Apocrine cystadenoma: A long-standing apocrine hidrocystoma with an adenomatous proliferation

BACKGROUND

Apocrine cystadenoma is a rare, benign adenomatous cystic neoplasm, the pathogenesis of which is not fully understood. We sought to characterize the clinical, dermatoscopic, and histopathologic features of apocrine cystadenoma and its relationship to hidrocystoma.

METHODS

We retrospectively analyzed cases of apocrine cystadenoma and hidrocystoma retrieved from the dermatopathology laboratory information system.

RESULTS

Of the 350 cases apocrine cystic lesions, 13 cases of apocrine cystadenomas met the inclusion criteria. The age ranged from 20 to 84 years with an average of 64 years. They were long-standing (duration 3-15 years), slow-growing, large tumors usually found on the scalp. Dermatoscopy accentuated translucent light to dark blue color and prominent vessels that were present more at the periphery. All lesions were multilocular with columnar to cuboidal lining and decapitation secretion. A large portion of the lesion consisted of a simple nonproliferative epithelial lining, identical to that observed in apocrine hidrocystomas, while the proliferative adenomatous component made up a smaller portion with two patterns: (1) tubular proliferation, which either protruded into the cystic cavity or expanded outward peripherally, or (2) papillary projections, which were multiple layers thick with fibrovascular core, sometimes accompanied by tubular proliferation. Immunohistochemical stains showed strong staining for p40 and a sparse number of cells stained for Ki-67 and p53.

CONCLUSIONS

The long duration of the lesion and the large areas of simple apocrine epithelial lining suggest that apocrine cystadenomas arise from long-standing apocrine hidrocystomas. However, the retrospective nature of the study from a single institution is a limitation.

Cytomorphological features of syringocystadenoma papilliferum mimicking pilomatricoma at a rare location and in an unusual age group: A cytological diagnostic challenge

Syringocystadenoma papilliferum (SCAP) is a rare, benign skin adnexal tumor of apocrine or eccrine differentiation usually occurring in the head and neck region of children. It is a difficult entity to diagnose clinically and even cytological diagnosis remains challenging due to overlapping and masquerading cyto-morphological features with other benign cutaneous adnexal tumors. Here we present, one such intriguing case of SCAP with its cytological features mimicking those of pilomatricoma. Moreover, the lesion was located at the right lower abdomen, which in itself is a rare site and its presentation was in an adult male which is an unusual age group. However, fine needle aspiration cytology still remains a very useful investigation for cutaneous tumors as it helps in differentiating benign lesions from malignant and metastatic neoplasms and therefore aids in correct treatment and follow-up of patients.

Papillary cystadenoma of the major salivary gland: A case report and review of literature

Papillary cystadenoma (PC) of the salivary gland is an uncommon benign epithelial neoplasm that shows predominantly multicystic growth pattern with intraluminal papillary proliferation and areas of oncocytic differentiation. We report a case of papillary cystadenoma of the parotid gland in a 44-years-old female. The patient presented with painful nodular swelling in the right parotid region for two months. Ultrasonography revealed a well marginated oval lesion with altered signal intensity involving the superficial lobe. The excision specimen showed a neoplasm with multicystic spaces having papillary projections lined by benign low-grade epithelium and supported by fibrovascular cores. No significant cytological atypia or mitosis was observed. The cells were immunoreactive for Keratin, Keratin 7, and were negative for Keratin 20, AR, HeR2/neu, TTF1, CDX2, and GATA3. p63 and Keratin 5/6 highlighted the myoepithelial cell layer lining the cystic spaces as well as the papillary projections. The Ki-67 proliferation index was 6%. The patient is on close clinical and imaging follow-up for the last 1year and 8 months without any evidence of disease recurrence or metastasis. Rarity of the lesion and distinct histomorphology warrants appropriate knowledge and discussion of the subject.

Apocrine Cystadenoma of the Eyelid, a Rare Neoplasm: Expanded Immunohistologic Profile

An 83-year-old woman experienced the slow enlargement of a right lower eyelid mass. Histopathologic examination of the excised tissue showed a mucin-filled cystic tumor emanating from an apocrine bilayer that displayed bleb-like apocrine decapitation secretion. The outer flattened myoepithelial layer of the bilayer reacted with immunohistochemical stains for smooth muscle actin and calponin. In foci, the tumor exhibited a cribriform architecture with small pockets of mucin. Tumor cells were reactive for cytokeratin 7, Gross Cystic Disease Fluid Protein 15 (BRST-2), estrogen and progesterone receptors, androgen receptors, mammaglobin, epithelial membrane antigen, and GATA3. Ki67 showed a very low proliferation fraction. The lesion exemplifies the fourth instance of an eyelid apocrine cystadenoma in the literature.

Low-grade myofibroblastic sarcoma of the liver misdiagnosed as cystadenoma: A case report

BACKGROUND

Low-grade myofibroblastic sarcoma (LGMS) is a rare malignant tumor. It has no specific clinical manifestations and commonly occurs in the head and neck, extremities and other body parts, with the liver not as its predisposing site.

CASE SUMMARY

We report a case report of a 58-year-old man with right upper abdominal pain for 11 d. Contrast-enhanced computed tomography (CECT), CE magnetic resonance imaging and CE ultrasound (US) all showed a cystic-solid mass in the right liver. As the initial clinical diagnosis was hepatic cystadenoma, surgical resection was performed, and the postoperative pathology indicated hepatic LGMS. The 3-mo follow-up showed favorable recovery of the patient. However, at 7-mo follow-up, two-dimensional US and CECT showed a suspected metastatic lesion in the right-middle abdomen.

CONCLUSION

Hepatic MS is particularly rare and easily misdiagnosed, more cases will contribute to the understanding and the diagnosis accuracy.

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.

Laparoscopic spleen-preserving distal versus central pancreatectomy for tumors in the pancreatic neck and proximal body

For benign and borderline tumors in the pancreatic neck and proximal body, laparoscopic spleen-preserving distal pancreatectomy (LSPDP) and laparoscopic central pancreatectomy (LCP) are alternative surgical procedures. Choosing between LSPDP and LCP is difficult. This retrospective cohort study was looking forward to provide evidence for clinical decision.A total of 59 patients undergoing LSPDP (Kimura procedure) and LCP between June 2013 and March 2017 were selected. The clinical outcomes of patients were compared by χ test or Fisher exact test and Student t test.This study included 36 patients in LSPDP group, and 23 patients in LCP group. The overall complications incidence in LCP group was significantly higher than LSPDP group (35 vs 6%, P = .004), and the postoperative pancreatic fistula (POPF) (grade B and C) rate and abdominal infection rate in LCP group were still significantly higher than LSPDP group (POPF 22 vs 3%, P = .019; abdominal infection 35 vs 3%, P = .001, respectively). The length of resected pancreas was significantly longer in LSPDP group (9.8 ± 2.0 vs 5.3 ± 1.1 cm, P = .007). The median follow-up was 39 months (range 12-57 months). No patient was confronted by tumor recurrence. The proportion of postoperative pancreatin and insulin treatment in LCP group were similar to LSPDP group (9 vs 17%, P = .383; 0 vs 3%, P = 1.000, respectively).For patients with poor general condition, the safety of LCP needs to be taken seriously; in some ways, LSPDP may be more secure, physiological, and easier operation for tumor located in pancreatic neck and proximal body.

Synchronous Warthin tumor and papillary oncocytic cystadenoma in the ipsilateral parotid gland: an unreported association

The occurrence of ipsilateral, synchronous, primary salivary gland tumors of different histological type is rare. In this report, we present the case of a 52-year-old male, established smoker, who showed simultaneously two different benign tumors in the right parotid gland. The patient complained of swelling below the angle of the mandible. Ultrasonography and computed tomography imaging revealed one mass of about 2.8 cm in the right gland. Besides, one small nodule in the left parotid gland was observed. The cytological diagnosis of the right gland was benign tumor, type IVa of the Milan system, consistent with Warthin tumor (WT). The clinical diagnosis was bilateral parotid WT. The histopathological (HP) study of the surgical specimen revealed a WT in combination with a papillary oncocytic cystadenoma (POC) in the right parotid. To our knowledge, this combination of tumors has not been previously reported. In our case, the association of tumors was not detected by imaging or fine-needle aspiration cytology (FNAC). WT and POC are difficult to distinguish by FNAC because their epithelial component is very similar. POC can resemble WT without lymphoid stroma, but the totality of HP features allows the differentiation of both processes. These tumors can be related to a common causal determinant and should not be considered as a result of chance. Both tumors follow favorable courses and are curable by surgical resection.

Relation between Ovarian Carcinoma-Associated Antigens in Tumor Tissue and Detached Cyst Fluid Cells of Patients with Ovarian Neoplasms

Aims

The expression and potential diagnostic value of ovarian carcinoma-associated antigens were estimated in different types of epithelial ovarian neoplasms. The comparison of antigenic expression was performed on solid tumor tissues and loose cyst fluid cells in individual cases of malignant and benign ovarian neoplasms.

Methods

All studies were performed using monoclonal antibodies (mAbs) against ovarian carcinoma-associated antigens (OC125, OV-TL3, OV632, 10B, 8C) by 3-step peroxidase-antiperoxidase test.

Results

All ovarian carcinoma-associated antigens were detected in most serous and endometrioid carcinomas. In mucinous carcinomas as well as in benign ovarian neoplasms these antigens were present only in some cases. Significant inter- and intratumoral immunological heterogeneity was evident; however, the antigens detectable in tissue sections were also found in detached cyst fluid cells.

Conclusions

Our results show that mAb show OV-TL3 is the best marker for endometrioid carcinomas and confirmed that mAbs OV632, OC125 and OV-TL3 could be good complementary markers for differentiating malignant and benign lesions in the ovary. The percentage content of all ovarian carcinoma-associated antigens in solid tumors and respective cyst fluid cells was comparable.

Histochemical Study of Mucinous Ovarian Cystomas of Intestinal and Mixed Types: O-Acetylated Sialomucin Content in Relation to Biologic Behavior

The subgroup of mucinous ovarian cystomas of intestinal type containing site 8 O-acetylated sialomucins and its relation to malignant behavior were studied. Of 75 mucinous cystomas of the ovary from the files of the Institute of Pathological Anatomy and Histology (University of Genoa), 54 were endocervical, 19 were mixed, and 2 were intestinal. As regards their histologic pattern, the 54 mucinous endocervical cystomas were benign, whereas the 19 mixed type group included 8 benign, 5 borderline and 6 malignant; the 2 intestinal type tumors were borderline. According to histochemical investigations, the frequency of tumors with goblet cells containing site 8 O-acetylated sialomucins (positive to PB/KOH/PAS) was 47% In the mixed type cystomas and 100% in the intestinal type cystomas. Twenty-five percent of benign mixed cystomas, 60 % of borderline mixed cystomas, and 67 % of mixed cystadenocarcinomas were positive to PB/KOH/PAS. One hundred percent of the borderline cystomas of intestinal type were positive. Our results confirm that among mucinous ovarian cystomas, those containing intestinal type epithelium are the most likely to fall within the borderline or malignant categories. Moreover, of all ovarian cystomas of intestinal type, those characterized by site 8 O-acetylated sialomucins seem to be more aggressive and, in general, to have a more malignant behavior than the mucinous cystic tumors of müllerian or endocervical type.

Blue Nevus of the Endocervix. A Study of Five Cases

The pathologic and immunohistochemical features of 5 cases of blue nevus of the endocervix are presented: 4 of them were studied ultrastructurally. The lesions were incidentaly discovered at microscopic examination and showed pigmented dendritic cells in the cervical stroma. Immunocytochemical examination showed all cases to be positive for S-100 protein. Ultrastructurally they contained melanosomes, were surrounded by a basement membrane, and displayed occasional desmosome-like devices. Histogenesis is discussed, and support for a schwannian origin is presented.

Morphologic Heterogeneity of Cell Populations Isolated by Density Gradient Centrifugation from Serous Fluids of Ovarian Tumors

The cells of tumor fluid from patients with malignant and benign serous ovarian neoplasms were fractionated using Ficoll-Uropoline density gradient centrifugation. Density distribution and morphologic characteristics of cell fractions were analyzed. It was found that serous ovarian adenocarcinomas contained three to four types of morphologically malignant cells focused in low density layers. Borderline ovarian neoplasms showed the presence of one subpopulation of cells with some features of malignancy and cells with some atypical but non-malignant features. The fluids of serous cysts contained mainly normal epithelial cells representing different stages of morphological maturity and were focused in denser layers. The results allowed us to catalogue ovarian tumor cell subpopulations present in each density fraction of individual patients and confirmed that ovarian tumors could be diagnosed by morphologic identification of cells from tumor fluids.

Intrahepatic biliary cystadenoma mimicking hydatid cyst of liver: a clinicopathologic study of six cases

BACKGROUND

Intrahepatic biliary cystadenomas are rare hepatic neoplasms, which are usually cystic. These tumors are often misdiagnosed as simple liver cysts and hydatid cysts clinically and radiologically owing to nonspecific clinical and radiologic features. These tumors require complete resection, as recurrence and malignant transformation can occur following incomplete excision. It is essential that these tumors be diagnosed accurately so that they can be adequately excised.

METHODS

Clinical and radiological features of six cases of biliary cystadenoma are described.

RESULTS

All of these cases were resected with the clinical and/or radiological impression of simple liver cysts and/or hydatid cysts. Out of the six patients, five were female and one was male. Ages of the patients ranged from 28 to 60 years (mean 45 years). The patients presented with nonspecific symptoms. Internal septations were seen on preoperative imaging (when available). On gross examination, all tumors were cystic; their sizes varied from 5.5 to 14 cm, mean size was 9.0 cm. On histopathologic examination, cystic spaces were lined by cuboidal to columnar mucin-secreting epithelium with underlying ovarian-type stroma. In one case, ovarian-type stroma was not seen. Recurrence was seen in three cases at 1 to 5 years of follow up.

CONCLUSIONS

Owing to their malignant potential and high recurrence rate following incomplete resection, an aggressive surgical approach is recommended. Prognosis is excellent after complete resection.

Benign and Malignant Salivary Gland Tumors - Clinical and Demographic Characteristics

AIM

To examine the demographic, ethnic, and clinical characteristics of salivary benign and malignant tumors for better etiological understanding.

PATIENTS AND METHODS

We examined medical records of 287 primary salivary gland tumor patients.

RESULTS

Overall, 216 tumors were benign and 71 malignant. The mean age at diagnosis was 56.4 years for those with malignant tumors and 48.5 years for those with benign, a highly significant difference (p=0.001). Females had 45% of malignant tumors and 59% of benign, a significant difference (p=0.037). Ethnic origin, alcohol consumption and cigarette smoking rates were not significantly different (p>0.05) between groups. A total of 87% of benign and 55% of malignant tumors were in the parotid glands, a highly significant predilection (p<0.0001), sublocated mostly in the superfacial lobe; 36.6% of malignant tumors and 4.7% of benign (p<0.0001) were in the minor salivary glands, mostly in the hard palate.

CONCLUSION

Baseline clinical, demographic and locational aspects of benign and malignant tumors are substantiated.

Spectrum of Cystic Epithelial Tumors of the Prostate: Most Cystadenocarcinomas Are Ductal Type With Intracystic Papillary Pattern

Cystic epithelial tumors arising from the prostate are rare, and their full histologic spectrum has yet to be defined. Herein, we present 8 examples of prostatic cystic tumors including 1 giant multilocular cystadenoma and 7 cystadenocarcinomas. We divided the cystadenocarcinomas into "giant multilocular" cystadenocarcinoma (3) and "microscopic" cystadenocarcinoma (4) because of their differing clinical presentations with clinically apparent cystic masses in the former. The cystadenoma was an 11 cm multilocular cystic pelvic tumor in a 55-year-old man who presented with lower urinary tract symptoms. The cystadenoma was lined predominantly by benign acinar cells and had a distinct basal cell layer. No recurrence occurred 3 months after resection. The 3 patients with giant multilocular cystadenocarcinomas were 62 to 82 years old, had large pelvic cystic masses (up to 16 cm), and 2 presented with obstructive urinary and lower intestinal tract symptoms. One giant multilocular cystadenocarcinoma had a markedly high cystic fluid prostate-specific antigen at >80,000 ng/mL. All 3 giant multilocular cystadenocarcinomas were ductal adenocarcinoma with exuberant intracystic papillary formations. One tumor was associated with a high-grade noncystic conventional (acinar) adenocarcinoma (Gleason score 9 [ISUP grade group 5]). Follow-up on the 3 giant multilocular cystadenocarcinoma cases (7 to 21 mo) showed multiple metastases in 1 patient but was attributed to the high-grade conventional adenocarcinoma component. In addition, we described 4 examples of microscopic cystadenocarcinomas that were small (≤1 cm) solitary or multiple cystic tumors identified on pathologic examination of the prostate. In 3 of 4 microscopic cystadenocarcinomas the lining was ductal adenocarcinoma with occasional to exuberant papillae and appeared similar to the smaller cysts in the giant multilocular cystadenocarcinomas. One of the 4 microscopic cystadenocarcinomas had an acinar adenocarcinoma lining with occasional papillae and was associated with a conventional adenocarcinoma. Follow-up of the 4 patients with microscopic cystadenocarcinoma (1 to 14 mo) showed no evidence of disease. Review of literature highlighted similarities between the findings in our cases and previously published prostatic cystadenocarcinomas, including the markedly high cystic fluid prostate-specific antigen level in giant multilocular cystadenocarcinomas and the typical ductal adenocarcinoma morphology with intracystic papillary pattern. In conclusion, cystic epithelial tumors of the prostate exhibit unique clinicopathologic features. Cystadenocarcinomas, whether the clinically apparent giant multilocular form or the incidentally identified microscopic type, represent a rare underrecognized pattern of prostatic adenocarcinoma mostly within the histologic spectrum of the ductal variant.

A Comparative Study of Immunohistochemical Myoepithelial Cell Markers in Cutaneous Benign Cystic Apocrine Lesions

The use of immunohistochemical markers for myoepithelial cells (MEC) is a useful tool in the distinction of benign from malignant epithelial neoplasms. Although their use in breast tumors is well recognized, little is known concerning its application in comparable cutaneous lesions. Using benign cutaneous cystic apocrine lesions as a study model, the aim of this study was to compare 5 immunohistochemical markers [calponin, p63, smooth muscle actin (SMA), cytokeratin 14, and CD10] in their effectiveness to highlight MEC. Cases of apocrine hidrocystoma and cystadenoma (n = 44) were reviewed with a particular emphasis on proliferative features and apocrine change. The MEC staining pattern and the intensity and distribution scores in proliferative (n = 29) and nonproliferative (n = 15) lesions were assessed, and the differences between the 2 groups were statistically analyzed using Fisher exact test. Calponin and SMA stained MEC in the most consistent manner. Being a nuclear stain, p63 was easy to interpret but typically showed discontinuous staining. Cytokeratin 14 not only effectively highlighted MEC but also stained some luminal epithelial cells in an unpredictable manner. Because of prominent background dermal fibroblast staining, CD10 was often difficult to interpret. Only SMA and p63 showed a statistically significant difference in MEC staining intensity scores between the proliferative and nonproliferative groups. Our results show that immunohistological staining for MEC in benign cystic apocrine lesions of the skin is variable. The authors recommend that a panel of markers that includes calponin and p63 be used and highlight the need for awareness of specific caveats associated with individual markers.

Acinar cell cystadenoma of the pancreas: A retrospective analysis of ten-year experience from a single academic institution

BACKGROUND/OBJECTIVE

Acinar cell cystadenoma (ACA), also referred to as "acinar cystic transformation", is a rare and newly recognized cystic lesion of the pancreas displaying apparent acinar cell differentiation with benign outcomes. We summarized our experience with the diagnosis, clinicopathologic feature, treatment and prognosis of ACA to provide a reference for the disposal of this uncommon condition.

METHODS

We retrospectively analyzed the clinical data from eight patients with ACA treated in our hospital between March, 2005 and January, 2015.

RESULTS

Among eight patients, five of whom were female and the age at diagnosis ranged from 33 to 67 years (mean, 49.8 y). The most commonly clinical symptom was abdominal pain. Eight lesions were unifocal and either unilocular (n = 5) or multilocular (n = 3) with average size of 10.5 cm (range, 5.1-19.7 cm). All the patients were treated surgically and a definite diagnosis of ACA was obtained by the histopathological, histochemical and immunohistochemical tests. The length of stay range was from 11 to 17 days and there were no perioperative deaths. At a median follow-up of 57.3 months, all the patients were alive and there was no evidence of recurrence, distant metastasis or malignant transformation.

CONCLUSIONS

Appropriately preoperative differential diagnosis of ACA remains challenging and the final result is usually gained by the histopathology and immunohistochemistry. Although the origin of ACA is still contradictory, surgery is actively advocated as the most effective method for relieving the symptoms and preventing the tumor from local extension or malignant transformation so as to obtain an optimal long-term survival.

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.

GNAS mutation is a frequent event in pancreatic intraductal papillary mucinous neoplasms and associated adenocarcinomas

In contrast to pancreatic ductal adenocarcinomas (PDAs), intraductal papillary mucinous neoplasms (IPMNs) frequently harbour GNAS mutations. To characterise GNAS-mutated pancreatic carcinomas, we examined mutations of GNAS and KRAS in 290 pancreatic adenocarcinomas and 77 pancreatic intraepithelial neoplasias (PanINs). In 64 % (39/61) of IPMNs and 37 % (11/30) of IPMN-associated adenocarcinomas, a GNAS mutation was found. GNAS mutations were frequent (78 %, 7/9) in mucinous carcinomas, with or without associated IPMN. In contrast, GNAS mutations were rarely observed in PDAs (1 %, 1/88) and PanINs (3 %, 2/77), and not at all in mucinous cystic neoplasms (MCNs) (0/10), neuroendocrine neoplasms (0/52), acinar cell neoplasms (0/16), serous cystadenomas (0/10), and solid-pseudopapillary neoplasms (0/14). We found GNAS mutations in 55/91 IPMNs with or without associated invasive carcinoma, solely in intestinal-type (78 %, 21/27) and gastric-type (62 %, 34/55) IPMNs. Of the IPMN-associated adenocarcinomas, mucinous-subtype tumours harboured GNAS mutations more frequently (83 %, 5/6) than tubular-subtype tumours (25 %, 6/24) (p = 0.02). We separately analysed GNAS in the adenocarcinoma and the IPMN component in the IPMN-associated adenocarcinomas. In all mucinous-subtype tumours, the two components exhibited identical genotypes. In contrast, the two components in 8 of 24 tubular-subtype tumours exhibited different genotypes, indicating intratumour heterogeneity. In conclusion, mucinous carcinomas with or without associated IPMN as well as IPMNs frequently harbour a GNAS mutation, reinforcing the notion that these constitute a spectrum of pancreatic tumours. Clinically and pathologically, these tumours are associated, but GNAS mutation sheds further light on this spectrum.

Comparison of nine morphological scoring systems to detect ovarian malignancy

PURPOSE OF INVESTIGATION

The aim of this study was to prospectively compare the diagnostic performances of nine gray-scale sonographic prediction models to detect ovarian malignancy.

MATERIALS AND METHODS

Clinical data of 322 women presenting with an adnexal mass were obtained and used in nine scoring systems. For each model a ROC curve demonstrating the capacity of the model to diagnose malignancy was constructed for all cases and for the subgroups of premenopause and postmenopause. The performance of each model was expressed as area under the ROC curve, sensitivity, and specificity.

RESULTS

The area under the ROC curve, sensitivity, and specificity of these models in the present study varied between 0.737 and 0.929, 70.7% and 87.9%, 60.2% and 80.3%, respectively.

CONCLUSIONS

This study has revealed the usefulness of morphological scoring systems to correctly discriminate between benign and malignant pelvic masses.

Multiple oncocytic cystadenoma with intraluminal crystalloids in parotid gland: case report

Oncocytic cystadenoma is a benign tumor of salivary glands, histologically characterized by multicystic growth of the oncocytic epithelial lining. Crystals in different shapes and nature associate oncocytic type of salivary gland neoplasms. An 82 year-old woman with right parotideal mass had an operation of superficial parotidectomy. Histological examination revealed multiple unilocular or multilocular cystic lesions with incomplete fibrous capsule, papillary foldings, and 1 or 2 layers of oncocytic epithelium lines. The epithelium lining the cysts were positive for CK8, CK14, CK18, CK19, and negative for SMA, S-100, and p63 immunohistochemically. Cystadenomas were described as mostly multilocular and we presented a multifocal cystic neoplastic lesion lined by oncocytic type epithelial cells with intraluminal crystalloids. Multiple cysts forming morphology, incomplete fibrous capsule of most cysts and immunohistocemical findings were considered as multiple oncocytic cystadenoma with intraluminal crystalloids in the parotid gland.

Linear syringocystadenoma papilliferum on female breast: a rare appendageal tumour on an uncommon location

Syringocystadenoma papilliferum is a rare benign adnexal tumor commonly located on the head and neck region and is usually associated with a nevus sebaceous. Linear lesions are uncommon and lesions on the breast are extremely rare. We report here a case of linear SCAP occurring de novo on the left breast of a 35-year-old healthy woman. Histopathology showed the characteristic papillary projections lined by double layer of cells inside epidermal invaginations.

The problem of an incidental uniloculated cyst

Incidental uniloculated cysts are diagnosed more frequently due to the increase in availability of high-quality abdominal imaging. The prevalence of incidental pancreatic cysts detected on abdominal imaging is 2.6% and is even higher in old patients. Pancreatic cysts are also found in up to 25% of autopsies, 3% of which present progression to carcinoma in situ. The most frequently incidental cysts detected are <10 mm in size and the spectrum has changed from inflammatory to mucinous lesions. Although some morphological and cytological features can help to establish the nature of these cysts, it is unclear how many of them carry a risk of malignant degeneration, how to identify those accurately, and, once recognized, how to establish which ones are likely to harbor incipient cancer and how to manage them. In the last years, some guidelines have been elaborated that summarize all the evidence published up to now and provide clinicians with useful recommendations regarding the management of pancreatic uniloculated cysts.

Fine needle aspiration cytology of acinar cell cystadenoma of the pancreas

BACKGROUND

Acinar cell cystadenoma (ACC) is a recently recognized cystic lesion of the pancreas that demonstrates acinar differentiation and is currently believed to behave in a benign fashion. ACC enters the differential diagnosis of pancreatic cystic lesions alongside better recognized entities such as mucinous cystic and intraductal papillary mucinous neoplasms. Although uncommon, patients with ACC can undergo fine needle aspiration (FNA) of the lesion. However, the diagnosis is rarely made on cytologic examination due to sparse cellularity. Furthermore, the eosinophilic amorphous material in the cyst lumen may be mistaken for mucin, resulting in an incorrect diagnosis of a mucinous cyst. To date, there is a paucity of literature on the cytomorphology of ACC, both in peer-reviewed publications and cytopathology texts.

CASE

To our knowledge, we present the first detailed case report of FNA of ACC in a 22-year-old asymptomatic female. The FNA cytology specimen was hypocellular, and the presence of amorphous secretions led to the initial diagnosis of a mucinous-type neoplasm. Following surgical resection, the cytology specimen was reviewed.

CONCLUSION

We discuss the cytomorphologic features of ACC along with the potential pitfalls and diagnostic implications.

Laparoscopic central pancreatectomy with pancreaticojejunostomy: preliminary experience with 8 cases

BACKGROUND

Central pancreatectomy has been accepted as an alternative procedure for treating benign or low-grade malignant tumors in the pancreatic neck or proximal body of the pancreas, which preserves pancreatic parenchyma and function. In this study, we present our experience of laparoscopic central pancreatectomy with pancreaticojejunostomy.

PATIENTS AND METHODS

From April 2011 to February 2013, 8 patients underwent laparoscopic central pancreatectomy with a Roux-en-Y modified "dunking" or duct-to-mucosa pancreaticojejunostomy for benign or low-grade malignant tumors in the pancreatic neck or proximal body of the pancreas at the Department of General Surgery, Sir Run Run Shaw Hospital, Hangzhou, China. Surgical procedure, postoperative course, and follow-up data were collected.

RESULTS

Laparoscopic central pancreatectomy was performed successfully in all the patients. The pancreaticojejunostomy was executed with a modified "dunking" pancreaticojejunostomy (n=7) or duct-to-mucosa pancreaticojejunostomy (n=1). The mean operative time was 286±27 minutes (range, 250-330 minutes), with a mean blood loss of 57±21 mL (range, 30-100 mL). Mortality was 0%, and perioperative morbidity was 37.5% (pancreatic fistula [grade A], bleeding of a splenic vein branch, and retroperitoneal infection). The median postoperative hospital stay was 10 days (range, 6-38 days). At a median follow-up of 7.5 months (range, 2-24 months), all patients were alive without any exocrine or endocrine insufficiency or recurrence.

CONCLUSIONS

Laparoscopic central pancreatectomy is feasible and safe. The modified "dunking" pancreaticojejunostomy can be performed safely in this approach.

Equivalent benefit of rapamycin and a potent mTOR ATP-competitive inhibitor, MLN0128 (INK128), in a mouse model of tuberous sclerosis

Tuberous sclerosis complex (TSC) is a hamartoma syndrome in which brain, renal, and lung tumors develop and cause both morbidity and death. Loss of either TSC1 or TSC2 in TSC hamartomas leads to activation of mTORC1. Rapamycin and related drugs have been shown to have clinical benefit for these tumors in patients with TSC and those with sporadic forms of TSC-related neoplasms. However, lifelong therapy seems to be required, as tumors are not eliminated by this treatment. We examined the potential benefit of MLN0128, a novel potent mTOR ATP-competitive inhibitor, as a therapeutic strategy for renal cystadenomas that develop in A/J Tsc2(+/-) mice. Rapamycin given by intraperitoneal injection at 3 mg/kg 3 times per week, and MLN0128 given by gavage at 0.75 mg/kg 5 times per week had equivalent effects in suppressing tumor development during a 4-week treatment period, with an approximate 99% reduction in microscopic tumor cell volume. Marked reduction in activation of mTOR complex (mTORC)1 and blockade of cell growth was seen with both drugs, whereas only MLN0128 treatment had effects in blocking mTORC2 and 4EBP1 phosphorylation. However, when either drug was discontinued and mice were observed for two additional months, there was dramatic recovery of tumor growth, with extensive proliferation. Hence, longlasting tumor growth control is not achieved with transient treatment with either drug, and MLN0128 and rapamycin have equivalent therapeutic benefit in this mouse model. Differences in side-effect profiles might make MLN0128 more attractive for treatment of patients with TSC-related tumors, but will require additional study in humans.

Imaging features of intrahepatic biliary cystadenoma and cystadenocarcinoma on B-mode and contrast-enhanced ultrasound

PURPOSE

To investigate the imaging features of intrahepatic biliary cystadenoma and cystadenocarcinoma on B-mode and contrast-enhanced ultrasound.

MATERIALS AND METHODS

The B-mode and contrast-enhanced ultrasound features of 6 intrahepatic biliary cystadenomas and 7 intrahepatic biliary cystadenocarcinomas were retrospectively analyzed, and the differences between cystadenomas and cystadenocarcinomas were compared.

RESULTS

There were no significant differences between cystadenomas and cystadenocarcinomas in terms of patient gender, age, lesion location, size, and shape (all p > 0.05). On conventional ultrasound, biliary cystadenomas were more likely to be multilocular (6/6 for cystadenoma vs. 2/7 for cystadenocarcinoma) and cystadenocarcinomas more likely presented the features of a mural or septal nodule and a nodule diameter > 1.0 cm (0/6 for cystadenoma vs. 5/7 for cystadenocarcinoma). On contrast-enhanced ultrasound, hyper-enhancement (n = 4) or iso-enhancement (n = 2) was present in the cystic wall, septations or mural nodules of the cystadenomas during the arterial phase and the enhancement washed out to hypo-enhancement (n = 6) during the late phase. Cystadenocarcinomas also showed hyper-enhancement (n = 4) or iso-enhancement (n = 3) in the cystic wall, septations or mural nodules during the arterial phase and iso-enhancement (n = 1) or hypo-enhancement (n = 6) during the late phase.

CONCLUSION

Intrahepatic biliary cystadenomas are more typically multilocular cystic lesions. A mural or septal nodule and a nodule diameter greater than 1.0 cm on conventional ultrasound are suggestive of cystadenocarcinomas. Contrast-enhanced ultrasound is helpful for depicting the vascularity of the lesions but there was no significant difference between cystadenomas and cystadenocarcinomas.

Diagnostic value of quantitative EUS elastography for malignant pancreatic tumors: relationship with pancreatic fibrosis

PURPOSE

EUS elastography has been used to facilitate the diagnosis of pancreatic cancer, but as yet the interpretation of this procedure has been largely subjective. The present study has been designed to validate a quantitative approach for the analysis of EUS elastography, and to assess its relationship with pancreatic fibrosis.

MATERIALS AND METHODS

86 patients with malignant pancreatic masses and 28 control subjects without any evidence of pancreatic diseases were examined by EUS elastography. EUS video sequences were subjected to a quantitative analysis based on mean hue histogram analysis. Pancreatic fibrosis was determined by quantitative morphometry in tissue specimens from 36 patients.

RESULTS

The mean RGB (red, green, blue) value was significantly higher in the cancer patients compared to the controls (14.0 ± 0.4 vs. 11.5 ± 0.9; p = 0.0085), albeit with significant overlap between the groups. In contrast, a much sharper separation between the groups was obtained based on the individual color values for blue, green and red (p < 0.0001, respectively). By these means, 100 % sensitivity and specificity for the distinction between tumor and normal tissue was obtained for the blue color value, while the red and green color values were less discriminative. The fractional fiber content of the tumors was unrelated to the respective hue histogram color values.

CONCLUSION

Quantitative EUS elastography allows for clear differentiation between malignant pancreatic tumors and normal tissue. Using this approach, we demonstrated that the stiffness of pancreatic tumors is largely independent of their fiber content.

Management of borderline ovarian tumors

Borderline ovarian tumors are an intermediate stage between benign cystadenomas and adenocarcinomas.

AIM

The paper evaluates the management of borderline ovarian tumors (BOTs) in the patients admitted and treated in our clinic in the interval January 2003 - June 2011.

MATERIAL AND METHODS

The observation sheets and pathology results of 264 patients with malignant ovarian tumors were analyzed.

RESULTS

Of the 264 malignant ovarian tumors 74 (28.03%) were low malignant potential. Patients with BOT were aged 18-72 years (mean 46 +/- 6.2 years) and those with invasive tumors 14-83 years (mean 53 +/- 9.8 years). 92.18% were in stage 1. Sixty tumors were graded G1. 53.52 % of the tumors were over 10 cm (maximum 30 cm) in size. The histological types were: serous - 35 cases, mucinous - 19 cases, mixed (serous and mucinous) - 8 cases, and endometrioid - 2 cases. Fifteen patients presented intraepithelial carcinoma and 11 noninvasive implants into the peritoneal cavity. Five women had recurrences.

CONCLUSIONS

Ovarian borderline tumors with histological characteristics of carcinoma, but with good behavior are now with better defined histological features. The biggest challenge in the management of women with these tumors is to identify the subset that will behave in a malignant fashion and to develop effective treatment for them.

Association of expression of XIAP-associated factor 1 (XAF1) with clinicopathologic factors, overall survival, microvessel density and cisplatin-resistance in ovarian cancer

XIAP-associated factor 1 (XAF1) was identified as a novel X-linked inhibitor of apoptosis (XIAP) binding partner that can reverse the anti-apoptotic effect of XIAP. XAF1 levels are greatly decreased in many cancer tissues and cell lines. The aim of this study was to investigate the expression of XAF1 and XIAP in advanced epithelial ovarian cancer and role of XAF1 in cisplatin resistance of ovarian cancer cells. Tissues from 94 patients with advanced epithelial ovarian cancer (EOC) and 30 ovarian cystadenomas were obtained. We analyzed the association of the immunohistochemical-determined expression of these two factors and clinicopathologic variables, overall survival, and angiogenesis. We established SKOV3 cells stably overexpressing XAF1 and explored the possible functions of XAF1 in ovarian cancer cells in vitro and in vivo. The protein expression of XAF1 was significantly lower and that of XIAP higher in malignant than nonmalignant tissues. Low XAF1 expression was associated with high-grade tumors and poor overall survival for patients. XAF1 expression was associated with microvessel density. Overexpression of XAF1 suppressed cell proliferation and enhanced SKOV3 cells sensitivity to cisplatin, as well as inhibited tumor growth and decreased MVD in vivo. Overexpression of XAF1 induced XIAP inactivation, caspase-3 activation and cytosolic expression of cytochrome c. These results suggested that XAF1 may be involved in ovarian cancer development and up-regulation of XAF1 may confer sensitivity of ovarian cancer cells to cisplatin-mediated apoptosis.

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.

Ovarian tumours, their characterisation and origins and ovarian screening

Ultrasound assessment of ovarian tumours cannot accurately predict pathology. Recent reviews suggest that the source of many epithelial ovarian carcinomas may be the distal fallopian tube. Further study of the natural history of these tubal lesions is required before resuming ovarian screening.

[Prostatic cystadenoma: a case report and review of the literature]

OBJECTIVE

To study the clinicopathological characteristics of prostatic cystadenoma (PC).

METHODS

A sample from surgically removed tissues of a PC patient was examined by conventional pathology and immunohistochemistry. The clinical data and clinicopathological features were analyzed, and the related literature reviewed.

RESULTS

The patient was a male aged 55 years, treated by TUVP for dysuria a year before. The tumor was a grey mass, with lots of different sized capsular spaces full of clear white liquid in the cross section. Histologically, the tumor cells were arranged in a sieve-like, microcapsule-shaped or adenoid pattern, lined with cuboidal and columnar epithelial cells, the nuclei located in the base with neither cellular atypia nor mitosis. Concerning the immunophenotype, PSA, PAP and CK7 were positively expressed in the columnar epithelial cells and 34betaE12 in the basal cells, while CK20, P504S, CEA and villin were negatively expressed, with Ki67 + < 2%.

CONCLUSION

Prostatic cystadenoma is a rare benign tumor originating in the prostate, with a unique morphological structure, and mostly with the expressions of PSA and PAP.

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.

[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.

Linear syringocystadenoma papilliferum: an uncommon event with a favorable prognosis

Syringocystadenoma papilliferum (SCAP) is an uncommon cutaneous adnexal tumor of uncertain histogenesis. Various authors have postulated that the tumor differentiates toward apocrine gland, eccrine gland, or the apo-eccrine gland. We present a patient with an unusual linear form.

Preservation of fertility after partial resection of bilateral ovarian cystadenofibromas: a case report

BACKGROUND

Benign cystadenofibromas and adenofibromas may represent precursors to malignant lesions.

CASE

A 20-year-old woman undergoing infertility treatment was found to have cystadenofibromas involving both ovaries, with no separable normal ovarian tissue visible. Because complete resection of the tumors would have required bilateral oophorectomy, the tumors were only partially resected using a shave technique. This patient subsequently had 3 normal-term deliveries over 7 years and did not have any clinically significant regrowth of her tumors during this time.

CONCLUSION

It may be reasonable to delay removing benign tumors in a young woman who has not completed her childbearing.

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.

Clinical experience of adnexal torsion: evaluation of 143 cases

We conducted this retrospective study to evaluate the outcomes, indications and post-operative findings of adnexal torsion cases and compared the features of benign cystic teratoma with the other cases. We analyzed a series of 143 cases of adnexal torsion from 2000 to 2009 at current clinic, retrospectively. The data were collected from the patient's specific files and hospital records descriptively. The demographic characteristics, sonographic findings and post-operative invention were evaluated. Statistical analyses were carried out by using the statistical packages for SPSS 15.0 for Windows (SPSS Inc., Chicago, IL, USA). A total of 143 cases were operated for adnexal torsion during the study period at our clinic. The clinical and demographic characteristics of the cases are shown in table 1. Of all patients, forty of them were diagnosed as benign cystic teratoma and this group of the adnexal torsion cases had statistically different gravidy, mass size and torsion number from the non-benign cystic teratoma group. Age was not a statistically different between two groups. According to this study, benign cystic teratoma increases risk of adnexal torsion. When detecting benign cystic teratoma the patients should be informed about the risk of torsion and explained the signs of this situation. The early diagnosis and appropriate surgical management of adnexal torsion is the only way to prevent complications and to preserve future fertility. Being aware of the different sonographic findings of torsionated adnexa may assist in the correct diagnosis of these patients.