Pathology Report: Presacral Noncommunicating Enteric Duplication Cyst

Retroperitoneal Foregut Duplication Cyst Containing Gastric, Respiratory, and Pancreatic Tissue Misinterpreted as an Adrenal Mass on Imaging: A Case Report and Review of the Literature

Foregut duplication cyst is most commonly seen in the posterior mediastinum without communication with adjacent organs or presence of other malformations and typically shows ectopic gastric or respiratory epithelium. The finding of ectopic pancreatic tissue is extremely rare. A 15-year-old female patient presented with elevated blood pressure, intermittent right flank pain for 18 months. An abdominal MRI revealed a 4 cm right cystic retroperitoneal mass, initially thought to arise from the right adrenal gland. Intraoperatively, the mass was centered in the retroperitoneum between the right adrenal gland and kidney, without attachments to these organs and no communication with other structures, and it was completely excised. Gross examination revealed a 3.5 cm well-circumscribed solid and cystic mass with orange-white cut surface and cloudy fluid surrounded by variable amounts of adipose tissue. On microscopic examination, the cysts were lined by respiratory and gastric antral/oxyntic-type mucosa, surrounded by muscularis mucosae, submucosal tissue, muscularis propria, and perienteric tissue. Within the muscular propria, exocrine pancreatic tissue was also noted. The patient is well with 7-months of follow up. This case is the first one reporting gastric, respiratory, and pancreatic epithelia.

Presacral tumors: A systematic review of literature

Presacral/Retrorectal tumors (RRT) are rare lesions that comprise a multitude of histological types. Data on surgical management are limited to case reports and small case series. The aim of the study was to provide a comprehensive review of the epidemiology, pathological subtypes, surgical approaches, and clinical outcomes. A PubMed search using terms "retrorectal tumor" and "presacral tumor" was used to identify articles reporting RRT of non-urological, non-gynecologic, and non-metastatic origin. Articles included were between 2015 and 2023. A total of 68 studies were included, comprising 570 patients. About 68.2% of patients were female, and the mean overall age of both sexes was 48.6 years. Based on histopathology, 466 patients (81.8%) had benign lesions, and 104 (18.2%) were malignant. In terms of surgical approach, 191 (33.5%) were treated anteriorly, 240 (42.1%) through a posterior approach, and 66 (11.6%) combined. The mean length of stay was 7.6 days. Patients treated using the posterior approach had a shorter length of stay (5.7 days) compared to the anterior and combined approaches. RRT are rare tumors of congenital nature with prevalence among the female sex. R0 resection is crucial in its management, and minimal access surgery appears to be a safer option in appropriate case selection.

An adult case of a retroperitoneal isolated enteric duplication cyst with the imaging changes over time

Background

Adult cases of retroperitoneal isolated enteric duplication cyst (IEDC) are rare, with only 17 case reports in the relevant literature. We herein present a case, which was characterized by changes in intra-cystic density on computed tomography (CT), which was safely resected by laparoscopic surgery.

Case presentation

The patient was a 60-year-old male who received abdominal CT to investigate the cause of increased serum CA19-9 levels. CT revealed a unilocular cystic mass located in the lower right retroperitoneum. The size increased from 5 to 10 cm in three and a half years and the CT value decreased from 101 Hounsfield Units (HU) to 20 HU. We performed laparoscopic surgical resection, because the possibility that the enlargement of the lesion represented malignant transformation could not be denied. The large cystic mass firmly adhered to the appendix and its mesentery via the retroperitoneum, the appendix was resected en bloc with the cystic lesion. Microscopically, it had no communication with the appendix, and had an intestinal wall structure of muscularis mucosae and muscularis propria. The final pathological diagnosis was IEDC in the retroperitoneal space. There was no histological evidence of malignancy.

Conclusion

When we encounter a retroperitoneal cystic lesion, we should consider the possibility of malignancy to determine the treatment strategy and perform a careful operation without breaking the cyst wall, irrespective of the preoperative diagnosis.

Primary Cutaneous Enteric Duplication Cyst: A Novel Entity

ABSTRACT

Enteric duplication cysts (EDCs) are rare congenital malformations consisting of double-walled cystic or tubular structures lined by gastrointestinal type epithelium. EDCs share a common muscular wall and blood supply with the adjacent duplicated bowel with very rare exceptions. The majority of EDCs are intraabdominal with cases less commonly intrathoracic or thoracoabdominal. To the best of our knowledge, we present the first reported case of primary cutaneous EDC to occur outside the abdominal and thoracic cavities. A 17-year-old male without a significant medical or surgical history underwent excision of a cystic nodule on the left hip. On histopathology, a dermal to subcuticular cyst exhibited an epithelial lining with 2 distinct components including cuboidal to columnar mucinous cells (CK7+, CK20-, and CDX2-) and complex glandular colonic-type mucosa (CK7-, CK20+, and CDX2+). A thick muscular wall resembling muscularis mucosa and muscularis propria surrounded the cyst. Findings supported a primary cutaneous enteric duplication cyst of uncertain developmental etiology. The novel nature of this entity could represent a diagnostic challenge.

Rare presentation of rectal duplication cyst as perineal hernia in an adult

Rectal duplication cysts are rare congenital anomalies of the gastrointestinal tract. They can present with pain, gastrointestinal bleeding, infection or compressive symptoms on the rectum and urinary bladder. A 79-year-old man presented with a 8×5 cm swelling in the sacral region above the natal cleft with a positive cough impulse. During surgical exploration, there were two cysts with the posterior one presenting as the hernia. The cyst was excised and histopathological examination confirmed a diagnosis of rectal duplication cyst. Rectal duplications can lie anterior or more commonly posterior to the rectum. Differential diagnoses include dermoid cyst, diverticular cyst, sacrococcygeal teratoma or meningocele and endoscopic ultrasound is imaging of choice for diagnosis. Surgical excision is the treatment of choice. This is a rare presentation of a rectal duplication cyst as a perineal hernia with only a handful of cases in literature.

Enteric duplication cysts in children: varied presentations, varied imaging findings

Enteric duplication cysts (EDCs) are rare congenital malformations formed during the embryonic development of the digestive tract. They are usually detected prenatally or in the first years of life. The size, location, type, mucosal pattern and presence of complications produce a varied clinical presentation and different imaging findings. Ultrasonography (US) is the most used imaging method for diagnosis. Magnetic resonance (MR) and computed tomography (CT) are less frequently used, but can be helpful in cases of difficult surgical approach. Conservative surgery is the treatment of choice. Pathology confirms the intestinal origin of the cyst, showing a layer of smooth muscle in the wall and an epithelial lining inside, resembling some part of the gastrointestinal tract (GT). We review the different forms of presentation of the EDCs, showing both the typical and atypical imaging findings with the different imaging techniques. We correlate the imaging findings with the surgical results and the final pathological features. TEACHING POINTS: • EDCs are rare congenital anomalies from the digestive tract with uncertain pathogenesis. • More frequently, diagnosis is antenatal, with most EDCs occurring in the distal ileum. • Ultrasonography is the method of choice for diagnosis of EDCs. • Complicated EDCs can show atypical imaging findings. • Surgery is necessary to avoid complications.