PMC3135210_01
Imaging studies and intraoperative appearance. (a) A contrast-enhanced computed tomography slice of the upper abdomen, showing a mildly hyperintense nodule, about 1 cm in diameter, located between the body and the tail of the pancreas (red arrow). (b) A gadolinium-enhanced magnetic resonance slice of the upper abdomen, showing a mildly hyperintense nodule, about 1 cm in diameter between the body and the tail of the pancreas (red arrow), in the same location as identified by CT. (c) A digital subtraction angiography with the catheter positioned in the proximal splenic artery, showing nodular vascularization from the arteria pancreatica magna (red arrow). (d) Isolation and enucleation of the adenoma using the CUGA Excel system. (e) Macroscopic appearance of the adenoma soon after resection (scale bar in cm).
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fig1
Given that MIR sometimes failed to exactly locate the pancreatic adenomas, this finding was confirmed by a CT scan, which also revealed the presence of multiple accessory spleens located within the spleen ilum and near the pancreatic tail (Figures 1(a) and 1(b)). Enucleation was performed with care to spare the surrounding pancreatic tissue, using the CUSA EXcel (Tyco) ultrasonic surgical aspiration system (Figures 1(d) and 1(e)).
Histopathological analysis of the surgical specimen. (a) Hematoxylin and eosin staining (low magnification) showing gross appearance of the tissue and presence of a pseudocapsule with variable thickness. (b) Hematoxylin and eosin staining (200x) showing monomorphic cells with abundant granular cytoplasm and central nuclei, in contact with capillary basement membranes, stained with Period-Acid Schiff (PAS) reaction (c, 200x). (d) Capillaries are stained with anti-CD34 (200x). The strong chromogranin (e) and Synaptophysin (f) immunoreactivity indicates a neuroendocrine origin, while the few areas staining for cytokeratin-7 (g) are residual exocrine tissue (100x). A visual comparison between insulin (h) and proinsulin (i) staining (200x) suggests a stronger proinsulin immunoreactivity.
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fig2
Insulin staining was weak and inhomogeneous among cells, while proinsulin staining was stronger and more homogenous (Figure 2).