Presentation
Incidental pancreatic cystic mass on ultrasound.
Patient Data
Heterogeneous T2 hyperintense lesion in the pancreatic tail with thin enhancing low signal fibrous wall and some internal septations. No connection to the main pancreatic duct. Posterior wall thickened T1 high signal. Anterior and lateral wall enhancement with small enhancing nodules. There is no calcification on CT (not shown).
No central enhancement and no restricted diffusion.
Scattered tiny body and head small pancreatic cysts, likely side branch IPMN.
The pancreatic duct is not dilated
Macroscopy: One piece of fatty tissue measuring 50 mm (from the stapled resection margin to opposing side) x 31 x 22 mm. On sectioning into 6 slices there is a ill-defined pale tan and cystic lesion within the pancreatic tissue measuring 17 x 12 x 15 mm. This abuts green inked margins and is 8 mm clear of the stapled resection margin. Inked black at stapled resection margin and green externally.
Microscopy: Sections show pancreatic tissue containing a well circumscribed solid and cystic tumor. The solid component comprises a trabecular and nested proliferation of cells with fairly frequent rosettes. Tumor cells have uniform, round to oval nuclei with dispersed chromatin and inconspicuous nucleoli. There are foci within the tumor composed of cells with voluminous pale to foamy cytoplasm. Mitotic figures are not seen (0 per 10 HPF). No extrapancreatic extension is identified. No lymphovascular invasion is seen. Resection margins are clear. The surrounding pancreatic tissue is within normal limits.
Immunohistochemistry:
Positive: chromogranin, synaptophysin
Ki67 shows a proliferative index of approximately 1%.
Conclusion: Distal pancreas,excision: Pancreatic neuroendocrine tumor, grade 1, 18mm in size with cystic change. No extraprostatic extension, resection margins clear (pT1).
Case Discussion
Given the imaging appearance and patient epidemiology, the main concern was for a pancreatic mucinous cystadenoma. Resection confirmed a well differentiated neuroendocrine tumor with cystic changes.
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