Long-Term Survival of Resected Pancreatic Carcinoma Which Was Coincidentally Detected at the Occurrence of Incarcerated Inguinal Hernia : A Case Report

Surgical intervention of asymptomatic and accidentally detected pancreatic carcinoma can prolong survival. A 67-year-old man with the right incarcerated inguinal hernia was referred to our hospital, he immediately underwent manipulative treatment followed by hernioplasty on the next day. Upon the first visit, a pancreatic tumor was accidentally detected in CT images in the pancreatic tail. About approximately a month, abdominal CT revealed a slightly developed tumor; accordingly, distal pancreatectomy with lymph node dissection was performed. The patient was histopathologically diagnosed with tubular adenocarcinoma, and his final pathological stage was ypT2, pN0, cM0, Stage Ib, based on the TNM classification of malignant tumors (8th edition). For postoperative six months, he was treated with adjuvant chemotherapy using gemcitabine (1000 mg/m). Remarkably, the patient reported no recurrence and has been alive for postoperative 7.5 years, thereby attaining excellent outcomes for accidentally detected pancreatic carcinoma at the occurrence of an incarcerated inguinal hernia.

vival.Because pancreatic carcinoma displays minimal symptoms at an early stage, it is often diagnosed at an advanced stage when treatment options are scarce.Even if it is asymptomatic and an accidentally detected, its early detection is imperative to initiate the relevant treatment as soon as possible.To the best of our knowledge, no study has yet reported a case of asymptomatic pancreatic carcinoma that has been accidentally detected when the patient visited hospital at the occurrence of other abdominal diseases, resected, and still obtained excellent prognosis.
Herein, we report the case of a long-term survivor following curative resection for pancreatic ductal adenocarcinoma (PDAC) that was coincidentally detected at the occurrence of incarcerated inguinal hernia.

Case Report
In October 2010, a 67-year-old man with the right incarcerated inguinal hernia was referred to our hospital (Figure 1); he immediately underwent manipulative treatment followed by mesh plug hernioplasty the next day.
At the first visit, plain CT detected a pancreatic tumor (Figure 2), which was confirmed to be of 2.9 cm in diameter in the pancreatic tail by enhanced CT performed immediately after the hernia surgery (Figure 3).At that point, the patient did not display any pancreatic tumor-related symptoms and declined to undergo a close examination such as biopsy, thus, we inevitably decided to observe the patient for a month.After approximately a month of the initial examination, abdominal CT revealed the tumor to be slightly enlarged to 3.5 cm in diameter (Figure 4).However, compared with a month before, as cites retention, lymph node enlargement, and distant metastases were not detected.In December 2010, the patient underwent distal pancreatectomy with lymph node dissection (Figure 5).Notably, no metastatic lesion, as cites, or disseminated lesions were detected in the peritoneal cavity.Later, he developed a grade A postoperative pancreatic fistula [1].After postoperative 20 days, the drain was removed; the patient was discharged on postoperative 30 days.Further, on postoperative day 38, we initiated adjuvant chemotherapy comprising gemcitabine (1000 mg/m 2 ) for six months.To date, the patient reported no recurrence and has been alive for postoperative 7 years and 6 months.

Discussion
As patients with pancreatic carcinoma display minimal symptoms at an early stage, it is often diagnosed at an advanced stage when treatment options are scarce.Therefore, early detection of pancreatic carcinoma, while symptoms are poor, it is the gospel for these patients.
Asymptomatic PDAC is associated with improved long-term outcomes than symptomatic PDAC because of the earlier stage at presentation and a higher probability of resectability [2].In addition, establishing screening programs for the early detection of PDAC in selected high-risk populations is imperative.
While it is crucial to attempt early detection of pancreatic carcinoma by focusing on high risk groups, it is also essential to focus on pancreatic lesions through every opportunity to perform abdominal imaging studies for other diseases.
While examining the abdomen of patients, clinicians should also consider the possibility of the presence of pancreatic carcinoma.Among the patients who vi-

Figure 1 .
Figure 1.Plain abdominal computed tomography showing the right inguinal hernia with an extended sac (arrow).

Figure 2 .
Figure 2. Plain abdominal computed tomography showing a low-density mass lesion in the pancreatic tail (arrow).

Figure 3 .
Figure 3. Enhanced abdominal computed tomography showing a pancreatic tumor with a diameter of 2.9 cm in the pancreatic tail.In the arterial phase, it was also of low density compared with pancreatic parenchyma and seemed to be a hypovascular tumor mass (arrow).

Figure 4 .
Figure 4.About a month from the initial CT, abdominal CT revealed that the tumor had slightly enlarged to 3.5 cm in diameter (arrow).

Figure 5 .
Figure 5.A surgical specimen, the tumor incised in the middle following surgery, was curatively resected (black arrow).