Case Report
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.