Laparoscopic spleen-preserving pancreatic resection for epidermoid cyst in an intrapancreatic accessory spleen: case report and literature review

Figures & data

Figure 1 The abdominal computed tomography (CT) scan confirmed a well-defined cystic neoplasm in the pancreatic tail (A), without enhancement in the arterial phase (B) and the portal phase (C). Endoscopic ultrasonography (EUS) showed a 3.5 cm multilocular cystic lesion in the pancreatic tail with an internal nodule (D).

Figure 2 (A) Gross appearance of the epidermoid cyst in an intrapancreatic accessory spleen (ECIPAS), with 4 cm at its greatest diameter. (B) Microscopic analysis revealed a multilocular cyst surrounded by accessory splenic tissue in the pancreas parenchyma, and the cyst wall showed a thin multilayered squamous epithelium (H&E staining, ×50).

Table 1 Reported studies of an ECIPAS in the English language literature

Case	Authors	Sex/age	Symptom	Location	Size (cm)	Cyst	CA19-9	CT	MRI	Preoperative diagnosis	Surgery
1	Davidson et al^Citation2	M/40	Nausea	Tail	5.5	Multilocular	NI	Cystic lesion surrounded by thin rim of tissue	NI	Pseudocyst, cystadenoma and cystadenocarcinoma	DP
2	Hanada et al^Citation3	M/51	Abdominal pain	Tail	6	NI	NI	Cystic mass with a rim of dense density	NI	Pseudocyst	DP
3	Morohoshi et al^Citation4	F/32	Abdominal pain	Tail	6	Unilocular	Normal	Well-demarcated cystic lesion	NI	Pancreatic cyst	Cyst removal
4	Nakae et al^Citation5	F/37	Epigastric pain	Tail	6.5	Unilocular	NI	Cystic lesion with a thin wall of high density	T1 low, T2 high	Pancreatic cyst	SPDP
5	Tang et al^Citation6	M/38	Asymptomatic	Tail	1.4	Multilocular	NI	Well-demarcated hypodense lesion	NI	NI	DP
6	Furukawa et al^Citation7	M/45	Asymptomatic	Tail	2	Multilocular	NI	Peripherally enhanced area, its density is equal to the spleen	NI	Primary cystic neoplasm	DP
7	Higaki et al^Citation8	F/46	Left back pain	Tail	3	Multilocular	+	Oval nodule with a distinct margin	NI	Malignant tumor	DP
8	Tateyama et al^Citation9	F/67	Abdominal pain	Tail	3	Multilocular	+	Cystic mass of low density	NI	NI	DP
9	Sasou et al^Citation10	F/49	Asymptomatic	Tail	4.3	Multilocular	NI	NI	NI	Pancreatic cystic tumor	DP
10	Choi et al^Citation11	F/54	Epigastric pain	Tail	15	Multilocular	NI	Major cystic component, small solid component with the same homogeneous attenuation as in the spleen	Cyst: T1 low, T2 high; solid lesion: T1 low, T2 intermediate-high	Benign cyst of the pancreas or accessory spleen	DP
11	Tsutsumi et al^Citation12	M/51	Asymptomatic	Tail	2.5	Multilocular	Normal	Well-demarcated cystic lesion containing a solid portion	Cystic lesion containing a solid portion	Benign cyst of the pancreas	DP
12	Horibe et al^Citation13	M/48	Asymptomatic	Tail	2	Unilocular	+	No substance in the cyst by enhanced image	NI	Mucin-producing pancreatic tumor	DP
13	Sonomura et al^Citation14	F/45	Epigastric pain	Tail	3.5	Multilocular	NI	Parenchymal medial lesion with calcification and cystic lateral lesion	NI	Cystadenocarcinoma or solid tumor of the pancreas	DP
14	Fink et al^Citation15	F/12	Fever	Tail	10	Multilocular	NI	Rim enhancing cystic lesion, with a medial mural nodule	NI	Infected abdominal cyst	Cyst removal
15	Yokomizo et al^Citation16	M/38	Asymptomatic	Tail	3.0	Multilocular	+	NI	Cyst: T2 super-high, cyst wall: delineated enhancement	MCN, adenocarcinoma and ECIPAS	DP
16	Kanazawa et al^Citation17	F/58	Asymptomatic	Tail	2.5	Multilocular	+	Septated low-density area	Cystic component: T1 hypo, T2 hyper	MCN	SPDP
17	Watanabe et al^Citation18	F/55	Postprandial epigastralgia	Tail	3	Multilocular	+	Multilocular cystic tumor. No protruded lesion in the inner lumen	T1 low, T2 high	Mucinous cystadenoma and cystadenocarcinoma	DP
18	Won et al^Citation19	M/32	Asymptomatic	Tail	7.5	Unilocular	+	Well-circumscribed cystic mass with inner fluid debris or hemorrhagic fluid	NI	Pancreatic pseudocyst	SPDP
19	Won et al^Citation19	F/49	Abdominal pain	Tail	2.0	Multilocular	Normal	Well-circumscribed cystic tumor with septation	NI	Serous or mucinous cystadenoma	Laparoscopic DP
20	Ru et al^Citation20	M/41	Asymptomatic	Tail	2.5	Unilocular	NI	Well-circumscribed tumor which partially compressed the spleen	NI	Cystic lesion of the pancreas	DP
21	Itano et al^Citation21	M/40	Asymptomatic	Tail	4.0	Unilocular	Normal	Solid component with the same homogeneous attenuation as the spleen	Cyst: T1/T2 high; solid component: T1 intermediate-low	ECIPAS	DP
22	Servais et al^Citation22	F/52	Asymptomatic	Tail	11.5	Multilocular	+	Cystic mass which was thin walled and contained single peripheral septation	NI	Malignant pancreatic neoplasm	DP
23	Gleeson et al^Citation23	F/32	Abdominal pain	Tail	1.5	Unilocular	NI	Demarcated cyst without septation, calcification and satellite lesions	NI	Pancreatic cystic neoplasm	DP
24	Zhang and Wang^Citation24	F/26	Asymptomatic	Tail	2.5	Unilocular	Normal	Cystic wall revealed a density similar to that of the pancreas	NI	Primary MCN	SPDP
25	Reiss et al^Citation25	M/49	Asymptomatic	Tail	3.6	Multilocular	NI	Heterogeneously enhancing mass	NI	MCN	DP
26	Kadota et al^Citation26	F/57	Asymptomatic	Tail	6	Multilocular	Normal	Cystic wall: a partial enhancement	NI	Pancreatic cystic tumor	DP
27	Kadota et al^Citation26	F/70	Asymptomatic	Tail	1.7	NI	+	Cystic mass lesion	NI	MCN	DP
28	Kadota et al^Citation26	M/37	Asymptomatic	Tail	10	NI	+	Cystic mass lesion with a partial enhancement of the cystic wall	NI	Serous cystic tumor or lymphoepithelial cyst	DP
29	Itano et al^Citation27	M/67	Epigastric pain	Tail	1.5	Unilocular	+	Cystic tissue and smooth solid component	Cyst: T1 intermediate, T2 high. Solid lesion: T1 intermediate-low	ECIPAS	Laparoscopic DP
30	Horn and Lele^Citation28	M/62	Abdominal pain	Tail	4.8	Multilocular	NI	Left-sided retroperitoneal mass with a possible cystic component	NI	NI	DP
31	Iwasaki et al^Citation29	F/36	Asymptomatic	Tail	3.4	Unilocular	+	Septate low-density lesion, with an area showing higher degree of enhancement than the pancreas	NI	MCN	Laparoscopic DP
32	Yamanishi et al^Citation30	F/55	Asymptomatic	Tail	2.5	Unilocular	+	Cyst wall was relatively thick, but not enhanced	Cyst: T1 slightly high, T2 strongly high	MCN	DP
33	Urakami et al^Citation31	F/50	Asymptomatic	Tail	3.0	Unilocular	NI	Single cyst with a contrasted mass beside it	Cyst: T1 low, T2 high	ECIPAS	Laparoscopic SPDP
34	Khashab et al^Citation32	F/49	Abdominal pain	Tail	2.3	Unilocular	NI	Solid mass	NI	PNET	Laparoscopic SPDP
35	Harris et al^Citation33	F/39	Asymptomatic	Tail	2.5	NI	NI	Stable hypodense lesion	Pancreatic cystic neoplasm	Malignant cystic tumor	Laparoscopic DP
36	Hong et al^Citation34	F/54	Abdominal discomfort	Tail	2	Multilocular	NI	Cystic mass	NI	NI	SPDP
37	Hamidian Jahromi et al^Citation35	F/36	Asymptomatic	Tail	5	Multilocular	NI	Cystic lesion	NI	NI	DP
38	Zavras et al^Citation36	F/63	Nausea and vomiting	Tail	12.6	NI	+	Mass lesion with solid and cystic components	NI	Malignant tumor of the pancreas	DP
39	Kumamoto et al^Citation37	M/39	Diarrhea	Tail	3.8	NI	+	A cyst lesion, surrounded by a crescent-like solid component with the same enhancement as the spleen	Typical findings of an intrapancreatic accessory spleen	ECIPAS	Laparoscopic SPDP
40	Kwak et al^Citation38	F/21	Abdominal pain and fever	Tail	2.5	Multilocular	Normal	The wall of the cyst was relatively regular, thick and enhanced	Cyst: T1 iso, T2 hyper. Rim showed hyperintensity in DWI	SPT	Laparoscopic DP
41	Kato et al^Citation39	F/33	Asymptomatic	Tail	3	Multilocular	Normal	The densities of the solid component and spleen on enhanced CT were similar	The intensity of the solid component on T1 and T2 was similar to that of the spleen	SPT and NET	Laparoscopic SPDP
42	Modi et al^Citation40	F/62	Abdominal pain	Tail	2.4	NI	NI	Cystic lesion	NI	NI	Laparoscopic DP
43	Fujii et al^Citation41	F/50	Asymptomatic	Tail	4	Unilocular	+	A unilocular cystic lesion with same enhancement as the adjacent spleen	T1 low/T2 high	MCN	Laparoscopic SPDP
44	Fujii et al^Citation41	F/60	Back discomfort	Tail	3.5	Multilocular	+	A multilocular cystic lesion, solid component with enhancement similar to the spleen	Low T1 and high T2	IPMN	Laparoscopic DP
45	Hirabayashi et al^Citation42	M/38	Asymptomatic	Tail	3	Multilocular	Normal	NI	NI	NI	DP
46	Hirabayashi et al^Citation42	F/40	Abdominal pain	Tail	3.5	Multilocular	+	NI	NI	NI	Enucleation
47	Hirabayashi et al^Citation42	F/39	Asymptomatic	Tail	2	Multilocular	+	NI	NI	NI	DP
48	Hirabayashi et al^Citation42	M/54	Asymptomatic	Tail	2.7	Multilocular	Normal	NI	NI	NI	Enucleation
49	Hirabayashi et al^Citation42	M/55	Asymptomatic	Tail	3.5	Multilocular	+	NI	NI	NI	Enucleation
50	Hirabayashi et al^Citation42	M/36	Asymptomatic	Tail	13.4	Multilocular	+	NI	NI	NI	DP
51	Matsumoto et al^Citation43	F/40	Asymptomatic	Tail	1.5	Multilocular	Normal	A multilocular cystic lesion, solid periphery, with the same enhancement as the spleen	High T1- and T2-weighted images	ECIPAS	No
52	Our patient	M/32	Asymptomatic	Tail	3.5	Multilocular	Normal	A well-defined cystic neoplasm without enhancing mural nodes	NI	MCN	Laparoscopic SPDP

Note: +, higher than normal.

Abbreviations: CA19-9, carbohydrate antigen 19-9; CT, computed tomography; DP, distal pancreatectomy; DWI, diffusion weighted image; ECIPAS, epidermoid cyst in an intrapancreatic accessory spleen; F, female; IPMN, intraductal papillary mucinous neoplasm; M, male; MCN, mucinous cystic neoplasm; MRI, magnetic resonance imaging; NET, neuroendocrine tumor; NI, no information; PNET, pancreatic neuroendocrine tumor; SPDP, spleen preserving distal pancreatectomy; SPT, solid pseudopapillary tumor; hyper, hyperintensity; hypo, hypointensity.

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