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Plexiform neurofibroma mimicking a pancreatic cystic tumour
  1. A Handra-Luca1,
  2. D Vidaud2,
  3. M-P Vullierme3,
  4. N Colnot4,
  5. D Henin5,
  6. P Ruszniewski6,
  7. P Bedossa7,
  8. A Couvelard7
  1. 1Department of Pathology, Jean Verdier and Beaujon Hospitals, Assistance Publique-Hôpitaux de Paris, France
  2. 2Department of Biochemistry, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, France
  3. 3Department of Radiology, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, France
  4. 4Department of Pathology, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, France
  5. 5Department of Pathology, Bichat-Claude Bernard Hospital, Assistance Publique-Hôpitaux Paris, France
  6. 6Department of Gastroenterology, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, France
  7. 7Department of Pathology, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, France
  1. Correspondence to:
    Dr A Handra-Luca
    MD PhD, Service d’Anatomie Pathologique, Assistance Publique-Hopitaux Paris, Hôpital Jean Verdier, Avenue du 14 Juillet, 93143 Bondy, France; adriana.handra-lucajvr.ap-hop-paris.fr

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Pancreatic neurogenic tumours are extremely rare.1–3 Among benign neurogenic tumours, schwannoma is more frequently encountered.2,3 We report here the case of a plexiform neurofibroma, a type of neurogenic tumour in the pancreas, to our knowledge previously unreported.

History

A 44 year old Caucasian female patient was hospitalised for epigastric and right abdominal pain lasting for seven months. Abdominal ultrasound and computed tomography showed a cystic lesion located in the superior and anterior part of the pancreatic isthmus, with a maximal diameter of 3.5 cm (fig 1A, B). T2 magnetic resonance imaging demonstrated a trilobar cystic lesion with strong hyperintensity (fig 1B); no communication with the main pancreatic duct was noted at magnetic resonance cholangiopancreatography (fig 1C). Endoscopic ultrasound (EUS) showed a cystic lesion containing heterogeneous fluid (fig 1D). EUS guided fine needle aspiration provided mucoid fluid with no epithelial cells. Fluid pancreatic enzyme concentrations were 423 and 1204 U/l for amylase and lipase, respectively, while CEA, CA 19.9, and CA 72.4 were 17 ng/ml, 9 U/ml, and 140 U/ml, respectively. Despite the low CA 19.9 concentration and lack of mucinous cells in cystic fluid, other findings were consistent with a diagnosis of mucinous cystadenoma. Surgical exploration confirmed a cystic lesion of the superior part of the pancreatic isthmus, distant from the main pancreatic duct (fig 1A, B). Tumour enucleation was performed. On macroscopy there was a well delineated, trilobated, translucent mass, measuring 3.5 cm (fig 1E). The tumour consisted of aggregates of benign spindle cells embedded in a fibrillar matrix (fig 1F). These aggregates formed a thin rim around a large central low cellular zone of oedema and myxoid degeneration. The tumour cells expressed neurofilaments and S100 protein on immunohistochemistry. P53 immunostaining was negative and sparse nuclei were Ki67 positive. These features were consistent with a benign plexiform neurofibroma (PNF). No neurofibromatosis related lesions were found and no mutation of the NF1 (neurofibromatosis 1) gene was identified on analysis of DNA both from blood lymphocytes and tumour tissue. At follow up, two years after surgical resection, the patient did not present with any complaints and there was no evidence of pancreatic lesions.

Figure 1

 (A) Enhanced computed tomography. Hypoattenuating round lesion located in the anterior part of the pancreatic isthmus (arrow). (B) The caudal part of the main lesion is encased in the isthmus of the pancreas (white arrow). The pancreatic parenchyma is normal upstream (black arrow). The main portal vein is normal, distant from the lesion (arrowhead). (C) T2 magnetic resonance imaging. The lesion is strongly hyperintense as cysts; another similar lesion was seen on the right side (arrows). (D) Magnetic resonance cholangiopancreatography with thick slice. The two lesions are well visible, with a third one indicated (arrows). The main pancreatic duct is normal (arrowhead) with no obvious communication with the lesions. (E) Endoscopic ultrasound. Anechoic cystic lesion without defined cyst wall or mural nodule (arrow). (F) Surgical specimen consisted of a bilobated, firm, translucent, well delineated mass. (G) On microscopy, at low magnification, the lesion was heterogeneous with a solid cellular part (arrows) and a central oedematous acellular zone (*), giving the pseudocystic aspect of the lesion (haematoxylin and eosin stain, magnification ×10). (H) At high magnification, the solid part of the lesion was composed of a regular spindle cell proliferation. Intratumoral vessels showed a thin fine wall (arrow) (magnification ×40).

Discussion

The presence of PNF in the pancreas has several clinical implications, as indicated by the present case. Firstly, PNF may mimic a pancreatic cyst, as was hypothesised in this case before surgery. The cystic appearance of neurogenic tumours is frequently encountered, with intratumoral oedematous and myxoid changes probably being the underlying lesions.4 A bright appearance on T2 weighted magnetic resonance images is a characteristic of PNF.5 Secondly, surgical resection was necessary to exclude malignancy which is more frequently encountered in PNF compared with classical neurofibromas.2 In addition to classical benign features, similar to published data on benign PNF,6,7 a high cell proliferation and p53 protein expression were absent in our case. Thirdly, PNF is a morphological variant of neurofibroma, generally considered pathognomic for an NF1 syndrome.8 When diagnosed in adult patients, it is frequently a solitary tumour and is considered a mosaic located form of NF1 syndrome.9 The absence of detectable genetic abnormalities and other clinical NF1 syndrome associated lesions in the present case could be explained by such a mechanism.9 For these patients, there is a low risk of developing other diseases associated with NF1 syndrome.

In conclusion, we have reported an uncommon case of PNF, unique in its pancreatic location. Intratumoral myxoid and oedematous changes that develop in this type of neurofibroma give a cystic appearance which may lead to a misdiagnosis of a pancreatic cyst. Such lesions should be added to the list of benign pancreatic tumours with a cystic appearance.

References

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Footnotes

  • Conflict of interest: None declared.

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