Laparoscopic resection of epidermoid cyst arising from an intrapancreatic accessory spleen: a case report with a review of the literature

Laparoscopic spleen-preserving distal pancreatectomy for epidermoid cyst in an intrapancreatic accessory spleen: A case report

RATIONALE

Pancreatic tail cystic lesions are increasingly encountered in clinical practice, however, it is difficult to make a correct diagnosis preoperatively because there are many types of pancreatic neoplastic and non-neoplastic cysts. Epidermoid cyst in an intrapancreatic accessory spleen (ECIPAS) is a rare non-neoplastic cyst locating in the pancreatic tail, and it is commonly misdiagnosed as another cystic neoplasm.

PATIENT CONCERNS

A 51-year-old man was admitted for investigation of abdominal pain. The physical examination and laboratory tests found no abnormalities, except for an elevation of carbohydrate antigen (CA)19-9. Imaging revealed a cystic lesion within the pancreatic tail, and the solid component surrounding the cyst was enhanced similarly to those of the splenic tissue.

DIAGNOSIS

ECIPAS was diagnosed based on the pathology after surgery. The mass was composed of a cyst and brown solid spleen-like tissue. The microscopic analysis demonstrated that the solid component was accessory splenic tissue, and the cyst wall was lined with a thin stratified squamous epithelium.

INTERVENTIONS

Laparoscopic spleen-preserving distal pancreatectomy was performed.

OUTCOMES

The patient was discharged on day 5 postoperatively after an uneventful recovery. CA19-9 returned to normal after surgery. During a 2-years follow-up, there was no evidence of tumor recurrence.

LESSONS

Although rare ECIPAS should be considered in the differential diagnosis of pancreatic tail cystic lesions, and the typical imaging features might facilitate the preoperative diagnosis. Laparoscopic distal pancreatectomy is a safe and effective approach for treating ECIPAS.

A lymphoepithelial cyst in the pancreatic accessory spleen: A case report

We present the first report of a lymphoepithelial cyst. As additional cases will likely be encountered in the future, our study sets the precedent for future research.

Epithelial cyst arising in an intrapancreatic accessory spleen: a case report of robotic surgery and review of minimally invasive treatment

Background

An epithelial cyst in an intrapancreatic accessory spleen (ECIPAS) is rare. We report a case of ECIPAS that was treated with robot-assisted distal pancreatectomy with splenectomy.

Case presentation

The case was a 59-year-old woman who was referred to our hospital after a pancreatic tail tumor was found on computed tomography prior to surgery for small bowel obstruction at another hospital. A cystic lesion in the pancreatic tail was discovered and evaluated by magnetic resonance imaging and endoscopic ultrasonography. Based on clinical and radiological features, mucinous cystic neoplasm was included in the differential diagnosis. The patient underwent robot-assisted distal pancreatectomy with splenectomy. The postoperative course was uneventful. Pathological evaluation revealed a 20-mm ECIPAS in the pancreatic tail.

Conclusions

If a pancreatic tail tumor is present, ECIPAS should be included in the differential diagnosis. However, preoperative diagnosis is difficult, and a definitive diagnosis is often not obtained until after surgery. Surgery should be minimally invasive. Laparoscopic distal pancreatectomy has become a standard surgical procedure because it is minimally invasive. Robot-assisted surgery is not only minimally invasive, but also advantageous, because it has a stereoscopic magnifying effect and allows the forceps to move smoothly. Robot-assisted distal pancreatectomy may be a good option, when performing surgery for a pancreatic tail tumor.

Malignant Transformation of an Epidermoid Cyst in an Intrapancreatic Accessory Spleen: A Case Report

A 33-year-old man was evaluated because of an incidentally found cyst in the pancreatic tail, which was first seen 6 years ago. The cyst was a unilocular cystic mass, 13.0 cm in diameter, and had increased in size in last 2 months. On F-18 fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT), the cystic wall showed increased FDG uptake. The patient underwent distal pancreatectomy with suspicion of mucinous cystic neoplasm of the pancreas. The mass turned out to be a squamous carcinoma arising from an epidermoid cyst in an intrapancreatic accessory spleen (ECIPAS). FDG PET/CT may assist recognition of a potential malignant lesion arising from an ECIPAS.

Laparoscopic spleen-preserving pancreatic resection for epidermoid cyst in an intrapancreatic accessory spleen: case report and literature review

Introduction

An epidermoid cyst in an intrapancreatic accessory spleen (ECIPAS) is a rare non-neoplastic cyst, typically occurring in the pancreatic tail. It is difficult to preoperatively differentiate ECIPAS from other types of pancreatic neoplastic cysts.

Case presentation

We herein report a case of a 32-year-old man with a cystic tumor in the tail of the pancreas. The patient underwent a laparoscopic spleen-preserving distal pancreatectomy, and histological examination revealed the presence of ECIPAS. In addition, we also performed a literature review of 42 case reports of ECIPAS.

Conclusion

Although the preoperative diagnosis of ECIPAS is relatively difficult, familiarity with the imaging features, the clinical presentation and the location of the cyst could lead to a correct preoperative diagnosis of ECIPAS, which might thereby reduce the number of unnecessary resections.

Laparoscopic Resection of an Epithelial Cyst in an Intrapancreatic Accessory Spleen

An epithelial cyst in an intrapancreatic accessory spleen (ECIAS) is rare. We herein report a case of a patient with ECIAS who underwent laparoscopic surgery. A 57-year-old woman was referred to our hospital because of a pancreatic tail tumor. She was asymptomatic, and a physical examination revealed no remarkable abnormalities. The levels of the tumor marker carbohydrate antigen 19-9 (CA19-9) and s-pancreas-1 antigen (SPan-1) were elevated. Ultrasonography showed a well-defined homogeneous cystic tumor. Computed tomography showed a well-demarcated cystic tumor in the pancreatic tail. Magnetic resonance imaging showed that the cystic tumor exhibited low intensity on T1-weighted images and high intensity on T2-weighted images. The cystic tumor was diagnosed as mucinous cystic neoplasm preoperatively. The patient underwent laparoscopic spleen-preserving distal pancreatectomy. A histopathological examination revealed the cyst wall to be lined by stratified squamous epithelium within splenic parenchyma, and the ultimate diagnosis was ECIAS. The postoperative course was uneventful, and the patient was discharged on postoperative day 12. ECIAS is very difficult to diagnose preoperatively. Laparoscopic surgery is a safe and minimally invasive procedure for patients with difficult-to-diagnose pancreatic tail tumor suspected of having low-grade malignancy.

Rare Case of an Epithelial Cyst in an Intrapancreatic Accessory Spleen Treated by Robot-Assisted Spleen Preserving Distal Pancreatectomy

Epithelial cyst in an intrapancreatic accessory spleen (ECIPAS) is exceedingly rare with only 57 cases reported since the first publication in 1980. Comprehensive clinical and diagnostic features remain to be clarified. We present a case of ECIPAS in a 21-year-old Philippine woman who was admitted with right upper quadrant abdominal pain. A cystic lesion in the pancreatic tail was discovered and evaluated by computed tomography and magnetic resonance images. Based on clinical and radiological features a solid pseudopapillary neoplasm was suspected. The patient underwent robot-assisted spleen preserving distal pancreatectomy. Pathological evaluation revealed a 26 mm intrapancreatic accessory spleen with a 16 mm cyst, lined by multilayered epithelium in the tail of the pancreas. The postoperative course was uneventful. Differentiating ECIPAS from (pre)malignant cystic pancreatic neoplasms based on clinical and radiological features remains difficult. When typical radiological signs can be combined with scintigraphy using Technetium-99m labelled colloid or Technetium-99m labelled erythrocytes, which can identify the solid component of the lesion as splenic tissue, it should be possible to make the right diagnosis noninvasively. When pancreatectomy is inevitable due to symptoms or patient preference, minimally invasive laparoscopic or robot-assisted spleen preserving distal pancreatectomy should be considered.

Two Cases of an Epidermoid Cyst Developing in an Intrapancreatic Accessory Spleen Identified during Laparoscopic Distal Pancreatectomy

Epidermoid cysts presenting within an intrapancreatic accessory spleen are rare non-neoplastic cysts typically occurring in the pancreatic tail. This entity is difficult to diagnose given there are many types of pancreatic neoplastic cysts. We herein describe two cases of an epidermoid cyst within an intrapancreatic accessory spleen for which we performed a resection by laparoscopic distal pancreatectomy. Epidermoid cysts in an intrapancreatic accessory spleen should therefore be considered in the differential diagnosis of pancreatic tail cystic lesions. Laparoscopic distal pancreatectomy can be a useful, minimally invasive surgical approach for treating these cysts as well as for the treatment of benign or low-grade malignant tumors located in the pancreatic body or tail.

Epidermoid Cyst in an Intrapancreatic Accessory Spleen: Case Report and Literature Review of the Preoperative Imaging Findings

An epidermoid cyst arising within an intrapancreatic accessory spleen (ECIAS) is rare, and also difficult to correctly diagnose before surgery. It is mostly misdiagnosed as a cystic tumor, such as a mucinous cystic neoplasm or as a solid tumor with cystic degeneration, such as a neuro endocrine tumor. We herein report a case of ECIAS and also perform a literature review of 35 reports of ECIAS. Although the preoperative diagnosis of ECIAS using conventional imaging is relatively difficult to make, careful preoperative examinations of the features on computed tomography and magnetic resonance imaging could lead to a correct preoperative diagnosis of ECIAS which might thereby reduce the number of unnecessary resections.

Epidermoid cyst of an intrapancreatic accessory spleen: a case report and literature review

Background

An epidermoid cyst in an intrapancreatic accessory spleen is a rare lesion. Despite advances in radiologic techniques, in most cases it has been diagnosed preoperatively as a possible pancreatic neoplasm.

Case presentation

Herein, we present a 63-year-old Caucasian woman, diagnosed preoperatively with enhanced-contrast abdominal computed tomography, as having a potential cystic tumor in the tail of the pancreas. The patient underwent a distal pancreatectomy and splenectomy, and the histological examination revealed the presence of an epidermoid cyst of an accessory intrapancreatic spleen.

Conclusions

Familiarity with the imaging features, the clinical presentation and the location of the cyst are important to consider if this rare entity is to be included in the differential diagnosis of cystic neoplasms of the pancreas.

Epidermoid cyst of intrapancreatic accessory spleen: A case report and literature review

Epidermoid cyst of intrapancreatic accessory spleen is exceedingly rare; only 30 new cases have been reported in the English literature over the last 30 years. An accurate preoperative diagnosis was made in almost none of them because of the lack of reliable preoperative diagnostic methods. In this report, we present a case diagnosed with fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET). A 41-year-old female who had breast cancer was routinely followed up by measuring the concentration of tumor makers. An increasing level of serum carbohydrate antigen 19-9 was detected and a cystic lesion located at the tail of pancreas was found by ultrasonography. A whole body fluorine-18 FDG positron emission tomography was performed because of a high suspicion for either a malignancy of the pancreas or a recurrence of breast cancer. No increased uptake of FDG was noted and therefore the cystic lesion was considered as pancreatic benign disease. Because pancreatic malignancy could not be entirely ruled out, distal pancreatectomy and splenectomy were performed. The final pathological diagnosis was epidermoid cyst of intrapancreatic accessory spleen (ECIAS). The FDG-PET findings matched the histopathology. A literature review reveals that the common clinical manifestations of ECIAS include asymptomatic findings on clinical examination, an occasional increase in tumor makers on laboratory results and occurrence only in the pancreatic tail. It is often misdiagnosed due to its extreme rarity and lack of a specific radiographic sign. There is no evidence of malignancy in ECIAS. Open or laparoscopic spleen preserving distal pancreatectomy is the minimally invasive procedure that would provide the best surgical management for epidermoid cyst of intrapancreatic accessory spleen.

Epidermoid cyst of the spleen

BACKGROUND

The aim of this study is to elucidate the characteristics, clinical presentations, and management of epidermoid cysts located in the spleen and the intrapancreatic accessory spleen.

METHODS

Data pooled for analysis were collected from epidermoid cyst cases encountered in the study institution and sporadic case reports obtained from the English literature.

RESULTS

There were 115 cases of epidermoid cyst. Seventy eight (67.8 %) were found in the spleen, whereas 37 (32.2 %) were found in the intrapancreatic accessory spleen. Comparing between the two groups, the splenic group showed female predominance, younger age, and larger cystic size. For symptoms, left upper abdominal mass (57.7 %) and left upper abdominal pain (39.0 %) were more commonly found in the spleen group. Meanwhile, the intrapancreatic accessory spleen group had higher percentage of asymptomatic cysts (59.5 %). As for surgical indication, majority of patients in the spleen group underwent surgery for symptomatic relief (75.4 %), while the intrapancreatic accessory spleen group underwent surgery mainly for suspicious malignancy (90.0 %).

CONCLUSIONS

Surgical treatment for epidermoid cysts of the spleen is considered the optimal treatment for either alleviating the symptoms caused by a bulky cyst or for determining the histopathologic nature of a suspicious malignant cystic neoplasm.

Epidermoid cyst arising from an intrapancreatic accessory spleen: A case report and review of the literature

We describe an epidermoid cyst arising from an accessory spleen of the pancreas. A 56-year-old female with iron deficiency anemia presented with dizziness. During the clinical workup, a 2×4 cm-sized mass was incidentally detected in the tail of the pancreas in a computed tomography (CT) scan. Under a clinical diagnosis of pancreatic cystic malignant tumor, a distal pancreatectomy was carried out. Grossly, the lesion was composed of a solid and cystic portion. Microscopic analysis revealed that the solid portion was an intrapancreatic accessory spleen and the cystic portion was an epidermoid cyst. An epidermoid cyst in an intrapancreatic accessory spleen is extremely rare and hence difficult to diagnose pre-operatively. Taking into account the possibility of such a cyst in the differential diagnosis of intrapancreatic cystic lesion is recommended.