Solid Pseudopapillary Tumor of the Pancreas: An Unexpected Finding After Minor Abdominal Trauma

Abstract

A 20-year-old female college student presented to the emergency department with epigastric pain and vomiting several hours after being struck in the abdomen with a soccer ball. She had no significant past medical or surgical history. On examination the patient was afebrile and hemodynamically stable. Her abdominal examination was significant for epigastric and right upper quadrant tenderness. Computed tomography (CT) of the abdomen and pelvis was obtained to rule out traumatic intra-abdominal injury. CT revealed a multi-septated cystic mass at the pancreatic neck measuring 6.1 9 6.6 cm, with associated mural nodules and rim enhancement (Fig. 1). The mass appeared to invade the posterior wall of the stomach and compress the portal vein near the confluence of the superior mesenteric vein and splenic vein. Lymphadenopathy of the celiac axis and greater curvature of the stomach was noted. The patient was admitted and underwent endoscopic ultrasound with fine needle aspiration of the cystic pancreatic mass. Cytology from this procedure showed clusters of polygonal cells with abundant cytoplasm, surrounding fibrovascular structures in a background of blood and necrotic debris. Mitotic figures were not apparent. The findings were interpreted as consistent with solid pseudopapillary tumor of the pancreas. The patient was taken for surgical resection at which time there was noted to be extensive inflammatory change surrounding the tumor, involving the duodenum and transverse mesocolon, with adherence of the tumor to the SMV, portal vein and hepatic artery. The patient ultimately required total pancreatectomy, duodenectomy, splenectomy, partial gastrectomy and right hemicolectomy for complete resection. Final pathology revealed a solid pseudopapillary neoplasm with borderline malignant potential, 6.5 cm in greatest dimension, with negative lymph nodes (0/25). There was submucosal inflammation and necrosis of the adjacent posterior wall of the stomach, but microscopic examination showed no evidence of tumor invasion into any adjacent structures. The patient recovered from surgery and received an insulin pump for insulin replacement. With three-year follow up with CT surveillance, she has no evidence of tumor recurrence.