Clinical Case Summary

About 1-2% of pancreatic tumors are neuroendocrine pancreatic tumors (NETs). They are often solid masses; rarely they appear as cystic lesions.
The authors report the clinical case of a 66-year-old woman with unspecific abdominal pain, who was referred to the Pancreato-biliary clinic for pancreatic cystic lesions. Magnetic resonance cholangiopancreatography and abdominal CT showed multiple cystic lesions in the distal body and a lesion of 26 mm in the anterior region of the body with diffusion restriction; the duct of Wirsung was dilated (8 mm). Endoscopy ultrasound showed: several hyperechoic foci in the pancreatic parenchyma; a nodular hyperechoic lesion measuring 9 mm in the pancreatic body; a cystic lesion measuring 6 mm in the body; and two cystic lesions measuring 38 and 25 mm in the tail. Fine needle biopsy of the nodular lesion and fine needle aspiration of the larger cystic lesions was performed; the aspiration punction showed amylase 33207 U/L and carcinoembryonic antigen 0.9 ng/mL; however, the cytology of both lesions was inconclusive. Somatostatin receptor scintigraphy showed uptake in the pancreatic body's anterior region and high somatostatin receptor expression, suggesting a neuroendocrine pancreatic tumor diagnosis. In the multidisciplinary team discussion, the decision was to perform total duodenopancreatectomy with splenectomy, which occurred without complications. Histological examination revealed several well-differentiated NETs, the largest of which measured 4 cm, with < 2 mitoses per 2 mm², a proliferation index of 3-20% and regional ganglionic metastasis (pT3(m)N1). At 2 years of follow-up, the patient remains clinically stable without evidence of recurrence of the disease.
This case report, while displaying remarkable images, intends to highlight the challenge of the differential diagnosis between cystic lesions and neuroendocrine tumors of the pancreas; both entities can coexist synchronously and they may share imagiological features.

References

Images list:

1. Multiple cystic pancreatic lesions and a pancreatic lesion in the anterior region of the body with diffusion restriction (Magnetic Resonance Cholangiopancreatography).
2. Multiple cystic lesions in the distal body and a pancreatic lesion in the anterior region of the body (Abdominal Computed Tomography).
3. Several hiperecoic foci in the pancreatic parenchyma; a nodular hiperecoic lesion measuring 9 mm in the pancreatic body; a cystic lesion measuring 6 mm in the body; and two cystic lesions measuring 38 and 25 mm in the tail (Endoscopy ultrasound).
4. Uptake in the pancreatic body's anterior region and high somatostatin receptor expression (Somatostatin receptor scintigraphy)