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A Case of Intraductal Papillary Mucinous Carcinoma in the Head of the Pancreas Associated With Absence of the Duct of Wirsung

Isamu Makino, Takahisa Yamaguchi, Mitsuyoshi Okazaki, Tomoharu Miyashita, Hidehiro Tajima, Tetsuo Ohta

A Seventy-one-year-old woman received CT scan for a checkup of elevated serum amylase. It revealed a solid tumor associated with cystic portion in the head of the pancreas. The duct of Wirsung was not detected by endoscopic retrograde cholangio-pancreatography form Vater’s papilla. The cystic lesion and dilated pancreatic duct of the body of the pancreas was detected by pancreatography form the accessory papilla. We performed pancreaticoduodenectomy and pathological diagnosis was intraductal papillary mucinous carcinoma. Fluorography from Vater’s papilla of the resected specimen revealed the absence of duct of Wirsung connecting to the Vater’s papilla. Fluorography from main pancreatic duct in the stump of the resected specimen revealed communication between the cystic portion of the tumor and the duct of Santorini. Histopathological study with serial section also revealed absence of duct of Wirsung connecting to Vater’s papilla. However, the posterior area of the head of the pancreas was positive for anti-pancreatic polypeptide antibody that is a specific marker for ventral pancreas on immuno-histopathological analysis, which explained the presence of ventral pancreas. Comparing the resected specimen with preoperative pancreatography, we confirmed that the pancreatic duct existed in the ventral pancreas connecting to the accessory papilla. The pathophysiology of absence of duct of Wirsung may not a hypoplasia or deficiency of ventral pancreas itself, but a congenital anomalous connection of the duct of ventral pancreas. Received January