An Epithelial Splenic Cyst in an Intrapancreatic

Zhuo Zhang, Jian Cheng Wang
Department of Surgery, Rui Jin Hospital Medical College Jiao Tong University.
Shanghai, PR China
ABSTRACT
Context Generally, ectopic splenic tissue such as an accessory spleen is reported to have an incidence of 10% in the general
population. However, an intrapancreatic accessory spleen has seldom been reported and cyst formation of the intrapancreatic
accessory spleen is extremely rare. Case report A 26-year-old female patient with no clinical manifestations presented with a cyst in
the tail of the pancreas which had been diagnosed by ultrasonography. A spleen-preserving distal pancreatectomy was performed
with the presumptive diagnosis of a mucinous cystic tumor originating from the pancreas. The intraoperative frozen section showed
the possibility of serous cystadenoma of the pancreas. The pathological examination revealed the cyst to be stratified squamous
epithelium and was surrounded by splenic tissue and the final diagnosis was epithelial splenic cyst in an intrapancreatic accessory
spleen. Conclusion Although great progress has been made with modern imaging techniques, it is still difficult to make a definitive
diagnosis of cystic lesions in the pancreas.
INTRODUCTION
An accessory spleen has an incidence of 10% in the
general population and 16-20% of accessory spleens
are reported to be attached to the tail of the pancreas.
The incidence of accessory spleens in the pancreas is
rare and cystic formation, which has often been
misdiagnosed as a mucinous cystic tumor originating
from the pancreas, has seldom been reported. We
herein report the case of an epithelial cyst in an
intrapancreatic accessory spleen.
CASE REPORT
A 26-year-old female patient with a cystic lesion in the
tail of the pancreas was admitted for further evaluation.
Clinically, the patient had no symptoms, such as
epigastric discomfort, nausea, and dyspepsia or weight
loss. She had no history of acute pancreatitis or
abdominal trauma. Physical examination did not show
any pathological findings. Bilirubin levels and
transaminases were within the normal range. Serum
amylase, CA 1-99 and CEA were found to be normal in
serum analysis.
Ultrasonography imaging demonstrated a cystic lesion
in the tail of pancreas adjacent to the spleen. Contrast-
enhanced CT scans revealed a cystic lesion without a
septum (diameter 2.5 cm) in the tail of the pancreas
(Figure 1); contrast-enhanced imaging of the cystic
wall revealed a density similar to that of the pancreas.
Endoscopic ultrasonography (EUS) imaging showed
the same findings as the CT scans and ultrasonography.
EUS-guided FNA revealed some monostratum cubical
epithelium and the CEA of the aspirated fluid was
within the normal serum level.
The patient underwent a spleen-preserving distal
pancreatectomy with a presumptive diagnosis of
primary mucinous cystic tumor of the pancreas. During
the operation, a lesion with a diameter of 2.5cm was
found in the tail of the pancreas, closely attached to the
spleen and was completely resected (Figure 2). Clear
fluid was found in the cyst and an intraoperative frozen
section suggested a diagnosis of serous cystadenoma of
the pancreas. After the operation, the specimen was
sent for histopathological examination. Macroscopical-
ly, the lesion had clear borders with the surrounding
pancreatic tissue and a unilocular cyst measuring
2.5x2.5 cm was found in its center. Microscopically,
the inner surface of the cyst was lined with stratified
squamous epithelium without sebaceous or sweat
glands. Normal splenic tissue including splenic red
pulp, splenic white pulp and trabecula of the spleen
was found in the layer of the cystic wall. The exterior
of the cyst was composed of fibrous connective tissue
and some tubular elements. Final diagnosis of the
Received May 29th, 2009 - Accepted July 20th, 2009
Key words Epidermal Cyst; Pancreas; Spleen
Correspondence Jian Cheng Wang
Department of Surgery, Rui Jin Hospital, Medical College Jiao
Tong University, 197 Rui Jin 2 Road, 200025 Shanghai, P.R. China
Phone: +86-21.6437.0045/666.048; Fax: +86-21.5466.1128
E-mail: jiancheng_wang@hotmail.com
Document URL http://www.joplink.net/prev/200911/03.html

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665
lesion was an epithelial splenic cyst in an intra-
pancreatic accessory spleen (Figure 3).
DISCUSSION
Seventy-five percent of splenic cysts are post-traumatic
pseudocysts; other cysts of the spleen can be classified
into parasitic and non-parasitic cysts [1, 2]. Cyst
formation of an accessory spleen in the tail of the
pancreas is extremely rare and only few cases have
been reported. Clinically, most patients with this
disease have no clinical symptoms or signs and it is
often detected incidentally by imaging studies. Serum
tumor markers, such as CEA, CA 19-9 and CA 125,
have no role in diagnosing this disease [3, 4, 5]. A
hypervascular blush of the wall of the cyst, which has
the same density on enhanced CT as that of the spleen,
was said to be of help in diagnosing this abnormality
but not in all cases [6] as was demonstrated in our case.
Histologically, epithelial cysts are lined with stratified
squamous epithelium with no skin appendages, such as
sebaceous and sweat glands [2].
Until now, there have been no reports of malignancy of
epithelial splenic cysts of an intrapancreatic accessory
spleen. The patient can be followed up without any
further treatment if the cyst is small and has no
symptoms or signs. Since an epithelial splenic cyst in
the pancreas lacks particular characteristics on
radiological examination, it is especially difficult to
differentiate it from a pancreatic mucinous cystic
lesion. EUS and FNA, together with measurement of
CEA levels would provide diagnostic assistance since
elevated CEA leads to a mucinous cyst while normal
CEA does not. Most cases lacked a proper preoperative
Figure 1. Abdominal computed tomography. A cystic lesion in the
tail of the pancreas. No septum was found in the cyst and the lesion
measured about 2.5 cm.
Figure2. The cyst was found in the tail of the pancreas and
completely resected with normal pancreatic tissue around it. The
spleen was preserved. A: splenic artery; c: cyst; p: pancreas.
Figure 3. Pathological findings of the cyst (H&E). The cyst
contained homogeneous eosinophilic fluid (F) and was lined with
stratified squamous epithelium (E). Accessory spleen tissue (S) was
found under the epithelium and surrounded by a complete fibrous
capsule (FC). L: lumen of the cyst.

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JOP. J Pancreas (Online) 2009 Nov 5; 10(6):664-666.
JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 10, No. 6 - November 2009. [ISSN 1590-8577]
666
diagnosis and therefore the suspicion of a mucinous
cyst tumor mandated surgery [7, 8]. Finally, epithelial
splenic cysts should be considered in the differential
diagnosis of a cystic lesion in the tail of the pancreas,
and en-bloc resection of the cyst including normal
pancreatic tissue should be performed with
preservation of the spleen when possible.
Conflict of interest The authors have no potential
conflicts of interest
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