Internal Cyst Research Articles

S2808 Diagnostic Dilemma: Utilizing Endoscopic Ultrasound (EUS) Guided Biopsy to Assist With the Diagnosis of the Duodenal Duplication Cyst

Introduction: Duodenal duplication cyst (DDC) is a rare congenital anomaly that often presents in the neonatal period with presentations later in life less common. Duplication cysts can develop anywhere from the mouth to the anus with only 4-12% are located in the duodenum. DDC is an uncommon cause of acute pancreatitis but the diagnosis is difficult to make in adults because the symptoms are non-specific. We present a case of diagnostic dilemma of a 53 years old female patient with recurrent acute pancreatitis (RAP), attributed to DDC. Case Description/Methods: Her first index episode of pancreatitis was 12 years prior to her presentation. Patient was found to have a large cyst in the 2nd portion of the duodenum that appeared to be separate from the biliary tree and pancreas on EGD (Figure a), EUS (Figure b) and MRI (Figure c), abutting the major papilla. The initial EUS showed a 20 mm x 13.4 mm anechoic cyst with layering and debris seen in the cavity. Aspiration of the cyst was performing, returning with elevated CEA at 817 ng/mL. No features of chronic pancreatitis were seen. Given elevated CEA, there was a concern for mucinous cyst, prompting a repeat EUS. EUS guided biopsy of the internal cyst wall was performed and histology was consistent with small bowel suggestive of a duplication cyst. Discussion: Our patient presented with recurrent episodes of pancreatitis that could be explained by the intermittent occlusion of the pancreatic duct by debris and sludge found within the cyst. The elevated CEA and inconclusive radiographic results initially suggested possible mucinous cyst, presenting a diagnostic dilemma. Therefore, EUS guided biopsies were essential to confirm the diagnosis and allowing for further endoscopic management. The presence of a smooth muscle coat is absolutely essential for the diagnosis of a duplication cyst which was the case for our patient. DDC are covered both inside and outside by duodenal mucosa containing a distinct layer of smooth muscle. Given its malignancy potential, resection of these cysts is indicated. Endoscopic resection is minimally invasive and has been proposed as an alternative to surgery in selected patients especially given the close proximity of major papilla. Resection techniques using standard polypectomy, or large incision of the roof of the duplication cyst has been discussed in the literature. In our case, endoloop was applied around the base of the cyst, leading to strangulation and necrosis for obliteration of the cyst.Figure 1.: (a) shows a large cyst in the 2nd portion of the duodenum that appeared to be separate from the biliary tree and pancreas on EGD abutting the major papilla, (b) shows the cysts on EUS and (c) shows the cyst on MRI.

Reproducible imaging-based prediction of molecular subtype and risk stratification of gliomas across different experience levels using a structured reporting system.

To determine reproducible MRI parameters predictive of molecular subtype and risk stratification in glioma and develop a structured reporting system. All study patients were initially diagnosed with glioma, 141 from the Cancer Genome Atlas and 131 from our tertiary institution, as training and validation sets, respectively. Images were analyzed by three neuroradiologists with 1-7 years of experience. MRI features including contrast enhancement pattern, necrosis, margin, edema, T2/FLAIR mismatch, internal cyst, and cerebral blood volume higher than normal cortex were reported using a structured reporting system. The pathology was stratified into five risk types: (1) oligodendroglioma, isocitrate dehydrogenase [IDH]-mutant, 1p19q co-deleted; (2) diffuse astrocytoma, IDH-mutant, grade II-III; (3) glioblastoma, IDH-mutant, grade IV; (4) diffuse astrocytoma, IDH-wild, grade II-III; and (5) glioblastoma, IDH-wild, grade IV. Significant predictors were selected using multivariate logistic regression, and diagnostic performance was tested using a validation set. Reproducible imaging parameters exhibiting > 50% agreement across readers included the presence of necrosis, T2/FLAIR mismatch, internal cyst, and predominant contrast enhancement. In the validation set, prediction of risk type 5 exhibited the highest diagnostic performance with AUCs of 0.92 (reader 1) and 0.93 (reader 2) with predominant enhancement, followed by risk type 2 with AUCs of 0.95 and 0.95 with T2/FLAIR mismatch sign and no necrosis, and risk type 1 with AUCs of 0.84 and 0.83 with internal cyst or necrosis. Risk types 3 and 4 were difficult to visually predict. Imaging parameters with high reproducibility enabling prediction of IDH-wild-type glioblastoma, IDH-mutant/1p19q co-deletion oligodendroglioma, and IDH-mutant diffuse astrocytoma were identified. • Reproducible MRI parameters for determining molecular subtypes of glioma included the presence of necrosis, T2/FLAIR mismatch, internal cyst, and predominant contrast enhancement. • IDH-wild type glioblastoma, IDH-mutant/1p19q co-deletion oligodendroglioma, and IDH-mutant low-grade astrocytoma were identified using MRI parameters with high inter-reader reproducibility. • Identification of IDH-wild type low-grade glioma and IDH-mutant glioblastoma was difficult by visual analysis.

Two-photon polymerization nanofabrication of ultracompact light scattering spectroscopic probe for detection of pre-cancer in pancreatic cyst

Pancreatic cancer has one of the worst survival rates of all major cancers, with pancreatic cystic lesions accounting for one in three pancreatic surgeries. The current gold-standard for diagnosis of pancreatic cyst malignancy is based on the endoscopic ultrasound guided fine-needle aspiration (EUS-FNA) procedure, which suffers from a low accuracy in detecting malignancy. Here we present the design and two-photon polymerization based fabrication of refractive and reflective non-contact probes, capable of rapid surveillance of the entire internal cyst surface-an advance over the contact probe we recently developed that allowed, for the first time, reliable evaluation of pancreatic cyst malignant potential in vivo. We employed a novel two-photon polymerization technique, which allows direct laser-writing to an accuracy of tens of nanometers, to fit the probe within the 540 micrometer internal diameter EUS-FNA needle. The newly constructed probes show excellent separation of the illumination and collection beams, essential for proper operation of the spatial gating method. These probes can be used clinically to perform rapid “optical biopsy”, ultimately eliminating unnecessary pancreatic surgeries on benign cysts and dangerous delays in surgical removal of malignant cysts, improving patient prognosis and quality of life.

Evaluation of the Clinical, Laboratory, and Radiological Findings and Treatment of 19 Cases of Pancreatic Echinococcosis.

BackgroundHydatid disease is a severe health problem in endemic areas. In recent years, the incidence of this disease in China has been increasing. As the imaging characteristics of pancreatic echinococcosis (PE) are similar to those of cystic diseases, such as cysts, tuberculosis, and tumors, PE is often misdiagnosed and mistreated.MethodsThe clinical manifestations, laboratory tests, radiological findings, and treatment of 19 patients with PE between January 2006 and December 2018 in 2 hospitals were retrospectively analyzed.ResultsThe mean age of the patients was 38 years, and the ratio of women to men was 2. All patients came from rural areas. Clinical manifestations included cholestatic jaundice, mass, nausea, pain, and swelling. Hemagglutination inhibition test results were positive for all patients. Enzyme-linked immunosorbent assay test results were positive in 17 cases (89.5%). Foci in the pancreas were head in 52.6%, body in 26.3%, body and tail in 15.8%, tail in 5.3%. The size of lesions’ diameter ranged from 1 to 12 cm (mean, 6.5 cm). The imaging features of PE included the presence of (a) daughter cysts on abdominal computed tomography (CT) and/or magnetic resonance imaging (MRI); (b) internal cyst wall dissection and ribbon sign on abdominal CT and/or MRI; (c) typical eggshell cyst wall calcification on abdominal CT.ConclusionsFor patients with cystic lesions on CT and/or MRI combined with epidemiological history and positive echinococcosis serology, doctors can correctly diagnose PE earlier. Surgical treatment combined with drugs can reduce the mortality of PE, leading to a better prognosis.

Cerebellar abscess secondary to extradural internal protuberance epidermal cyst

An Intracranial epidermoid cyst is a rare congenital anomaly developed because of dysembryoplasia during the third to fifth week of gestation. We describe the unusual epidermal cyst which originating extradurally in internal protuberance in which causes cerebellar brain abscess. Neurosurgical intervention is advocated to prevent the ongoing risk of significant complications. Meticulous care was taken to grossly excised all the pathologic tissue to avoid recurrence.

MR Imaging Characteristics of Myoepithelial Carcinoma Ex Pleomorphic Adenoma of the Palate: Rare Case Report

: Carcinoma ex pleomorphic adenoma is an uncommon tumor of salivary gland; moreover, myoepithelial carcinoma of palate is exceedingly rare. This report documents a case of carcinoma ex pleomorphic adenoma arising in the hard palate. A 51-year-old woman presented with foreign body sensation without pain. Preoperative biopsy was performed and resulted in pleomorphic adenoma of the hard palate. MR imaging findings were well circumscribed, dome-shaped, lobulated mass with hyposignal intensity at peripheral fibrous capsule on T2WI. The mass showed internal cyst, hemorrhage, necrosis and heterogeneous enhancement. Because it showed both benign and malignant findings, the radiologic diagnosis was likely to be a malignant tumor of palate. Postoperative pathological analysis revealed invasive myoepithelial carcinoma ex pleomorphic adenoma.

Long-term outcome after flexible ureteroscopy with holmium laser for simultaneous treatment of a single renal cyst and ipsilateral renal stones.

ObjectiveTo assess the long-term outcome of simultaneous treatment of a single renal cyst and ipsilateral stones with transurethral flexible ureteroscopy (FURS) lithotripsy and internal cyst drainage.MethodsPatients who underwent simultaneous treatment with FURS lithotripsy and internal cyst drainage in our institution between July 2014 and September 2017 were enrolled. The cyst wall was identified endoscopically and a 1–3-cm window was created in the wall using a holmium laser. The proximal end of a double-J stent was placed in the cystic cavity to facilitate internal drainage.ResultsThirteen patients underwent simultaneous treatment. No intraoperative complications with Clavien grading score >2 were noted in any patients. Mean stone burden and cyst diameter were 1.6 (range: 0.9–2.5) cm and 5.8 (range: 3.0–7.1) cm, respectively. Stone-free rates after single and complementary procedures were 84.6% and 92.3%, respectively. During the mean 33.1-month follow-up period (range: 17–54 months), seven patients (53.8%) achieved full resolution of renal cysts, five patients (38.5%) maintained >50% size reduction, and one patient (7.6%) experienced recurrence at 18 months postoperatively.ConclusionsFURS with a holmium laser may constitute a safe and effective alternative procedure for simultaneous treatment of a single renal cyst and ipsilateral stones.

Preoperative Grading of Sacrococcygeal Teratoma: A Roadmap to Successful Resection

Purpose: to include the most relevant preoperative imaging features of sacrococcygeal teratoma (SCT) in a grading system that would provide guidance to surgeons during excision of such rare tumors.Patients and Methods: The medical records of patients with SCT, who were managed at our hospital during the period 2009 through 2016, were retrospectively reviewed. Only cases of SCT with available preoperative cross-sectional imaging studies (MRI and/or CT scans) were included in the study. The preoperative imaging features were correlated to the operative and pathological findings.Results: The study included 24 cases of SCT (20 females and 4 males). Their age at presentation ranged from day one to 36 months. The following were identified as relevant preoperative imaging features to be included in our proposed grading system: tumor size, level of deep extension of the tumor, and tumor consistency. Among predominantly cystic SCT, a special subtype C3 could be identified with its characteristic irregular internal cyst wall thickening caused by the in-growth of solid tumor component. These cases were always associated withimmature pathology. Conclusion: MRI is a useful modality in the preoperative assessment of cases of SCT by providing a grading system that can indicate for the prognosis and degree of expected surgical challenge.

A Simple Ultrasound Examination as Diagnostic Tool for Malignant Ovarian Tumor

Objective: To know the diagnostic value of simple ultrasound examination to detect malignant ovarian tumor.
 
 Method: This study used cross-sectional design in gynecology outpatientclinic at Dr. Cipto Mangunkusumo Hospital. We recruited the patients with ovarian tumor undergoing surgery between March
 and July 2015. Samples were taken using consecutive sampling.
 Analysis was done using Chi-square test and logistic regression to
 find the relationship between ultrasound morphologic patterns with
 histopathologic findings, where the significant relationship was p
 value less than 0.05. Furthermore, a model derived from logistic regression was made to calculate the probability having ovarian malignancy.
 
 Result: There were 80 subjects which 58 subjects (72.5%) had
 benign tumor and 22 subjects (27.5%) had malignant tumor. Ultrasound examination result using  2 morphologic patterns gave malignant result in 53.8% subjects with the sensitivity of 100%, specificity of 82.8%, positive predictive value of 68.8%, and negative predictive value of 100%. The most important patterns were irregular
 internal cyst wall, multilocular, presence of papillary projection, and
 presence of solid component. The probability of subject having ovarian
 malignancy with  3 morphologic patterns was more than
 88.9%.
 
 Conclusion: Simple ultrasound examination can be used to detect
 malignant ovarian tumor.
 
 [Indones J Obstet Gynecol 2016; 4-4: 222-226]
 
 Keywords: diagnostic, histopathology, morphology pattern; ovarian
 tumor; ultrasonography

Intracavitary brachytherapy using stereotactically applied phosphorus-32 colloid for treatment of cystic craniopharyngiomas in 53 patients

This paper summarizes outcomes of a single-center study of intracavitary brachytherapy (IBT) with stereotactically applied phosphorus-32 ((32)P) colloid for treatment of cystic craniopharyngiomas. We assessed its efficacy and safety, on the basis of clinical and radiological outcomes in one of the largest reported patient series. Between 1992 and 2011, 53 patients were treated with IBT, 14 without previous treatment and 39 who had previously been treated for recurrent cysts. Intervention was performed by applying 200 Gy to the internal cyst wall (median volume 6.1 ml). Median clinical and radiological follow-up were 60.2 and 53.0 months, respectively. Actuarial tumor cyst control was 86.0 ± 5.3 % at 12, 24, and 60 months. Actuarial out-of-field control (development of new cysts or progression of solid tumor parts) was 90.9 ± 4.3, 84.0 ± 5.6, and 54.5 ± 8.8 % after 12, 24, and 60 months, respectively. Corresponding actuarial overall progression-free survival was 79.4 ± 6.1, 72.4 ± 6.8, and 45.6 ± 8.7 % at 12, 24, and 60 months, respectively. Visual function improved for 12 patients (23.5 %), remained unchanged for 34 patients (66.7 %), and worsened for five patients (9.8 %), correlating with tumor progression in each case. Endocrinological deterioration occurred for ten patients (19.6 %); for nine patients this was a result of tumor progression or after tumor resection and for one it was attributed to irradiation. Within six months of IBT seven patients (13.7 %) experienced transient neurological deficits and two patients (3.9 %) deteriorated permanently (hemiparesis and third nerve palsy). Stereotactically applied (32)P is highly efficacious for control of cystic components of craniopharyngiomas and is associated with a low risk of permanent morbidity. The procedure does not, however affect the development of new cysts or the progression of solid tumor parts.

Pancreatic benign schwannoma: Combined with hemorrhage in an internal cyst

Pancreatic benign schwannoma: Combined with hemorrhage in an internal cyst

Brunner's Gland Hamartoma

To describe the computed tomographic (CT) features of Brunner's gland hamartoma with histopathologic correlation. The CT images of 9 patients with pathologically proven Brunner's gland hamartoma were reviewed retrospectively. All patients underwent CT performed on multidetector-row CT scanner with various protocols, all of which included portal venous phase. Brunner's gland hamartomas presented as small (mean, 1.9 cm) Yamada type II or III (67%, 6/9) polyps with frequent internal cyst (33%, 3/9). They were isoattenuated on unenhanced CT (83%, 5/6) and hypoattenuated in portal phase (56%, 5/9) when compared with the pancreas. Peripheral rimlike enhancement in earlier phase was commonly found (67%, 6/9) and most of them enhanced homogeneously in the later phase (100%, 4/4). In a patient with asymptomatic small submucosal mass in the duodenal first or second portion, hypoattenuated mass with peripheral rimlike enhancement or internal cystic change suggests the possibility of Brunner's gland hamartoma.

Bleb Needling in Encapsulated Filtering Blebs: Evaluation by Optical Coherence Tomography

Purpose: To evaluate the role of anterior segment optical coherence tomography (OCT) in describing the morphology and outcome of encapsulated filtering blebs after bleb needling. Procedures: Prospective assessment of 9 patients – before, 2 days and 6 months after filtering bleb needling with 5-FU – using slit-lamp examination, Goldmann tonometry and OCT. Results: Before the needling, the average internal height of the cyst was 1.3 ± 0.8 mm. Two days after the needling procedure, the cyst collapsed in 5 patients. After 6 months, the average internal cyst height was 0.7 ± 0.4 mm. All patients with a collapsed cyst at day 2 after needling had controlled regulated IOP without glaucoma medication. Conclusions: The preoperative internal height of the cyst does not correlate with the outcome of the needling. A collapsed cyst at day 2 after needling is an indicator of controlled intraocular pressure, whereas a prominent cyst after 6 months indicates poor function.

Preoperative diagnosis of ovarian tumors using Bayesian kernel‐based methods

To develop flexible classifiers that predict malignancy in adnexal masses using a large database from nine centers. The database consisted of 1066 patients with at least one persistent adnexal mass for which a large amount of clinical and ultrasound data were recorded. The outcome of interest was the histological classification of the adnexal mass as benign or malignant. The outcome was predicted using Bayesian least squares support vector machines in comparison with relevance vector machines. The models were developed on a training set (n=754) and tested on a test set (n=312). Twenty-five percent of the patients (n=266) had a malignant tumor. Variable selection resulted in a set of 12 variables for the models: age, maximal diameter of the ovary, maximal diameter of the solid component, personal history of ovarian cancer, hormonal therapy, very strong intratumoral blood flow (i.e. color score 4), ascites, presumed ovarian origin of tumor, multilocular-solid tumor, blood flow within papillary projections, irregular internal cyst wall and acoustic shadows. Test set area under the receiver-operating characteristics curve (AUC) for all models exceeded 0.940, with a sensitivity above 90% and a specificity above 80% for all models. The least squares support vector machine model with linear kernel performed very well, with an AUC of 0.946, 91% sensitivity and 84% specificity. The models performed well in the test sets of all the centers. Bayesian kernel-based methods can accurately separate malignant from benign masses. The robustness of the models will be investigated in future studies.

Cooperative study by the Italian neuroendoscopy group on the treatment of 61 colloid cysts

Microsurgical resection, stereotactic aspiration and VP shunt have for years been the choice options for the treatment of colloid cysts of the third ventricle. Recently, endoscopic approaches have aroused increasing interest and gained acceptance. Although safer, this minimally invasive approach is considered less efficacious than microsurgery. Relatively long-term results are now available and some conclusions might be inferred on the usefulness of this procedure. Between 1994 and 2005, 61 patients harbouring a colloid cyst of the third ventricle were treated with neuroendoscopic technique in 11 Italian neurosurgical centres. Cyst diameters ranged from 6 to 32 mm. A flexible endoscope was used in 34 cases, a rigid one in 21, both instruments in six. The technique consisted in cyst fenestrations, colloid aspiration, coagulation of the internal cyst wall and, occasionally, capsule excision. Mean postoperative hospital stay was 6.7 days. Early postoperative neuroimaging revealed a cyst residue in 36 cases (mean diameter 4.3 mm). There were two complications (3.2%). Follow-up varied between 1 and 132 months (mean 32 months, more than 5 years in 17 patients). There were seven asymptomatic recurrences, three of them evolving from a previous residue. The endoscopic approach to the treatment of colloid cysts is safe, effective and well accepted by patients. Although asymptomatic, recurrences (11.4%) cast a persisting shadow on the long-term results, and, therefore, the controversy with the traditional microsurgical treatment remains open.

Logistic Regression Model to Distinguish Between the Benign and Malignant Adnexal Mass Before Surgery: A Multicenter Study by the International Ovarian Tumor Analysis Group

To collect data for the development of a more universally useful logistic regression model to distinguish between a malignant and benign adnexal tumor before surgery. Patients had at least one persistent mass. More than 50 clinical and sonographic end points were defined and recorded for analysis. The outcome measure was the histologic classification of excised tissues as malignant or benign. Data from 1,066 patients recruited from nine European centers were included in the analysis; 800 patients (75%) had benign tumors and 266 (25%) had malignant tumors. The most useful independent prognostic variables for the logistic regression model were as follows: (1) personal history of ovarian cancer, (2) hormonal therapy, (3) age, (4) maximum diameter of lesion, (5) pain, (6) ascites, (7) blood flow within a solid papillary projection, (8) presence of an entirely solid tumor, (9) maximal diameter of solid component, (10) irregular internal cyst walls, (11) acoustic shadows, and (12) a color score of intratumoral blood flow. The model containing all 12 variables (M1) gave an area under the receiver operating characteristic curve of 0.95 for the development data set (n = 754 patients). The corresponding value for the test data set (n = 312 patients) was 0.94; and a probability cutoff value of .10 gave a sensitivity of 93% and a specificity of 76%. Because the model was constructed from multicenter data, it is more likely to be generally applicable. The effectiveness of the model will be tested prospectively at different centers.

Radiological Features of Germinoma Arising From Atypical Locations-Three Case Reports-

Three cases of intracranial germinoma arising from atypical locations occurred in 13-, 22-, and 28-year-old males. The location of the tumor was the corpus callosum (2 cases) and the temporal lobe. Computed tomography and magnetic resonance imaging showed all three tumors had a largest dimension, including the internal cyst, of over 6 cm, and the cysts were larger than 2.5 cm. Radiotherapy and chemotherapy caused all tumors to disappear. Large tumor and large cyst are features of germinoma arising from atypical locations.

Controversias en el manejo quirúrgico del endometrioma ovárico

La supresión hormonal del endometrioma ovárico mayor de 1 cm no es efectiva; sin embargo, tal supresión puede mejorar los síntomas en el 40% a 65% de los pacientes por un período de 6 a 12 meses. La aspiración de endometrioma ya sea transvaginal o transabdominal mediante la guía ultrasonográfica o por laparoscopía no es aconsejable como tratamiento quirúrgico de primera línea. Estos procedimientos están seguidos de una alta tasa de recurrencia (28% a 100%) dentro de 1 a 9 meses siguientes a la aspiración. La supresión hormonal antes o después de la aspiración no afecta el resultado. La vaporización laparoscópica de las paredes del quiste previa apertura de éste ya sea con láser o electrocauterio es mejor que el tratamiento de aspiración solo. La tasa de mejoría de los síntomas después del procedimiento es de 74% a 91%, la tasa de recurrencia es de 8% a 13% con una tasa de embarazo del 45% al 50%.El tratamiento laparoscópico del endometrioma ovárico por extirpación de la pared del quiste parece ser el mejor tratamiento quirúrgico. Este procedimiento es técnicamente más difícil que la vaporización de la pared del quiste, pero se asocia con una mejoría prolongada de la sintomatología, baja recurrencia del dolor pélvico, y bajas tasas de reoperación. Las tasas acumulativas de embarazo son más altas que después de vaporización. Los estudios actuales concluyen primero, que la vaporización de la pared interna del endometrioma no daña la función ovárica en términos de los parámetros de FIV y resultados; segundo, que los riesgos teóricos de pérdida de tejido ovárico viable durante la cistectomía existen pero se puede evitar con una técnica microquirúrgica laparoscópica, teniendo el cuidado de preservar la corteza ovárica residual normal; y tercero, los resultados de FIV después de extirpar o destruir los endometriomas en los pacientes con endometriosis son similares cuando se comparan con mujeres con factor tubárico o infertilidad idiopática.

7176 Value of endoscopic ultrasound in the diagnosis and treatment of unusual gastrointestinal cystic lesions.

Introduction /Aims: EUS is currently the best imaging modality to assess the nature of submucosal tumors of the gastrointestinal tract. The layer of origin of the tumor can be defined with unmatched precision, and discrimination between solid and cystic lesions can be accurately made. We assessed the value of EUS in the diagnosis and management of unusual gastrointestinal cystic lesions. Methods /Results: Esophageal bronchogenic cyst. A 46-year-old male patient was submitted to upper endoscopy for dyspeptic complaints, showing a submucosal tumor in the middle esophagus measuring 1.8 cm. CT could not detect the lesion. EUS demonstrated a cystic lesion in the submucosa layer of the esophagus, with anechoic content. Endoscopic needle aspiration of the cyst revealed a mucoid fluid. Biopsy of the cyst wall after needle knife incision showed respiratory type epithelium. Gastric duplication cyst. In a 66-year-old woman presenting with epigastric fullness, abdominal ultrasound detected a cystic lesion, of uncertain origin, between the pancreas and the gastric wall. At upper endoscopy no submucosal bulging of the gastric wall was evident. EUS demonstrated a cystic lesion measuring 6.3 x 3.5 cm in the gastric wall, with anechoic content and inner septa, originating from the submucosa. EUS- guided puncture of the cyst using a linear array echoendoscope and a 22 G needle was performed and analysis of the aspirate fluid showed no malignant cells and normal CEA and CA 19-9 levels.A 3 cm incision with needle knife was performed and biopsy of the internal cyst wall revealed gastric columnar epithelium with no displasia. A small remnant cyst (1.7 cm) was seen on follow up EUS 4 weeks later. Duodenal duplication cyst. In a 53 yearold male presenting with vague epigastric discomfort, upper endoscopy showed a submucosal bulging lesion in the 2nd part of the duodenum, 2 cm above the major papila. EUS demonstrated a cystic lesion arising from the submucosa, and measuring 2.4 x 1.2 cm. The cyst content had some debris, and EUS guided aspiration produced a thick brownish fluid. Cytology analysis showed only inflammatory cells. Microbiological examination was negative. However, determination of CEA was 2360 ng/ml. Since the patient refused surgery, endoscopic cystotomy was performed. Biopsy of the cyst wall showed duodenal mucosa with no evidence of malignancy. Pneumatosis cystoides intestinalis. A 69-year-old male was admitted for rectal bleeding, diarrhea and lower abdominal pain. Colonoscopy showed multiple polyp-like bluish masses protruding into the lumen of the sigmoid and descending colon. Endoscopic Ultrasound showed submucosal gas-containing cystic lesions within the submucosa, confirming the diagnosis of PCI without the need to puncture the cysts. Conclusions: EUS was very useful in assessing submucosal cysts. The contents of the cyst could be displayed with great detail and analysis of aspirated fluid helped in therapeutic decisions.

7175 Value of endoscopic ultrasound in the diagnosis and treatment of unusual gastrointestinal cystic lesions.

Introduction /Aims: EUS is currently the best imaging modality to assess the nature of submucosal tumors of the gastrointestinal tract. The layer of origin of the tumor can be defined with unmatched precision, and discrimination between solid and cystic lesions can be accurately made. We assessed the value of EUS in the diagnosis and management of unusual gastrointestinal cystic lesions. Methods /Results: Esophageal bronchogenic cyst . A 46-year-old male patient was submitted to upper endoscopy for dyspeptic complaints, showing a submucosal tumor in the middle esophagus measuring 1.8 cm. CT could not detect the lesion. EUS demonstrated a cystic lesion in the submucosa layer of the esophagus, with anechoic content. Endoscopic needle aspiration of the cyst revealed a mucoid fluid. Biopsy of the cyst wall after needle knife incision showed respiratory type epithelium. Gastric duplication cyst . In a 66-year-old woman presenting with epigastric fullness, abdominal ultrasound detected a cystic lesion of uncertain origin, between the pancreas and the gastric wall. At upper endoscopy no submucosal bulging of the gastric wall was evident. EUS demonstrated a cystic lesion measuring 6.3 x 3.5 cm in the gastric wall, with anechoic content and inner septa, originating from the submucosa. EUS-guided puncture of the cyst using a linear array echoendoscope and a 22 G needle was performed and analysis of the aspirate fluid showed no malignant cells and normal CEA and CA 19-9 levels. A 3 cm incision with needle knife was performed and biopsy of the internal cyst wall revealed gastric columnar epithelium with no displasia. A small remnant cyst (1.7 cm) was seen on follow up EUS 4 weeks later. Duodenal duplication cyst . In a 53 year-old male presenting with vague epigastric disconfort, upper endoscopy showed a submucosal bulging lesion in the 2nd part of the duodenum, 2 cm above the major papila. EUS demonstrated a cystic lesion arising from the submucosa, and measuring 2.4 x 1.2 cm. The cyst content had some debris, and EUS guided aspiration produced a thick brownish fluid. Cytology analysis showed only inflammatory cells. Microbiological examination was negative. However, determination of CEA was 2360 ng/ml. Since the patient refused surgery, endoscopic cystotomy was performed. Biopsy of the cyst wall showed duodenal mucosa with no evidence of malignancy. Pneumatosis cystoides intestinalis . A 69-year-old male was admitted for rectal bleeding, diarrhea and lower abdominal pain. Colonoscopy showed multiple polyp-like bluish masses protruding into the lumen of the sigmoid and descending colon. Endoscopic Ultrasound showed submucosal gas-containing cystic lesions within the submucosa, confirming the diagnosis of PCI without the need to puncture the cysts. Conclusions: EUS was very useful in assessing submucosal cysts. The contents of the cyst could be displayed with great detail and analysis of aspirated fluid helped in therapeutic decisions.