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DOI: 10.1055/s-0030-1256272
© Georg Thieme Verlag KG Stuttgart · New York
Endosonographic and elastographic features of a rare epidermoid cyst of an intrapancreatic accessory spleen
S. Giday
Center for Digestive Health
1817 North Mills Avenue
Orlando
Florida
32803
USA
Email: samgiday@gmail.com
Publication History
Publication Date:
16 May 2011 (online)
Accessory spleens are found in approximately 10 % of the general population, of which 16 % are intrapancreatic [1]. A previously healthy 49-year-old patient was referred to our tertiary center for further evaluation of a pancreatic mass. She had initially presented to another hospital with nonspecific abdominal pain. An abdominal computed tomography (CT) scan had revealed a solid mass in the tail of the pancreas. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) was suggestive of a pancreatic neuroendocrine tumor (PNET).
At our institution, the patient had a normal physical examination with no lymphadenopathy, organomegaly, or a palpable abdominal mass. The patient was referred for EUS-guided tattooing to guide laparoscopic distal pancreatectomy. The EUS revealed a hypoechoic, 2.3-cm mass in the tail of the pancreas. The mass was round and homogeneous, with well-demarcated and sharp borders, and a small cystic component ([Fig. 1]).
EUS-elastography showed inhomogeneous hardness as compared with the surrounding tissue ([Fig. 2]).
EUS-guided tattooing was carried out by injecting 2.5 mL of sterile, purified carbon particle just proximal to the lesion as the needle was withdrawn to the surface of the pancreas ([Fig. 3]).
The patient subsequently underwent laparoscopic spleen-preserving distal pancreatectomy without complications. The tattoo was readily identified and demarcated a precise line of resection. Pathologic examination of the surgical specimen demonstrated a cystic mass within the pancreas. The mass had a well-defined capsule within which was splenic parenchyma and a small cyst lined by a layer of benign squamous epithelium. Pathologic diagnosis was consistent with an epidermoid cyst in an intrapancreatic accessory spleen (IPAS) ([Fig. 4]).
None of the 16 reported IPAS cases were diagnosed preoperatively as they are known to be difficult to clinically distinguish from other tumors. The value of EUS-FNA for their diagnosis needs further study. FNA was not done in the current case because the lesion was presumed to represent a PNET according to outside pathologic diagnosis.
Elastography is a means of measuring tissue stiffness. Malignant tissue is harder than benign tissue and elastography may be able to differentiate between them [2]. The system is set up to use a hue color map (red-green-blue), in which hard tissue areas are shown in dark blue, medium-hard tissue areas in cyan, intermediate hardness tissue areas in green, medium-soft tissue areas in yellow, and soft tissue areas in red [3]. In the current case, the epidermoid cyst demonstrated inhomogeneous hardness (mixture of blue and green). EUS-elastography has been used for the diagnosis of pancreatic cancer and malignant lymphadenopathy with variable sensitivity, specificity, and accuracy in different studies [3] [4] [5].
Endoscopy_UCTN_Code_CCL_1AF_2AZ_3AB
Competing interests: None
#References
- 1 Halpert B, Alden Z A. Accessory spleens in or at the tail of the pancreas. A survey of 2 700 additional necropsies. Arch Pathol. 1964; 77 652-654
- 2 Gao L, Parker K J, Lerner R M et al. Imaging of the elastic properties of tissue – a review. Ultrasound Med Biol. 1996; 22 959-977
- 3 Iglesias-Garcia J, Larino-Noia J, Abdulkader I et al. EUS elastography for the characterization of solid pancreatic masses. Gastrointest Endosc. 2009; 70 1101-1108
- 4 Saftoiu A, Vilmann P, Ciurea T et al. Dynamic analysis of EUS used for the differentiation of benign and malignant lymph nodes. Gastrointest Endosc. 2007; 66 291-300
- 5 Saftoiu A, Vilmann P, Gorunescu F et al. Neural network analysis of dynamic sequences of EUS elastography used for the differential diagnosis of chronic pancreatitis and pancreatic cancer. Gastrointest Endosc. 2008; 68 1086-1094
S. Giday
Center for Digestive Health
1817 North Mills Avenue
Orlando
Florida
32803
USA
Email: samgiday@gmail.com
References
- 1 Halpert B, Alden Z A. Accessory spleens in or at the tail of the pancreas. A survey of 2 700 additional necropsies. Arch Pathol. 1964; 77 652-654
- 2 Gao L, Parker K J, Lerner R M et al. Imaging of the elastic properties of tissue – a review. Ultrasound Med Biol. 1996; 22 959-977
- 3 Iglesias-Garcia J, Larino-Noia J, Abdulkader I et al. EUS elastography for the characterization of solid pancreatic masses. Gastrointest Endosc. 2009; 70 1101-1108
- 4 Saftoiu A, Vilmann P, Ciurea T et al. Dynamic analysis of EUS used for the differentiation of benign and malignant lymph nodes. Gastrointest Endosc. 2007; 66 291-300
- 5 Saftoiu A, Vilmann P, Gorunescu F et al. Neural network analysis of dynamic sequences of EUS elastography used for the differential diagnosis of chronic pancreatitis and pancreatic cancer. Gastrointest Endosc. 2008; 68 1086-1094
S. Giday
Center for Digestive Health
1817 North Mills Avenue
Orlando
Florida
32803
USA
Email: samgiday@gmail.com