Virginia Research Day 2021

Fight Like A Girl: A Perplexing Pancreatic Position Reginald S. Pinder II DO 1,2 , Mark Rogers DO 1,2 ,Charles Bissell MD 3 , Anne Bryan ATC 2 Edward Via College of Osteopathic Medicine, Blacksburg, VA 1 Virginia Tech Sports Medicine, Blacksburg, VA 2 Carilion Clinic, Roanoke, VA 3

Introduction

Physical Examination

Discussion

Solid pseudopapillary neoplasms are rare and comprise about 1% of all forms of pancreatic cancer (1). These tumors are predominately found in young Asian and African American females with 22 years old being the mean age of diagnosis (1). Overall, they carry a better prognosis than the usual pancreatic adenocarcinoma, but malignancy has been found in 15% of cases (2). Prompt surgical resection is the mainstay treatment and is correlated with a 97% 5-year survival rate (3).

Lower abdominal pain in a young, otherwise healthy student athlete is generally a benign process. However, when the case does not present or resolve in an expected manner, the astute clinician should maintain a broad differential and proceed with additional diagnostic modalities to further evaluate the presenting complaint. A 19 year-old female college lacrosse player presents with complaint of sudden onset right lower quadrant (RLQ) abdominal pain. She described the pain as sharp and intermittent in nature without radiation. A complete blood count, urinalysis, and pregnancy test were obtained all of which were within normal limits. Unfortunately, her pain continued to wax and wane leading her to return for second evaluation two days later. On further questioning she was able to tolerate PO intake, there was no change in stooling habits, and she noted taking oral contraceptive pills for irregular menses, though denies sexual activity. Case Description

Vitals were within normal limits and her cardiopulmonary exam was unremarkable. The abdomen was soft, but with minimal tenderness in the RLQ overlying the right ovary. Special testing for inflammation of the appendix was negative and there was no rebound tenderness or guarding.

Differential Diagnoses

1. Ovarian Cyst/ Torsion/ Abscess 2. Inguinal hernia 3. Appendicitis 4. Nephrolithiasis 5. Referred pain from unknown origin

Diagnostics

Additional workup included a CT abdomen-pelvis which showed an 8x7x6cm heterogeneous mass arising in exophytic fashion from the greater curvature of the stomach with mass effect involving the splenic vasculature and pancreatic tail. Supplementary labs including a complete metabolic panel, lipase, Alpha Fetoprotein (AFP), Carcinoembryonic Antigen (CEA), CA 19-9, and CA-125 were all negative. General surgery was consulted to perform a core needle biopsy which demonstrated a grade 1 well-differentiated neuroendocrine carcinoma. A subsequent PET-scan did not reveal other areas of involvement. Approximately 2 months after initial presentation, she underwent surgical resection of the mass where her spleen and pancreatic tail were also removed due to tumor involvement. A second biopsy was performed and was consistent with a solid pseudopapillary neoplasm, a rare form of pancreatic cancer.

Outcome

This student athlete’s history, physical exam, and clinical course did not correlate with expected etiologies and therefore a broad differential was maintained. Fortunately, this athlete is recovering well and plans to return to competition. She will undergo regular surveillance with a CT chest and abdomen-pelvis every 3 months for at least 1 year with oncologic follow-up. 1. Reddy, Sushanth et al. “Surgical management of solid -pseudopapillary neoplasms of the pancreas (Franz or Hamoudi tumors): a large single- institutional series.” Journal of the American College of Surgeons vol. 208,5 (2009): 950-7; discussion 957-9. doi:10.1016/j.jamcollsurg.2009.01.044 2. Vareedayah , Ashley A et al. “Pancreatic Adenocarcinoma.” Missouri medicine vol. 115,3 (2018): 230-235. 3. Law, Joanna K et al. “A systematic review of solid -pseudopapillary neoplasms: are these rare lesions?.” Pancreas vol. 43,3 (2014): 331-7. doi:10.1097/MPA.0000000000000061 References

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