S3544 What's That Cyst?

Abstract

INTRODUCTION: Pancreatic cysts are rare in children and consist of six classifications: congenital, retention, duplication, pseudocyst, neoplastic, or parasitic. Most pancreatic cysts are asymptomatic but can be symptomatic if causing mass effect on adjacent structures. This is a case of a pediatric pancreatic cyst. CASE DESCRIPTION/METHODS: An 11-year-old Caucasian Female presented for progressive acute on chronic abdominal pain with associated nausea, vomiting, and weight loss for 2 to 3 years. The patient had no previous medical, surgical, or travel history. Right upper quadrant abdominal ultrasound demonstrated a complex cystic mass measuring 7.41 × 7.11 × 7.17 cm with a focal solid area representing hemorrhage, concerning for a complex mesenteric cyst or duplication cyst. Given this finding, the patient underwent a computed tomography scan of the abdomen and pelvis that re-demonstrated the same thick-walled mass, abutting the anterior medial aspect of the second portion of the duodenum, concerning again for a duplication cyst. Of note, there was no biliary ductal dilatation or pancreatic ductal dilation. Comprehensive metabolic panel was significant for only mild elevation of total bilirubin to 0.8 mg/dl. Magnetic resonance imaging of the abdomen again showed a large cystic mass with a diameter of 6.3 cm, contiguous with the pancreatic head and neck with local mass effect on the duodenum, and a moderately thick wall and internal debris. Endoscopic ultrasound demonstrated a septate cystic mass with internal debris measuring 7.2 × 6.0 cm. Given these findings, the decision was made to forego fine needle aspiration of the sterile mass. The patient ultimately underwent a pancreaticoduodenectomy. Final pathology demonstrated a benign pancreatic cyst or congenital pancreatic cyst with no definite epithelial lining. Lymph nodes were negative for malignancy. DISCUSSION: This case highlights a pancreatic cyst that was discovered due to obstructive symptoms. The patient underwent a noninvasive multi-modal imaging technique consisting of ultrasound, CT scan, and MRI leading to endoscopy and eventually surgery to delineate the final pathology of the cyst. Unlike most congenital pancreatic cysts which originate at the pancreatic neck or tail, our patient had a cyst in the pancreatic head with close proximity to the duodenum. As demonstrated in this patient, pancreatic cysts are rare in children and involve a multi-disciplinary approach for appropriate evaluation and management.