The value of transoesophageal ultrasonography in the management of a mediastinal foregut cyst

A systematic review of the prevalence of germline pathogenic variants in patients with pancreatic cancer

The genetics of pancreatic ductal adenocarcinoma (PDAC) is complex with patients reported to harbor germline pathogenic variants (PVs) in many different genes. PDAC patients with familial pancreatic cancer (FPC) are more likely to carry germline PVs but there is no consensus main gene involved in FPC. We performed a systematic review of publications from PubMed and Scopus reporting PVs in patients with FPC, sporadic pancreatic cancer (SPC) and unselected cohorts of PDAC patients undergoing genetic testing and calculated a cumulative prevalence of PVs for each gene evaluated across these three groups of patients. When available, variants in the selected publications were reclassified according to the American College of Medical Genetics and Genomics classification system and used for prevalence calculations if classified as pathogenic or likely pathogenic. We observed an increased prevalence of PVs in FPC compared to SPC or unselected PDAC patients for most of the 41 genes reported. The genes with the highest prevalence of carriers of PVs in FPC were ATM, BRCA2, and CDKN2A. BRCA2 and ATM showed the highest prevalence of PVs in both SPC and unselected PDAC cohorts. Several genes with the highest prevalence of PVs are involved in breast and ovarian cancer suggesting strong overlap with underlying genetics in these disorders but no single gene was predominant. More research is needed to further understand the risk of PDAC associated with these many diverse genes.

Endoscopic ultrasound-guided fine-needle aspiration in the diagnosis of foregut duplication cysts: the value of demonstrating detached ciliary tufts in cyst fluid

BACKGROUND

The management of foregut duplication cysts is controversial, especially in asymptomatic patients. The safety and accuracy of endoscopic ultrasound (EUS) and EUS-fine-needle aspiration EUS-FNA) in confirming the nature of cysts by using electron microscopy (EM) has not been reported. In this study, the authors describe the utility of demonstrating detached ciliary tufts (DCTs) in the diagnosis of foregut duplication cysts with EUS-FNA.

METHODS

Consecutive patients with suspected mediastinal masses or mediastinal cysts on imaging studies were evaluated prospectively by EUS and EUS-FNA. Cyst fluid was examined by routine cytologic techniques. In two patients, EM was performed to confirm the nature of DCTs.

RESULTS

Ten consecutive patients were evaluated with EUS and EUS-FNA. Seventy percent of the cysts were characterized by computed tomography (CT) scans as solid masses. The mean greatest cyst dimension measured 34 mm x 48 mm by EUS. Microscopic examination of the cyst content revealed mucinous material, cellular debris, and DCTs. The latter were seen in routine cytologic preparations and by EM. Patients were followed up to a median of 321 days. Due to EUS-FNA confirmatory diagnoses of foregut duplication cysts, none of the patients except 1 underwent surgical resection after developing pneumonia 6 months later. Histologic sections of the resected specimen confirmed the presence of (foregut cyst, bronchogenic type). All other patients were asymptomatic. Cysts size and nature did not change on repeated imaging studies.

CONCLUSIONS

EUS was superior compared with CT scanning in characterizing foregut duplication cysts. EUS-FNA is safe and accurate in the diagnosis of foregut duplication cysts. The demonstration of DCTs in cyst fluid and the absence of malignant cells confirmed the benign nature of these lesions, allowing conservative and expectant management for these patients.

Case report: Squamous carcinoma in an oesophageal foregut cyst

Cysts within the oesophageal wall may represent inclusion cysts, retention cysts or developmental cysts. Foregut duplications are developmental anomalies, which occur as a result of abnormal canalization of the foregut during intrauterine life. Malignant transformation is an extremely rare event occurring within oesophageal cysts, adenocarcinoma being the most common histology. We report a case of squamous cell carcinoma arising within an oesophageal cyst affecting the upper third of the oesophagus. The malignant cyst was not amenable to primary surgical resection and hence was treated using chemo-radiotherapy. The treatment gave good disease control, at the expense of a high oesophageal stricture. Chemo-radiotherapy is an alternative treatment modality to achieve long-term disease control in squamous cell carcinoma complicating oesophageal foregut cyst when primary surgical resection is not possible.

Predictive factors for acute pancreatitis and hyperamylasemia after endoscopic papillary balloon dilation

BACKGROUND

Although endoscopic papillary balloon dilation may result in acute pancreatitis or hyperamylasemia, the risk factors for these complications have not been well documented. Risk factors predictive of acute pancreatitis and hyperamylasemia after endoscopic papillary balloon dilation were retrospectively analyzed.

METHODS

In 118 patients who underwent endoscopic papillary balloon dilation for choledocholithiasis, postendoscopic papillary balloon dilation acute pancreatitis and hyperamylasemia (at least 3-fold elevation) were investigated. A multivariate analysis was conducted for 20 potential risk factors related to clinical and procedure characteristics.

RESULTS

Bile duct clearance was achieved in 113 patients. Early complications in the form of mild pancreatitis occurred in 7 patients (6%). Multivariate analysis identified history of acute pancreatitis as the only risk factor for postendoscopic papillary balloon dilation pancreatitis. Postendoscopic papillary balloon dilation hyperamylasemia occurred in 30 patients (25%). Multivariate analysis identified 4 independent risk factors for hyperamylasemia: an age of 60 years or less, previous pancreatitis, bile duct diameter 9 mm or less, and difficult bile duct cannulation.

CONCLUSIONS

Endoscopic papillary balloon dilation is associated with a relatively low occurrence (6%) of pancreatitis but a high frequency (25%) of hyperamylasemia. The latter may represent pancreatic irritation or latent pancreatic injury. Particular care is necessary when endoscopic papillary balloon dilation is performed in younger patients, those with a history of pancreatitis, patients with a nondilated bile duct, and when cannulation is difficult.

Mixed foregut cyst associated with esophageal atresia

The authors report an unusual case of a thoracoabdominal foregut malformation with components of bronchogenic, esophageal duplication, and pancreatic enterogenous cysts, that presented in a child with esophageal atresia. J Pediatr Surg 36:939-940.

Minimally invasive approaches to mediastinal neoplasms

The goal of minimal-access surgery is to cause the least trauma necessary to gain exposure for an operative procedure. Application of this principle to mediastinal neoplasms involves the use of small incisions with both mediastinoscopy and video-assisted thoracoscopic surgery (VATS). The mediastinum is divided into anterior, middle, and posterior compartments, and this anatomy provides a framework for discussion of diagnostic and therapeutic procedures. Neoplasms occur with a characteristic frequency that varies with age and location. Neurogenic tumors and thymic neoplasms account for one third of all masses. Knowledge of the potential cause of a neoplasm and the surrounding anatomy provides the context for determining the surgical approach. The operative indications and goals of a procedure should not be significantly affected by the operative approach. Conversion from a minimal-access approach to a more traditional incision should be an anticipated possibility that is often undertaken as the next logical step rather than an expression of exasperation.

Diagnosis of foregut duplication cysts by endoscopic ultrasonography

BACKGROUND & AIMS

Foregut duplication cysts are rare congenital anomalies of enteric origin found most commonly in children and rarely in adults. They are usually found in adults on routine radiological studies and represent a challenging diagnostic problem. Conventional imaging tests do not lead to a conclusive diagnosis. With endoscopic ultrasonography, it is possible to distinguish between cystic and solid masses and to accurately establish the location of the cyst in relation to the gastrointestinal wall and to the mediastinum.

METHODS

Seven patients who had endoscopic ultrasonography performed because of differentiation between a cystic or solid mass lesion in the chest or abdomen could not be made with conventional radiological methods are described.

RESULTS

In all patients, a definite diagnosis was established by endoscopic ultrasonography. The diagnosis was confirmed in 2 patients after surgical excision.

CONCLUSIONS

Surgery can be avoided in patients with asymptomatic enteric duplication cysts diagnosed by endoscopic ultrasonography.

Transesophageal echocardiography in the evaluation of mediastinal masses

To assess the diagnostic impact of transesophageal echocardiography in the evaluation of mediastinal masses, 30 patients with mediastinal abnormalities detected by routine chest roentgenogram underwent transthoracic and transesophageal echocardiography. Subsequently, 29 of the patients underwent computed tomography and 16 underwent magnetic resonance imaging. The location and structure of the masses as well as their relationship to the surrounding structures were assessed. Anatomic confirmation and histopathologic diagnosis of the mediastinal masses by surgical resection and biopsy was available for all patients. Transesophageal echocardiography was more accurate than transthoracic echocardiography in detecting mediastinal masses (90% versus 73%), in identifying their structure (100% versus 90%), and in evaluating their relationship to contiguous organs (89% versus 81%). No complication was observed during the examinations. Computed tomography correctly diagnosed the location, structure, and relationships in all patients but one; magnetic resonance imaging correctly evaluated the mediastinal masses in all 16 patients. Our study suggests that transesophageal echocardiography is a valuable and safe complementary method of evaluating mediastinal masses. Moreover, this technique allows the obstruction of vessels and heart cavities, valve regurgitation, and right and left ventricular function to be easily assessed.

Symptomatic congenital lesions of the alimentary tract in adults

Congenital anomalies of the alimentary tract can evade detection into adulthood because they cause only moderate symptoms or they escape purview of a prepared observer. In other instances, evolution or copathogenesis may need to occur before the lesions become manifest. We have managed 17 of these patients presenting at ages 23 to 71 years. The median duration of symptoms was 5 years, ranging from 1 months to 23 years. Defects of foregut embryogenesis predominated (71%). We were able to establish the correct diagnosis before operating on nine patients, but three had already had a previous celiotomy for the same problem so a truly preoperative diagnosis was possible in only six (35%). The literature validates the dominance of foregut anomalies in adults. There is no older age limit that would exclude consideration of these lesions. Endoscopy, computerized tomography, and ultrasonography have greatly facilitated recognition, but our experience suggests that the principal obstacle to timely diagnosis is the reluctance to consider a congenital cause for an adult's symptoms.

Imaging of congenital esophageal cysts in adults

The radiologic imaging of esophageal cysts (EC) in adults is described. These rare cysts, often detected incidentally on routine chest radiographs, seldom produce symptoms, but they may cause precordial sensations, arrhythmias, and dysphagia. They may also bleed and become malignant. As surgical excision is the treatment of choice, the preoperative diagnosis must be exact. For this, magnetic resonance imaging (MRI) or endoscopic ultrasound seem to be the imaging methods of choice even if a plausible diagnosis can be advanced on computed tomography (CT). Chest x-ray or esophagus roentgenogram have little differential diagnostic value.