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Intrapancreatic Splenule in a Pancreas Allograft: Case Report
Intrapancreatic Splenule in a Pancreas Allograft: Case Report K. Yadav*, O.K. Serrano, and R. Kandaswamy Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
ABSTRACT A 16-year-old white man was involved in a motor vehicle collision and suffered head, chest, and abdominal trauma. Despite initial resuscitative efforts, he progressed to brain death and was designated to be an organ donor by his family. He had no earlier medical or surgical history and no high-risk behaviors. Blood work revealed normal creatinine, liver function tests, lipase, and amylase. Viral serologies were negative except for cytomegalovirus IgG and Epstein-Barr virus nucleic acid. Imaging revealed a right kidney contusion, a manubrial fracture, and fractures of right first rib and bilateral scapulae. No other abdominal trauma was identified, specifically to the pancreas, duodenum, or spleen. Our transplant center accepted the pancreas from this donor. During back-table inspection of the pancreas, a 1.5 1.5 cm dark purple rubbery mass was identified within the parenchyma of the pancreas in the tail. An incisional biopsy of the lesion was sent for frozen section, which yielded a mixed inflammatory infiltrate consisting of neutrophils and lymphocytes and an overlying fibrous capsule. The diagnosis of lymphoma or another neoplasm could not be definitely ruled out. Owing to uncertainty in diagnosis, the entire lesion was excised along with the distal pancreas with the use of a linear stapler. The staple line was oversewn with running 4-0 polypropylene suture, and the pancreas was transplanted. After surgery, the pancreas allograft functioned well with a small pancreatic leak, which had resolved by the first postoperative outpatient visit.
D
ESPITE careful pre-transplantation evaluation of donors, abnormal lesions are found during surgery, which can be a problem for successful transplant of organs. Pancreatic lesions can be especially difficult to diagnose and pose a challenge to transplant surgeons. Owing to dire consequences of transplanting an organ with cancer, such organs are usually not transplanted. CASE REPORT A 16-year-old white man was involved in a motor vehicle collision and suffered head, chest, and abdominal trauma. Despite initial resuscitative efforts, he progressed to brain death and was designated to be an organ donor by his family. He had no earlier medical or surgical history and no high-risk behaviors. His blood work after the initial resuscitation was: hemoglobin, 7.8 g/dL; creatinine, 0.7 mg/dL; amylase, 160 U/L; lipase, 4 U/L; alanine transaminase, 46 U/L; aspartate transaminase, 41 U/L. His viral serologies were negative except for cytomegalovirus IgG and Epstein-Barr virus nucleic acid. As part of his trauma work-up, he had a chest/abdomen/pelvis computerized tomographic (CT) scan, which revealed a right 0041-1345/16 http://dx.doi.org/10.1016/j.transproceed.2016.09.003
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kidney contusion with a surrounding perinephric hematoma, a nondisplaced fracture of the posterior cortex of the manubrium with a mild retromanubrial superior mediastinal hematoma, and fractures of the right first rib and bilateral scapulae. No other abdominal trauma was identified, specifically to the pancreas, duodenum, or spleen. Our transplant center accepted the pancreas from this donor as an import. During back-table inspection of the pancreas, a 1.5 1.5 cm mass was identified within the parenchyma of the pancreas in the tail (Fig 1). The mass had a dark blue-purple hue to it and it was rubbery in consistency and well incorporated into the pancreatic parenchyma. An incisional biopsy of the lesion was sent for frozen section, which was reported as a mixed inflammatory infiltrate consisting of neutrophils and lymphocytes with an overlying fibrous capsule. The diagnosis of lymphoma or another neoplastic process could not be definitely ruled out. Owing to uncertainty in diagnosis, the decision was made to excise the entire lesion along
*Address correspondence to Kunal Yadav, University of Minnesota, 420 Delaware Street, MMC 195, Minneapolis, MN 55455. E-mail: [email protected] Published by Elsevier Inc. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 48, 3214e3216 (2016)
INTRAPANCREATIC SPLENULE IN A PANCREAS ALLOGRAFT
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Fig 1. Pancreatic tail mass in donor pancreas allograft (A). Distal pancreatectomy specimen demonstrating an intrapancreatic splenule (B). with the distal pancreas with the use of an Ethicon Echelon Endopath linear stapler (Somerville, NJ) for complete evaluation of the lesion. The staple line was oversewn with the use of running 4-0 polypropylene suture. The pancreas was then transplanted as a pancreas transplant alone (PTA) in a recipient with type 1 diabetes mellitus with hypoglycemic unawareness and diabetic neuropathy but normal kidney function. The pancreas was enteric drained. The recipient had normal postoperative pancreas allograft function (no insulin requirement after surgery) with a small postoperative pancreatic leak (presumably from the cut surface),
which healed after 3 weeks of octreotide and low-fat diet. She is now off octreotide and on a regular diet with no evidence of pancreatic leak. The pathology results are shown in Fig 2.
DISCUSSION
An undetected pancreatic mass in the pre-transplantation setting presents a challenge to the transplant surgeon. It is difficult to make a diagnosis without a biopsy. The
Fig 2. Hematoxylin and eosin stain of the pancreatic mass. (A). 40 resolution demonstrate spleen-like tissue (S) surrounded by pancreatic parenchyma (P). Islets of Langerhans (arrow) can be identified. (B). 100 resolution demonstrates splenic tissue consists of red pulp and white pulp (*) within a meshwork of reticular fibers enclosed by a dense connective capsule.
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differential diagnosis includes cystic neoplasms, pancreatic endocrine tumors, intraductal papillary mucinous neoplasm, adenocarcinoma, metastasis, and intrapancreatic accessory spleen (IPAS). IPAS is rare. The most common location for splenules is in the splenic hilum (80%) [1]. Splenules are distinct from native spleen and have their own separate blood supply. The pancreas is the 2nd most frequent location (16.8%) of accessory spleens, but most of them are located outside of the pancreatic parenchyma. It is rare to have a splenule inside the pancreatic parenchyma. The diagnosis of IPAS may be suggested on cross-sectional imaging (CT/MRI), with an enhancement pattern similar to the native spleen. But other lesions can have a similar enhancement pattern, which makes the diagnosis difficult. Other tests have been suggested when the CT/ magnetic resonance imaging results are equivocal, such as Tc99 sulfur colloid scan, Tc99 radiolabeled heat-damaged red blood cell scan, and In111-labeled autologous platelet scan [2]. Despite all these imaging modalities, which may
YADAV, SERRANO, AND KANDASWAMY
be impractical in the pre-transplantation setting, the definitive diagnosis can be made only with excision of the lesion. Herein, we present a case of an unusual location of an IPAS, which was excised by means of a distal pancreatectomy as part of the pre-transplantation work up of an incidental pancreatic tail mass. The postoperative course was complicated with a small pancreatic leak, but that healed after a few weeks and the recipient achieved insulin independence. Therefore, we conclude that in certain cases, pancreas allografts with lesions can be used for transplantation with good results. REFERENCES [1] Tozbikian G, Bloomston M, Stevens R, Ellison EC, Frankel WL. Accessory spleen presenting as a mass in the tail of the pancreas. Ann Diagn Pathol 2007;11:277e81. [2] Läuffer JM, Baer HU, Maurer CA, Wagner M, Zimmermann A, Büchler MW. Intrapancreatic accessory spleen. A rare cause of a pancreatic mass. Int J Pancreatol 1999;25:65e8.
ABSTRACT A 16-year-old white man was involved in a motor vehicle collision and suffered head, chest, and abdominal trauma. Despite initial resuscitative efforts, he progressed to brain death and was designated to be an organ donor by his family. He had no earlier medical or surgical history and no high-risk behaviors. Blood work revealed normal creatinine, liver function tests, lipase, and amylase. Viral serologies were negative except for cytomegalovirus IgG and Epstein-Barr virus nucleic acid. Imaging revealed a right kidney contusion, a manubrial fracture, and fractures of right first rib and bilateral scapulae. No other abdominal trauma was identified, specifically to the pancreas, duodenum, or spleen. Our transplant center accepted the pancreas from this donor. During back-table inspection of the pancreas, a 1.5 1.5 cm dark purple rubbery mass was identified within the parenchyma of the pancreas in the tail. An incisional biopsy of the lesion was sent for frozen section, which yielded a mixed inflammatory infiltrate consisting of neutrophils and lymphocytes and an overlying fibrous capsule. The diagnosis of lymphoma or another neoplasm could not be definitely ruled out. Owing to uncertainty in diagnosis, the entire lesion was excised along with the distal pancreas with the use of a linear stapler. The staple line was oversewn with running 4-0 polypropylene suture, and the pancreas was transplanted. After surgery, the pancreas allograft functioned well with a small pancreatic leak, which had resolved by the first postoperative outpatient visit.
D
ESPITE careful pre-transplantation evaluation of donors, abnormal lesions are found during surgery, which can be a problem for successful transplant of organs. Pancreatic lesions can be especially difficult to diagnose and pose a challenge to transplant surgeons. Owing to dire consequences of transplanting an organ with cancer, such organs are usually not transplanted. CASE REPORT A 16-year-old white man was involved in a motor vehicle collision and suffered head, chest, and abdominal trauma. Despite initial resuscitative efforts, he progressed to brain death and was designated to be an organ donor by his family. He had no earlier medical or surgical history and no high-risk behaviors. His blood work after the initial resuscitation was: hemoglobin, 7.8 g/dL; creatinine, 0.7 mg/dL; amylase, 160 U/L; lipase, 4 U/L; alanine transaminase, 46 U/L; aspartate transaminase, 41 U/L. His viral serologies were negative except for cytomegalovirus IgG and Epstein-Barr virus nucleic acid. As part of his trauma work-up, he had a chest/abdomen/pelvis computerized tomographic (CT) scan, which revealed a right 0041-1345/16 http://dx.doi.org/10.1016/j.transproceed.2016.09.003
3214
kidney contusion with a surrounding perinephric hematoma, a nondisplaced fracture of the posterior cortex of the manubrium with a mild retromanubrial superior mediastinal hematoma, and fractures of the right first rib and bilateral scapulae. No other abdominal trauma was identified, specifically to the pancreas, duodenum, or spleen. Our transplant center accepted the pancreas from this donor as an import. During back-table inspection of the pancreas, a 1.5 1.5 cm mass was identified within the parenchyma of the pancreas in the tail (Fig 1). The mass had a dark blue-purple hue to it and it was rubbery in consistency and well incorporated into the pancreatic parenchyma. An incisional biopsy of the lesion was sent for frozen section, which was reported as a mixed inflammatory infiltrate consisting of neutrophils and lymphocytes with an overlying fibrous capsule. The diagnosis of lymphoma or another neoplastic process could not be definitely ruled out. Owing to uncertainty in diagnosis, the decision was made to excise the entire lesion along
*Address correspondence to Kunal Yadav, University of Minnesota, 420 Delaware Street, MMC 195, Minneapolis, MN 55455. E-mail: [email protected] Published by Elsevier Inc. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 48, 3214e3216 (2016)
INTRAPANCREATIC SPLENULE IN A PANCREAS ALLOGRAFT
3215
Fig 1. Pancreatic tail mass in donor pancreas allograft (A). Distal pancreatectomy specimen demonstrating an intrapancreatic splenule (B). with the distal pancreas with the use of an Ethicon Echelon Endopath linear stapler (Somerville, NJ) for complete evaluation of the lesion. The staple line was oversewn with the use of running 4-0 polypropylene suture. The pancreas was then transplanted as a pancreas transplant alone (PTA) in a recipient with type 1 diabetes mellitus with hypoglycemic unawareness and diabetic neuropathy but normal kidney function. The pancreas was enteric drained. The recipient had normal postoperative pancreas allograft function (no insulin requirement after surgery) with a small postoperative pancreatic leak (presumably from the cut surface),
which healed after 3 weeks of octreotide and low-fat diet. She is now off octreotide and on a regular diet with no evidence of pancreatic leak. The pathology results are shown in Fig 2.
DISCUSSION
An undetected pancreatic mass in the pre-transplantation setting presents a challenge to the transplant surgeon. It is difficult to make a diagnosis without a biopsy. The
Fig 2. Hematoxylin and eosin stain of the pancreatic mass. (A). 40 resolution demonstrate spleen-like tissue (S) surrounded by pancreatic parenchyma (P). Islets of Langerhans (arrow) can be identified. (B). 100 resolution demonstrates splenic tissue consists of red pulp and white pulp (*) within a meshwork of reticular fibers enclosed by a dense connective capsule.
3216
differential diagnosis includes cystic neoplasms, pancreatic endocrine tumors, intraductal papillary mucinous neoplasm, adenocarcinoma, metastasis, and intrapancreatic accessory spleen (IPAS). IPAS is rare. The most common location for splenules is in the splenic hilum (80%) [1]. Splenules are distinct from native spleen and have their own separate blood supply. The pancreas is the 2nd most frequent location (16.8%) of accessory spleens, but most of them are located outside of the pancreatic parenchyma. It is rare to have a splenule inside the pancreatic parenchyma. The diagnosis of IPAS may be suggested on cross-sectional imaging (CT/MRI), with an enhancement pattern similar to the native spleen. But other lesions can have a similar enhancement pattern, which makes the diagnosis difficult. Other tests have been suggested when the CT/ magnetic resonance imaging results are equivocal, such as Tc99 sulfur colloid scan, Tc99 radiolabeled heat-damaged red blood cell scan, and In111-labeled autologous platelet scan [2]. Despite all these imaging modalities, which may
YADAV, SERRANO, AND KANDASWAMY
be impractical in the pre-transplantation setting, the definitive diagnosis can be made only with excision of the lesion. Herein, we present a case of an unusual location of an IPAS, which was excised by means of a distal pancreatectomy as part of the pre-transplantation work up of an incidental pancreatic tail mass. The postoperative course was complicated with a small pancreatic leak, but that healed after a few weeks and the recipient achieved insulin independence. Therefore, we conclude that in certain cases, pancreas allografts with lesions can be used for transplantation with good results. REFERENCES [1] Tozbikian G, Bloomston M, Stevens R, Ellison EC, Frankel WL. Accessory spleen presenting as a mass in the tail of the pancreas. Ann Diagn Pathol 2007;11:277e81. [2] Läuffer JM, Baer HU, Maurer CA, Wagner M, Zimmermann A, Büchler MW. Intrapancreatic accessory spleen. A rare cause of a pancreatic mass. Int J Pancreatol 1999;25:65e8.