A case of retroperitoneal pseudomyxoma

We experienced a rare case of pseudomyxoma that progressed into the retroperitoneum. This patient presented with complaints of polyuria and back pain. CT and MRI showed a retroperitoneal cystic tumor. Surgical and pathological findings confirmed mucinous cystadenoma of the appendix that reached the posterior space behind the right kidney through the retroperitoneum.

Management of cystic lesions of the tail of the pancreas

OBJECTIVE

To emphasize that although cystic pancreatic neoplasms are stated to make up only 10% of pancreatic cysts, this number may be significantly higher if patients who are misdiagnosed with pseudocysts are considered.

DESIGN

A small case series.

SETTING

A tertiary-care centre.

PATIENTS

A consecutive sample of three patients with cystic lesions of the tail of the pancreas seen between 1992 and 1994. All three were women ranging in age from 28 to 42 years. Two had been treated previously for pancreatic pseudocysts by cystenterostomy. None had a history of pancreatitis or alcohol abuse, and gallstones were not present on ultrasonography.

INTERVENTIONS

Distal pancreactectomy and splenectomy.

RESULTS

The excised specimens from the two patients treated initially elsewhere revealed mucinous cystadenoma with atypia in one and mucinous cystadenocarcinoma with invasion into stomach in the other. In the third patient, a cystic neuroendocrine tumour and two other intrapancreatic nodules of neuroendocrine tumour were found on pathological examination.

CONCLUSIONS

Pancreatic neoplasms may be misdiagnosed as pancreatic pseudocysts. In patients without a history or risk factors for pancreatitis, a cystic pancreatic mass is not necessarily a pseudocyst, and such patients should be considered for pancreatic resection.

Preoperative cyst fluid analysis is useful for the differential diagnosis of cystic lesions of the pancreas

BACKGROUND/AIMS

It has been suggested that activity of pancreatic enzymes and concentrations of tumoral markers in cyst fluid may help to distinguish pseudocyst, serous, and mucinous cystadenomas. The aim of this study was to prospectively assess the reliability of preoperative biochemical and tumor marker analysis in cyst fluids obtained by fine-needle aspiration for pathological diagnosis.

METHODS

Cyst fluid was obtained preoperatively by fine-needle aspiration, and biochemical and tumoral marker values were measured. The diagnosis of cystic tumors (7 serous cystadenomas and 12 mucinous tumors) was established by surgical specimen analysis. Thirty-one pancreatic pseudocysts complicating well-documented chronic pancreatitis were also studied.

RESULTS

Carbohydrate antigen 19.9 levels of > 50,000 U/mL had a 75% sensitivity and a 90% specificity for distinguishing mucinous tumors from other cystic lesions. Carcinoembryonic antigen levels of < 5 ng/mL had a 100% sensitivity and an 86% specificity for distinguishing serous cystadenomas from other cystic lesions. Amylase levels of > 5000 U/mL had a 94% sensitivity and a 74% specificity for distinguishing pseudocysts from other cystic lesions.

CONCLUSIONS

High carbohydrate antigen 19.9, low carcinoembryonic antigen, and high amylase levels in cyst fluid are very indicative of mucinous tumors, serous cystadenomas, and pseudocysts, respectively.

Pancreatic cystadenoma and cystadenocarcinoma: diagnostic value of preoperative morphological investigations

OBJECTIVE

To find out whether preoperative morphological investigations differentiated between serous cystadenoma, mucinous cystadenoma, and cystadenocarcinoma of the pancreas.

DESIGN

Multicentre retrospective study of casenotes.

SETTING

24 Adult gastroenterology units (1 private, 8 non-university teaching hospitals, and 15 university teaching hospitals) in France.

SUBJECTS

71 Patients with 74 tumours diagnosed between January 1978 and January 1988.

MAIN OUTCOME MEASURES

Correlation between histological diagnosis and results of ultrasonography, computed tomography, angiography, and magnetic resonance imaging.

RESULTS

6 of 59 ultrasound scans (10%), 7 of 52 computed tomograms (13%), 0 of 18 angiograms, 1 of 12 pancreatograms (8%), and the single magnetic resonance scan correctly diagnosed the type of pancreatic tumour. Ultrasonography or computed tomography, or both, diagnosed cystadenoma (but not the type) in 26 cases (37%). "Pseudocyst" was diagnosed in 14 cases (20%).

CONCLUSIONS

In contrast to other studies, our results indicate that preoperative morphological investigations are of limited value in diagnosing cystadenomas of the pancreas. In particular, their ability to differentiate between different types of cystadenoma is poor.

Mucin-secreting tumors of the pancreas

Mucinous pancreatic neoplasms present diagnostic and therapeutic challenges. These tumors behave in an indolent nature, with frequent overlap of symptoms and radiographic appearance with other forms of pancreatic cysts, pseudocysts, and malignancy. Some authors propose that all mucin-producing tumors of the pancreas are variants of the same basic entity and have subclassified them on the basis of their predominant location within the pancreas. These disorders must be considered in the evaluation of chronic abdominal pain, particularly in the presence of a cystic pancreatic lesion or when associated with idiopathic chronic or acute recurrent pancreatitis. The clinicopathologic features of IMHN overlap to a great extent with classic mucinous cystic neoplasms but are different significantly enough to be distinct clinical entities. These tumors originate from the pancreatic duct epithelium, produce mucin, demonstrate a papillary growth pattern, and are considered premalignant or frankly malignant at the time of diagnosis. Both lesions biologically are much less aggressive than that of pancreatic ductal adenocarcinoma and appear to infiltrate peripancreatic tissue and to metastasize to lymph nodes or other adjacent structures late in the course of disease. Nevertheless, IMHNs are located primarily in the head of the pancreas, commonly affect elderly men, and present clinically with obstructive pancreatitis, often leading to pancreatic insufficiency, whereas mucinous cystic neoplasms are more likely to develop in the pancreatic body or tail, predominate in young women, and present with symptoms referable to tumor compression of adjacent structures. The location of the lesion is the primary differentiating feature because the lining epithelium of the two tumor types is indistinguishable pathologically. In mucinous cystic tumors, the mucus is secreted and retained within the cyst lumen because of the absence of communication between the cyst and the main pancreatic duct. In contrast, mucus produced in MDE flows into the main pancreatic duct, resulting in obstructive pancreatitis and, ultimately, dilatation of the pancreatic duct. Intraductal mucus provides an important clue to the diagnosis of intraductal pancreatic neoplasms and, whenever present, should prompt an aggressive diagnostic evaluation. Both lesions are managed by resectional surgery because the opportunity for cure is high in the absence of metastatic disease.

[Appendicular mucocele. A report of a case diagnosed preoperatively]

Mucocele of the appendix is an unusual clinical entity. Despite a recognized constellation of findings, the diagnosis is not usually made prior to surgical exploration. A 35 year old man is reported in whom clinical evaluation, including US and CT scans, resulted in the correct preoperative diagnosis confirmed at surgery and leading to appropriate operative decisions.

[Transvaginal ultrasonography and nuclear magnetic resonance. Comparison of techniques in the evaluation of ovarian lesions]

A total of 53 patients were included in this study, aged between 21 and 72 years old and hospitalised with the diagnosis of ovarian tumour. All patients underwent a clinical examination, ultrasonography and NMR prior to surgery. The findings of ultrasonography and NMR were correlated with histological results in order to evaluate the value of these methods in the differential diagnosis of benign and malignant ovarian tumours. Histological tests revealed 46 benign tumours, 3 borderline cases and 4 malignant growths. Transvaginal ultrasonography revealed precisely 47 out of 53 ovarian tumours, and NMR 49 out of 53. The main limitation of both techniques was the tendency to overestimate ovarian lesions (specificity: ultrasonography 89%, NMR 93%). As far as concerns the identification of malignant lesions NMR does not appear to offer significant advantages in comparison to ultrasonography (sensitivity 85% ultrasonography = NMR).

[Cystic neoplasm diagnosed as pancreatic pseudocyst: report of 5 cases and review of the literature]

The majority of cystic lesions of the pancreas are pseudocysts. Nine to thirteen per cent of pancreatic cyst are neoplastic, benign or malignant. Failure to recognize neoplastic nature of a cyst leads to an improper management. The authors present five cases of cystic tumors mistaken for pancreatic pseudocysts, including three mucinous cystadenomas and two mucinous cystadenocarcinomas. Four were drained by cystojejunostomy and one cystogastrostomy. One patient with no metastases at first operation had metastatic spread at reoperation. In the other four cases, subsequent resection was possible and probably curative. Review of the literature and guidelines are given for the purpose of differential diagnosis between theses entities.

[Giant ovarian cystoma in mature pregnancy]

Ovarian tumours occurring during pregnancy pose considerable problems in respect of diagnosis and treatment. Unexpected difficulties arose in the case of patient suffering from a giant ovarian cystoma which ruptured sub partu and was diagnosed only during an emergency Caesarean section. Ileus occurred on the sixth postoperative day. This had been caused by an operation cloth left in the abdomen following the Caesarean section. The patient was awarded damages of DM 5000,-.

[Mucinous cystadenomas and cystadenocarcinomas of the pancreas--the pancreaticoscopy as a new device for endoscopic and histological diagnosis]

Recent advances in diagnostic imaging procedures offer the opportunity for detection of rare cystic neoplasms of the pancreas. Cystadenomas of the pancreas have been reported to represent 10% of cystic pancreatic lesions. Serous microcystic cystadenoma, megacystic mucinous and duct-ectatic mucinous cystadenoma were distinguished. While the serous cystadenoma is benign, in general the megacystic and the duct-ectatic mucinous cystadenoma have a significant malignant potential. With pancreatoscopy, a rather new endoscopic technique, five cases of mucinous megacystic cystadenoma were diagnosed preoperatively by macroscopic and microscopic means. In one case, development of malignant neoplasm was diagnosed, one patient did not undergo surgery because of her age. Three patients were operated (total pancreatectomy in one case, duodeno-hemipancreatectomy in two cases) and are without any further signs of recurrence and free of symptoms in a one year to four year clinical follow-up.

Mucinous cystic tumor of the retroperitoneum. A report of two cases

Two cases of retroperitoneal mucinous cystic tumors and some diagnostic problems on aspiration cytology are presented. The first was a mixed benign, borderline and malignant mucinous tumor, and the second was a mixed benign and borderline mucinous tumor. Our knowledge of the cytology of ovarian mucinous cystic tumors was not helpful in making a correct diagnosis in these cases. Based on our experience, we emphasize the following. First, consider methods of collecting enough cells to make a diagnosis. Second, consider the possibility of mixed histologic features. Direct aspiration, if possible, from papillary lesions inside the cyst will probably lead to an accurate diagnosis. Measurement of carcinoembryonic antigen levels in the cystic fluid is useful in checking for underdiagnosis of such tumors.

[Value of CT scan and MRI in primary tumors of the ovary]

Characterisation of an ovarian mass is of utmost importance in the preoperative evaluation of an ovarian neoplasm. It enables the surgeon to anticipate carcinoma of the ovary before the operation, so that adequate procedures are planned. Although, ultrasonography (US) remains the foremost imaging modality for screening patients with adnexal lesions, computed tomography (CT) recently has proved to be of value in the characterisation and management of tumors of the ovary. Magnetic resonance (MR) imaging has also been shown to have a high degree of diagnostic specificity for certain types of ovarian masses, such as dermoid cysts, and endometriomas. However, the potential of MR imaging to characterize tumors of the ovary has not yet been established. This study assesses the value of MR imaging and CT for the purpose of predicting the malignancy of ovarian lesions, and comparing findings of MR imaging with those of CT.

Ovarian mucinous cystadenoma: evaluating the pelvic mass

An ovarian mucinous cystadenoma does not cause symptoms until it becomes very large. In women who present with nonspecific abdominal complaints, a pelvic examination must be performed and a high index of suspicion for pelvic pathology must be maintained. Mucinous cystadenomas are benign, allowing a conservative approach to treatment, especially in young patients who wish to maintain fertility.