A Rare Hypervascular Mass in the Uncinate Process of the Pancreas

Question: A 56-year-old woman suffered frequent urination, increased thirst, and increased hunger for 3 months before visiting the local hospital. Fatigue blood glucose was 16.97 mmol/L and diabetes mellitus was diagnosed. Insulin and oral glucophage were prescribed to control the blood glucose levels. Abdominal color Doppler ultrasound examination incidentally found there was an approximately 2-cm hyperechoic mass in the uncinate process of the pancreas. She was transferred to pancreatic center of our hospital for further evaluation and treatment. In 1986, she underwent open left adrenalectomy for aldosterone adenoma and the after operation, her blood pressure became normal. She denied any history of smoking or alcohol use. She had no familial history of pancreatic disorders or any other diseases. On presentation, physical examination revealed no abnormalities. Laboratory data indicated an elevated fasting blood glucose of 6.4 mmol/L (normal, 3.9–6.1), elevated glycosylated hemoglobin at 7.2% (normal, 3.9%–6.3%), and normal amylase and lipase. Serum tumor markers were normal. A triphase intravenous enhanced abdominal computed tomography scan showed that there was a 14.5 × 25.1-mm elliptical solid mass in the uncinate process of pancreas and the mass was obviously enhanced in all of the 3 phases (Figure A–D, arrow). A laparotomy was performed under general anesthesia. It was found to be a 2.5 × 1.5-cm soft reddish mass without an obvious capsule in the uncinate process of pancreas. The mass was en bloc enucleated. The postoperative period was uneventful. She was discharged 10 days after surgery. What is the most likely diagnosis of this hypervascular mass in the uncinate process of the pancreas? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Pathologic examination showed there was only thyroid tissue with normal architecture and cytology with none of the nuclear features of thyroid cancer (Figure E). Ectopic thyroid tissue (ETT) is a very rare entity and the incidence is about 1 per 100,000 to 300,000. More than 90% of the ETTs are located at the bottom of the tongue, with the remaining 10% in the neck and superior mediastinum.1Noussios G. Anagnostis P. Goulis D.G. et al.Ectopic thyroid tissue: anatomical, clinical, and surgical implications of a rare entity.Eur J Endocrinol. 2011; 165: 375-382Crossref PubMed Scopus (199) Google Scholar ETTs in the abdomen have been seldom reported.2Casadei G.P. Bertarelli C. Giorgini E. et al.Ectopic thyroid tissue in the adrenal gland: report of a case.Int J Surg Pathol. 2015; 23: 170-175Crossref PubMed Scopus (15) Google Scholar ETTs located in the uncinate process of the pancreas have not been reported. Most of the reported abdominal ETTs were asymptomatic, and this ETT was also an incidental mass. Hypervascular masses in the pancreas are always referred to pancreatic endocrine tumors and occasionally pancreatic gastrointestinal stromal tumors, angioma, metastatic renal cancer, and thyroid cancer have been reported.3Mondal U. Henkes N. Henkes D. et al.Cavernous hemangioma of adult pancreas: A case report and literature review.World J Gastroenterol. 2015; 21: 9793-9802Crossref PubMed Scopus (13) Google Scholar It is always extremely difficult to give a definitive diagnosis for this kind of mass before surgery, especially when it is asymptomatic. Laparotomy is the first choice to curatively resect the mass and obtain a final diagnosis. For this case, pathologic examinations reported it was ETT with normal architecture without features of thyroid cancer. Thus, the final diagnosis was ETT in the uncinate process of the pancreas. This first reported interesting case of ETT in the uncinate process of the pancreas will undoubtedly add our knowledge and experience to diagnose and treat hypervascular masses in pancreas.