Presentation of case
A 43-year-old male patient was found to have a pancreatic tail cyst upon
abdominal ultrasonography on physical examination. He had no subjective
symptoms, or medical history. Laboratory data, such as complete blood
cell count, hepatic and renal functions, as well as serum levels of
carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA 19-9)
were within conventional limits. In addition, amylase, lipase, and blood
glucose levels were normal. On further referral to the study hospital,
computed tomography (CT) revealed a cyst with a diameter of 15 mm in the
pancreatic tail. The cystic lesion was monocystic and had an
intensity-enhanced area around the cyst in the low intensity area (Fig.
1). Magnetic resonance imaging (MRI) revealed a lesion with depleted and
enhanced intensities on the T1 and T2-weighted figures, respectively.
Diffusion-weighted MRI displayed increased signal potency in the
peripheral portion of the cystic lesion (the wall and the septa); the
cystic contents presented reduced intensity on an enhanced MRI (Fig. 2).
Endoscopic ultrasonography (EUS) revealed a cyst with high-echoic
lesions, a pancreatic tail, and calcification on the cyst margin (Fig.
3a). Endoscopic retrograde cholangiopancreatography (ERCP) displayed a
slight displacement of the pressure superior to the duct, with no
narrowing or disruption (Fig. 3b).
The findings of suspected cyst degeneration on CT and MRI with low
intensity on T1-weighted figures and high intensity on T2-weighted
figures were consistent with the characteristics of pNET. The
preoperative diagnosis was pNET. According to the guidelines mentioned
above, the first-line of treatment for pNET is surgery. A distal
pancreatectomy was performed with concomitant splenectomy. The
postoperative course was uneventful. The excised surface of the resected
specimen revealed a multilocular cyst with solid nodules (Fig. 4a).
Histopathological findings revealed the spleen, as well as, the red and
white pulp in the parenchyma of the pancreatic tail. Since spleen tissue
was found in the pancreatic tissue, we diagnosed it as an
intrapancreatic accessory spleen cyst. The major and minor multilocular
cysts had a maximum diameter of 17 mm; the luminal epithelium consisted
of mature squamous epithelium with display of the subepithelial lymphoid
tissue. The cyst lumen revealed keratin and cholesterol deposits in the
clefts. The fact that lymphatic tissue occupies the majority of the cyst
is a major feature of LECs and meets the diagnostic criteria for LECs.
Ultimately, the patient was diagnosed with a LEC of the pancreatic
accessory spleen.