Vol 39 # 2 June 2007 - Kma.org.kw

KUWAIT MEDICAL JOURNAL June 2007Case ReportSolid and Papillary Epithelial Neoplasm (SPEN) of thePancreas in a Pregnant LadyMargaret Linny Austin 1 , Sameer M Humad 1 , Vinod Kumar Grover 21Departments of *Radiology and 2 Surgery, Al-Jahra Hospital, KuwaitKuwait Medical Journal 2007, 39 (2):170-173ABSTRACTState-of-the-art cross-sectional imaging has led to therealization that the prevalence of cystic neoplasms in thepancreas is much higher than initially estimated. This hasalso permitted the diff e rentiation of most cystic neoplasmsbased on cyst size, shape, wall thickness, internalarchitecture, location and presence of calcifications. Thesolid and papillary epithelial neoplasm (SPEN) of thepancreas is a rare low-grade cystic malignancy, seenmainly in adolescent and young adult females. Wepresent the imaging findings of SPEN of the pancreas ina young pregnant lady that was accurately diagnosedpreoperatively.KEYWORDS: imaging, pancreas, SPENINTRODUCTIONSolid and papillary epithelial neoplasm of thepancreas (SPEN) is a rare low-grade malignancymainly found in adolescent and young women ofAsian and far Eastern origin. Clinically, patients areasymptomatic or may present with non-specificsigns and symptoms including nausea, vomitingand upper abdominal discomfort caused by theusually great size of the tumor. Surgical resection iscurative in most instances [1,2,3] .CASE REPORTA 34-yr-old Arab pregnant lady, a mother of six,presented with complaints of a dragging sensationin the upper abdomen. The gestational age of herfetus was 16 weeks at the time of examination.T h e re was no history of previous biliary tractdisease, pancreatitis, or trauma. She denied rearinganimals at home. There were no complaints ofarthralgia. Her laboratory tests including her bloodand eosinophil count were normal.Ultrasound of 8/2/2003 revealed a 14 x 11 cmwell encapsulated complex, heterogeneous masswith cystic and solid components in the tail of thep a n c reas, displacing the spleen laterally andcompressing the left kidney posteriorly withoutevidence of invasion. The cystic mass showedposterior enhancement (Fig. 1). The other organs,including the liver, spleen, kidneys, gallbladderand biliary tract were normal. Pelvic ultrasoundrevealed a single live fetus (of gestational age 16weeks) in the uterine cavity. The ovaries andadnexae were normal. There was no free fluid.Because of the high radiation dose delivered bycomputed tomography (CT) abdomen to thepatient and in particular to the fetus, it was decidedto proceed to magnetic resonance imaging (MRI) ofthe abdomen rather than CT scan. MRI revealed awell encapsulated predominantly cystic mass (asrevealed by the low signal on T1- Fig. 2 and highsignal on T2- Fig. 3) with peripheral mural orfrond-like areas of intermediate signal intensitydue to the solid component. The fat suppressedimages emphasized the cystic nature of the mass(Fig. 4). Gross hemorrhage was not pre s e n t ,although a minimal hemorrhagic component couldnot be excluded. The fibrous capsule was seen as ahypointense rim on T1 and T2. Administration ofgadolinium would have enhanced the evaluationof this tumor but was refused by the patient, eventhough its use is safe for the mother and the fetus.Because of the clinical presentation and theradiographic findings, the strong possibility of aSPEN of the pancreas was raised.On ultrasound guided aspiration of the cyst, 40ml watery blood stained fluid was withdrawn.Cytology from the solid area of the cyst and fluidshowed few sheets and dispersed small cuboidalepithelial cells without nuclear atypia and withscanty cytoplasm, macrophages, eosinophils andneutrophils. Findings were suggestive of a benignepithelial neoplasm.Address Correspondence to:Dr. Margaret Linny Austin, Dept. of Radiology Al-Jahra Hospital, Kuwait. P O Box 21396 Safat 13074, Kuwait. Tel: +965- 4577198, E-mail:Linny_Austin@Hotmail.Com