Coexisting ovarian serous cystadenoma with fibroma: A very unusual combination

Surface epithelial neoplasms are the most common ovarian tumors, constituting around 60% of all ovarian malignancies. They are classified as benign, borderline, and malignant. Ovarian cystadenomas are common benign epithelial neoplasms which carry an excellent prognosis. Ovarian thecoma-fibroma groups are uncommon sex cord-stromal neoplasms, constituting 1.0%-4.0% of all ovarian tumors. Most of them are benign and often found in postmenopausal patients. Combination tumors in the ovary are known. The most common combination is mucinous cystadenoma which occurs in association with Brenner tumor, mature cystic teratoma, Sertoli-Leydig cell tumor, or even a serous cystadenoma. A combination of surface epithelial and thecoma-fibroma group is very rarely encountered. A case of one such combination of serous cystadenoma and fibroma of the ovary is being presented here in a postmenopausal woman.

[Neonatal bilateral ovarian cystadenoma: Conservative or surgical treatment?]

INTRODUCTION

Bilateral complex ovarian cysts in newborns are rare and their reporting becomes imperative to in crease knowledge about the best therapeutic management.

OBJECTIVE

To describe the clinical case of a newborn with a diagnosis of bilateral complex ovarian cysts and to discuss the conditions for conservative or surgical management according to the ultrasound characteristics of the cyst.

CLINICAL CASE

At 35 weeks of gestational age, prenatal ultrasound identified the presence of cystic masses in both adnexa, so it was decided to interrupt the pregnancy by cesarean section at 37 weeks. After birth, bilateral ovarian cysts of 3.5 x 4.4 x 2.7 and 3.4 x 2.4 x 3.3 cm, right and left, respectively, were corro borated. The right cyst had a septum of 1.4 mm thick and thickened wall of 3 mm which was com patible with complex cysts. On the 4th day of extrauterine life, laparoscopic vacuum aspiration and deroofing with electrocautery of the upper wall of both cysts was performed, without complications. The diagnosis of ovarian serous cystadenoma was made by pathological anatomy.

CONCLUSIONS

We describe a case with adequate prenatal diagnosis and laparoscopic surgical intervention of a bilateral ovarian cyst > 4 cm. Prenatal diagnosis is essential for choosing the best therapy management (con servative or surgical) depending on the echography characteristics of the cyst. Neonatal surgery is recommended for simple ovarian cysts >4 cm, complex cysts regardless of their size, and those that become complex cysts during conservative management.

Biliary cystadenoma: A rare occurrence

Biliary cystadenoma is a rare benign tumour with the potential to transform into malignant carcinoma of the biliary ductal system. There is difficulty in differentiating a benign one from a malignant biliary cystadenoma, and therefore these lesions should always be completely resected. We report a case of biliary cystadenoma which underwent a complete resection.

Overview and comparison of guidelines for management of pancreatic cystic neoplasms

Pancreatic cysts are identified at an increasing frequency. Although mucinous cystic neoplasms represent a pre-malignant condition, the majority of these lesions do not progress to cancer. Over the last 10 years several societies have established guidelines for the diagnosis, initial evaluation and surveillance of these lesions. Here we provide an overview of five commonly used guidelines: 2015 American Gastroenterological Association, 2017 International Association of Pancreatology, American College of Gastroenterology 2018, European Study Group and American College of Radiology. We describe the similarities and differences between the methods used to formulate these guidelines, the population they target and their approaches towards initial evaluation and surveillance of cystic lesions.

Biliary cystadenoma associated with Opisthorchis viverrini infection in a domestic cat (Felis catus)

A 12-year-old, female, domestic cat (Felis catus) presented with dehydration, emaciation, anorexia, and lethargy. The cat was unresponsive to medical treatment and euthanized; the carcass was submitted for pathological diagnosis. Necropsy revealed icteric mucous membranes. The liver was enlarged, with multinodular, cystic, white masses, 0.5-4.0 cm in diameter, scattered throughout. Microscopically, the biliary epithelium presented with a proliferation of multifocal cystic masses, occasionally with periodic acid-Schiff-positive fluid within the cysts. Simple cuboidal epithelial cells showed small, round to oval, vesicular nuclei and rare mitotic figures. There were also multifocal trematode-like parasites situated within the biliary tracts. Immunohistochemistry of the cystic masses was positive for pan-cytokeratin and proliferating cell nuclear antigen, while negative for vimentin. Molecular analysis and gene sequencing of the parasite indicated that it was Opisthorchis viverrini. Based on the pathological findings and molecular analysis, the cat was diagnosed with biliary cystadenoma related to O. viverrini infection. This report described an unusual case of O. viverrini infection associated with biliary tumor in a cat, and raises the possibility of domestic cats as a reservoir host of the human liver fluke.

[A 12-kg benign ovarian tumour in a teenage girl]

This is case report of a 14-year-old girl with severe abdominal swelling over a period of 12 months. The patient was admitted to the local children's hospital, and an ultrasound scan was performed. The scan showed a tumour in the right ovary. Further investigation with MRI confirmed the tumour as cystic, and resection and pathological examination revealed a 12-kg benign cystadenoma of the right ovary.

A novel approach for selecting combination clinical markers of pathology applied to a large retrospective cohort of surgically resected pancreatic cysts

OBJECTIVE

Our objective was to develop an approach for selecting combinatorial markers of pathology from diverse clinical data types. We demonstrate this approach on the problem of pancreatic cyst classification.

MATERIALS AND METHODS

We analyzed 1026 patients with surgically resected pancreatic cysts, comprising 584 intraductal papillary mucinous neoplasms, 332 serous cystadenomas, 78 mucinous cystic neoplasms, and 42 solid-pseudopapillary neoplasms. To derive optimal markers for cyst classification from the preoperative clinical and radiological data, we developed a statistical approach for combining any number of categorical, dichotomous, or continuous-valued clinical parameters into individual predictors of pathology. The approach is unbiased and statistically rigorous. Millions of feature combinations were tested using 10-fold cross-validation, and the most informative features were validated in an independent cohort of 130 patients with surgically resected pancreatic cysts.

RESULTS

We identified combinatorial clinical markers that classified serous cystadenomas with 95% sensitivity and 83% specificity; solid-pseudopapillary neoplasms with 89% sensitivity and 86% specificity; mucinous cystic neoplasms with 91% sensitivity and 83% specificity; and intraductal papillary mucinous neoplasms with 94% sensitivity and 90% specificity. No individual features were as accurate as the combination markers. We further validated these combinatorial markers on an independent cohort of 130 pancreatic cysts, and achieved high and well-balanced accuracies. Overall sensitivity and specificity for identifying patients requiring surgical resection was 84% and 81%, respectively.

CONCLUSIONS

Our approach identified combinatorial markers for pancreatic cyst classification that had improved performance relative to the individual features they comprise. In principle, this approach can be applied to any clinical dataset comprising dichotomous, categorical, and continuous-valued parameters.

Impact of next-generation sequencing on the clinical diagnosis of pancreatic cysts

BACKGROUND AND AIMS

The value of next-generation sequencing (NGS) of pancreatic cyst fluid relative to the clinical and imaging impression has not been well-studied. The aim of this study was to assess the impact of NGS on the clinical diagnosis from imaging and carcinoembryonic antigen (CEA) and thus the management of pancreatic cysts.

METHODS

Ninety-two pancreatic cyst fluids from 86 patients were analyzed by cytology, CEA, and targeted NGS. Cysts were classified by imaging as nonmucinous, mucinous, or not specified. NGS results were compared with the imaging impression stratified by CEA and cytology.

RESULTS

NGS impacted the clinical diagnosis by defining a cyst as mucinous in 48% of cysts without elevated CEA levels. The VHL gene in 2 intraductal papillary mucinous neoplasms (IPMNs) supported a serous cystadenoma. Twenty percent of cysts that were nonmucinous by imaging were mucinous by NGS. Of the 14 not-specific cysts, CEA levels were not elevated in 12 (86%), and NGS established a mucinous etiology in 3 (25%). A KRAS or GNAS mutation supported an IPMN with nonmucinous CEA in 71%. A KRAS mutation reclassified 19% of nonneoplastic cysts with nonmucinous CEA as mucinous. Seven cyst fluids (8%) had either a TP53 mutation or loss of CDKN2A or SMAD4 in addition to KRAS and/or GNAS mutations; 5 of 7 (71%) were clinically malignant, and high-grade cytology was detected in all 5. Overall, CEA was more specific for a mucinous etiology (100%), but NGS was more sensitive (86% vs 57%).

CONCLUSIONS

NGS of pancreatic cyst fluid impacts clinical diagnosis and patient management by defining, supporting, or changing the clinical diagnosis based on imaging and CEA. NGS was most valuable in identifying mucinous cysts with nonmucinous CEA. An added benefit is the potential to detect mutations late in the progression to malignancy that may increase the risk classification of the cyst based on imaging and cytology.

Arrangements of hepatobiliary cystadenoma complicated with congenital choledochal cyst: a case report and literature review

Hepatobiliary cystadenoma complication with congenital choledochal cyst is extremely rare and has never been reported in literatures so far.The aim of the study was to investigate the disease arrangements by analyzing the case and performing a systematic review of the literature.This case report documents the details and clear patterns of the patient. A 65-year-old woman with fever (39.2°C), nausea, vomiting, and chronic hepatitis B imaging demonstrated a left hepatic multilocular cystic mass and cystic dilated common bile duct.A regular left hemihepatectomy was performed with resection of the entire tumor and choledochal cyst.The surgical margins were negative and a final diagnosis of hepatobiliary cystadenoma complicated with congenital choledochal cyst was established. The patient had an uneventful postoperative recovery and liver function returned to normal levels.Main lessons learned from this case are: the awareness should be raised about the disease to avoid misdiagnosis; preoperative ultrasonography, computed tomography, magnetic resonance imaging, and magnetic resonance cholangiopancreatography play an important role in detecting the lesion; the scope and timing of the surgery should be determined, which provide the chance of cure to complete resection of the tumor.

[Clinicopathologic characteristics of the pancreatic cystic tumors]

Formerly an infrequent pathology, pancreatic cystic tumors stand nowadays for 25% of all pancreatic surgical diseases.

OBJECTIVE

Evaluate the frequency of the presentation of each type and the behavior of the pancreatic cystic tumors that went to surgery in our unit.

MATERIALS AND METHODS

In our Pancreas Unit, 708 patients with pancreatic tumors underwent surgery in the period between October 2002 and December 2013. 146 cases of pancreatic cystic tumors taken from that group are the topic of the present study.

RESULTS

Even when diagnosing pancreatic tumors as cystic tumors was possible in 91% of cases during pre-op evaluation, categorizing the type of cystic tumor was only possible in 73% of cases. In 128 cases (88%), cystic tumors were removable. Due to advanced disease, in 3 cases only diversion surgery was possible and, in 15 cases, exploration and biopsy was the only choice. When the frequency of malignancy was assessed for all four types of pancreatic cystic tumors, the one most frequently becoming malignant was mucinous papillary intraductal (53%), followed by mucinous cystic (50%). Solid pseudopapillary pancreatic cystic tumors became malignant in 29% of cases and for serous cystoadenoma the frequency of malignancy was nihil.

CONCLUSIONS

Cystic tumors are the most frequent type of pancreatic lesion. It's of paramount importance to categotize them since risk of malignancy can be as high as 52% in case of mucinous intraductal papillary type.

Mammary analogue secretory carcinoma mimicking salivary adenoma

Mammary analogue secretory carcinoma (MASC) is a recently described salivary gland tumor characterized by ETV6 translocation. It appears that prior studies have identified MASC by reviewing salivary gland carcinomas, such as acinic cell carcinoma and adenocarcinoma, not otherwise specified. To address the possibility of MASC mimicking benign salivary neoplasms we reviewed 12 salivary gland (cyst)adenomas diagnosed prior to the discovery of MASC. One encapsulated (cyst)adenoma of the parotid gland demonstrated features of MASC. The diagnosis was confirmed by fluorescence in situ hybridization with an ETV6 break-apart probe. An unusual complex pattern of ETV6 rearrangement with duplication of the telomeric/distal ETV6 probe was identified. This case illustrates that MASC may mimic salivary (cyst)adenomas. To more accurately assess true clinical and morphologic spectrum of MASC, future studies may have to include review of salivary (cyst)adenomas. The differential diagnosis of MASC may have to be expanded to include cases resembling salivary (cyst)adenomas.

Giant biliary cystadenoma complicated with polycystic liver: A case report

Biliary cystadenoma (BCA) is a rare hepatic neoplasm. Although considered a benign cystic tumor of the liver, BCA has a high risk of recurrence with incomplete excision and a potential risk for malignant degeneration. Correct diagnosis and complete tumor excision with negative margins are the mainstay of treatment. Unfortunately, due to the lack of presenting symptoms, and normal laboratory results in most patients, BCA is hard to distinguish from other cystic lesions of the liver such as biliary cystadenocarcinoma, hepatic cyst, hydatid cyst, Caroli disease, undifferentiated sarcoma, intraductal papillary mucinous tumor, and hepatocellular carcinoma. Ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI) may be necessary. They demonstrate intrahepatic cystic lesions with features such as mural nodules, varying wall thickness, papillary projections, and internal septations. Nevertheless, surgery is still the only means of accurate diagnosis. Definitive diagnosis requires histological examination following formal resection. We describe a 57-year-old woman initially diagnosed with polycystic liver who was subsequently diagnosed with giant intrahepatic BCA in the left hepatic lobe. This indicates that both US physicians and hepatobiliary specialists should attach importance to hepatic cysts, and CT or MRI should be performed for further examination when a diagnosis of BCA is suspected.

Evaluation of hepatic cystic lesions

Hepatic cysts are increasingly found as a mere coincidence on abdominal imaging techniques, such as ultrasonography (USG), computed tomography (CT) and magnetic resonance imaging (MRI). These cysts often present a diagnostic challenge. Therefore, we performed a review of the recent literature and developed an evidence-based diagnostic algorithm to guide clinicians in characterising these lesions. Simple cysts are the most common cystic liver disease, and diagnosis is based on typical USG characteristics. Serodiagnostic tests and microbubble contrast-enhanced ultrasound (CEUS) are invaluable in differentiating complicated cysts, echinococcosis and cystadenoma/cystadenocarcinoma when USG, CT and MRI show ambiguous findings. Therefore, serodiagnostic tests and CEUS reduce the need for invasive procedures. Polycystic liver disease (PLD) is arbitrarily defined as the presence of > 20 liver cysts and can present as two distinct genetic disorders: autosomal dominant polycystic kidney disease (ADPKD) and autosomal dominant polycystic liver disease (PCLD). Although genetic testing for ADPKD and PCLD is possible, it is rarely performed because it does not affect the therapeutic management of PLD. USG screening of the liver and both kidneys combined with extensive family history taking are the cornerstone of diagnostic decision making in PLD. In conclusion, an amalgamation of these recent advances results in a diagnostic algorithm that facilitates evidence-based clinical decision making.

Intrahepatic biliary cystadenoma presenting with pleural effusion

Hepatobiliary cystadenomas are rare cystic neoplasms that often occur in middle aged women. The exact etiology of these tumors is unknown. Diagnosis is often delayed in these cases. However, misdiagnosis and inappropriate treatment may result in unfavorable outcome. We report a case of hepatobiliary cystadenoma with pleural effusion. We also review the literature and discuss the current diagnostic and treatment modalities.

Cystic tumors of the pancreas: imaging and management

Cystic tumors of the pancreas are a subset of rare pancreatic tumors that vary from benign to malignant. Many have specific imaging findings that allow them to be differentiated from each other. This article (1) reviews the imaging features of the common cystic pancreatic lesions, including serous microcystic adenoma, mucinous cystic tumor, intraductal papillary mucinous tumor, and solid pseudopapillary tumor, and including the less common lesions such as cystic endocrine tumors, cystic metastases, cystic teratomas, and lymphangiomas; and (2) provides comprehensive algorithms on how to manage the individual lesions, with recommendations on when to reimage patients.

Surgical management of simple liver cysts

BACKGROUND

To date there is no consensus about the treatment of choice for symptomatic or complicated simple liver cysts.

METHODS

A retrospective study of all patients diagnosed with simple liver cyst surgically managed at Ramon y Cajal Hospital during the period between 1998 and 2008 was performed.

RESULTS

We analyzed 21 patients, 18 females (85.7%) and three males (14.3%) with a mean age of 64.2 years. Ten patients (47.6%) were asymptomatic. During follow-up, cyst growth was determined. Three patients (14.3%) presented an infected simple liver cyst. Seven patients (33.3%) presented abdominal pain and one patient (4.8%) reported an abdominal mass during self-examination. Treatment consisted of unroofing and cyst drainage in 18 patients (85.7%) and cyst enucleation in three patients (14.3%). Postoperative complications appeared in two patients (9.6%). There was no mortality. Pathology revealed simple liver cyst in 17 patients (80.9%) and liver cystadenoma in four (19.1%). The latter were reoperated for complete cyst resection. Recurrence rate was 23.5% (four cases) for the simple liver cysts. In all cases, unroofing was performed.

CONCLUSION

In some cases, cystadenomas show ultrasonographic and radiological features similar to simple liver cysts, implying an incorrect surgical approach. We recommend performing an intraoperative biopsy of all resected liver cysts to confirm its nature. Unroofing is associated with a high recurrence rate (>20%). Therefore, we propose cyst enucleation as the best surgical treatment.

Giant multilocular sex cord tumor with annular tubules associated with precocious puberty

We report a case of sex cord tumor with annular tubules featuring a giant multilocular cyst, grossly similar to cystadenoma, in the ovary of an 8.5 year old girl. Estrogen-related symptoms, including precocious puberty and irregular uterine bleeding, immediately improved after tumor resection.

[Increasing abdominal girth in a female patient with a gastric band]

BACKGROUND

Insufficient weight loss after gastric band placement is generally linked to band-related complications or a persistently unhealthy diet.

CASE DESCRIPTION

A 47-year-old woman with a history of gastric band placement presented with complaints of decreased mobility, dyspnoea, gastro-oesophageal reflux and a progressive increase in abdominal girth. Initially, these symptoms were attributed to an unhealthy diet. However, additional testing showed a large intra-abdominal multicystic lesion originating from the ovaries. The patient was operated and two large serous cystadenomas were removed, after which the symptoms disappeared almost immediately.

CONCLUSION

Abdominal complaints after bariatric surgery can often be explained by surgical complications or unhealthy eating habits. Although the cause of certain complaints is sometimes obvious, alternative diagnoses need to be considered. If the abdominal girth in middle-aged women increases, ovarian disorders must always be considered in the differential diagnosis and appropriate additional diagnostic testing need to be carried out.

[Intrahepatic biliary cystadenoma: experience with 10 consecutive cases at a single center]

OBJECTIVE

To summarize the clinical experience with diagnosis and treatment of intrahepatic biliary cystadenoma (IBCA).

METHODS

We retrospectively analyzed the data of 10 consecutive IBCA cases treated in our department in light of the characteristics of the epidemiology, radiology, lab tests, pathology and prognostic.

RESULTS

The patients are all female with an average age of 48.9 (16-73) years. The number of asymptomatic, slightly symptomatic and severe symptomatic patients was 4, 4 and 2, respectively. Radiological examination showed segmented cystic lesions in all the cases with an average diameter is 13.3∓4.9 cm. The incidence of segmentation, papillary or nodular hyperplasia, and calcification within the lesions was 90%, 60% and 20%, respectively. Macroscopic examination of the specimen showed compartmentation in the lesions, and microscopically, the lesions all showed lining of cubic or columnar epithelium on the inner wall with ovary-like or fibrous stroma. Complete resection of the tumor was achieved in 8 cases and partial resection was performed in 2 cases. The patients were followed up for a mean of 55.3 (12-164) months, and none of the patients with complete tumor resection showed recurrence, while both of the two patients with partial resection had postoperative recurrence.

CONCLUSION

IBCA is a rare cystic lesion occurring primarily in middle-aged women. The preoperative diagnosis of this disease relies primarily on radiological evidences, and a complete resection of IBCA may prolong the patient survival.

Primary retroperitoneal acinar cell cystadenoma

In this report, we describe a case of hitherto unreported primary retroperitoneal acinar cell cystadenoma that morphologically and immunophenotypically resembled pancreatic acinar cell cystadenoma. Pancreatic acinar cell cystadenoma is a very uncommon benign lesion characterized by acinar cell differentiation, the evidence of pancreatic exocrine enzyme production, and the absence of cellular atypia. Our case occurred in a 55-year-old woman presenting a 10-cm multilocular cystic lesion in the retroperitoneum thought to be a mucinous cystic neoplasm. At laparotomy, the cystic mass, which showed no connection with any organ, was completely resected with a clinical diagnosis of cystic lymphangioma. The diagnosis of retroperitoneal acinar cell cystadenoma was based on the recognition of morphological acinar differentiation, the immunohistochemical demonstration of the acinar marker trypsin, and the absence of cellular atypia. These peculiar features can be used in the differential diagnosis with all the other cystic lesions of the retroperitoneum.

Extrahepatic biliary cystadenoma with mesenchymal stroma: a true biliary cystadenoma? A case report

Biliary cystadenomas are benign but potentially malignant cystic neoplasms, which classically contain mesenchymal stroma similar to ovarian tissue. We report a case of an extra-hepatic biliary cystadenoma with mesenchymal stroma along with a discussion of current pathological opinion.

CASE PRESENTATION

A 54-year-old female presented with abdominal pain, abnormal liver function tests and a mass on ultrasound. Computerized Tomography identified a complex multi-locular cyst in the common hepatic duct. Radical excision of the lesion and a Roux-en-Y loop bilio-enteric anastomosis was performed. Histology confirmed the presence of a benign biliary cystadenoma with ovarian type stroma.

CONCLUSION

Biliary cystadenomas classically contain mesenchymal stroma similar to ovarian tissue. It now appears that cystadenomas without mesenchymal stroma appear to be more akin to similar cystic lesions of the pancreas, and may represent a dissimilar neoplasm. Therefore, malignant transformation can occur, so complete excision is recommended.

Liver transplantation for symptomatic centrohepatic biliary cystadenoma

Biliary cystadenoma is a rare benign cystic tumor of the liver. The mainstay of treatment is complete resection, either by enucleation or by formal hepatectomy, since incomplete removal entails not only constant recurrence but also the risk of malignant transformation to cystadenocarcinoma. A case of symptomatic centrohepatic biliary cystadenoma involving the main vasculobiliary structures of the liver is reported. After an unsuccessful attempt at resection resulting in an intrahepatic biliary injury, relief of jaundice and radical excision were achieved by total hepatectomy and liver transplantation. The patient is now alive and well 4 years after transplant, disease-free, with normal liver and renal function while receiving everolimus monotherapy. This is the first report of liver transplantation performed for the treatment of this tumor. With the case on the background, diagnostic aspects and available therapeutic strategies for biliary cystadenoma are reviewed and discussed.

Pancreatic true cysts--diagnosis and treatment difficulties

Pancreatic true cysts represent a rare, heterogeneous group of pancreatic tumors; therapeutic strategy is based on patient's general status, cyst topography, and especially the estimated risk of malignancy. This paper aim is to present 7 cases of pancreatic true cysts, operated on a six years period (January 2004-January 2010) in our surgical clinic: 2 men and 5 women, aged between 24-61 years old; cyst diameter varies between 3.5-15 cm, tumor location being pancreatic head in two cases and the distal pancreas in 5 cases. Surgical treatment consisted in cyst enucleation (two cases), splenopancreatectomy (three cases), duodenopancreatectomy (one case), and subtotal splenopancreatectomy (one case). Histology was represented by serous cystadenoma (one case), mucinous cystadenoma (2 cases), intraductal papillary mucinous cystadenoma (one case), and papillary cystadenocarcinoma (3 cases).Postoperative results were good in all cases, with 3 postoperative pancreatic external fistulas, resolved conservatory; no case of post-pancreatectomy diabetes mellitus was registered. In conclusion, surgical removal of the pancreatic cystic tumors is necessary, especially due to the risk of malignancy, at least in the absence of rigorous histological proofs of benignancy. Postoperative results are favorable in terms of postoperative morbidity and mortality.

Hepatobiliary cystoadenoma: a wolf in sheep's clothing

Hepatobiliary cystoadenoma is a rare cystic tumor of the liver that can undergo malignant change and become lethal. Accurate diagnosis of such lesions, even though not always possible, is of importance as the management is totally different from that of other nonneoplastic cysts. We report a case of a 60-year-old woman with aspecific symptoms, which was diagnosed using ultrasound scan and CT scan and treated with hepatic resection, and review the main features of this tumor.

Cytologic diagnosis of hepatobiliary cystadenoma with mesenchymal stroma during intraoperative consultation: a case report

BACKGROUND

Hepatobiliary cystadenoma with mesenchymal stroma (HCMS) is a rare cystic tumor characterized by a layer of mucinous cuboidal to columnar epithelium situated on top of a basement membrane resting on an ovarian-like stroma. Cytologic features of this entity have not been extensively studied. We present a case of HCMS with emphasis on cytologic material obtained at the time of intraoperative consultation (IOC).

CASE

A 51-year-old woman had partial resection of a liver cyst. Seven months later she sought further medical attention and presented for surgical reevaluation and reexcision of the same lesion. Initial computed tomography revealed a multiloculated liver cyst. Five months after reexcision the lesion recurred and was again excised. During IOC, scrape cytology revealed both biliary epithelial and mesenchymal stromal cells in a cystic background. Permanent sections showed histologic features of HCMS. To the best of our knowledge, this is the first cytologic description of such a neoplasm to include both epithelial and mesenchymal stromal elements.

CONCLUSION

The use of scrape cytology during IOC can be a fast and effective way of identifying both the epithelium and mesenchymal stroma when HCMS is in the differential diagnosis of a cystic liver lesion.

[Mucocele of the appendix: an unusual finding in a patient with ulcerative colitis]

BACKGROUND

Patients with ulcerative colitis (UC) or Crohn's disease (CD) have an increased risk for the development of colorectal dysplasia and carcinoma. Although appendiceal inflammation occurs histologically in 40-86% of colectomy specimens from patients with inflammatory bowel disease (IBD), appendiceal neoplasms have been reported only infrequently, and the notion of a direct association between IBD and appendiceal neoplasia is speculative.

CLINICAL CASE

A 54-year-old male patient developed abdominal pain and bloody diarrhea 3 years prior. Colonoscopy and biopsy established the diagnosis of UC (proctosigmoiditis). Disease activity was moderate at the beginning and the patient initially received medical treatment with mesalazine and prednisone. He was admitted to our clinic for right lower abdominal pain. Physical examination revealed tenderness on palpation at this site. Laboratory tests were normal (including serum carcinoembryonic antigen and CA 19-9). Colonoscopy showed intrinsic compression of the cecum. The patient underwent partial cecum resection and extirpation of the mucocele. He presented postsurgical ileus resolved with medical treatment. Final histological report revealed cystadenoma of the appendix. At the 20-month follow-up, the patient was in satisfactory condition.

CONCLUSIONS

We present the eighth patient, to our knowledge, with a primary cystadenoma of the appendix and UC. Special attention should be paid to patients with extraordinary symptoms during follow-up, even in UC patients.

[Diseases mimicking advanced-stage epithelial ovarian cancer]

This paper draws attention towards 3 cases with different pathologies all of which suggesting however both clinically and by imaging means as the most likely diagnosis advanced-stage epithelial ovarian cancer since all these three postmenopausal women had been admitted to the hospital with ascites, pelvic masses and deterioration of the physical wellbeing (fatigue, decreased appetite, weight loss, pallor). Findings during exploratory laparotomy on all these three pacients included ascites (hemorragic in one case) diffuse tumorous implants throughout the abdominal and pelvic peritoneal surfaces (in two cases) and the ovarian tumour. Postoperatively, the final histopathologic diagnoses consisted of primary peritoneal carcinoma (one pacient), peritoneal tuberculosis (TB, one pacient) and hepatic cirrosis with an incidental benign adnexial mass (one pacient). Moreover, nonmalignant ovarian tumours were certified in all three cases under current presentation. The differential diagnosis of the ovarian cancer and a tailored approach to treatment for each of these three pathologic entities will also be described in detail.

[Rare tumors of the gallbladder and bile ducts. A case review]

The authors deal with the problem of benigh tumours of the bile duct which might occur as a very suprising intraoperative finding instead of preoperatively diagnosed "gallstones". This situation can happen because of possible mistakes that might accompany today's modern practical investigative techniques. The presented report is an example of the pre-operatirely assumed choledocholithiasis which was not confirmed during the operation. Instead a rare bile duct tumour was found.

Solid pseudopapillary tumor of the pancreas with concomitant pancreas divisum. A case report

CONTEXT

Solid pseudopapillary tumor of the pancreas is a rare neoplasm which affects young women. On the other hand, pancreas divisum is an anomaly which develops at 7 weeks of gestation. Here, we report a case of a solid pseudopapillary tumor of the pancreas with concomitant pancreas divisum.

CASE REPORT

A 26-year-old woman was diagnosed as having a pancreatic tumor with solid and cystic components in the pancreatic head. Pancreatograms obtained by ERCP and MRCP showed no communication between the ventral and dorsal pancreatic ducts, indicating that pancreas divisum was present. Microscopically, the resected tumor had solid and cystic components. Immunohistochemical study demonstrated that the tumor cells were positive for alpha-1-antitrypsine, vimentin and progesterone receptors but negative for estrogen receptors, NSE, insulin or glucagon. The tumor was diagnosed as a solid pseudopapillary tumor of the pancreas. Although more than 700 cases of solid pseudopapillary tumors of the pancreas have been reported in the English literature, a search of PubMed turned up no reports of concomitant solid pseudopapillary tumor and pancreas divisum.

CONCLUSION

Solid pseudopapillary tumors of the pancreas with concomitant pancreas divisum are extremely rare.

Pregnancy and adnexal torsion: analysis of 20 cases

OBJECTIVE

To study the clinical profile, management and outcome of pregnancy complicated by adnexal torsion.

METHODS

All pregnancy cases complicated by adnexal torsion admitted between January 2001 and January 2009 were analyzed.

RESULTS

The total number of pregnant cases was 20. Age range of pregnant women with adnexal torsion was 18 to 42 years. Of these cases 70% were seen in the first and second trimester. Seventy percent of cases were operated by the laparotomy route and 30% by laparoscopy. Salpingo-oophorectomy was performed in 70% of cases and detorsion in 30% of cases. Histopathologic examinations revealed five patients (25%) had serous cystadenoma, four patients (20%) mucinous cystadenoma, six patients (20%) dermoid cyst and five patients (25%) hemorrhagic cyst.

CONCLUSIONS

Adnexal torsion as a differential diagnosis of acute abdomen in pregnancy should be considered and we recommend early surgical treatment that will save the adnexa.

[Liver cystadenoma]

THE INTRODUCTION: Biliary cystadenomas of the liver are less often complicated cystic lesions of the liver with a malignant potential.

THE AIM

The aim of the work was to assess the results of the set of an own working place emphasising new findings in the diagnostics and the treatment of benign tumours of the liver.

THE SET OF THE PATIENTS AND THE METHOD

From 2004 till 2009 three patients were operated on biliary cystadenomas of the liver at the Surgical Clinic of Medical Faculty of Charles University and Faculty Hospital in Plzen. In all cases these patients were women with the average age 42 years of the age category 36-58 years. In all cases the formation was located centrally close to the branching of the big biliary ducts. The diagnosis was established preoperativelly in 66% of cases. An enucleation was performed two times and the right hepatectomy once. Mortality was 0% and morbidity was 33%.

THE CONCLUSION

Regarding to the fact that cystadenomas of the liver as benign tumours have a malignant potential for rising the cystadenocarcinoma, it is always necessary to perform their surgical removing--resection or the enucleation. With respect to their central location their surgical treatment belongs to more difficult performances carried out on the liver parenchyma. Long-term results after the surgical treatment are very good.

Extrahepatic biliary cystadenoma: an unusual cause of recurrent cholangitis

Extrahepatic biliary cystadenoma is a rare benign lesion with malignant potential. Fewer than 100 cases have been reported in the literature. The most common clinical presentation is obstructive jaundice. Frank cholangitis is extremely rare. The authors report a case of extrahepatic biliary cystadenoma in a 55-year-old woman who presented with recurrent episodes of cholangitis.

Cystic neoplasms of the pancreas: current diagnostic modalities and management

Cystic neoplasm of the pancreas is a relatively uncommon condition covering a wide spectrum of pathology. The increasing incidence as a result of routine imaging tests in asymptomatic patients presents a diagnostic and therapeutic problem to the clinician. This paper discusses the role of the various investigative modalities in the management of cystic neoplasia of the pancreas.

Primary retroperitoneal mucinous cystadenoma

Primary mucinous neoplasms of the retroperitoneum, including mucinous cystadenocarcinomas, mucinous borderline tumors, and mucinous cystadenomas are uncommon tumors found exclusively in women. Since the retroperitoneum does not contain mucinous epithelium, the origin, and histogenesis of these tumors remain unclear. It is speculated that these tumors can arise from teratomas, supernumerary ovaries, or mucinous metaplasia of the retroperitoneal mesothelium. We describe a case of a primary mucinous cystadenoma of the retroperitoneum in a 44 year-old female that presented as a palpable abdominal mass. There was no evidence of recurrence 16 months after complete laparoscopic excision of the tumor. The morphology and immunohistochemical analysis in this case support the hypothesis that mucinous metaplasia of the retroperitoneal mesothelium overlying a preceding inclusion cyst can give rise to retroperitoneal mucinous tumors.

Current management of cystic neoplasms of the pancreas

Over the last decade there has been a dramatic increase in the number of patients identified with pancreatic cysts. This increase has been largely attributed to advances in imaging. The majority of these cysts represent benign neoplasms; however, a significant fraction of these are pre-malignant or malignant. Because the majority of these neoplasms are benign, many reports have advocated a selective approach to surgical resection. Here we review the literature that has contributed to the development of our approach to the management of these cystic neoplasms. We provide an overview of the key features in diagnosis and in predicting malignancy. Particular attention is given to the natural history and management of intraductal papillary mucinous neoplasms (IPMN).

[Cystic pancreatic tumor treated by distal spleno-pancreatectomy with occasional diagnosis of neuroendocrine tumor: case report]

INTRODUCTION

Cystic and neuroendocrine pancreatic neoplasms are quite rare tumors which diagnosis is often difficult due to their non specific symptomatology and limited diagnostic accuracy of conventional diagnostic instruments. Their treatment is still controversial.

CASE REPORT

A young woman is admitted with abdominal pain and dyspepsia. Instrumental diagnosis reveals a cystic pancreatic lesion which seems to be malignant as CEA of pancreatic liquid is increased. The patient undergoes distal spleno-pancreatectomy and postoperative histological examination found IPMN associated with MCN and furthermore there was occasional diagnosis of a small neuroendocrine tumor in the pancreatic tail.

DISCUSSION

A correct diagnostic approach is indispensable for a correct therapeutic approach. Radical surgical treatment is indicated in all cases of main- and branch duct IPMN and in case of MCN with signs of malignant transformation. Surgical treatment is also the gold standard for pancreatic neuroendocrine tumors if they are singular and in M0 stage.

CONCLUSIONS

In case of cystic and neuroendocrine neoplasms of the pancreas the preoperative diagnostic approach is often not enough to obtain a definite diagnosis. Review of literature and this case report show that a definite diagnosis can only be done after postoperative histological examination. Recent prospective studies suggest the possibility for a follow up instead of surgical treatment for some neuroendocrine tumors.

Surgical treatment of biliary cystadenomas

Biliary cystadenomas are rare cystic tumors. They are typically multilocular lesions containing mucinous fluid. Most reported cases are intrahepatic lesions. Biliary cystadenomas are thought to be premalignant tumors. It is also difficult to differentiate biliary cystadenoma from biliary cystadenocarcinoma preoperatively by imaging studies or tumor markers. Complete resection is the treatment of choice for biliary cystadenoma. We reported our institutional experience in treating 7 cases with intrahepatic biliary cystadenoma by complete resection. There is no recurrence during the period of follow-up.

Cystic lesions of the liver: 6 years of surgical management in New Zealand

INTRODUCTION

Cysts are a common radiological finding in the liver. Many affected patients do no require treatment. However a minority require further investigation and treatment for symptoms or risk of underlying malignancy.

METHODS

A computerised database of patients presenting to Auckland Hospital for the management of liver lesions was established in 2000. Details of demographics, presentation, investigations, management, and follow-up are entered prospectively.

RESULTS

Forty-seven patients (36 female, median age 61, range 37-86 years) requiring surgical treatment of cystic liver lesions were identified from a total of over 800 patients enrolled in the database. Twenty-five patients presented with simple cysts, of whom 12 had radiological evidence of polycystic liver and kidney disease. All 25 patients were symptomatic and all were managed successfully with laparoscopic fenestration. Nine patients presented with complex cysts which were treated with liver resection. Of these patients, four had benign cysts, three had underlying biliary cystadenomas, and two had biliary cystadenocarcinomas. One patient with a biliary cystadenocarcinoma is dead of disease. The median follow-up for all 47 patients was 26 months.

CONCLUSIONS

Cystic liver lesions can represent a spectrum of underlying conditions. All cysts require investigation and complex cysts or symptomatic simple cysts require further treatment.