Hidden Threat: Incidental Finding of Pancreatic Body Solid Pseudopapillary Tumor During Bariatric Evaluation With an Open Central Pancreatectomy Resolution

Abstract

Incidentalomas, or tumors found incidentally, are very common. However, pancreatic tumors are usually not found as incidentalomas. To date, these tumors represent a diagnostic and therapeutic challenge, since the risks and benefits associated with surgeries that can be performed to remove these tumors must be evaluated due to perioperative complications. It is vitally important to always carry out a correct approach that includes a histopathological study to allow timely identification of tumors that require surgical management or other preoperative treatment, such as chemotherapy or radiotherapy. The majority of these tumors are benign cystic tumors; however, there are cases, like the one presented here, where the tumor turns out to be a solid pseudopapillary tumor (SPT) that requires a different diagnostic and surgical approach. Also, in this case, the importance of evaluating the patient's general health status is highlighted to determine whether or not the required surgery can be performed at that moment or if any prior intervention is required. This case report talks about a patient in whom an incidental pancreatic tumor was found and how its management was carried out from diagnosis to the postoperative period.

Keywords: central pancreatectomy; gastric bypass; modified blumgart-type; pancreatic resection; pancreaticojejunal anastomosis; pseudopapillary solid tumor.

Figure 1. Pancreatic tumor dissection.

Surgical dissection involving the stomach, body of pancreas, head of the pancreas, and portomesenteric confluence. S: stomach, PT: pancreatic tumor, BP: body of the pancreas, HP: head of the pancreas, PC: portomesenteric confluence.

Figure 2. Pancreas after tumor resection.

Pancreas remnant including head and body after central pancreatectomy. S: stomach, BP: body of the pancreas, HP: head of the pancreas, PC: portomesenteric confluence, PV: portal vein, SV: splenic vein, SMV: superior mesenteric vein.

Figure 3. Blumbart’s modified pancreaticojejunostomy.

A: Picture taken from surgery showing the Blumbart’s modified duct-to-mucosa pancreaticojejunostomy (PJ). B: illustration depicting the outcome of the surgical procedure, image credits to Natalia M. Barron-Cervantes. PPS: proximal pancreatic stump, IPS: intrapancreatic space.

Figure 4. Gross examination of the pancreatic tumor.

The tumor was well demarcated by a calcified fibrous capsule (C). It was pale brown, soft, with cystic (Cy), hemorrhagic and necrotic (N) areas. Proximal (PM) and distal (DM) margins were macroscopically negative for the tumor.

Figure 5. Histopathological study.

A: Sections stained with hematoxylin and eosin showed solid pattern features discohesive monomorphic cells that are densely packed and adhere to fibrovascular stalks (*). B: As these cells detach from the stalks (*), they form structures resembling papillae (pseudopapillae) or rosettes. C: Additionally, the neoplastic cells display distinctive longitudinal grooves, highlighted by red circles, imparting a coffee bean-like appearance to the cells.

Figure 6. Immunohistochemical study.

The neoplasm was positive for (A) β-catenin, nucleus and cytoplasm, (B) CD10, (C) progesterone receptors, and (D) synaptophysin.

Figure 7. Abdominal CT scan.

Edema and stenosis of the jejunum-jejunum anastomosis (green arrow).