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Essoun S, Adu-Aryee NA, Obaka HE, Seshie B, Dey D, Naporo S. An unusual case of incidental pancreatic neuroendocrine tumor presenting with main pancreatic duct cystic dilatation. Oxf Med Case Reports 2024; 2024:omae104. [PMID: 39246612 PMCID: PMC11380084 DOI: 10.1093/omcr/omae104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 06/07/2024] [Accepted: 07/15/2024] [Indexed: 09/10/2024] Open
Abstract
INTRODUCTION Pancreatic lesions have varied morphology and presentation making their diagnosis challenging. The lesions may be asymptomatic incidentalomas on abdominal imaging for other conditions, symptomatic producing specific hormone effects or causing local effects. CASE We report a 35-year-old woman with recurrent abdominal pain confirmed gastroesophageal reflux disease. Initial CT imaging reported findings of a pancreatic pseudocysts. A careful review of the imaging showed cystic dilatation of the main pancreatic duct mimicking a main pancreatic duct intra-ductal papillary mucinous neoplasm. At surgery, a small nodule palpated in the pancreatic head with sacculation in the body and tail. A histopathological review showed a pancreatic neuroendocrine tumour blocking the main pancreatic duct at the neck causing downstream dilatation and sacculation. This case highlights the difficulty of diagnosing small asymptomatic pancreatic tumours especially with limited range of imaging modalities while increasing awareness of these conditions to improve our ability to manage them effectively.
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Affiliation(s)
- Samuel Essoun
- Department of Surgery, Korle Bu Teaching Hospital, P.O. Box KB 77, Korle Bu, Accra, Ghana
| | - Nii A Adu-Aryee
- Department of Surgery, University of Ghana Medical School, P.O. Box GP 4236, Accra, Ghana
| | - Henry E Obaka
- Department of Surgery, Korle Bu Teaching Hospital, P.O. Box KB 77, Korle Bu, Accra, Ghana
| | - Bernard Seshie
- Department of Surgery, Tema General Hospital, Hospital Road, Tema, Ghana
| | - Dzifa Dey
- Department of Medicine and Therapeutics, University of Ghana Medical School, P.O. Box GP 4236, Accra, Ghana
| | - Simon Naporo
- Department of Pathology, Greater Accra Regional Hospital (Ridge Hospital), P.O. Box GP 473, Accra Ghana
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2
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Farina R, Foti PV, Iannace FA, Conti A, Pennisi I, Calcagno MC, Basile A. True congenital multicystic disease of the pancreas in the infant: a very rare case. J Ultrasound 2022; 25:721-723. [PMID: 32445079 PMCID: PMC9402859 DOI: 10.1007/s40477-020-00472-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 04/27/2020] [Indexed: 10/24/2022] Open
Abstract
The most frequent pancreatic cysts in patients of developmental age are pseudocysts, neoplastic cysts, posttraumatic cysts, and parasitic cysts. Retention cysts, duplication cysts, and congenital cysts are called true cysts. Among the true cysts, congenital cysts are very rare and include 1% of all pancreatic cysts. The finding of true congenital pancreatic cysts in children under 3 years represents a very rare event; less than 30 have been described in the literature. We describe the case of a 3-year-old male who came to our observation for abdominal pain and underwent an abdomen ultrasound examination. The ultrasound examination showed unilocular sub-centimeter cystic lesions, distributed throughout the pancreatic parenchyma. The patient was, therefore, not subjected to any treatment, and after a few days, the symptoms regressed spontaneously. This description probably represents the first case in the literature of "congenital multicystic disease" of the pancreas.
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Affiliation(s)
- Renato Farina
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Via Santa Sofia 78, 95123, Catania, Italy.
| | - Pietro Valerio Foti
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Via Santa Sofia 78, 95123, Catania, Italy
| | - Francesco Aldo Iannace
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Via Santa Sofia 78, 95123, Catania, Italy
| | - Andrea Conti
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Via Santa Sofia 78, 95123, Catania, Italy
| | - Isabella Pennisi
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Via Santa Sofia 78, 95123, Catania, Italy
| | - Maria Carla Calcagno
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Via Santa Sofia 78, 95123, Catania, Italy
| | - Antonio Basile
- Radiodiagnostic and Radiotherapy Unit, Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", Via Santa Sofia 78, 95123, Catania, Italy
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3
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McCarty TR, Garg R, Rustagi T. Pancreatic cyst fluid glucose in differentiating mucinous from nonmucinous pancreatic cysts: a systematic review and meta-analysis. Gastrointest Endosc 2021; 94:698-712.e6. [PMID: 33964311 DOI: 10.1016/j.gie.2021.04.025] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 04/27/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Recently, low levels of intracystic glucose acquired with EUS-guided pancreatic cyst fluid sampling have been shown to help to differentiate mucinous from nonmucinous cystic neoplasms. The aim of this study was to perform a systematic review and meta-analysis to evaluate the diagnostic characteristics of pancreatic cyst fluid glucose compared with carcinoembryonic antigen (CEA) for pancreatic cystic lesions. METHODS Individualized searches were developed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-Analysis of Observational Studies in Epidemiology guidelines and meta-analysis analyzed according to Cochrane Diagnostic Test Accuracy working group methodology. A bivariate model was used to compute pooled sensitivity and specificity, likelihood ratio, diagnostic odds ratio, and summary receiver operating characteristics curve for intracystic glucose or CEA alone or combination testing. RESULTS Eight studies (609 lesions; mean patient age, 63.56 ± 2.75 years; 60.36% women) were included. The pooled sensitivity for pancreatic cyst fluid glucose was significantly higher compared with CEA alone (91% [95% confidence interval {CI}, 88-94; I2 = .00] vs 56% [95% CI, 46-66; I2 = 537.14]; P < .001) with no difference in specificity (86% [95% CI, 81-90; I2 = 24.16] vs 96% [95% CI, 90-99; I2 = 38.06]; P > .05). Diagnostic accuracy was significantly higher for pancreatic cyst fluid glucose versus CEA alone (94% [95% CI, 91-96] vs 85% [95% CI, 82-88]; P < .001). Combination testing with pancreatic cyst fluid glucose and CEA did not improve the diagnostic accuracy compared with glucose alone (97% [95% CI, 95-98] vs 94% [95% CI, 91-96]; P > .05). CONCLUSIONS Low pancreatic cyst fluid glucose was associated with a high sensitivity and specificity with significantly improved diagnostic accuracy compared with CEA alone for the diagnosis of mucinous versus nonmucinous pancreatic cystic lesions.
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Affiliation(s)
- Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rajat Garg
- Department of Hospital Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, USA
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4
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Sato H, Liss AS, Mizukami Y. Large-duct pattern invasive adenocarcinoma of the pancreas–a variant mimicking pancreatic cystic neoplasms: A minireview. World J Gastroenterol 2021; 27:3262-3278. [PMID: 34163110 PMCID: PMC8218369 DOI: 10.3748/wjg.v27.i23.3262] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/09/2021] [Accepted: 05/17/2021] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer currently has no subtypes that inform clinical decisions; hence, there exists an opportunity to rearrange the morphological and molecular taxonomy that guides a better understanding of tumor characteristics. Nonetheless, accumulating studies to date have revealed the large-duct type variant, a unique subtype of pancreatic ductal adenocarcinoma (PDA) with cystic features. This subtype often radiographically mimics intraductal papillary mucinous neoplasms (IPMNs) and involves multiple small cysts occasionally associated with solid masses. The “bunch-of-grapes” sign, an imaging characteristic of IPMNs, is absent in large-duct PDA. Large-duct PDA defines the mucin profile, and genetic alterations are useful in distinguishing large-duct PDA from IPMNs. Histologically, neoplastic ducts measure over 0.5 mm, forming large ductal elements. Similar to classic PDAs, this subtype is frequently accompanied by perineural invasion and abundant desmoplastic reactions, and KRAS mutations in codon 12 are nearly ubiquitous. Despite such morphological similarities with IPMNs, the prognosis of large-duct PDA is equivalent to that of classic PDA. Differential diagnosis is therefore essential.
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Affiliation(s)
- Hiroki Sato
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa 0788510, Hokkaido, Japan
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Andrew Scott Liss
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Yusuke Mizukami
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa 0788510, Hokkaido, Japan
- Institute of Biomedical Research, Sapporo Higashi Tokushukai Hospital, Sapporo 0650033, Hokkaido, Japan
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5
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Park JI. Squamoid cyst of pancreatic ducts: A case report. Ann Hepatobiliary Pancreat Surg 2021; 25:293-298. [PMID: 34053935 PMCID: PMC8180390 DOI: 10.14701/ahbps.2021.25.2.293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/05/2021] [Accepted: 03/07/2021] [Indexed: 11/23/2022] Open
Abstract
The term squamoid cyst of pancreatic ducts (SCOP) has been proposed recently, and it is a very rare benign lesion. We report a case of SCOP in a patient who underwent laparoscopic distal pancreatectomy. A 51-year-old woman presented with a pancreatic cystic lesion (3.3 cm) as an incidental finding on abdominal ultrasonography. A computed tomography scan showed a well-defined cystic lesion in the body of the pancreas with peripheral nodular calcification. Histology showed a unilocular cyst with a thin, fibrotic wall, and it was surrounded by normal-appearing pancreatic tissue. The lining of the cyst was composed of stratified non-keratinized squamous epithelium without significant nuclear atypia. Immunohistochemistry showed positive nuclear p63 expression in the cyst lining. The final diagnosis of SCOP was established. It is important to distinguish SCOPs from mucinous pancreatic cysts that have malignant potential. Preoperative diagnosis of SCOP is still difficult, and further studies are needed to identify specific preoperative characteristics that can accurately distinguish this lesion.
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Affiliation(s)
- Jeong-Ik Park
- Department of Surgery, Ulsan University Hospital, University of Ulsan, College of Medicine, Ulsan, Korea
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6
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McCarty TR, Paleti S, Rustagi T. Molecular analysis of EUS-acquired pancreatic cyst fluid for KRAS and GNAS mutations for diagnosis of intraductal papillary mucinous neoplasia and mucinous cystic lesions: a systematic review and meta-analysis. Gastrointest Endosc 2021; 93:1019-1033.e5. [PMID: 33359054 DOI: 10.1016/j.gie.2020.12.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 12/09/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Although molecular analysis of pancreatic cyst fluid may aid pancreatic cyst classification, clinical practice remains highly variable. Therefore, we performed a systematic review and meta-analysis to evaluate the diagnostic performance of KRAS and GNAS mutations in EUS-acquired pancreatic cyst fluid for diagnosis of intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystic lesions (MCLs). METHODS Individualized searches were developed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines and meta-analysis analyzed according to the Cochrane Diagnostic Test Accuracy working group methodology. A bivariate model was used to compute the pooled sensitivity and specificity and to plot the summary receiver operating characteristics curve with summary point and corresponding 95% confidence interval (95% CI). RESULTS Six studies (785 lesions) were included. For IPMNs and MCLs, KRAS + GNAS (combination) had significantly higher diagnostic accuracy than KRAS alone and GNAS alone (all P < .001). The pooled sensitivity, specificity, and diagnostic accuracy of KRAS + GNAS mutations for diagnosis of IPMNs were 94% (95% CI, 72-99; I2 = 86.74%), 91% (95% CI, 72-98; I2 = 89.83), and 97% (95% CI, 95-98), respectively, with each significantly higher compared with carcinoembryonic antigen (CEA) alone (all P < .001). For diagnosis of MCLs, KRAS + GNAS had a similar sensitivity and specificity compared with CEA alone; however, diagnostic accuracy was significantly improved (97% [95% CI, 95-98] vs 89% [95% CI, 86-91]; P < .001). CONCLUSIONS Molecular analysis for KRAS + GNAS mutations in EUS-acquired pancreatic cyst fluid has high sensitivity and specificity with significantly improved diagnostic accuracy for diagnosis of IPMNs and MCLs when compared with CEA alone.
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Affiliation(s)
- Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Swathi Paleti
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
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Yamamoto R, Konagaya K, Iijima H, Kashiwagi H, Hashimoto M, Shindo A, Sasaki Y, Yamamoto K, Nakagawa M, Suno Y, Abe T, Takaki M, Suda K, Watanabe K. A Rare Case of Pancreatic Endometrial Cyst and Review of the Literature. Intern Med 2019; 58:1097-1101. [PMID: 30568111 PMCID: PMC6522422 DOI: 10.2169/internalmedicine.1702-18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Pancreatic cysts include a variety of benign, premalignant, and malignant lesions. Endometrial cysts in the pancreas are extremely rare lesions that are difficult to diagnose before surgery. We report the case of a 26-year-old patient with a recent episode of left abdominal pain who presented with a large cyst in the pancreatic body. Laboratory results showed white blood cell and C-reactive protein elevation, whereas the patient's tumor marker levels were within the normal range. Distal pancreatectomy with splenectomy was performed. The final histopathological examination confirmed the presence of endometriotic cysts within the pancreas. Only 13 cases of endometriotic cysts of the pancreas have been previously reported. The preoperative diagnosis is challenging, and most patients undergo pancreatic resection because of suspected neoplasms. This case report reviews previous studies and discusses the clinicopathological features, pathogenesis, and appropriate treatment for pancreatic endometrial cysts.
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Affiliation(s)
- Ryuichi Yamamoto
- Department of Gastroenterology, Tokyo-west Tokushukai Hospital, Japan
| | | | - Hirokazu Iijima
- Department of Surgery, Tokyo-west Tokushukai Hospital, Japan
| | - Hiroyuki Kashiwagi
- Department of Hepato-Biliary-Pancreatic Surgery, Shonan Kamakura General Hospital, Japan
| | | | - Asumi Shindo
- Department of Surgery, Tokyo-west Tokushukai Hospital, Japan
| | - Yuki Sasaki
- Department of Surgery, Tokyo-west Tokushukai Hospital, Japan
| | - Kota Yamamoto
- Department of Surgery, Tokyo-west Tokushukai Hospital, Japan
| | | | - Yuma Suno
- Department of Surgery, Tokyo-west Tokushukai Hospital, Japan
| | - Toshiyuki Abe
- Department of Gastroenterology, Saitama Sekishinkai Hospital, Japan
| | - Mutsuo Takaki
- Department of Surgery, Tokyo-west Tokushukai Hospital, Japan
| | - Koichi Suda
- Department of Pathology, Tokyo-west Tokuhsukai Hospital, Japan
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8
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Kromrey ML, Bülow R, Hübner J, Paperlein C, Lerch MM, Ittermann T, Völzke H, Mayerle J, Kühn JP. Prospective study on the incidence, prevalence and 5-year pancreatic-related mortality of pancreatic cysts in a population-based study. Gut 2018; 67:138-145. [PMID: 28877981 DOI: 10.1136/gutjnl-2016-313127] [Citation(s) in RCA: 200] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 08/25/2017] [Accepted: 08/27/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To analyse the prevalence, incidence and clinical relevance of pancreatic cysts detected as incidental finding in a population-based longitudinal study. DESIGN A total of 1077 participants (521 men, mean age 55.8±12.8 years) of 2333 participants from the population-based Study of Health in Pomerania (SHIP) underwent magnetic resonance cholangiopancreaticography (MRCP) at baseline (2008-2012). MRCP was analysed for pancreatic cysts with a diameter ≥2 mm. 676/1077 subjects received a 5-year follow-up (2014-2016). The prevalence and incidence of pancreatic cysts (weighted for study participation) were assessed in association to age, gender and suspected epidemiological risk factors. Mortality follow-up was performed in 2015 for all SHIP participants (mean follow-up period 5.9 years, range 3.2-7.5 years). RESULTS At baseline pancreatic cysts had a weighted prevalence of 49.1%, with an average number of 3.9 (95% CI 3.2 to 4.5) cysts per subject in the subgroup harbouring cysts. Cyst size ranged from 2 to 29 mm. Prevalence (p<0.001), number (p=0.001) and maximum size (p<0.001) increased significantly with age. The 5-year follow-up revealed a weighted incidence of 12.9% newly detected pancreatic cysts. 57.1% of the subjects initially harbouring pancreatic cysts showed an increase in number and/or maximum cyst size. Of all subjects undergoing MRCP, no participant died of pancreatic diseases within mortality follow-up. CONCLUSION The prevalence of pancreatic cysts in the general population is unexpectedly high, and their number and size increase with age. Overall, no pancreatic cancer was observed in this collective during a 5-year follow-up. Nevertheless, prospective follow-up imaging showed minimal progress in more than 50%. Only about 6% of cysts and 2.5% of the study group initially presented with cysts of more than 1 cm and thus might be clinically meaningful.
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Affiliation(s)
- Marie-Luise Kromrey
- Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany
| | - Robin Bülow
- Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany
| | - Jenny Hübner
- Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany
| | - Christin Paperlein
- Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany
| | - Markus M Lerch
- Department of Internal Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Till Ittermann
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Henry Völzke
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Julia Mayerle
- Department of Internal Medicine A, University Medicine Greifswald, Greifswald, Germany.,Medizinische Klinik und Poliklinik II, Universitätsklinikum der Ludwig-Maximilians-Universität München, Greifswald, Germany
| | - Jens-Peter Kühn
- Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany.,Department of Radiology, Universitätsklinikum Dresden, Carl Gustav Carus University Dresden, Greifswald, Germany
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Abstract
There are a few entities that account for most solid and cystic masses of the pancreas. The pancreas harbors a wide array of diseases, including adenocarcinoma, and its variants, such as anaplastic and adenosquamous carcinoma. Other neoplasms include acinar cell carcinoma, solid pseudopapillary tumor, and sarcomas. Benign lesions include hamartomas, hemangiomas, lymphangioma, and plasmacytoma. Isolated metastases include renal cell carcinoma, melanoma, and other carcinomas. Benign inflammatory conditions, such as autoimmune pancreatitis and groove pancreatitis can also mimic solid neoplasms of the pancreas.
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Affiliation(s)
- John A Stauffer
- Department of Surgery, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224, USA
| | - Horacio J Asbun
- Department of Surgery, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224, USA.
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10
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Abstract
PURPOSE The purpose of this retrospective study was to evaluate imaging features of mucinous nonneoplastic cyst (MNNC) of the pancreas. MATERIALS AND METHODS Three (0.9%) patients with MNNC of the pancreas were found in 335 surgically resected pancreatic cystic lesions. Three MDCT and two MRI/MRCP studies were retrospectively reviewed. RESULTS Three cases of MNNC were found in the pancreatic neck, body, and tail, respectively. All the three cases were multilocular without communication with the main pancreatic duct (MPD), although upstream MPD dilatation was seen in two of the three cases. The signal intensity of the cyst fluid was low on T1-weighted, high on T2-weighted, and low on diffusion-weighted images. Cyst wall was thin in two cases, and the remaining case with obstructive pancreatitis showed visible cyst wall enhancement. CONCLUSION Imaging findings of MNNC of the pancreas were nonspecific without communication with the MPD. Cyst wall is typically thin without visible enhancement.
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Abstract
CONTEXT - According to the 2014 Baltimore Consensus Meeting, simple mucinous cysts are defined as macroscopic cysts that are greater than 1 cm in size with gastric-type flat mucinous lining and minimal cytologic atypia without ovarian-type stroma. This lesion has not been widely recognized and has undergone a recent nomenclature change owing to unclear pathogenesis and biologic behavior. Mucinous pancreatic cystic lesions are generally considered precursor lesions of pancreatic adenocarcinoma. However, simple mucinous cysts generally have benign behavior with no recurrence or malignant transformation during short follow-up periods. OBJECTIVE - To provide a brief update and summary of the evolving nomenclature and current knowledge of simple mucinous cysts with an overview of their clinical, histopathologic, immunohistochemical, and molecular characteristics, as well as discussion of their differential diagnoses and biological behavior. DATA SOURCES - Analysis of the pertinent literature (PubMed) and authors' clinical practice experience based on institutional and consultation materials. CONCLUSIONS - Simple mucinous cyst has undergone a nomenclature evolution from mucinous nonneoplastic cyst to the current recommended name of simple mucinous cyst to reflect its unclear pathogenesis and progression. The malignant potential of simple mucinous cyst is still debatable. Recent molecular studies support a neoplastic process, but these cysts generally exhibit benign behavior without recurrence or malignant transformation. Therefore, accurate diagnosis of simple mucinous cysts is critical to distinguish them from other more common and aggressive mucinous pancreatic cysts. Studies with larger cohorts and longer clinical follow-up data are needed to further determine the biologic behavior of this cyst and implications for prognosis.
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12
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Pancreatic Cystic Lesions: A Challenging Entity in Children. Pancreas 2017; 46:e59-e60. [PMID: 28697143 DOI: 10.1097/mpa.0000000000000868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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13
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Mederos MA, Villafañe N, Dhingra S, Farinas C, McElhany A, Fisher WE, Van Buren II G. Pancreatic endometrial cyst mimics mucinous cystic neoplasm of the pancreas. World J Gastroenterol 2017; 23:1113-1118. [PMID: 28246486 PMCID: PMC5311101 DOI: 10.3748/wjg.v23.i6.1113] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 01/13/2017] [Accepted: 01/17/2017] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cysts include a variety of benign, premalignant, and malignant lesions. Endometrial cysts in the pancreas are exceedingly rare lesions that are difficult to diagnose pre-operatively. This report describes the findings in a 43-year-old patient with a recent episode of acute pancreatitis who presented with a large cyst in the tail of the pancreas. Imaging demonstrated a loculated pancreatic cyst, and cyst fluid aspiration revealed an elevated amylase and carcinoembryonic antigen. The patient experienced an interval worsening of abdominal pain, fatigue, diarrhea, and a 15-pound weight loss 3 mo after the initial episode of pancreatitis. With concern for a possible pre-malignant lesion, the patient underwent a laparoscopic distal pancreatectomy with splenectomy, which revealed a 16 cm × 12 cm × 4 cm lesion. Final histopathology was consistent with an intra-pancreatic endometrial cyst. Here we discuss the overlapping imaging and laboratory features of pancreatic endometrial cysts and mucinous cystic neoplasms of the pancreas.
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14
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Dalal KS, DeWitt JM, Sherman S, Cramer HM, Tirkes T, Al-Haddad MA. Endoscopic ultrasound characteristics of pancreatic lymphoepithelial cysts: A case series from a large referral center. Endosc Ultrasound 2016; 5:248-53. [PMID: 27503157 PMCID: PMC4989406 DOI: 10.4103/2303-9027.187879] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Lymphoepithelial cysts (LECs) of the pancreas are benign lesions that can mimic cystic neoplasms on imaging. Endoscopic ultrasound (EUS) features have not been well described. We aimed to describe the clinical and EUS characteristics of LECs and the present outcomes of management at a high-volume referral center. MATERIALS AND METHODS We identified patients who underwent EUS and were found to have LECs based on fine-needle aspiration (FNA) cytology or surgical pathology from existing databases. EUS features, imaging characteristics, and pathology results were described. RESULTS Sixteen patients were found to have 17 LECs. The mean size was 33 mm ± 15 mm. Locations within the pancreas included 10 lesions in the tail, 3 in the body, 1 in the uncinate process; the remaining 3 were exophytic. Six lesions were anechoic, 6 were hypoechoic, and 5 had mixed echogenicity. Nine lesions had mixed solid/cystic components, 7 were purely cystic, and 1 was solid. Cyst fluid was thick or viscous in six cases and thin in three. Eleven patients had diagnostic cytopathology. Six patients ultimately underwent surgery due to symptoms, nondiagnostic FNA, or other clinical concerns for malignancy. CONCLUSIONS Pancreatic LECs have variable morphology and echogenicity on EUS, but the appearance of a cyst with variable solid and cystic components combined with the appearance of thick, turbid, and viscous aspirate should raise suspicion for an LEC. The majority of patients with LECs at our center avoided surgery for LECs on the basis of diagnostic EUS-FNA.
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Affiliation(s)
- Kunal S Dalal
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - John M DeWitt
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Stuart Sherman
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Harvey M Cramer
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Temel Tirkes
- Department of Radiology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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15
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Matsui T, Matsubayashi H, Sugiura T, Sasaki K, Ito H, Hotta K, Imai K, Tanaka M, Kakushima N, Ono H. A Splenic Epithelial Cyst: Increased Size, Exacerbation of Symptoms, and Elevated Levels of Serum Carcinogenic Antigen 19-9 after 6-year Follow-up. Intern Med 2016; 55:2629-34. [PMID: 27629958 DOI: 10.2169/internalmedicine.55.6970] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 58-year-old man, who had presented with a large cyst between the pancreatic tail and splenic hilum 6 years previously, was referred to our hospital with exacerbation of abdominal distention. Computed tomography revealed a well-demarcated, unilocular cyst, with a beak sign for the pancreas, without wall thickening or nodules suggestive of a non-neoplastic cyst. Compared with 6 years previously, the cyst had increased in size from 14.7 cm to 19.5 cm, and the serum carcinogenic antigen 19-9 level had increased from 635 U/mL to 1,918 U/mL. To prevent spontaneous rupture, laparotomy was performed, and the cyst was pathologically diagnosed as a splenic epithelial cyst.
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Affiliation(s)
- Toru Matsui
- Division of Endoscopy, Shizuoka Cancer Center, Japan
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Surgery for cystic pancreatic lesions in the post-sendai era: a single institution experience. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2015; 2015:847837. [PMID: 25873753 PMCID: PMC4383461 DOI: 10.1155/2015/847837] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 03/13/2015] [Accepted: 03/14/2015] [Indexed: 12/16/2022]
Abstract
Introduction. The management of cystic pancreatic lesions has changed in recent years as a result of increasing knowledge of their biological behaviour, better diagnostic options, and international guidelines. Methods. Retrospective analysis of a cohort of 86 patients operated for cystic pancreatic lesions during a seven-year period (2007–2014). Results. Final histopathology revealed 53 intraductal papillary mucinous neoplasms (19 branch duct IPMNs, 15 mixed type IPMNs, and 19 main duct IPMNs), 14 serous and 13 mucinous cystic neoplasms, 3 solid pseudopapillary neoplasms, and 3 other lesions. 4 cases displayed high grade intraepithelial neoplasia and 2 cases displayed invasive cancer. A pylorus-preserving partial duodenopancreatectomy was carried out in 27 patients, a total pancreatectomy was carried out in 9 patients, a left resection was carried out in 42 patients, and segmental resections and enucleations were carried out in 4 patients each. Overall postoperative morbidity and mortality were 40% and 2.3%, respectively. The preoperative diagnosis of a specific cystic tumor was accurate in 79% of patients and 9 patients (10%) could have avoided surgery with the correct preoperative diagnosis. Conclusion. Cystic pancreatic lesions are still a diagnostic challenge, requiring a dedicated multidisciplinary approach. The rate of malignancy is relatively small, whereas postoperative morbidity is substantial, underscoring the importance of adequate patient selection considering both the risk of surgery and the long term risk of malignancy.
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Kim YS, Cho JH. Rare nonneoplastic cysts of pancreas. Clin Endosc 2015; 48:31-8. [PMID: 25674524 PMCID: PMC4323429 DOI: 10.5946/ce.2015.48.1.31] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 01/14/2015] [Accepted: 01/14/2015] [Indexed: 01/04/2023] Open
Abstract
Pancreatic cysts represent a small proportion of pancreatic diseases, but their incidence has been recently increasing. Most pancreatic cysts are identified incidentally, causing a dilemma for both clinicians and patients. In contrast to ductal adenocarcinoma, neoplastic pancreatic cysts may be cured by resection. In general, pancreatic cysts are classified as neoplastic or non-neoplastic cysts. The predominant types of neoplastic cysts include intraductal papillary mucinous neoplasms, mucinous cystic neoplasms, serous cystic neoplasms, and solid pseudopapillary neoplasms. With the exception of serous type, neoplastic cysts, have malignant potential, and in most cases requires resection. Non-neoplastic cysts include pseudocyst, retention cyst, benign epithelial cysts, lymphoepithelial cysts, squamous lined cysts (dermoid cyst and epidermal cyst in intrapancreatic accessory spleen), mucinous nonneoplastic cysts, and lymphangiomas. The incidence of nonneoplastic, noninflammatory cysts is about 6.3% of all pancreatic cysts. Despite the use of high-resolution imaging technologies and cytologic tissue acquisition with endosonography, distinguishing nonneoplastic from neoplastic cysts remains difficult with most differentiations made postoperatively. Nonetheless, the definitive distinction between non-neoplastic and neoplastic cysts is crucial as unnecessary surgery could be avoided with proper diagnosis. Therefore, consideration of these rare disease entities should be entertained before deciding on surgery.
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Affiliation(s)
- Yeon Suk Kim
- Division of Gastroenterology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University of Medicine and Science, Incheon, Korea
| | - Jae Hee Cho
- Division of Gastroenterology, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University of Medicine and Science, Incheon, Korea
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Abstract
PURPOSE OF REVIEW Diagnosis of pancreatic cysts remains challenging due to limitations of currently available radiologic and endoscopic tools. The diagnostic approach should focus on identifying mucinous and malignant cysts. Mucinous cysts require further differentiation to allow appropriate management. RECENT FINDINGS Although the overall rate of malignant pancreatic cysts is low, it remains higher than the general population. MRI with magnetic resonance cholangiopancreatography is the preferred imaging modality for pancreatic cysts. Attempts to improve diagnostic yield of endoscopic ultrasound-guided fine needle aspiration include performing cyst wall cytology and DNA analysis. The 2012 international consensus guidelines for mucinous cystic neoplasm and intraductal papillary mucinous neoplasm are superior to the original 2006 guidelines, although issues include the relatively poor ability to diagnose malignant cysts leading to unnecessary surgeries and the de-emphasis of cyst size. Cyst size remains an important predictor of malignancy. Translational research involving genomics, microRNA, proteomics, and metabolomics holds promise for improved biomarkers. Endoscopic innovations may safely aid in cyst diagnosis. SUMMARY Incremental improvements in pancreatic cyst diagnosis have occurred with new biomarkers and endoscopic tools requiring validation in large-scale studies.
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