Benign Mucinous Cysts Research Articles

Intraneural and Extraneural Ganglion Cysts at the Greater Sciatic Notch Involving the Sciatic Nerve Causing Sciatica: Two Case Reports

Intraneural ganglion cysts (IGCs) are benign mucinous cysts within the epineurium of peripheral nerves. Hip joint-related IGCs are much rarer than those that arise from peripheral nerves around the joints of limbs. The unifying articular synovial theory has been accepted as explaining the pathogenesis of IGCs. Herein, we present two cases of hip joint-related ganglion cysts—one case of an IGC and one case of an extraneural ganglion cyst—that involved the sciatic nerve through the articular branch of the hip joint and caused sciatica. Preoperative and postoperative magnetic resonance imaging (MRI) findings of the articular branch derived from a paralabral cyst of the hip are presented, as well as photographic findings of a ganglion cyst with the articular branch addressed through a transgluteal approach. Despite improvement in postoperative sciatica due to cyst decompression and treatment aimed at addressing the articular branch, the articular branch remained present on postoperative MRI. Unlike IGCs arising from peripheral nerves associated with limb joints, involvement of the sciatic nerve might make it challenging to treat articular branches due to the location of the sciatic nerve over the greater sciatic notch of the deep gluteal region.

A case of intraneural ganglion cyst of the peroneal nerve: A rapid recovery after incision of cyst

Introduction : Intraneural ganglion cysts (INGCs) are an infrequent cause of foot drop. INGCs are benign mucinous cysts within the epineurium of peripheral nerves, which are usually observed in the peroneal nerve at the knee typically leading to symptoms and signs of peripheral neuropathy. Case Report: A 40-year-old man with foot drop who had undergone a spinal study for discopathy was examined in this study. The patient had peroneal nerve compression at the neck of the fibula resulting from an extra neural cyst. Surgical exploration revealed an intraneural cyst. Epineurium was incised and the cyst was evacuated. In a two-week post-surgery follow up, his foot drop had improved partially and the remainder of his symptoms resolved. Conclusion: Awareness of the intraneural cysts of peroneal nerve as a cause for foot drop is important because early surgical intervention could reverse the course of disease.

Utility of a Commercial Molecular Panel (REDPATH) in Pancreatic Cyst Fluid Analysis: A Single Center Experience

Background: Promising studies using molecular analysis to characterize pancreatic cysts as benign, pre-malignant, or malignant have led to the development of commercial molecular analysis panels, the role of which remains to be fully elucidated. Objective: To determine the clinical utility of commercial molecular analysis (RedPath) of pancreatic cyst fluid. Methods: Retrospective review of 105 consecutive EUS/FNA patients with pancreatic cysts referred to UC Davis Medical Center was completed. Among this group, 34 cases for which RedPath was obtained were used in the ensuing analysis. A CEA cutoff >192 ng/ml was used to classify cysts as mucinous. RedPath criteria for cyst classification as benign non-mucinous, indolent, or malignant included presence of a K-ras-2 mutation, two or more LOH mutations, or greatly elevated DNA quantity. Concordance was assessed using Cohen Kappa values. Simple probit regression was used to model clinical predictors of concordance. Sensitivity and specificity were determined using clinical consensus diagnosis as reference. Results: Fair agreement was noted between CEA and RedPath analysis (K=0.38). There were 24 concordant cases and 10 discordant cases. REDPATH did not predict more malignant pathology in any of the discordant cases. Regression analysis was used to assess whether clinical predictors such as family history of malignancy, presence of symptoms, diabetes, and cyst size were associated with discordance. No statistical significance was observed among these clinical predictors (p=0.69, p=0.98, p=0.30, p=0.63 respectively). No cases were identified in which RedPath results directly altered follow-up interval or referral to surgery. The results were used as supportive evidence in 62% of patients, to confirm surveillance recommendations. In the remaining 38% of patients, RedPath results were either unavailable or not addressed at follow-up. The sensitivity/specificity/accuracy of RedPath for diagnosing benign nonmucinous cysts was 100%/50%/75% and for benign mucinous cysts was 50%/100%/75%. Conclusion: CEA and RedPath analysis had fair concordance. Among discordant cases, RedPath neither predicted more malignant disease than CEA, nor did it alter follow-up intervals. RedPath was used mainly to corroborate CEA/EUS/cytology-based clinical decision on surveillance intervals. No clinical predictors were associated with discordant CEA and RedPath results. The high sensitivity of RedPath for benign nonmucinous cysts suggests a potential role for this modality as a reliable rule-out test for benign nonmucinous pathology. Further research should focus on cost effectiveness, and defining a specific role for its use in the management of pancreatic cystic neoplasms.

Diagnostic Performance of Pancreatic Cyst Fluid Carcinoembryonic Antigen (CEA) and Amylase: A Community Hospital Experience

Purpose: EUS/FNA is performed on pancreatic cystic lesions (PCL) when feasible and fluid sent for CEA/amylase. Although the literature has varied CEA cutoff values, many centers use CEA (ng/mL) of <5 for distinguishing non-mucinous cysts from mucinous cysts (MC) and >192 for mucinous cystadenomas (MCA). Amylase of 250 U/L is often used to differentiate pseudocysts (PC) from other cysts. Sensitivities (SN) and specificities (SP) differ between studies. Analyses of PCL in a community/non-academic setting may be an important addition to exiting data. Using our cyst data, our goals were to: (1) analyze the performance of CEA in differentiating MC from non-MC and benign from malignant; (2) test the ability of amylase in differentiating MC from non-MC, benign from malignant, IPMN from MCA, PC from non-PC; (3) calculate SN and SP of commonly used CEA and amylase values. Methods: Retrospective review of PCL which had EUS/FNA for CEA and amylase then confirmation of cyst type via cytology/histopathology. Results: Twenty-three cases met the search criteria between December 2007 and November 2011. Median (IQR, interquartile range) of CEA (ng/mL) in MC and non-MC were 642.50 (68.53-9,278.25) and 10.05 (1.65-22,238), respectively (p=0.19). Median (IQR) of CEA in benign MC and malignant MC were 642.50 (28.38-9,466.75) and 2,283 (284-4,282), respectively (p=1.00). Median (IQR) of amylase (U/L) in MC and non-MC were 283 (131-800) and 800 (411.5-14,579), respectively (p=0.35). Median (IQR) of amylase in benign MC and malignant MC were 541.50 (104.25-800) and 227 (227-227), respectively (p=0.60). Median (IQR) of amylase in IPMN and MCA were 125.50 (24-227) and 800 (207-800), respectively (p=0.11). Median (IQR) of amylase in PC and non-PC were 14,579 (800-28,358) and 314.5 (88.75-800), respectively (p=0.06). None of the differences were statistically significant; small sample size was a limitation. CEA <5 for diagnosis of non-MC had SN of 50% and SP of 94%. CEA >192 for the diagnosis of MCA had SN of 57% (increased to 64% when IPMN included) and SP of 67%. CEA of >800 in distinguishing MCA/MCAC (mucinous cystadenocarcinoma) from SCA (serous cystadenoma)/PC had SN of 46% and SP of 75%. Ability of amylase <250 to distinguish SCA, MCA, and MCAC from PC had SN of 30% and SP of 100%. Amylase in IPMN were low in our data with median (IQR) of 125.5 (24-227), which is contrary to prior reports of much higher IPMN amylase values. Conclusion: In a non-academic setting, commonly used CEA and amylase values for the diagnosis of PCL yielded similar SN and SP (slightly lower in some cases) as those reported in the medical literature. Cyst fluid CEA and amylase analyses pose diagnostic challenges in differentiating PCL. Amylase in IPMNs were lower compared to prior reports.

OC-112 Utility of cyst fluid amylase in the differentiation of suspected pancreatic neoplastic cysts

IntroductionThe Differentiation of mucinous (MCA, IPMN) from non-mucinous pancreatic cysts is important because of the malignant potential of the former. Cyst fluid amylase is known to be elevated in cysts...

Diagnostic accuracy of cyst fluid amphiregulin in pancreatic cysts

BackgroundAccurate tests to diagnose adenocarcinoma and high-grade dysplasia among mucinous pancreatic cysts are clinically needed. This study evaluated the diagnostic utility of amphiregulin (AREG) as a pancreatic cyst fluid biomarker to differentiate non-mucinous, benign mucinous, and malignant mucinous cysts.MethodsA single-center retrospective study to evaluate AREG levels in pancreatic cyst fluid by ELISA from 33 patients with a histological gold standard was performed.ResultsAmong the cyst fluid samples, the median (IQR) AREG levels for non-mucinous (n = 6), benign mucinous (n = 15), and cancerous cysts (n = 15) were 85 pg/ml (47-168), 63 pg/ml (30-847), and 986 pg/ml (417-3160), respectively. A significant difference between benign mucinous and malignant mucinous cysts was observed (p = 0.025). AREG levels greater than 300 pg/ml possessed a diagnostic accuracy for cancer or high-grade dysplasia of 78% (sensitivity 83%, specificity 73%).ConclusionCyst fluid AREG levels are significantly higher in cancerous and high-grade dysplastic cysts compared to benign mucinous cysts. Thus AREG exhibits potential clinical utility in the evaluation of pancreatic cysts.

Diagnostic performance of cyst fluid carcinoembryonic antigen and amylase in histologically confirmed pancreatic cysts.

The objective of this study was to evaluate and validate cyst fluid carcinoembyronic antigen (CEA) and amylase in differentiating (1) nonmucinous from mucinous pancreatic cystic lesions (PCLs), (2) benign mucinous from malignant mucinous PCLs, and (3) pseudocysts from nonpseudocysts (amylase only). A retrospective analysis of patients with histologically confirmed PCLs from February 1996 to April 2007 was performed. Cyst fluid CEA (n=124) and/or amylase (n=91) were measured and correlated to cyst type. Carcinoembyronic antigen levels (P=0.0001), but not amylase, were higher in mucinous versus nonmucinous cysts. The sensitivity, specificity, and diagnostic accuracy of CEA 200 ng/mL or greater for the diagnosis of mucinous PCLs were 60%, 93%, and 72%, respectively. Carcinoembyronic antigen levels did not differentiate benign from malignant mucinous cysts. Whereas amylase levels were higher in pseudocysts than nonpseudocysts (P=0.009), 54% of noninflammatory PCLs had a level greater than 250 IU/L, including mucinous cystic neoplasms (median, 6800 IU/L; interquartile range, 70-25,295 IU/L). Malignant mucinous cysts had lower amylase levels than benign mucinous cysts (P=0.0008). Cyst fluid CEA and amylase levels are suggestive but not diagnostic in differentiating PCLs. Unlike CEA, amylase may help differentiate benign from malignant mucinous cysts. Novel biomarkers are needed.

Evaluation of Cyst Fluid CEA Analysis in the Diagnosis of Mucinous Cysts of the Pancreas

BackgroundAlthough cyst fluid carcinoembryonic antigen (CEA; >192 ng/ml) is the preferred test for identifying mucinous pancreatic cysts, the data are more robust for mucinous cystic neoplasms (MCN) than for intraductal papillary mucinous neoplasms (IPMN). The role of cyst fluid CEA as a marker for either malignancy or malignant progression is uncertain. MethodsAll patients with pancreatic cysts who had undergone endoscopic ultrasound with cyst fluid CEA measurement between 2001 and 2009 were identified. Patient outcomes and pathology from operative resections were recorded. ResultsTwo hundred sixty-seven patients were identified; pathological diagnosis was obtained in 97. Mucinous cysts were identified in 66 of 97 (68%): benign IPMN, n = 42; malignant IPMN, n = 10; benign MCN, n = 12; malignant MCN, n = 2. CEA > 192 ng/mL had a sensitivity and specificity of 73% and 65% for identifying mucinous cysts; cyst fluid CEA was not associated with malignancy (p = 0.85). One hundred seventy-eight patients were managed with an initial non-operative strategy. Eight (4%) developed radiographic changes necessitating surgery; pathology demonstrated seven benign mucinous cysts and one retention cyst. CEA was not associated with radiographic progression (p = 0.37). ConclusionsCyst fluid CEA is a useful test for identifying mucinous cysts, including MCN and IPMN. In mucinous cysts, cyst fluid CEA is not associated with malignancy or radiographic progression.

A distinct molecular profile associated with mucinous epithelial ovarian cancer

Mucinous epithelial ovarian cancers (MOC) are clinically and morphologically distinct from the other histological subtypes of ovarian cancer. To determine the genetic basis of MOC and to identify potential tumour markers, gene expression profiling of 49 primary ovarian cancers of different histological subtypes was performed using a customised oligonucleotide microarray containing >59 000 probesets. The results show that MOC express a genetic profile that both differs and overlaps with other subtypes of epithelial ovarian cancer. Concordant with its histological phenotype, MOC express genes characteristic of mucinous carcinomas of varying epithelial origin, including intestinal carcinomas. Differences in gene expression between MOC and other histological subtypes of ovarian cancer were confirmed by RT–PCR and/or immunohistochemistry. In particular, galectin 4 (LGALS4) was highly and specifically expressed in MOC, but expressed at lower levels in benign mucinous cysts and borderline (atypical proliferative) tumours, supporting a malignant progression model of MOC. Hence LGALS4 may have application as an early and differential diagnostic marker of MOC.

P141Benign mucinous ovarian cysts: transvaginal sonography with color Doppler features

AimTo evaluate the accuracy of transvaginal sonography with color Doppler (TVSCD) in identifying mucinous ovarian cysts.Material and methodsFive hundred 18 adnexal masses were diagnosed by TVSCD before surgery. We identified those adnexal masses in which an ultrasonographic diagnosis of mucinous ovarian cyst was done. This diagnosis was based on the presence of a cystic lesion with thin, grape‐like appearing septa and diffuse internal echoes. This diagnosis was compared with the pathological features.ResultsA total of 49 mucinous cysts were diagnosed by TVSCD, 26 of them were histologically confirmed. Twenty‐three cysts were misdiagnosed (9 were serous, 4 were interpreted as malignant and one was an endometrioma). TVSCD was unable to diagnose 14 out of 40 mucinous cysts confirmed by histology. The ultrasonographic features most frequently seen as suspicious of malignancy were thin, grape‐like appearing septa (84.6%) and diffuse internal echoes (53.8%). The sensitivity, specificity, and positive and negative predictive values and accuracy of TVSCD were 65%, 95.2%, 53.1%, 97%, and 92%, respectively.ConclusionsThe accuracy of TVCD for the diagnosis of benign mucinous cysts is very high, being the most frequently cause of confusion simple serous cysts.AcknowledgementsThe authors are grateful to the Càtedra d'Investigació en Obstetrícia i Ginecologia (Universitat Autónoma de Barcelona).

Measurement of pS2 protein in pancreatic cyst fluids. Evidence for a potential role of pS2 protein in the pathogenesis of mucinous cystic tumors.

Elevated levels of the growth factor pS2 protein in the cyst fluids of mucinous cystic tumors correlate with earlier observations using immunohistochemical techniques showing that pS2 protein is expressed by these tumors. The markedly elevated levels of pS2 protein compared to normal plasma values suggest that this growth factor may be important in the pathogenesis of pancreatic mucinous cystic tumors. Cystic lesions of the pancreas include inflammatory pseudocysts, serous cystadenomas, and mucinous cystic tumors, some of which are malignant. Previous studies using immunohistochemical techniques have shown that virtually all pancreatic mucinous tumors express pS2 protein. pS2 protein is a growth factor that is believed to be important in the normal process of inflammation and repair. We measured pS2 protein and other growth factors in pancreatic cyst fluids to assess their potential pathophysiologic and diagnostic significance. Levels of pS2 protein were measured in 54 pancreatic cyst fluids by radioimmunoassay. The growth factors, epidermal growth factor (EGF), transforming growth factor-alpha (TGF-alpha), and insulin-like growth factors I and II (IGF-I, IGF-II) were measured in 22 cyst fluids using commercial immunoassays. Mucinous cysts exhibited significantly higher levels of cyst fluid pS2 protein than nonmucinous lesions, including pseudocysts and serous cystadenomas (median: 78,303 pg/mL; range: 218-361,176 pg/mL vs median: 886 pg/mL; range: 0-14,206 pg/mL; p = 0.0001). The level of pS2 in mucinous tumors was markedly higher than plasma values (median: 392 pg/mL). Levels of pS2 protein in malignant mucinous lesions tended to be higher than those in benign mucinous cysts, but this difference was not statistically significant (median: 88,817 vs 64,350 pg/mL; p = 0.159). Levels of other growth factors, including EGF, TGF-alpha, IGF-I, and IGF-II, did not discriminate among the different cyst types, and the values were within normal plasma ranges.