Inflammatory Pseudocyst Research Articles

S1582 Rare Cause of Pancreatic Cystic Lesion: Pancreatic Lymphangioma

INTRODUCTION: Lymphangiomas are rare benign cystic malformation of the lymphatic vessels, usually reported in the pediatric population. It is commonly seen in the head, neck, and axilla, rarely in the mediastinum, mesothelium, pericardium, and abdominal organs like the pancreas. We report a case of a patient with lymphangioma of the pancreas. CASE DESCRIPTION/METHODS: A 33-year-old female with recent diagnosis of left-sided ulcerative colitis and idiopathic thrombocytopenic purpura presented to the hospital with epigastric pain for three weeks, which got worse over a few days. Laboratory workup revealed lipase level of 265 IU/ml. CT scan of the abdomen with contrast showed homogeneously enhancing pancreas and a 2.5 cm × 1.1 cm cystic lesion adjacent to the uncinate process of the pancreas. MRI abdomen with contrast revealed 3.2 × 2.3 × 4 cm cystic lesion with thin separations without any mural nodularity. The patient subsequently underwent endoscopic ultrasound (EUS) that confirmed a septate cystic lesion within the uncinate process, and 15cc of chylous milky white was aspirated via fine-needle aspiration (FNA) and fluid analysis showed triglyceride level >8000 mg/dl and cytology negative for malignancy and thus confirming lymphangioma. Patient declined surgery and is being followed up with surveillance imaging. DISCUSSION: Cystic lymphangioma of the pancreas is extremely rare, accounting for less than 1% of lymphangiomas. It occurs due to malformation of the lymphatic system. It can be secondary to infections, trauma, obstruction, and chronic inflammation, but underlying cause is unknown in most cases. Patients are usually asymptomatic but can present with an abdominal mass, abdominal pain, nausea, and vomiting. The differential diagnosis includes other cystic lesions like inflammatory pseudocyst, serous or mucinous cyst of the pancreas, and cystic adenocarcinoma. Most pancreatic cysts are discovered incidentally, and lesion size varies from 3 cm to 20 cm. Radiographic imaging like CT, MRI of the abdomen are used for initial diagnostic tools. Pathologic diagnosis with EUS-guided FNA is needed for definitive diagnosis. Even if lymphangioma is pathologically benign, surgical removal should be the first choice for symptomatic lymphangiomas. Complete surgical resection is curative as there is a high recurrence rate reported with partial resection. Although cystic lymphangioma of the pancreas is uncommon, it should be kept in the differential in patients with cystic pancreatic lesions, especially in females.Figure 1.: MRI abdomen showing Pancreatic lymphangioma (arrow).Figure 2.: Endoscopic ultrasound showing Pancreatic lymphangioma.Figure 3.: Fluid obtained from pancreatic lymphangioma by EUS guided FNA.

Pediatric sublingual dermoid and epidermoid cysts: A 20-year institutional review

IntroductionPediatric cystic sublingual masses often present a diagnostic dilemma for practitioners. Though uncommon, dermoid or epidermoid cysts can present in the sublingual space at any age and are often misdiagnosed as an inflammatory pseudocyst (ranula) or lymphatic malformation. Imaging may not always identify the underlying etiology, requiring physicians to maintain a high index of suspicion for these relatively rare oral cysts. ObjectivesTo describe the presentation and treatment of sublingual dermoid and epidermoid cysts presenting to a tertiary children's hospital over 20 years. MethodsA retrospective review of all pathology specimens identified as dermoid or epidermoid cysts within the sublingual space from 1999 to 2019. Patient charts were then reviewed for relevant clinical, imaging, and operative data. ResultsTwelve pediatric patients were identified (8 female, 4 male) with a mean age of 7.2 years (SD 5.6). Eighty six percent (6/7) of dermoid cysts were found in female patients, while 60% (3/5) of epidermoid cysts were in male patients. Multiple dermoid and epidermoid cysts were each found in one patient (8%). Two epidermoid cysts presented in the neonatal period. Preoperative diagnosis included nondiagnostic “cystic mass” (33%), ranula (25%), lymphatic malformation (LM) (17%), and dermoid/epidermoid cyst (17%). Two thirds of patients (8/12) underwent imaging, with all receiving either MRI or CT. Although MRI was the most likely to suggest the possibility of a dermoid/epidermoid cyst (2/4), ranula was the most common primary radiographic diagnosis (5/8). One patient underwent sclerotherapy for presumed LM one year prior to surgical excision of the cyst. Eleven patients (92%) underwent intraoral excision, one (8.3%) underwent a combined intraoral/extraoral approach. ConclusionsTo our knowledge, this review represents the largest case series of pediatric sublingual dermoid and epidermoid cysts to date. This series contained higher levels of epidermoid cysts and female patients than previously reported in the literature. Identifying more dermoid cysts in females and epidermoid cysts in males is also a new finding. MRI was superior to CT and US regarding the presence of a dermoid/epidermoid cyst. Frequently misdiagnosed, it is important to consider these relatively rare pathologies when treating children presenting with sublingual masses in order to avoid delayed and/or inappropriate treatment.

Use of EUS-Guided Needle-Based Confocal Laser Endomicroscopy and Microforceps Biopsy to Prevent an Unnecessary Cyst-Gastrostomy

Introduction: Current radiologic and endoscopic studies for pancreatic cystic lesions have known poor sensitivity and accuracy for distinguishing any particular cystic lesion. The current case describes the use of two novel EUS-guided tools for the diagnosis and management of a large, symptomatic pancreatic cyst. Case Description: 30 year old female with prior history of pancreatitis presented with left upper quadrant abdominal pain. MRCP revealed a large 28 mm x 39 mm unilocular cyst in the tail of the pancreas. Based on the history, the possibility of a pancreatic pseudocyst was raised. However, given the patient's young age and female gender, as well as the cyst morphology and location, a clinical suspicion was raised for a possible mucinous cystic neoplasm (MCN). Given the diagnostic uncertainty, and the vast differences in management of these lesions, the decision was made to perform further diagnostic testing to help guide management. EUS evaluation with multimodality sampling was performed. nCLE imaging revealed multiple thickened epithelial bands lining the cyst wall. Four biopsies were then obtained using the MFB. Following this, FNA was performed. Seventeen ml of dark brown watery fluid was obtained. Cyst fluid analysis demonstrated glucose 1,500 ng/ml, amylase 11,859 u/L. Cytology revealed foamy macrophages and a few clusters of bland glandular cells. MFB pathology yielded tissue with ovarian-like stroma with mucinproducing epithelial lining consistent with an MCN. The patient was referred for a distal pancreatectomy. Final surgical pathology revealed the cyst wall to be lined by flat cuboidal epithelium and ovarian-type stroma without cytologic atypia, papillary architecture or epithelial proliferation. Final diagnosis favored an endometrial cyst of the pancreas over an atypical MCN. The patient had resolution of her symptoms following surgery. Discussion: Standard EUS-FNA and cyst fluid analysis are suboptimal in their ability to make a cytopathologic diagnosis of a pancreatic cyst. In the current case, standard biochemical fluid analysis produced conflicting results showing both an elevated cyst fluid CEA and amylase, and thus unable to distinguish an inflammatory pseudocyst from a neoplastic or non-inflammatory cystic lesion. Cyst fluid cytology was similarly non-diagnostic. However, the combined use of EUS-guided nCLE and MFB produced highly detailed diagnostic information allowing for appropriate management. Watch the video: https://goo.gl/XkPkfy

An evidence-based etiology study of synovial cyst of knee cruciate ligament: a real or pseudo-cyst

Synovial cyst of knee cruciate ligament (SCKCL) is a rare condition but can cause severe knee pain. The understanding of its etiology is relatively poor. This current study aimed to elucidate the pathogenesis of SCKCL based on a series of histo- and cytopathological examination. Ten SCKCL patients who underwent arthroscopy were enrolled, among five patients claimed past knee injury. Hematoxylin & eosin staining was conducted to the cyst wall tissue sections and Papanicolaou staining to the cyst fluid smear. Prussian blue staining was employed to both the wall section and fluid smear. Immumohistochemical staining for mesothelial cells (MC), epithelial cells (CK), vascular endothelial cells (CD31), monocytes (CD68), and hematogenous stem cells (CD117) were taken to elucidate the possible involvement of various cell types in the development of SCKCL. No erythrocyte was discovered in the fluid; however, Prussian blue stained hemosiderin particles were found in the cyst wall and fluid, suggesting past hemorrhage in all patients. Abundant lymphocytes and plasmocytes were observed in the cyst wall and fluid. In addition, the cyst lining was infiltrated with abundant CD68(+) monocytes while only few MC(+) mesothelial cells were sporadically observed in four samples. The cyst submucosa was also diffused with abundant CD68(+) monocytes and proliferated capillaries stained with CD31. CD117-positve hematogenous stem cells were sporadically observed in eight specimens. Our findings provided evidence that SCKCL is not a mature synovial cyst but rather an inflammatory pseudo-cyst. It may have resulted from past minor hemorrhage and intra-ligament chronic inflammation.

Intra‐abdominal pseudocyst and abscess formation caused by non‐typhoid salmonella

Intra-abdominal cystic masses can be difficult to characterize when they are large and fill most of the abdomen. Because normal anatomy is distorted, the origin of the mass can be diffi- cult to ascertain. 1 We report our experience treating an 18-month- old boy with a giant abdominal cystic mass infected by Salmonella enterica serogroup D. formed. The analysis of the cystic fluid showed a white blood cell count of 124 850/mL with 99% neutrophils. After 3 days, the turbid fluid culture grew Salmonella enterica serogroup D, which was susceptible to ampicillin and ceftriaxone. Both stool and blood cultures were negative for Salmonella enterica. The histo- logical sections showed a large cystic cavity in the mesocolon surrounded by granulation tissue with marked acute and chronic inflammation. The inner surface showed necrosis, marked inflammation, abscess formation and was without lining epithe- lium. No proliferation of vascular or lymphatic channels was detected, and therefore, inflammatory pseudocyst with abscess formation was concluded. Fever subsided postoperatively and he was given ceftriaxone for 10 days. The patient was doing well at his last follow-up visit one and a half months later.

Spontane Milzruptur bei chronischer Pankreatitis

A 50-year-old woman complained of upper abdominal pain for several weeks, getting worse and radiating towards the left shoulder in the 24 hours preceding her hospital admission. Plain X-ray film of the abdomen revealed plaque-like calcifications projecting onto the tail of the pancreas. Ultrasound imaging demonstrated splenic rupture with free intra-abdominal fluid. During an emergency laparotomy the spleen was removed. At first the postoperative course was uneventful. But epigastric pain recurred a few days after discharge. Serum amylase and lipase concentrations were elevated (280 U/l and 553 U/l, respectively). Endoscopic retrograde cholangiopancreatography revealed chronic pancreatitis with a 3 cm pseudocyst in the tail of the pancreas. A papillotomy was performed, after which the symptoms rapidly regressed and the pancreatic enzyme concentrations fell. This was thus a case of spontaneous splenic rupture associated with previously undiagnosed chronic pancreatitis with inflammatory papillary stenosis and pseudocyst in the pancreatic tail.

Cystic Masses of the Pancreas

Cystic masses of the pancreas are not uncommon, and they are being encountered on imaging studies with increasing frequency.1 They can be categorized histologically as inflammatory pseudocyst, benign neoplastic, and premalignant or malignant. Those in the “premalignant or malignant” category are either primarily cystic or result from the cystic degeneration of solid tumors. Approximately 75% to 90% of pancreatic cysts are inflammatory pseudocysts. Cystic neoplasms of the pancreas account for 5% to 15% of all cystic pancreatic masses. Most primary cystic neoplasms fall into one of three categories: serous cystadenomas (32% to 39%); mucinous cystic neoplasms (10% to 45%); and intraductal papillary mucinous neoplasms (21% to 33%).1 In addition to primary cystic pancreatic masses, peripancreatic cystic lesions such as lesions arising from gastric, duodenal, and retroperitoneal origin may simulate a pancreatic cystic mass.

Autoimmune pancreatitis associated with a large pancreatic pseudocyst

Pancreatic cystic lesions comprise various entities with different histopathological characteristics and their differential diagnosis is often a challenge for clinicians. Autoimmune pancreatitis (AIP) is usually not considered in the differential diagnosis of cystic lesions, but often mimics the morphological aspects of pancreatic neoplasm. We report the case of a 64-year-old male patient with a cystic pancreatic head lesion (diameter 5 cm) and stenosis of the distal bile duct requiring repeated stenting. Because of the clinical presentation together with moderate elevation of serum CA19-9 and massive elevation of cyst fluid CA19-9 (122.695 U/L; normal range: <37.0 U/L), the patient underwent explorative laparotomy and pylorus preserving partial pancreaticoduodenectomy. Histology revealed surprisingly AIP with an inflammatory pseudocyst. In conclusion, cyst fluid analysis of tumor markers and cyst fluid cytology lack high accuracy to clearly differentiate cystic pancreatic lesions. Although AIP is rarely associated with pseudocysts, the disease has to be considered in the differential diagnosis of cystic pancreatic lesions. Early examination of serum IgG, IgG4 and auto-antibodies might save these patients from unnecessary endoscopical and surgical procedures.

Diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration of cystic lesions of the pancreas

BACKGROUND: Endoscopic ultrasound and fine-needle aspiration (EUS-FNA) has gained wide acceptance as a modality for the diagnosis and staging of pancreatic cancer. EUS-FNA has also recemly been reported to differentiate benign from malignant cystic lesions of the pancreas. The aim of this study is to establish the accuracy of EUS-FNA in diagnosing cystic lesions when compared to surgical pathology. METHOD: We retrospecnvely analyzed all patients who underwent EUS-FNA of a cystic pancreatic lesion from 10/99 9/02. A positive FNA result was defined by the presence of adenocarcinoma mucin; cytology reported as highly suspicious for adenocarcinoma was also considered positive. Cyst fluid CEA levels were defined as consistent with malignancy if greater than 500 units/ml. Cyst fluid amylase levels were defined as consistent with a benign inflammatory pseudocyst if greater than 5000 IU/L. RESULTS: EUS-FNA was performed on 84 patients with a mean age of 58.9 years. 63% were female patients. Fluid and mucnions material was successfully aspirated from the pancreatic cyst in 73 patients. 24 of the 73 patients underwent surgical resection of the pancreas. 15 of the 24 surgical patients were found to have adenocarcinoma a mucinous neoplasm on final histopathology of the surgical specimen. 14 (93%) of the 15 patients were correctly diagnosed preoperatively by EUS-FNA. 9 of the 24 patients were found to have a nonmalignant diagnosis on final histopathology of the surgical specimen. 3 (30%) were correctly diagnosed either as serous cystadenomas (1) inflammatory pseudocysts (2). 49 of 73 patients did not undergo surgery. EUS-FNA was positive in 21 of these patients; surgery was not performed because of medical co-mothidities, metastatic disease or local tumor unresectability. Clinical follow-up supported advanced cancer in all 2t patients. EUS-FNA suggested benign disease in 28 of the 49 patients; clinical and radiographic follow-up has failed to demonstrate invasive cancer in any of these 28 patients. CONCLUSION: EUS-FNA of pancreatic cystic lesions is an accurate technique for the differentiation of benign and malignant disease. It is the diagnostic procedure of choice in those patients who require a cytological diagnosis of malignancy to allow the delivery of chemotherapy in patients with presumed benign disease (serous cystadenoma pseudocyst) in whom observation is most appropriate.

Anisakiasis of the small intestine mimicking a metastatic tumor: a new French case

Summary A 49-year-old woman underwent abdomino-perineal surgery for a recurrent poorly differentiated squamous cell carcinoma of the anus following unsuccessful radiotherapy. The per-operative investigation showed a nodule embedded in the serosa of the small intestine which was highly suggestive of a metastasis. Histological examination revealed an inflammatory pseudo-cyst containing an Anisakis simplex larva together with eosinophils and necrotic debris. A review of the pertinent literature established that anisakiasis was responsible for a wide variety of gastric disorders and systemic manifestations. This disease has most commonly been reported in countries where seafish is served raw or only lightly cooked. The relatively few cases documented in France may be explained by the different manner of preparing seafood.

Inflammatory Pseudocyst Associated with Trisomy 21 and Hirschsprung's Disease

A 15-month-old black male with trisomy 21 and Hirschsprung's disease developed an inflammatory abdominal pseudocyst 1 month after Swenson pull-through repair. Although abdominal pseudocyst associated with ventriculoperitoneal shunts, peritoneal dialysis catheters, meconium peritonitis, and pancreatitis have been reported, this is the first report of a pseudocyst developing 1 month after a surgical repair of Hirschsprung's disease.

Pancreatic choriocarcinoma presenting as inflammatory pseudocyst

A primary pancreatic choriocarcinoma was discovered at surgery in a patient with a clinical diagnosis of pancreatic inflammatory pseudocyst. To our knowledge, this is the first example of an extragonadal choriocarcinoma reported as a primary at this site. We consider this neoplasm to be another example of a visceral choriocarcinoma arising from a primary carcinoma through a process of metaplasia. This case illustrates the inherent difficulties in the preoperative evaluation of cystic lesions of the pancreas, and the importance of recognizing endocrinologic manifestations of malignant disease.