Lymphangioma of the pancreas: a multimodal approach to pre-operative diagnosis

Pitfalls in Lymph Node Fine Needle Aspiration Cytology

BACKGROUND

Fine needle aspiration cytology (FNAC) is an accurate, minimally invasive, and cost-effective biopsy method for enlarged lymph nodes. While the role of lymph node FNAC in the diagnosis of infectious or reactive conditions and metastatic malignancy is unquestioned, differing views still exist on its role in the diagnosis of lymphoma. Nevertheless, regardless of the practice setting, pitfalls and potential for error exist, and it is incumbent upon the pathologist to be aware of these pitfalls, as this is the first line of defence against errors.

SUMMARY

This discussion will focus on potential interpretational errors, specifically highlighting scenarios leading to false-negative and false-positive diagnosis and errors in tumour classification, with an emphasis on cytomorphology. Potential entities that may fly below the radar of the pathologist - so-called off-radar entities - are also discussed, as a reminder to consider broad differentials in cases with unusual morphologic features. Some reasons for false-negative diagnoses include low-grade lymphomas that mimic a mixed, polymorphous reactive lymphoid population or aspirates with a paucity of lesional cells, through either sampling error or the intrinsic nature of the entity, e.g., nodular lymphocyte predominant Hodgkin lymphoma. Some of the potential causes of false-positive diagnoses that are discussed include viral-associated lymphadenopathy, Kikuchi-Fujimoto lymphadenitis, or benign adnexal lesions mimicking metastatic malignancy. Errors in tumour classification covered include metastatic carcinoma, sarcoma, melanoma, and lymphoma mimicking each other, and Hodgkin lymphoma and its mimics. Finally, less common entities such as follicular dendritic cell sarcoma and others are briefly mentioned, to remind us of conditions that may slip under our diagnostic radar.

KEY MESSAGES

A systematic review of diagnostic pitfalls and traps is elucidated here, with some tips to avoid these traps. The triple approach to the diagnostic workup is emphasised, which includes rigorous clinicopathologic correlation, attention to cytomorphology, and judicious application of ancillary tests.

Solid pancreatic masses in children: A review of current evidence and clinical challenges

Pancreatic tumors in children are infrequently encountered in clinical practice. Their non-specific clinical presentation and overlapping imaging characteristics often make an accurate preoperative diagnosis difficult. Tumors are categorized as epithelial or non-epithelial, with epithelial tumors further classified as tumors of the exocrine or endocrine pancreas. Although both are tumors of the exocrine pancreas, solid pseudopapillary neoplasm is the most prevalent solid pancreatic tumor in children, while pancreatoblastoma is the most common malignant tumor. Insulinoma is the most common pediatric pancreatic tumor of the endocrine pancreas. Malignant tumors require a complete, often radical, surgical resection. However, pancreatic parenchyma-sparing surgical procedures are utilized for benign tumors and low-grade malignancy to preserve gland function. This review will discuss the epidemiology, pathophysiology, clinical and diagnostic characteristics, and management options associated with both common and rare solid pancreatic masses in children. We will also discuss current challenges encountered in their evaluation and treatment.

Pancreatic Lymphangioma: An Unusual Cause of Abdominal Lump

Lymphangiomas are uncommon benign malformations that can occur anywhere in the body. These are hamartomatous malformations with lymphatic differentiation, which uncommonly involve the abdomen and rarely the pancreas.

The size of the cysts in pancreatic lymphangioma directly correlates with the clinical manifestations; however, most of them are non-specific. Preoperative diagnosis is challenging because conventional imaging examinations like an abdominal ultrasonogram (USG), computed tomography, or magnetic resonance imaging cannot distinguish pseudocyst, mucinous cyst neoplasms, simple cyst, intraductal papillary mucinous neoplasms, and serous cystadenoma.

We are presenting a rare case of pancreatic lymphangioma where the definitive diagnosis was made postoperatively in histopathological examination. A female patient aged 27 years presented to the Surgery outpatient department with a slow-growing abdominal lump of 9 months duration. Clinical examination revealed large, non-tender, soft cystic swelling occupying the entire upper abdomen. Radiological imaging showed a large multiseptated cystic lesion occupying almost the entire abdomen and adhered to the pancreas with mass effect. USG-guided fine-needle aspiration revealed straw-colored aspirate with mature lymphocytes.

On exploration, there was a large multiloculated cyst occupying the whole abdomen. Cysts were decompressed, and the entire lesion was excised. Final histopathological examination showed unremarkable pancreatic tissue with attached lesion consisting of dilated lymphatic spaces with lymphatic follicles.

Pancreatic Lymphangioma: A Case Report and Literature Review

We report a case of a 29-year-old woman with a pancreatic lymphangioma who presented clinically as a case of acute pancreatitis. Lymphangiomas are benign tumors of vascular origin with lymphatic differentiation, most commonly found in the head and neck. Pancreatic lymphangiomas are extremely rare, accounting for only 1% of abdominal lymphangiomas, with approximately 60 cases reported in the literature. Although imaging findings are characteristic and can point to the diagnosis, confirmation with fine needle aspiration and histopathologic correlation is necessary. Although these lesions are benign, they can often present a diagnostic dilemma and can be mistaken for other cystic pancreatic lesions, namely, pseudocysts, cysts, cystadenomas, and cystadenocarcinomas.

Large cystic lympangioma of the pancreas: a case reportum

Lymphangioma of the pancreas is rare and presents as a large cystic mass in the retroperitoneum. The pancreatic origin can be confirmed by careful evaluation of cross sectional imaging. Preoperative differentiation from other pancreatic cystic neoplasms is difficult but possible. Large symptomatic lesions warrant surgery. The diagnosis is confirmed by typical features on histopathology and immunohistochemistry. Presented here is a case report of a pancreatic lymphangioma, discussed in the context of available literature.

Diagnosis of pancreatic cystic lymphangioma in an 11-year-old boy with endoscopic ultrasound-guided fine needle aspiration: A case report

Introduction: Pancreatic cystic lymphangioma (PCL) is an extremely rare benign tumor of lymphatic origin. Traditionally, it is diagnosed at surgery performed on a patient with a retroperitoneal cyst of unclear etiology. However, recently a few single case reports showed PCL was successfully diagnosed by endoscopic ultrasound with fine-needle aspiration (EUS-FNA). Case Report: We present a new case of PCL in an 11-year-old boy who came to our hospital for swelling of the body. A contrast-enhanced computed tomography scan revealed a 7.7×4.5 cm cystic lesion involving head and neck of the pancreas. EUS-FNA was subsequently performed and diagnosis of PCL was made based on result of cytological examination and measurement of aspirate. Conclusion: In agreement with previous reports, we show that EUS-FNA confirmed the cystic lesion in pancreas and further provided the gross, biochemical and cytological features supporting accurate diagnosis of PCL.

Cystic Pancreatic Lymphangioma - Diagnostic Role of Endoscopic Ultrasound

Pancreatic cystic lymphangiomas are rare benign lesions that arise from lymphatic vessels, accounting for less than 0.2% of all pancreatic cysts. Typically it is asymptomatic and discovery occurs during imaging exams for non-pancreatic disease. In the past, a definite diagnosis was made through surgery, with complete resection of all tumoral tissue to prevent recurrence. Nowadays, the development of endoscopic ultrasound (EUS) made it possible to identify these cysts combining morphologic ultrasound features, macroscopic aspirated fluid appearance, biochemical and cytological evaluation of the sample. We report two cases of cystic pancreatic lymphangioma diagnosed through EUS, allowing conservative management without surgery. These cases show that cystic pancreatic lymphangioma should be considered in the differential diagnosis of cystic pancreatic lesions and that EUS is an important tool for their recognition.

Incidental Cystic Lesions in the Pancreas: Resect? EUS? Follow?

Pancreatic cysts challenge clinicians due to their increased incidental identification on radiology imaging, the limitations of currently available diagnostic tools, and potential for malignancy. Following initial identification of an incidental pancreatic cyst, a dedicated pancreatic protocol abdominal CT scan or MRI pancreas with MRCP should be performed. Surgical resection is recommended for all surgical candidates with MD-IPMN, mixed or combined type IPMN, mucinous cystic neoplasm, and solid pseudopapillary neoplasm. Serous cystadenoma may be followed with serial imaging unless the patient develops symptoms, the cyst is larger than 4 cm or rapidly growing, or diagnostic uncertainty remains despite thorough evaluation. Surveillance is also recommended for BD-IPMN without the following features concerning malignancy: obstructive jaundice with a cyst in the head of the pancreas; solid component; nodule; main pancreatic duct ≥10 mm; or cytology suspected or positive for malignancy. BD-IPMN ≥3 cm without concerning features may also be followed carefully, although surgical resection should be considered in surgically fit patients. EUS-FNA for cyst wall cytology, CEA, amylase, and occasionally k-ras mutation are also likely aids in the diagnosis of pancreatic cysts beyond radiologic imaging. This author typically recommends EUS-FNA to further evaluate cysts larger than 1 cm without definitive indication for resection. EUS is also appropriate in patients with solid component, nodule, or size ≥3 cm to aid in decision making, especially in older patients who may be less suitable surgical candidates. A multidisciplinary approach with a team of dedicated gastrointestinal radiologists, pancreatic surgeons, gastrointestinal pathologists, and gastroenterologists is essential for managing patients with pancreatic cysts.

Cystic pancreatic neuroendocrine tumors: the value of cytology in preoperative diagnosis

BACKGROUND

Cystic pancreatic neuroendocrine tumors (cPanNETs) account for 13% to 17% of PanNETs. Although the value of endoscopic ultrasound (EUS) imaging and cyst fluid analysis (CFA) in their preoperative diagnosis has been well described, limited information is available about the diagnostic role of cytology samples obtained from fine-needle aspiration (FNA).

METHODS

Cytopathology records between 1992 and 2013 were searched for all reports of cysts interpreted as PanNET. Patient demographics, clinical and radiologic information, CFA, histopathology, and cytopathology findings were recorded. Performance characteristics of cytology and EUS for the accurate diagnosis of cPanNET were calculated.

RESULTS

In total, 35 FNAs from 33 patients with cPanNETs were identified, and 34 EUS were performed. Cytology made a specific diagnosis of a cPanNET in 71% of the biopsies compared with a specific diagnosis by EUS in 38% of cases. An interpretation of suspicious for cPanNET was given in 77% of cases by cytology and in 47% by EUS. Cytology identified 86% of the lesions as high-risk pancreatic cysts compared with 56% by EUS. Diagnostic morphology was present on both cytology and cell block preparations in 60% of aspirates, on cytology only in 20%, and on cell block only in 20%. CFA was performed on 51% cyst fluids. All cysts but 1 revealed low carcinoembryonic antigen levels (range, 0.2 to >500 ng/mL; mean, 29.5 ng/mL), and amylase levels were <500 U/L in all but 2 cases (range, 16-1493 U/L; mean, 205 U/L).

CONCLUSIONS

Cytology is the most accurate test for preoperative diagnosis of cPanNETs. EUS is insufficiently accurate for independent diagnosis, and carcinoembryonic antigen and amylase analyses are noncontributory.

Huge cystic lymphangioma of the pancreas mimicking pancreatic cystic neoplasm

Lymphangiomas of the pancreas are very rare benign tumors of lymphatic origin, accounting for less than 1% of these neoplasms. We report a case of a 55-year-old woman who presented with a palpable mass in the left abdomen. Abdominal sonography and computed tomography showed a lobulated, hypodense mass extending from the left diaphragm to the pelvis, measuring 10 × 25 cm. A preoperative diagnosis of mucinous cystadenoma of the pancreas was suggested and the patient underwent laparotomy. Distal pancreatectomy with splenectomy was performed, encompassing a segment of descending colon because of close relationship to the mass. The cystic mass was histologically diagnosed as lymphangioma of the pancreas. The patient is well and free of disease 12 months after surgery. Pancreatic lymphangioma should be kept in mind when a huge, multiloculated mass is encountered in the abdomen, especially in adult women. Although lymphangioma is considered a benign tumor, involvement of adjacent organs sometimes occurs and extended resection is required to obtain a radical treatment.