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Yasrab M, Kwak SJ, Khoshpouri P, Fishman EK, Zaheer A. Misdiagnosis of pancreatic intraductal papillary mucinous neoplasms and the challenge of mimicking lesions: imaging diagnosis and differentiation strategies. Abdom Radiol (NY) 2024:10.1007/s00261-024-04551-x. [PMID: 39327307 DOI: 10.1007/s00261-024-04551-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2024] [Revised: 08/20/2024] [Accepted: 08/25/2024] [Indexed: 09/28/2024]
Abstract
The rising prevalence of pancreatic cystic lesions (PCLs), particularly intraductal papillary neoplasms (IPMNs), has been attributed to increased utilization of advanced imaging techniques. Incidental detection of PCLs is frequent in abdominal CT and MRI scans, with IPMNs representing a significant portion of these lesions. Surveillance of IPMNs is recommended due to their malignant potential; however, their overlapping imaging features with benign entities can lead to misdiagnosis, overtreatment, and overutilization of healthcare resources. This paper aims to highlight and differentiate lesions often mistaken for IPMNs, providing insight into their imaging characteristics, diagnostic challenges, and distinctive features while highlighting the incidence of wrong diagnosis for these lesions. These lesions include serous cystadenomas, cystic pancreatic neuroendocrine tumors, mucinous cystic neoplasms, lymphoepithelial cysts, duodenal diverticula, pancreatic schwannomas, chronic pancreatitis, retention cysts, intrapancreatic accessory spleens, pancreatic lipomas, choledochal cysts, and others. Utilizing various imaging modalities, including contrast-enhanced CT, MRI, and EUS, alongside histological and molecular analyses, can aid in accurate diagnosis and appropriate management. Understanding these mimicry scenarios is crucial to avoid unnecessary surveillance, interventions, and the burden they place on both patients and healthcare systems. Improved recognition of these lesions can lead to better patient outcomes and resource allocation.
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Affiliation(s)
- Mohammad Yasrab
- Johns Hopkins Hospital, 1800 Orleans St., Baltimore, MD, 21287, USA.
| | - Stephen J Kwak
- Johns Hopkins Hospital, 1800 Orleans St., Baltimore, MD, 21287, USA.
| | | | - Elliot K Fishman
- Johns Hopkins Hospital, 1800 Orleans St., Baltimore, MD, 21287, USA
| | - Atif Zaheer
- Johns Hopkins Hospital, 1800 Orleans St., Baltimore, MD, 21287, USA
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Ciers P, Vanderhaeghe D, Vansteenkiste F, Moubax K, Vanooteghem S, Vanneste A, Van Moerkercke W. Lymphoepithelial cysts of the pancreas: case report and review of the literature. Acta Chir Belg 2023; 123:550-554. [PMID: 35249466 DOI: 10.1080/00015458.2022.2050032] [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: 09/27/2021] [Accepted: 03/02/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Lymphoepithelial cysts (LECs) of the pancreas are a rare type of true pancreatic cysts and represent an estimated 0.5% of all pancreatic cystic lesions. They are benign lesions and have no malignant potential. However, they are hard to differentiate from malignant lesions because their imaging and clinical presentation vary greatly. Seeing as these are benign lesions which are increasingly found incidentally during imaging for other indications, correct diagnosis is important to prevent unnecessary intervention and morbidity. CASE REPORT We report the case of a 41-year-old female who presented with abdominal discomfort, bloating and dyspepsia. An abdominal computed tomography (CT) showed a large mass in the left fossa. We describe the diagnostic and therapeutic measures taken in this case. METHODS We reviewed the literature for common features of the LEC. We grouped common imaging and histological features of the LEC of the pancreas to provide easily identifiable characteristics to facilitate diagnosis. For the review, we focused on papers, mostly case reports, presenting these common characteristics. We also reviewed the literature for key topics that should be taken into account when considering therapeutic interventions in a patient with a possible diagnosis of a LEC. CONCLUSION Cysts of the pancreas are increasingly identified due to widespread use and improved resolution of cross-sectional imaging. To obtain the correct diagnosis, it is sometimes necessary to combine advanced imaging, i.e. CT and MRI-imaging, and endoscopic ultrasound with fine needle aspiration (EUS/FNA), while CA 19-9 also has diagnostic value. We summarize all diagnostic characteristics in a table for ease of use. Furthermore we summarized possible therapeutic interventions.
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Affiliation(s)
- Philippe Ciers
- Department of Vascular Surgery, Klinikum Westmunsterland GmbH, Bocholt, Germany
| | | | | | - Kim Moubax
- Department of Gastroenterology, AZ Groeninge, Kortrijk, Belgium
| | - Sofie Vanooteghem
- Department of Gastroenterology, OLV van Lourdes Hospital, Waregem, Belgium
| | - Alain Vanneste
- Department of Pathological Anatomy, AZ Groeninge, Kortrijk, Belgium
| | - Wouter Van Moerkercke
- Department of Gastroenterology, AZ Groeninge, Kortrijk, Belgium
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, UZ Leuven, Leuven, Belgium
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Thompson ED, Zhang ML, VandenBussche CJ. The Diagnostic Challenge of Evaluating Small Biopsies from the Pancreatobiliary System. Surg Pathol Clin 2022; 15:435-453. [PMID: 36049827 DOI: 10.1016/j.path.2022.05.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Examination of fine needle aspirations and small core biopsies of the pancreas can be an extremely difficult and treacherous area for the diagnostic pathologist. The pancreas often yields small and often fragmented specimens, which, in combination with the morphologic overlap between numerous neoplastic and nonneoplastic mimickers, generate multiple potential diagnostic pitfalls. The authors review this challenging topic and provide insight into resolving these pitfalls using morphologic pattern recognition and ancillary testing.
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Affiliation(s)
- Elizabeth D Thompson
- Department of Pathology, The Johns Hopkins University School of Medicine, 600 N. Wolfe St., Baltimore, MD, USA; Department of Oncology, The Johns Hopkins University School of Medicine, 600 N. Wolfe St., Baltimore, MD, USA
| | - M Lisa Zhang
- Department of Pathology, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114 USA
| | - Christopher J VandenBussche
- Department of Pathology, The Johns Hopkins University School of Medicine, 600 N. Wolfe St., Baltimore, MD, USA; Department of Oncology, The Johns Hopkins University School of Medicine, 600 N. Wolfe St., Baltimore, MD, USA.
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Lymphoepithelial cyst of uncinated process of the pancreas associated with chronic cholecystitis: Case report and review of literature. Ann Med Surg (Lond) 2022; 80:104117. [PMID: 36045768 PMCID: PMC9422077 DOI: 10.1016/j.amsu.2022.104117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/27/2022] [Accepted: 06/28/2022] [Indexed: 12/01/2022] Open
Abstract
Introduction Lymphoepithelial cysts (LECs) are extremely uncommon disorders with pancreatic affection. It is predominant in middle-aged men and may be located in any portion of the pancreas. Differential diagnosis with malignant conditions is difficult. Case presentation A 53-year-old woman with abdominal pain and cystic lesion involving pancreas managed thorugh laparoscopic excision and colecistectomy due to chronic cholecystitis. Discussion and conclusion LECs are a type of true cysts that may occur in any portion of the pancreas, most common sites are the tail and body, with unclear pathogenesis. Accuracy in diagnosis with proper image investigation is necessary to separate surgical cases from conservatively managed. Lymphoepithelial cysts are uncommon conditions with pancreatic affection. Pancreatic lymphoepithelial cysts are benign cysts with higher predominance in middle-aged men (4:1). It may affect any portion of the pancreas, however the tail or body are the most common sets. Its diagnosis it is only possible through histopathological analysis and neoplasms must be included as differential diagnosis.
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Murokawa T, Okabayashi T, Oishi K, Sui K, Tabuchi M, Iwata J. Exophytic pancreatic lymphoepithelial cyst incidentally detected in a differentiated thyroid cancer patient on whole-body I-131 scan: a case report. Surg Case Rep 2022; 8:34. [PMID: 35211824 PMCID: PMC8873321 DOI: 10.1186/s40792-022-01389-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 02/17/2022] [Indexed: 11/10/2022] Open
Abstract
Background Radioiodine (I-131) whole-body scintigraphy (WBS) is a useful modality for identifying functionally preserved thyroid tissue and metastases from differentiated thyroid cancer (DTC); however, the specificity of I-131 uptake is limited, and its accumulation in the pancreas has not been well described. Case presentation A 70-year-old male patient with DTC who had previously undergone total thyroidectomy (pT3N1bM0 Stage IV) received radioiodine treatment at our facility. After treatment, an I-131 WBS revealed abnormal I-131 uptake in the head of the pancreas. Computed tomography identified a round hypodense mass (10 × 20 mm) adjacent to the pancreas head that was impervious to fluorodeoxyglucose (18F-FDG) during subsequent 18F-FDG-positron emission tomography. A diagnosis of pancreatic metastasis from the DTC could not be excluded; therefore, local resection was performed for diagnostic certainty and treatment. Histopathology confirmed the mass to be an exophytic lymphoepithelial cyst (LEC) of the pancreas. The patient also had a transient pancreatic leak which spontaneously resolved after surgery, and he was discharged from the hospital on postoperative day 8. Conclusion To the best of our knowledge, this is the first reported case of an exophytic pancreatic LEC producing a false-positive result during I-131 WBS. Knowledge of all potential I-131 false-positive findings may help improve the management of patients with DTC and circumvent misdiagnoses.
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Affiliation(s)
- Takahiro Murokawa
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, 2125-1 Ike, Kochi-City, Kochi, 781-8555, Japan
| | - Takehiro Okabayashi
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, 2125-1 Ike, Kochi-City, Kochi, 781-8555, Japan.
| | - Kazuyuki Oishi
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, 2125-1 Ike, Kochi-City, Kochi, 781-8555, Japan
| | - Kenta Sui
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, 2125-1 Ike, Kochi-City, Kochi, 781-8555, Japan
| | - Motoyasu Tabuchi
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, 2125-1 Ike, Kochi-City, Kochi, 781-8555, Japan
| | - Jun Iwata
- Department of Diagnostic Pathology, Kochi Health Sciences Center, 2125-1 Ike, Kochi-City, Kochi, 781-8555, Japan
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Practical Applications of Molecular Testing in the Cytologic Diagnosis of Pancreatic Cysts. JOURNAL OF MOLECULAR PATHOLOGY 2021. [DOI: 10.3390/jmp2010002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Mucinous pancreatic cysts are precursor lesions of ductal adenocarcinoma. Discoveries of the molecular alterations detectable in pancreatic cyst fluid (PCF) that help to define a mucinous cyst and its risk for malignancy have led to more routine molecular testing in the preoperative evaluation of these cysts. The differential diagnosis of pancreatic cysts is broad and ranges from non-neoplastic to premalignant to malignant cysts. Not all pancreatic cysts—including mucinous cysts—require surgical intervention, and it is the preoperative evaluation with imaging and PCF analysis that determines patient management. PCF analysis includes biochemical and molecular analysis, both of which are ancillary studies that add significant value to the final cytological diagnosis. While testing PCF for carcinoembryonic antigen (CEA) is a very specific test for a mucinous etiology, many mucinous cysts do not have an elevated CEA. In these cases, detection of a KRAS and/or GNAS mutation is highly specific for a mucinous etiology, with GNAS mutations supporting an intraductal papillary mucinous neoplasm. Late mutations in the progression to malignancy such as those found in TP53, p16/CDKN2A, and/or SMAD4 support a high-risk lesion. This review highlights PCF triage and analysis of pancreatic cysts for optimal cytological diagnosis.
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Esposito I, Haeberle L. Nonmucinous Cystic Lesions of the Pancreas. Arch Pathol Lab Med 2021; 146:312-321. [PMID: 33503226 DOI: 10.5858/arpa.2020-0446-ra] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2020] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Pancreatic cystic lesions are increasingly diagnosed. Among other criteria, they are often distinguished in mucinous versus nonmucinous cysts. Mucinous pancreatic cystic lesions have received increasing attention, especially those known as precursors of pancreatic ductal adenocarcinoma. However, the group of nonmucinous cystic lesions of the pancreas includes numerous entities that may pose a diagnostic challenge. Their accurate diagnosis and classification are crucial for adequate patient management. OBJECTIVE.— To review the spectrum of nonmucinous cystic lesions of the pancreas, taking into consideration their epidemiology and typical clinical context, their characteristic gross morphology and histomorphology, as well as their immunohistochemical and molecular profile. DATA SOURCES.— Literature was searched and reviewed with MEDLINE via PubMed. Macroscopic and microscopic images were obtained from the archives of the Institute of Pathology, Heinrich Heine University and University Hospital of Duesseldorf, Germany. CONCLUSIONS.— Nonmucinous cysts of the pancreas comprise numerous, mostly rare entities displaying different biological behaviors. The most frequent are serous cystic neoplasms, solid-pseudopapillary neoplasms, cystic neuroendocrine tumors, and pancreatitis-associated pseudocysts. Accurate diagnosis can be achieved if characteristic clinical context, histomorphology, and immunoprofile are taken into account.
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Affiliation(s)
- Irene Esposito
- From the Institute of Pathology, Heinrich Heine University and University Hospital of Duesseldorf, Duesseldorf, Germany
| | - Lena Haeberle
- From the Institute of Pathology, Heinrich Heine University and University Hospital of Duesseldorf, Duesseldorf, Germany
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Imaging features and pathological evaluation by EUS-FNA enable conservative management in patient of lymphoepithelial cyst of the pancreas: a case report. Clin J Gastroenterol 2020; 14:370-374. [PMID: 33063294 DOI: 10.1007/s12328-020-01240-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 09/10/2020] [Indexed: 02/07/2023]
Abstract
Pancreatic lymphoepithelial cysts (LECs) are rare cystic lesions filled with a keratinous substance and lined by squamous epithelium with underlying lymphoid tissue. Because pancreatic LECs are entirely benign, correct preoperative diagnosis is important to avoid unnecessary surgery. However, the imaging features of pancreatic LECs are not specific and preoperative diagnosis has proven difficult. A pancreatic mass was incidentally detected through abdominal ultrasonography in a 63-year-old male presenting without any symptoms. Computed tomography showed an exophytic cystic lesion in the pancreatic head. The lesion had heterogeneous high signal intensity with partial low intensity on T2-weighted magnetic resonance imaging (MRI) and high signal intensity on diffusion MRI. Endoscopic ultrasound (EUS) examination showed an encapsulated cystic lesion with relatively homogenous and highly echoic contents. EUS-guided fine-needle aspiration (EUS-FNA) revealed caseous appearance and rare fragments of apparently benign squamous epithelium on a background of keratinous debris, cyst contents, and scattered lymphocytes. We diagnosed a pancreatic LEC and opted for conservative management without surgery. Pathological evaluation based on images obtained through EUS-FNA showed macro- and microscopic features that were critical to determining the management strategy. In conclusion, the imaging and pathological features of pancreatic LECs can inform preoperative diagnosis, which may enable conservative management.
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A Rare Presentation of Pancreatic Lymphoepithelial Cyst: A Case Report and Review. Case Rep Med 2020; 2020:4590758. [PMID: 32099546 PMCID: PMC7040412 DOI: 10.1155/2020/4590758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 01/18/2020] [Indexed: 11/21/2022] Open
Abstract
Pancreatic lymphoepithelial cyst (LEC) is a rare, benign collection of keratinizing squamous epithelial cells encapsulated by lymphoid tissue. Because of its limited data and nonspecific features that can mimic malignant lesions, LECs can lead to unnecessary operations. A 62-year-old male with a known pancreatic mass presented with abdominal pain. CT scan showed an increased mass in the pancreatic head, and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) revealed “rare fragments of benign-appearing squamous epithelium in a background of keratin debris, cyst contents, and scattered lymphocytes,” consistent with a lymphoepithelial cyst. Pancreatic LEC is an extremely rare lesion that comprises of only 0.5% of all pancreatic cysts. EUS-FNA has become the mainstay for diagnosing pancreatic LECs. Given the slow growing and benign nature, conservative management and observation is adequate for pancreatic LECs with excellent long-term outcome. With increasing number of imaging ordered by clinicians, it is anticipated that there will be a greater number of incidental pancreatic LECs detected. Thus, EUS-FNA should be utilized more frequently to help distinguish benign pancreatic LECs from premalignant or malignant lesions to avoid surgery.
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