A 52-year-old Caucasian man with a past medical history of poor controlled diabetes mellitus and hypertension presented to the emergency room with diffuse abdominal pain and nausea for one day. He described the pain as dull aching, pain score 2 out of 10, and generalized. He has lost 120 Ibs unintentional in one year. Patient denied history of alcohol, tobacco or illicit drug use. His vital signs showed blood pressure 188/117 mm Hg, heart rate 96 beats per minute, respiratory rate 20 breaths/ minute, temperature 97.4°F and oxygen saturation 92% on room air. His body mass index of 27.3 kg/m². On examination, he was alert and in no acute distress. He had clear breath sounds on auscultation bilaterally. His abdomen was soft and non-distended, with tenderness at the epigastrium and normal bowel sounds.

Laboratory workup showed white blood cell count of 12.31 k/µl (ref 4.23-9.07), hemoglobin 13.6 g/dL (13.7-17.5 g/dL), and platelet count 219 k/µl (165-400 k/µl). Serum glucose 247 mg/dL, and hemoglobin A1c was 13.2% (4.0-6.0%), alkaline phosphate 115 IU/L (35-129 IU/L), aspartate transaminase 71 IU/L (5-37 IU/L), and alanine transaminase 166 IU/L (5-41 IU/L). Computed tomography (CT) pancreatic protocol showed a 1.7 cm x 1.5 cm solid appearing mass in the body of the pancreas (Figure 1A). Magnetic resonance imaging (MRI) of the abdomen without contrast re-demonstrated a 1.5 cm solid lesion in the body of the pancreas and a 5mm central calcification within the mass. A few mildly prominent lymph nodes are seen in the porta hepatis. An endoscopic ultrasound (EUS) showed a 18.2 mm x 15.4 mm hypoechoic, homogeneous, round mass with central calcification and acoustic shadowing near the genu/proximal body of the pancreas (Figure 1B), and fine needle biopsy (FNB) was obtained. Pathology showed an admixture of solid and pseudopapillary areas forming fibrovascular stalks and rosette-like structures; stroma showed various degrees of hyalinization and evidence of degeneration, foamy macrophages and calcification (Figure 2A and 2B). Tumor cells stained positive for beta-catenin, androgen receptor, CD56, CD10, focally positive for pancytokeratin and synaptophysin and stain negative for E-cadherin and CD45 (Figure 3A and 3B). The morphology and immunophenotype on pathology were most consistent with solid pseudopapillary neoplasm of the pancreas.

Patient was referred to hepato-pancreato-biliary surgery for surgical evaluation. With uncontrolled hypertension and diabetes, patient was considered high risk for surgery at this time. He is currently managed conservatively with annual imaging surveillance.