based on a review of the
PubMed database, no case of synchronous gastric cancer and PCIS. More
case reports are needed to determine whether the extent of lymph node
dissection can be safely reduced for advantage of nutrition.