COX-2 expression in pseudomyxoma peritonei

COX-2 expression was studied using an immunohistochemical method in 75 patients with pseudomyxoma peritonei (PMP). Twenty-five patients presented with disseminated peritoneal adenomucinosis (DPAM) and 50 with peritoneal mucinous carcinomatosis (PMCA). COX-2 was expressed in neoplastic mucinous epithelium of 30 cases (40%): 20 in PMCA (40%), 10 in DPAM (40%). Weak COX-2 expression was also noted in four of five patients with appendiceal mucinous neoplasms without peritoneal dissemination. In addition, COX-2 was detected in stromal, endothelial, inflammatory cells and reactive mesothelium. This preliminary information indicates a potential for the use of COX-2 inhibitors in patients with PMP.

CD56 expression aids in the differential diagnosis of cholangiocarcinomas and benign cholangiocellular lesions

CD56 (neuronal cell adhesion molecule, N-CAM) has been reported in neuroendocrine tumours and as a marker of reactive biliary epithelial cells. However, up to date, it is not used to distinguish malignant from non-malignant biliary lesions. In this study, we systematically examined CD56 expression on 98 tumours arising from the biliary tree as well as intrahepatic conditions with reactive neoductules. When neuroendocrine carcinomas are excluded, only 4 of 32 (12.5%) cholangiocarcinomas expressed CD56, 2 of which showed clear cell morphology. Reactive bile ductules adjacent to cirrhotic nodules as well as in focal nodular hyperplasia were CD56 positive. Twelve of 17 (70.5%) bile duct adenomas were CD56 positive, whereas von Meyenburg complexes expressed CD56 only very focally in less than 5% of lesional cells. Bile duct cysts were negative for CD56 with the exception of focally interspersed neuroendocrine cells, similar to that seen in segmental bile ducts. Thus, if van Meyenburg complexes are excluded, CD56 can be used to differentiate intrahepatic non-neoplastic from neoplastic proliferations, which is a helpful diagnostic tool in small liver biopsies.

A case of torsion of a mucinous cystadenoma in triple-X syndrome with pure gonadal dysgenesis

Triple-X female characterized by primary amenorrhea and pure gonadal dysgenesis is extremely rare. We present a patient of triple-X syndrome who has not had menarche or the development of the secondary sexual characteristics. She had a hypoplastic uterus and streaked gonads on both sides with a twisted mucinous cystadenoma in the right adnexa.

Ovarian mucinous cystadenoma with extended calcification in an 11-year-old girl: case report and review of the literature

The majority of ovarian masses in childhood and adolescence are non-epithelial in origin, with a predominance of germ cell tumors, while epithelial neoplasms comprise a small proportion of the total (approximately 15-20%). Mucinous cystadenomas in particular are only sporadically reported in this age group. We present a case of an ovarian mucinous cystadenoma with extended calcification in a premenarchal 11-year-old girl. Pediatric mucinous cystadenomas of the ovary may on rare occasions display extended calcification. Careful evaluation of the remaining pathological features of the tumor is needed in order to avoid misinterpreting this relatively non-specific finding as a feature of malignancy.

Intussusception of the appendix by mucinous cystadenoma. Report of a case with an unusual clinical presentation

Appendiceal mucocele is a very rare clinical condition. Associated ascites and an ovarian mass could suggest synchronous ovarian cystadenocarcinoma with pseudomyxoma peritonei. We describe the case of a 36-year-old female with a mucinous cystadenoma of the appendix causing intussusception, diagnosed by CT but not by US scan, since the associated anomalous fixation of the caecum was misleading in defining the precise anatomical site. Although the CT findings were accurate, the synchronous presence of an ovarian cyst and ascites did not allow us to rule out preoperatively a concurrent cystadenocarcinoma of the ovary with pseudomyxoma peritonei. The appropriate surgical treatment was performed on the basis of intraoperative frozen section examination. Surgical treatment depends on the nature of the mucocele: retention forms are effectively treated by appendectomy, while neoplastic conditions require a more extended resection. Treatment of associated ovarian cystadenocarcinoma and pseudomyxoma peritonei includes right colectomy, bilateral ovariectomy and omentectomy. Although a precise preoperative diagnosis of mucocele associated with intussusception of the appendix has been reported as possible, concomitant ascites and ovarian masses, as in the present case, could mimic pseudomyxoma peritonei from concurrent ovarian cystadenocarcinoma. Intraoperative histopathology is required in order to perform the most appropriate treatment.

Voluminous mucinous cystadenoma of the ovary in a 13-year-old girl

BACKGROUND

Mucinous cystadenoma of the ovary constitutes about 15% of ovarian tumors. It is more common in women between 20 and 40, but is rare in teenagers and exceptional in pre-menstrual girls. Malignant transformation is possible in 5-10% of cases. Spontaneous or iatrogenic breaks are more common. It makes the different diagnosis of pseudomixoma peritonei more difficult.

CASE REPORT

A 13-year-old girl came to the National Cancer Institute "Regina Elena" of Rome, with increasing abdominal distension over 2 months. The abdominal mass was removed and a left salpingo-oophorectomy was performed. Histological examination of the mass revealed a 40-cm diameter mucinous cystadenoma of the ovary.

CONCLUSION

The rapid enlargement of the ovarian mass, the young age and the difficulty of certain pre-operative diagnosis, make this case interesting. Management of this pathology and fertility-conserving treatment need careful follow-up because of the possibility of recurrence in the remaining ovary.

[Intususception of appendical cystadenoma imitating a caecal tumor]

Appendical cystadenoma is one of the histological forms of the appendical mucocele. Preoperative diagnostics is difficult, however, due to potential iatrogennic rupture during a surgical procedure, is very important. The authors present a case review of a 62-year-old patient with itususception of the appendical cystadenoma, until now rarely reported in literature. Upon the preoperative diagnosis the appendical cystadenoma appeared as a caecal tumor or a tumor of the terminal ileum. A histological, intraoperative, diagnosis was established, followed by a final histological examination of the resected tissue. The authors discuss contemporary options of the preoperative diagnostic measures of the appendical tumors, stressing up all risks of aspiration cytology as well as risks of laparoscopic approach in this pathology management

The differentiation between pancreatic neoplastic cysts and pancreatic pseudocyst

The number of small and often asymptomatic cystic lesions detected in pancreas has increased during the last decade. Historically the vast majority of the pancreatic cystic lesions were considered pseudocysts, but in recent series the incidence of various neoplastic cysts, such as intraductal papillary mucinous neoplasm, serous cystadenomas and cystic endocrine tumours, has increased. The possible malignant potential in these cystic neoplasms warrants careful diagnostic workup to choose the optimal treatment for each patient. Patient's age, symptoms and a possible history of acute or chronic pancreatitis with known aetiology together with high quality imaging studies are important in the differential diagnosis between pseudocysts and neoplastic cysts. Endoscopic ultrasound, cyst fluid analysis and positron emission tomography may be used in selected patients, but the accuracy of these methods needs further investigation.

Mucinous cystic neoplasm in a young male patient

A 25-year-old Japanese man was admitted to our hospital with a history of recurrent pancreatitis and a pseudocyst of the pancreas. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) revealed an encapsulated multilocular cystic mass 5 cm in diameter in the pancreatic tail. Endoscopic ultrasonography demonstrated a mural nodule, and endoscopic retrograde pancreatography showed a communication of the lesion with the main pancreatic duct. A neoplastic cystic tumor was suspected, and a resection of the body tail of the pancreas was performed. The lesion was a multilocular cyst having a common fibrous capsule and viscous content. Histologically, the cystic lesion was lined with a single layer of columnar cells with low-grade atypia. Ovarian-type stroma (OS) was confirmed, and it showed positive for antiestrogen receptor and antiprogesteron receptor staining. Based on these findings, the lesion was diagnosed as mucinous cystic neoplasm (MCN), an adenoma that shows extraordinarily high prevalence in women. Further study on the pathogenesis of MCN in male patients should be undertaken to elucidate the process of development.

The role of pancreatic cyst fluid molecular analysis in predicting cyst pathology

BACKGROUND & AIMS

Current methods to detect malignancy in mucinous cystic neoplasms of the pancreas remain inadequate. The role of detailed molecular analysis in this context was investigated.

METHODS

Endoscopic ultrasound-guided pancreatic cyst aspirates were prospectively collected during a period of 19 months and studied for cytology, carcinoembryonic antigen level, and molecular analysis. Molecular evaluation incorporated DNA quantification (amount and quality), k-ras point mutation, and broad panel tumor suppressor linked microsatellite marker allelic loss analysis by using fluorescent capillary electrophoresis. The sequence of mutation acquisition was also calculated on the basis of a clonal expansion model, and comparison was made to the final pathology.

RESULTS

Thirty-six cysts with confirmed histology were analyzed. There were 11 malignant, 15 premalignant, and 10 benign cysts. Malignant cysts could be differentiated from premalignant cysts on the basis of fluid carcinoembryonic antigen level (P=.034), DNA quality (P=.009), number of mutations (P=.002), and on the sequence of mutations acquired (P<.001). Early k-ras mutation followed by allelic loss was the most predictive of a malignant cyst (sensitivity, 91%; specificity, 93%).

CONCLUSIONS

Malignant cyst fluid contains adequate DNA to allow mutational analysis. A first hit k-ras mutation followed by allelic loss is most predictive of the presence of malignancy in a pancreatic cyst. This approach should serve as an ancillary tool to the conventional work-up of pancreatic cysts. Cumulative amount and timing of detectable mutational damage can assist in diagnosis and clinical management.

Intratesticular mucinous cystadenoma: immunohistochemical comparison with ovarian and colonic tissue

We report a case of a primary intratesticular mucinous cystadenoma in an asymptomatic 39-year-old man. The mass was found incidentally during a consultation for infertility. Pathologic examination of the orchiectomy specimen revealed a unilocular cyst lined with bland mucinous epithelium and mucinous extravasation, consistent with a diagnosis of mucinous cystadenoma. Foci of bone were also found in association with extensive chronic inflammation. Immunohistochemical stains performed showed immunoreactivity for cytokeratin 7, and nonreactivity for cytokeratin 20, CA125, chromogranin, and synaptophysin. The immunohistochemical staining patterns of the present case are compared with those of known mucinous cystadenomas of the ovary and nonneoplastic colonic mucosa. The histogenesis of this entity is discussed in light of the literature and the immunohistochemical findings in this rare case.

Tumeur intracanalaire papillaire mucineuse du pancréas révélée par une pancréatite aiguë et un diabète

INTRODUCTION

Imaging of the pancreas soon after diagnosis of diabetes can help screen for tumors.

CASE

A 45 year-old man with recently diagnosed insulin-dependent diabetes and no other notable history was found to have intraductal papillary mucinous tumour of the pancreas (IPMTP), a month after an unexplained and benign acute pancreatitis.

DISCUSSION

The histology of IPMTP differs from that of the adenocarcinomas usually described in these circumstances, and they are far rarer. Because they carry the risk of malignant degeneration, early diagnosis is important. Surgery is the only curative treatment and should therefore be discussed.

Mucinous cystadenoma of the lung presenting as localised bronchiectasis

Mucinous cystadenoma is a very rare pulmonary neoplasm. Here we report the case of a 59 year old woman who presented with clinical features of localized bronchiectasis, who on detailed evaluation was found to have this rare tumour.

Ureteral endometriosis and ovarian mucinous cystadenoma presenting with acute pyonephrosis

BACKGROUND

Endometriosis is a common disease, but ureteral involvement is rare. Nonspecific clinical presentations of ureteral endometriosis may result in diagnostic difficulty.

AIM

To discuss the diagnosis and management of such a case.

METHODS

To report a case of ureteral involvement with endometriosis and review the literature.

RESULTS

The case presented with right lower quadrant pain giving rise to initial diagnostic possibility of acute appendicitis. Subsequent evaluation revealed the diagnosis of right pyonephrosis due to midureteral endometriosis with right ovarian mucinous cystadenoma.

CONCLUSION

The diagnosis of ureteral endometriosis requires a high index of clinical suspicion. The importance of ultrasound in the evaluation of acute abdomen in women can not be overemphasised.

Mucinous cystadenoma of the pancreas associated with acute pancreatitis and concurrent pancreatic pseudocyst

We report an unusual occurrence of a recurrent pancreatic pseudocyst caused by an underlying mucinous cystadenoma of the distal pancreas. A 54-year old female was admitted for acute pancreatitis. Her only risk factors included the use of hydrochlorothiazide and two or three glasses of wine daily. Abdominal computed tomography (CT) done a week after onset of her symptoms showed a 5-cm cystic lesion in the tail of the pancreas suspected to be a pseudocyst. Her symptoms subsequently resolved. One month later, she had another episode of pancreatitis and an abdominal CT showed an 11 x 16 cm pseudocyst along with the previously mentioned cystic lesion. Approximately 6 weeks after her initial presentation, she was taken to the operating room for an exploratory laparotomy and cyst gastrostomy for a symptomatic pseudocyst. An intraoperative frozen section of the cyst wall showed a fibrous wall with acute and chronic inflammation without an epithelial lining. Six weeks after her cyst gastrostomy, she returned with abdominal pain, early satiety, and anorexia. Abdominal CT showed reaccumulation of fluid within the pseudocyst and endoscopic retrograde cholangiopancreatography (ERCP) revealed a normal caliber pancreatic duct with an abrupt cutoff at the distal duct. She underwent exploratory laparotomy with drainage of 3 L of fluid from the pancreatic pseudocyst. After gaining access to the lesser sac, a 6-cm cystic lesion was identified in the tail of the pancreas. She underwent a distal pancreatectomy and splenectomy. The intraoperative and final pathology confirmed the presence of a benign mucinous cystadenoma. The patient had an uneventful recovery, began to tolerate oral intake, and was discharged 7 days after surgery. The differentiation between a pancreatic pseudocyst and benign cystic neoplasms of the pancreas is crucial to determine treatment options. Cystic neoplasms of the pancreas, whether mucinous or serous, have the potential to harbor malignancy, and resection is recommended.

Accuracy of preoperative imaging methods in a retrospective series of 14 patients with operated intraductal papillary mucinous tumors of the pancreas

Accuracy of preoperative imaging methods for the diagnosis of intraductal papillary mucinous tumor of the pancreas (IPMT) is not well known.

AIMS

To compare diagnostic accuracy of various preoperative imaging methods with pathology data following surgical resection.

PATIENTS AND METHODS

Fourteen consecutive patients underwent pancreatic surgical resection for IPMT between January 1988 and May 2002. Imaging methods included endoscopic retrograde cholangiopancreatography and/or magnetic resonance cholangiopancreatography and/or endoscopic ultrasonography. Results of preoperative morphological examinations were compared with histopathological findings from surgical specimens.

RESULTS

IPMT was located to the pancreatic head or body in 72% of patients and involved the main pancreatic duct (MPD) in 79% of cases Carcinoma was diagnosed in 35% of the cases. Sensitivity of imaging methods varied from 64 to 80% to accurately locate the tumor and from 73 to 80% in distinguishing between types involving the MPD or the accessory ducts. Planned surgical resection based on preoperative imagery correlated with final surgery in 57% of the patients. Histological study of whole pancreas specimens revealed lesions in undilated ducts, and also dilated ducts without histological lesions.

CONCLUSION

The sensitivity of preoperative imaging methods is moderate in defining intraductal extension of IPMT. Duct dilatation is not predictive of histological involvement by tumors and ducts may be pathological without dilatation.

[Diagnostic and therapeutic implications in two cases of pancreatic cystic tumours: mucinous and serous]

Cystic tumours of the pancreas include a pathologically heterogeneous and rare group of tumours, which however have many common clinical features. They represent about 10% of pancreatic cystic lesions and 1% of all forms of neoplasms, thus having a certain relevance in organ surgery. So far two distinct categories of cystic tumours have been identified, the basically benign serous form and the potentially malign mucinous form, which may sometimes show malignant features as early as the diagnostic stage. As neoplasms are very difficult to interpret before operation, it is essential that diagnosis is as accurate as possible in order to streamline surgery, which will have to be carried out after histological tests have been performed on an adequate number of tumour sections. Basing on these two cases of cystic tumours of the pancreas and on current literature, the Authors discuss the effectiveness of imaging techniques, such as contrast echography, dosage of specific tumour markers and histological tests backed up by immunohistochemistry in identifying these neoplasms, in order to study this rare but interesting pathology more accurately.

[Giant benign mucinous cystadenoma of both ovaries in early puerperium: case report and review of literature]

OBJECTIVE

A case report of giant bilateral benign cystadenoma after vaginal delivery.

DESIGN

Case report.

SETTINGS

Department of Obstetrics and Gynaecology, University Hospital Ostrava. SUBJECT OF STUDY: A 35-year-old woman twelve days after vaginal delivery was presented with symptoms of an acute abdomen. On ultrasonographic examination, the presence of a cyst filling the complete abdominal cavity. Bilateral cystic mass measuring 25 x 30 cm was removed by laparotomy. Subsequent histological examination revealed a benign mucinous cystadenoma.

CONCLUSION

A case of giant mucinous cystadenoma is presented with clinical and pathological details. An ovarian cystadenoma was the cause of an acute abdomen in puerperium and led to clinical and therapeutic disconcerment.

[Mucus secreting tumors of the appendix. Report of 22 cases]

The retrospective study presented in this article was realized on a series of 22 cases of mucus secreting tumor of the appendix compiled among 8373 appendicectomies. The clinical picture was dominated by an appendiceal syndrome (73%). The diagnosis was made pre or peroperatively in 10 cases and it was only with to the systematic anatomopathologic exam that 12 other cases were discovered. The histological study of the appendectomy piece showed a retention mucocele (12 cases), a mucosal hyperplasia (8 cases) and a cystadenoma (2 cases). For 5 patients, the diagnosis of peritoneal pseudomyxoma (4 cases) or extraperitoneal (1 case) was retained. All the patients underwent an appendicectomy, associated to an evacuation of the peritoneal gelatinous ascites for 5 patients among whom two underwent in more an omentectomie. Two cases of recurrence were recorded 5 months later.

The first case of primary retroperitoneal mucinous cystadenoma in Korea: a case report

Primary mucinous cystic cystadenomas of the retroperitoneum are very rarely encountered, and there have been only about 30 cases reported in the literature. The histogenesis of primary mucinous cystadenomas is unclear. Most authors suggested that it develops through mucinous metaplasia in a pre-existing mesothelium-lined cyst. Complete surgical excision is the only treatment and it is required for the final diagnosis and cure. We present here a case report of a 38-year-old Korean woman with primary retroperitoneal cystadenoma. It was a thin-walled, multilocular cyst with a dominant loculus that measured 10.0 x 7.5 x 5.5 cm3 in size, and to the best of our knowledge, this is the first such case to be reported in in Korea.

Gastric duplication in an adult mimicking mucinous cystadenoma of the pancreas

Gastric duplication cyst (GDC) in an adult can have several clinical presentations. A review of the literature showed previously reported cases of GDC presenting as pancreatic pseudocyst or with greatly raised concentrations of carbohydrate antigen 19-9 (CA 19-9). It is often difficult to discriminate GDC from pancreatic cystic tumour, in particular pancreatic mucinous cystadenoma, in which concentrations of carcinoembryonic antigen and CA 19-9 are classically raised. This report describes an adult case of GDC mimicking a mucinous cystadenoma of the pancreas. This is the first report of a simultaneous increase in carcinoembryonic antigen and CA 19-9 in GDC in the absence of malignancy. Although few cases of carcinoma arising from a GDC having been reported, the production of oncofetal antigens raises the problem of a precancerous condition in long standing intestinal duplications. In this situation surgical resection must be performed.