Papillary Projections Research Articles

Atypical Renal Cysts: A Morphologic, Immunohistochemical, and Molecular Study.

There is a lack of standardized nomenclature for renal cysts lined by multiple cell layers or with short papillary projections but without nests of epithelial cells within the stroma. We retrieved 29 cases (15 nephrectomies, 14 partial nephrectomies) from the surgical pathology files of Johns Hopkins Hospital from 1993 to 2014 and performed immunohistochemistry for CK7, alpha-methylacyl-CoA racemase (AMACR), CAIX, and CD10 and fluorescence in situ hybridization for trisomy 7 and 17 and 3p deletion. The mean age at excision was 58 years (range, 29 to 80 y) with 16 men and 13 women. Mean size was 2.9 cm (range, 0.3 to 10 cm). The cysts were grouped by their morphology into (1) clear cell, (2) eosinophilic stratified, and (3) eosinophilic papillary. By immunohistochemistry, 7/9 (78%) of the clear cell cases were diffusely positive for both CK7 and CAIX resembling the pattern seen in clear cell papillary renal cell carcinoma. The majority of eosinophilic stratified (4/6; 67%) and eosinophilic papillary (12/14; 86%) cases were positive for CK7 and had variable staining for AMACR, CD10, or CAIX, suggesting a differentiation more aligned with papillary renal cell carcinoma. The most common molecular alterations detected were trisomy 17 (n=6) and trisomy 7 (n=4). One case showed deletion of chromosome 3p. Clinical follow-up information was available in 23 patients; 20 were alive with no evidence of disease after a median follow-up of 20 months (range, 3 to 120 mo), 1 patient was dead due to metastatic lung cancer, 1 of sepsis, and 1 of unknown reason. Atypical renal cysts present as complex radiologic lesions, as secondary lesions in patients with a renal mass, or in a background of chronic renal disease. These atypical cysts appear heterogenous, and some follow in their morphology and immunoprofile with well-established renal tumors. The presence of 3p deletion and trisomy 7/17 suggests that in some cases they may be precursors of renal cell carcinoma. Longer follow-up with more cases is needed, but on the basis of our data, these lesions should not be diagnosed as carcinoma.

Ultrasonographic features and CA125 levels of hormonally active ovarian tumors.

Subjective ultrasonographic assessment is currently considered to be the best method of differentiation between various types of ovarian tumors. The aim of the study was to evaluate selected ultrasonographic features and CA125 levels of hormonally active ovarian tumors. A total of 1135 women with ovarian tumors were diagnosed between 2006 and 2014 at the Division of Gynecologic Surgery, Poznan University of Medical Sciences. Within these tumors, there were 60 hormone-secreting ovarian tumors, including: 20 granulosa cell tumors, 28 fibrothecomas, 10 dysgerminomas, 2 struma ovarii, and 9 metastatic ovarian tumors. The tumors were evaluated by ultrasonography according to the International Ovarian Tumor Analysis group criteria. Additionally, we evaluated serum CA125 levels in all patients. Granulosa cell tumors occurred most frequently as large unilocular-solid cysts, moderately to highly vascularized, with low-resistance vascularization. Dysgerminomas were predominantly large unilocular-solid cysts or purely solid tumors, with minimal to moderate low-resistance vascularization. Fibrothecomas were solid masses with minimal, high-resistance vascularization. Struma ovarii occurred as small, solid masses with abundant, highresistance vascularization. Metastatic ovarian tumors presented mainly as multilocular-solid tumors with strong, low-resistance vascularization. Papillary projections were most frequently observed in metastatic tumors and granulosa cell tumors in 56% and 50% of the cases respectively, although only half of granulosa cell tumors papillary projections exceeded 3 mm. Elevated CA125 levels were found only in metastatic ovarian tumors. Hormonally active ovarian tumors present several ultrasonographic features which may facilitate preoperative diagnosis.

Papillary Cystadenocarcinoma of the Parotid Gland: A Rare Case Report

Papillary cystadenocarcinoma is a rare malignant neoplasm of the salivary gland, characterized by noticeable cystic and solid areas with papillary endophytic projections. These tumours lack features that characterize cystic variants of several more common salivary gland carcinomas. It was first described in 1991 by World Health Organization as a separate entity and cystadenocarcinoma with or without papillary component in the AFIP classification. Most of these tumours occurred in the major salivary glands followed by minor salivary glands. Cystadenocarcinoma is the malignant counterpart of cystadenoma. We report a case of papillary cystadenocarcinoma of parotid. A 40-year-old lady presented with gradually progressive swelling below the right ear associated with occasional pain. Clinical and radiological features suggested benign neoplasm. Right lobe superficial parotidectomy was performed. The histopathologic diagnosis showed papillary cystadenocarinoma of the parotid gland. Histologic confirmation of stromal invasion is required to differentiate it from the benign lesion. Conservative wide local surgical excision is the treatment of choice.

Ovarian endometriosis during pregnancy: a series of 53 endometriomas

ObjectivesThe sonographic features of endometriomas and their natural history during pregnancy remain poorly known. The objective of our study was to report our experience concerning the diagnosis, spontaneous progression and management of endometriomas during pregnancy. Study designA retrospective observational study in 46 patients (53 cysts) presenting with an ovarian endometrioma diagnosed during ultrasound examination at the first trimester of pregnancy. Sonographic findings (according to the criteria of the International Ovarian Tumor Analysis (IOTA) group and how they changed for each cyst during pregnancy and postpartum were reviewed, together with cyst management. The median follow-up was 4 years [IQR: 3–6]. Median age at diagnosis was 31 years [IQR: 27–35]. ResultsAmong the 53 cysts identified as “endometriomas” on the first-trimester ultrasound examination, 49 (92%) were described like “cyst fluid with ground-glass echogenicity”. Fifty-two cysts (98%) had a maximum diameter<100mm, only one cyst (2%) presented papillary projection and 5 cysts (9%) were multiloculated. During the second-trimester ultrasound monitoring of these cysts, of the 33 cysts that we monitored, 8 (24%) increased in size, 11 (34%) decreased in size, 5 (15%) disappeared and 9 (27%) did not change. During the third-trimester ultrasound monitoring of these cysts, of the 13 cysts that we monitored, 5 (39%) increased in size, 5 (39%) decreased in size, 2 (15%) disappeared and 1 (7%) did not change. All children (48 newborns) were born alive at a median gestational age of 39 weeks [IQR=39–40].Only 10 cysts (19%) required surgical treatment. In all cases, surgery consisted of cystectomy. Two cysts were operated on during pregnancy (between 14 and 17 weeks of gestation) because of symptoms of adnexal torsion, 3 during cesarean section, and 5 postpartum. Four of the 10 (40%) cysts operated on were histopathologically “endometriomas”, and one of them was decidualized. Four cysts were mucinous cystadenomas, one was a serous cystadenoma and one cyst was a dermoid cyst. ConclusionThis study underscores the difficulty of diagnosing endometriomas during pregnancy and the absolute necessity of surgical removal when ultrasonographic findings are doubtful.

Synchronous Endometrial and Ovarian Cancer With Sigmoid Colon Metastasis One Year After Primary Surgery: A Case Report

Introduction: We describe a patient who had ovarian and endometrial cancer which metastasized to sigmoid colon one year after surgery. Case Presentation: A 53-year-old woman was admitted with the complaints of abdominal pain, abdominal distension and postmenopausal bleeding. Her transvaginal ultrasound scan revealed a cystic mass containing papillary projections with the dimensions of 6.5 × 5 × 4 cm on the right ovary. Level of (carbohydrate antigen) (CA) 125 was 223 IU. Dilation and curettage revealed endometrioid adenocarcinoma. Debulking surgerywas carried out. Histopathological diagnosis was grade 2 adenocarcinoma with squamous differentiation for endometrial cancer and grade 2 endometrioid adenocarcinoma with squamous and mucinous differentiation for ovarian cancer. The stage was 1A for endometrial cancer and 1A for ovarian cancer. 12 months after the operation CA 125 level was 112 IU. Positron emission tomography (PET) scan showed a small lesion (1.5×1.5 cm) in the pelvic cavity with increased fluorodeoxyglucose (FDG) uptake. Five months after the chemotherapy, CA 125 level elevated from 10 to 60 IU and subsequent magnetic resonance imaging (MRI) revealed a tumoral mass with the dimensions of 3×2.2 cm. A second laparotomy was performed and the metastasis was excited. The tumor was endometrioid adenocarcinoma with infiltration in the serosa and muscularis propria of sigmoid colon. Conclusion: It is needed to consider the possibility of double cancer in the diagnosis and treatment of gynecological malignancies. Abstract War and poverty are 'extraordinary conditions created by human intervention' and 'preventable public health problems.' War and poverty have many negative effects on human health, especially women's health. Health problems arising due to war and poverty are being observed as sexual abuse and rape, all kinds of violence and subsequent gynecologic and obstetrics problems with physiological and psychological courses, and pregnancies as the result of undesired but forced or obliged marriages and even rapes. Certainly, unjust treatment such as being unable to gain footing on the land it is lived (asylum seeker, refugee, etc.) and being deprived of social security, citizenship rights and human rights brings about the deprivation of access to health services and of provision of service intended for gynecology and obstetrics. The purpose of this article is to address effects of war and poverty on the health of reproduction of women and to offer scientific contribution and solutions.

Endoscopic Ultrasound-Guided, Needle-Based Probe Confocal Laser Endomicroscopy (nCLE) of Intrapancreatic Accessory Spleen: Case Report and Literature Review

Introduction: Accessory spleens are often incidental findings on imaging and usually present as a solid mass at splenic hilum or other organs such as pancreas. Most patients with accessory spleens are asymptomatic however abdominal pain has been associated with an accessory spleen. Intrapancreatic accessory spleen (IPAS) can mimic a pancreatic neuroendocrine tumor (NET) on imaging studies and therefore posing a diagnostic dilemma. We present a case of IPAS in which the concomitant use of nCLE and fine needle aspiration (FNA) helped make the diagnosis. A 24 year old female referred for EUS for a pancreatic mass on CT scan. She presented with abdominal pain and during the workup a 3cm x 2.9cm round hypervascular hypodense mass in the tail of the pancreas was found. Her past medical history is significant for second degree relative with pancreatic cancer. Patient has a past medical history of Thrombotic Thrombocytopenic Purpura (TTP) and she underwent splenectomy 5 years ago for profound thrombocytopenia. On EUS a 2.8cm x 2.9cm round homogenous hypoechoic mass in pancreatic tail was identified. Initially the mass was punctured using a 19-G needle that was pre-loaded with AQ-Flex 19 probe inside the needle before puncture in lieu of the stylet. Fluorescein (2.5mL of 10 % fluorescein sodium) was injected simultaneously with probe insertion. Numerous thick white bands with floating small black particles inside the bands suggestive of network of blood vessels and floating Erythrocytes. Interrogation of the mass did not identify any finger-like papillary projections, crypt-like structures or dark aggregates of cells which is seen in a villous structure or neoplastic cells. Then 4 passes using a 22 G FNA needle was performed with onsite pathology and endomicroscopy review supported the final diagnosis of IPAS. Discussion: Accessory spleen is a rare entity which can be seen in the splenic hilum or at the tail of the pancreas. In 3000 autopsies reported by Halpert et al, 364 accessory spleens were found in which 17% were IPAS. Accessory spleens can be acquired entities (splenosis) which is the auto transplantation of splenic tissue in abnormal locations as a result of trauma or post splenectomy. This is the first case that incorporates real-time endomicroscopy and onsite pathology to diagnose IPAS. Patients with IPAS may undergo distal pancreatectomy because they mimic a hypervascular NET on CT and MRI scans. Onsite pathology and endomicroscopy review increases the diagnostic accuracy for differentiating between IPAS and pancreatic NET. In patients with a hypervascular mass in the tail of pancreas addition of real time nCLE to traditional FNA can increase the diagnosis yield of EUS and potentially prevent unnecessary surgery.Figure 1Figure 2Figure 3

A New Era in Digital Cholangio-Pancreatoscopy: A Case Series

FigureIntroduction: Intraductal biliary-pancreatic endoscopy has enhanced the diagnostic and therapeutic potential of ERCP. Image resolution and mechanical capabilities of available technologies were less than satisfactory. A new single operator, through the scope, high resolution digital cholangio-pancreatoscope (HRDCP) has just been introduced. We present 3 cases, highlighting the multifaceted capability of this new technology Methods: Case 1: 22 yr F presented with RUQ pain, elevated LFTs. Sonogram revealed gallstones, dilated CBD. EUS revealed CBD stone. ERCP revealed a large-faceted CBD stone. High resolution digital cholangioscopy (HRDC) with electrohydraulic lithotripsy (EHL) was performed with stone fragmentation/removal in single session. Easy maneuverability of the intraductal scope and high resolution imaging allowed effective and quick stone management. Patient discharged home same day, referred for cholecystectomy. Case 2: 90 yr F presented with weight loss, elevated alkaline phosphatase, new onset diabetes. MRI abdomen revealed dilated (10 mm) pancreatic duct (PD) and pancreatic head cystic lesion. EUS confirmed these findings. ERCP with high resolution digital pancreatoscopy revealed numerous papillary projections in the main PD, c/w IPMN. Intraductal biopsies confirmed main duct IPMN with dysplasia. Patient chose conservative management. Case 3: 64 yr M with decompensated cirrhosis presented with RUQ pain, elevated LFTs. Sonogram confirmed acute cholecystitis. Patient was non-surgical candidate due to advanced liver disease; he refused percutaneous Gallbladder drainage. ERCP with cystic duct cannulation was unsuccessful. HRDC was used to selectively cannulate the cystic duct, facilitate cystoscopy, enable successful gall bladder stentingdrainage. Patient was discharged home after 2 days. Results: The most recent and dramatic development in ERCP is the advent of high resolution/digital intraductal imaging. We present 3 patients with diverse pancreatico-biliary pathology, who were successfully managed at single session ERCP using the new digital cholangio-pancreatoscope. All procedures were performed under GA. There were no immediate or delayed complications in any patient. Conclusion: This new device represents a major advance in intraductal imaging and therapeutics, heralding a new era in ERCP with increased minimally invasive management options for our patients.

Endoscopic Ultrasound-Guided, Needle-based Confocal Laser Endomicroscopy in the Diagnosis of Cystic Pancreatic Neuroendocrine Tumor: Emerging Imaging Criteria From Surgical Pathologic Correlation in Two Cases

Introduction: Cystic pancreatic neuroendocrine tumors (NETs) are relatively rare, with the reported incidence of < 10% of resected pancreatic cystic lesions. Preoperative diagnosis of cystic pancreatic NET remains challenging. Needle-based confocal laser endomicroscopy (nCLE) during EUS guided fine needle aspiration (EUS-FNA) has been shown to be useful in other pancreatic cystic neoplasms (ex Intraductal papillary mucinous neoplasia or IPMN). However, the utility of EUS-guided nCLE in the diagnosis of cystic pancreatic NET has not been reported, and imaging criteria based on surgical pathologic correlation has not been established. Methods: Under EUS guidance, the pancreatic cystic lesion was punctured with a 19-gauge FNA needle. After confirmation of cyst entry, fluorescein was injected intravenously. The nCLE probe was then advanced through the needle into the cyst, and the cyst wall was carefully imaged. Results: [Case 1] A 65 year-old-male presented for rapid enlargement over one year of a known pancreatic cystic neoplasm. On EUS, a 23X22 mm unilocular cystic lesion was seen in the pancreatic tail. There was no evidence of wall thickening or mural nodules. nCLE demonstrated a high density of dark thick cord-like structures or dark nest-like structures (Fig 1 ). There was no evidence of papillary projections, dark rings, or a superficial vasculature network, suggesting IPMN or serous cystadenoma, respectively. Laparoscopic distal pancreatectomy was performed. Histology of the resected specimen revealed well-differentiated pancreatic NET. nCLE images corresponded well to histological images (Fig 2).Figure 1Figure 2[Case2] A 71-year-old male with diabetes presented for evaluation of a pancreatic tail lesion seen on CT during investigation of abdominal pain. EUS demonstrated a 21X16 mm unilocular cystic lesion in the pancreatic tail with partial wall thickening. On nCLE, a high density of dark cord-like structures was observed. Distal pancreatectomy was performed and histology revealed a pancreatic NET. Conclusion: EUS-guided nCLE images correlated well with surgical pathology in 2 cases of cystic pancreatic NET. A high density of dark thick cord-like structures or dark nest-like structures may be important diagnostic criteria. If these criteria are prospectively validated, nCLE may play a role in the diagnosis of cystic pancreatic neuroendocrine tumors.

Differentiation between borderline and benign ovarian tumors: combined analysis of MRI with tumor markers for large cystic masses (≥5 cm).

There is overlap in imaging features between borderline and benign ovarian tumors. To analyze diagnostic performance of magnetic resonance imaging (MRI) combined with tumor markers for differentiating borderline from benign ovarian tumor. Ninety-nine patient with MRI and surgically confirmed ovarian tumors 5 cm or larger (borderline, n = 37; benign, n = 62) were included. On MRI, tumor size, septal number (0; 1-4; 5 or more), and presence of solid portion such as papillary projection or septal thickening 0.5 cm or larger were investigated. Serum tumor markers (carbohydrate antigen 125 [CA 125] and CA 19-9) were recorded. Multivariate analysis was conducted for assessing whether combined MRI with tumor markers could differentiate borderline from benign tumor. The diagnostic performance was also analyzed. Incidence of solid portion was 67.6% (25/37) in borderline and 3.2% (2/62) in benign tumors (P < 0.05). In all patients, without combined analysis of MRI with tumor markers, multivariate analysis revealed solid portion (P < 0.001) and CA 125 (P = 0.039) were significant for predicting borderline tumors. When combined analysis of MRI with CA 125 ((i) the presence of solid portion or (ii) CA 125 > 44.1 U/mL with septal number ≥5 for borderline tumor) is incorporated to multivariate analysis, it was only significant (P = 0.001). The sensitivity, specificity, PPV, NPV, and accuracy of combined analysis of MRI with CA 125 were 89.1%, 91.9%, 86.8%, 93.4, and 90.9%, respectively. Combined analysis of MRI with CA 125 may allow better differentiation between borderline and benign ovarian tumor compared with MRI alone.

Structured Hysteroscopic Evaluation of Endometrium in Women With Postmenopausal Bleeding.

To evaluate visual pattern parameters obtained with hysteroscopy for the prediction of endometrial cancer, to evaluate observer variation of these parameters, and to present a scoring system of the parameters for the prediction of malignancy compared with subjective evaluation. A prospective controlled study (Canadian Task Force classification II-1). A university clinic. One hundred forty-nine consecutive women with postmenopausal bleeding and an endometrium thickness ≥ 5 mm. Sixty-one (41%) had endometrial cancer. Forty-six of 149 women were referred based on suspected malignancy. Endometrial pattern characteristics for endometrial cancer were evaluated in hysteroscopic video clips. The reference standard was pathologic evaluation of resectoscopic samples or hysterectomy. Using multivariate logistic regression, image parameters were correlated with the presence of endometrial cancer. A scoring system of visual parameters for the prediction of malignancy was compared with subjective evaluation of malignancy. A score for lesion surface, necrosis, and vessels had an area under the curve (AUC) of 0.89, 0.89, and 0.87, respectively. A hysteroscopic cancer (HYCA) scoring system based on unsmooth lesion surface, papillary projections, surface necrosis, "candy floss" necrosis, white hyperintense spots, irregular branching vessels, and irregular distribution of irregular vessels was able to predict cancer (AUC = 0.964) with higher accuracy than subjective evaluation (AUC = 0.859, p < .01). At a score value ≥ 3, sensitivity was 89% and specificity was 92% with moderate agreement between observers (kappa = 0.56 [0.42-0.71]). A systematic pattern evaluation of optimal parameters by a HYCA scoring system based on systematically defined terms may increase accuracy in the diagnosis of endometrial cancer and should be further elaborated and external validity tested in unselected women with postmenopausal bleeding.

PWE-077 Outcome following resection of biliary cystadenoma – a single centre experience

<h3>Introduction</h3> Biliary cystadenoma (BCA) are rare, benign, potentially malignant cystic lesions of the liver, accounting for less than 5% of cystic liver tumours. These lesions have potential for recurrence and malignant transformation. The aim of the study was to analyse the outcome following resection of biliary cystadenoma from a single tertiary centre. <h3>Method</h3> Patients who had resection of BCA between 1993 and 2014 (21 years) were included in the study. The data were obtained form a prospectively maintained liver surgical and pathological database. Patient demographics, clinico-pathological characteristics, operative data and post-operative outcome were collected. <h3>Results</h3> 29 patients had surgery for BCA. Median age was 62 (IQ 48–74) years and the Male:Female ratio was 28:1. The main clinical presentation was abdominal pain (74%) followed by jaundice (20%), abdominal mass (14%) and deranged LFTs (3%). On pre-operative imaging, single cyst was seen in 76% of patients. The majority of cysts were found at central location (48%). Cyst characteristics included septations (48%), wall thickening (31%), wall irregularity (38%), papillary projections (10%) and mural nodule (3%). Surgical procedures performed as follows: atypical liver resection (45%), left hemihepatectomy (34%), right hemihepatectomy (10%), excision of extra hepatic bile duct (7%) and left lateral segmentectomy (3%). Three patients had de-roofing for suspected simple liver cyst, which were confirmed on histology as biliary cystadenoma. All had re-resection with clear margins. Median length of stay was 7 (IQ 6.5 – 8.5) days. 2 patients developed bile leak, one each managed conservatively and with ERCP. There was no peri-operative mortality. None of the patients had evidence of malignancy on final histology. Median follow-up was 11 (IQ 2–44) months. One patient developed delayed biliary stricture requiring reconstruction. One died 11 years later due to development of inoperable cholangiocarcinoma. <h3>Disclosure of interest</h3> None Declared. <h3>Conclusion</h3> Biliary cystadenomas can be resected safely with significantly low morbidity. Malignant transformation and recurrence are rare. Complete surgical resection provides a cure.

Ultrasound Features for Determining the Risk of Malignancy in Unilocular-Solid Adnexal Masses in Premenopausal Women without Ascites and/or Carcinomatosis

ABSTRACT Purpose To assess what clinical and ultrasound features could be most helpful for discriminating benign from malignant unilocular cysts with solid components in premenopausal women with no signs of ascites or carcinomatosis. Materials and methods Retrospective study comprising 91 women with preoperative diagnosis of unilocular-solid cyst that underwent surgical removal. The following variables were assessed: age, complaints at presentation, bilaterality, mean size of the lesion, number of papillary projections, size of solid component, surface of solid component (smooth or irregular), amount of color within solid component (no flow, minimal flow, moderate flow, abundant flow). Definitive histopathological diagnosis was used as gold standard. Multivariate logistic regression analysis was performed to identify which variables were independent predictors of malignancy and their odds ratios (OR). Results Malignant lesions had significantly larger tumor size, more number of solid components, larger size of solid component, more frequency of irregular surface in the solid component and more frequent moderate or abundant vascularization within the solid component. Logistic regression analysis identified amount of color (OR: 48.7), solid component's surface (OR: 29.1) and mean size of the lesion (OR: 1.58) as independent predictors for malignancy. Conclusion Tumor size, irregular surface and the presence of moderate or abundant color score within the solid component are the features more frequently associated to malignancy in unilocular-solid adnexal cysts in premenopausal women. How to cite this article Juez L, Peces A, Corral TMA, Orozco R, Utrilla-Layna J, Caparros M, Alcazar JL. Ultrasound Features for Determining the Risk of Malignancy in Unilocular- Solid Adnexal Masses in Premenopausal Women without Ascites and/or Carcinomatosis. Donald School J Ultrasound Obstet Gynecol 2015;9(2):112-117.

MRI for differentiating ovarian endometrioid adenocarcinoma from high-grade serous adenocarcinoma.

PurposeTo investigate magnetic resonance imaging (MRI) features for differentiating ovarian endometrioid adenocarcinoma (OEC) from high-grade serous adenocarcinoma (HGSC).Materials and methodsTwenty-three patients with 25 OECs and 93 patients with 139 HGSCs confirmed by surgery and pathology underwent conventional MRI and diffusion-weighted imaging (DWI). The MRI features of the tumors, including laterality, size, shape, configuration, signal intensity, ADC value of solid component, enhancement, ascites, synchronous primary cancer (SPC) of the ovary and endometrium, and clinical stage, were evaluated and compared between two groups.ResultsThe following characteristics were significantly more common for OECs than HGSCs: unilateral (91.3% vs 50.5%, P < 0.001), larger mass (80.0% vs 48.2%, P = 0.005), round or oval shape (64.0% vs 17.3%, P < 0.001), mainly cystic with mural nodules or papillary projections (72.0% vs 18.7%, P < 0.001), cystic component with homogeneous iso- or hyperintensity on T1WI (82.6% vs 4.3%, P < 0.001), moderate enhancement (52.0% vs 26.6%, P = 0.011), no or mild ascites (91.3% vs 57.0%, P = 0.002), and SPC (43.5% vs 4.3%, P < 0.001). The ADC value of the solid component was higher in OECs (0.979 ± 0.197 × 10−3 mm2/s) than in HGSCs (0.820 ± 0.112 × 10−3 mm2/s) (P = 0.002). When a mainly cystic mass with mural nodules or papillary projections was associated with any one of homogeneously iso- or hyperintense cystic component on TIWI, a relatively higher ADC value and SPC, the sensitivity, specificity, accuracy, and positive and negative predictive values for characterizing OEC were 87.0%, 93.5%, 92.2%, 76.9%, and 96.7%, respectively.ConclusionsConventional MRI combining DWI is helpful for differentiating OECs from HGSCs.

Syringocystadenoma Papilliferum

Syringocystadenoma Papilliferum (SCAP) is a rare papilloma resembles to benign tumour. It is characterized by extensive papillary epithelial elements growing in to dermis. A 9 years old boy presented with slowly growing dome shaped plaque consists of clusters of rose-red like vesicles of firm consistent, smooth-surfaced papules over the occipital region of the scalp. There was no family history of such type of lesions. Histopathological examination showed few cystic invaginations from the epidermis into dermis. Papillary projections are extending from the base of the cyst into lumen of the cystic spaces that consistent with Syringocystadenoma Papilliferum (SCAP).The treatment of choice is surgical excision.Northern International Medical College Journal Vol.5(2) 2014: 349-350

1041 Diagnostic Accuracy of Directed Cholangioscopic Biopsies and Confocal LASER Endomicroscopy in Cytology-Negative Indeterminate Bile Duct Stricture: a Multicenter Comparison Trial

experts in determining final diagnosis based on visual impression alone was 70%. Conclusion: The Monaco classification identifies 8 consensus criteria that may be used in the visual characterization of biliary lesions on cholangioscopy. Use of these criteria demonstrated that ulceration and papillary projections were more greatly associated with a malignant diagnosis, while previously believed diagnostic findings of abnormal vessels were not. A large, prospective study is needed to validate potential malignant criteria to develop a scoring system to optimize the diagnostic accuracy of cholangioscopy. Table 1. Revised Criteria Observed in Benign or Malignant diagnoses clips

Lymphoepithelial cysts of the pancreas. Can preoperative imaging distinguish this benign lesion from malignant or pre-malignant cystic pancreatic lesions?

Lymphoepithelial cysts of the pancreas are rare true benign cystic tumors of the pancreas of uncertain etiology. Cystic neoplasms of the pancreas present a significant diagnostic dilemma in differentiating benign from premalignant or malignant variants. Since the first description of lymphoepithelial cysts in 1985, 109 cases have been reported in the literature. We describe 6 cases of this rare tumor, the preoperative imaging results, and a review the literature. Five males and one female ranging in age from 47 to 76 years underwent resection for lymphoepithelial cysts. Five patients presented with abdominal pain related to the lesion and in one patient the lesion was discovered incidentally. Four patients had elevated serum CA 19-9 levels. Pre-operative imaging with a CT scan and MRI of the abdomen typically revealed a well defined hypodense mass with Hounsfield units (HU) in the range of 15 to 20. One patient had papillary projections into the lesion. The mean size was 3.3 cm (ranging from 1.8 cm to 4 cm). All lesions were exophytic off the pancreatic parenchyma (1 cyst was located in the head of the pancreas, 2 were in the body, and 3 were in the tail region). Pre-operative EUS-guided/CT-guided needle aspiration, when performed, was not diagnostic. All patients underwent resection (one pancreaticoduodenectomy, five left pancreatectomies) to remove these cystic neoplasms. Pathology revealed a cyst lined by non-dysplastic squamous cells surrounded by sheets of benign lymphocytes. No evidence of malignancy was found. Lymphoepithelial cysts of the pancreas are rare and are characteristically seen in men. While a hypodense mass (less than 20 HU) with papillary projections should be considered suspicious for lymphoepithelial cyst, a definitive diagnosis cannot be made solely based on preoperative imaging. EUS-guided biopsy coupled with biochemical/tumor marker studies are increasingly being used as a diagnostic tool to help differentiate between the various types of cystic pancreatic neoplasms. Imaging findings of lymphoepithelial cysts are non-specific and hence surgical resection is often required to rule out the presence of a malignant or pre-malignant cystic pancreatic lesion. In true lymphoepithelial cysts, malignant transformation is not seen and patients who have these cysts are not at increased risk of developing a pancreatic malignancy.

Diagnosis and treatment of biliary cystic tumors

Biliary cystic tumors (BCTs) are rare cystic tumors and are accounted for less than 5% of liver cysts. BCTs are very common in middle-aged and elderly women, and depend on diagnosis of imaging including papillary projection or multilocular cystic liver mass. BCTs are frequently misdiagnosed due to the absence of specific diagnostic indicators, which should differentiate from diagnosis of hepatic cystic. Complete surgical resection is the first choice for BCTs with a good outcome, in addition to low recurrence. Once recurrence was identified in follow-up, BCTs can be treated by reoperation with a good outcome. Key words: Biliary cystadenoma; Biliary cystadenocarcinoma; Diagnosis; Therapy

Interobserver agreement in describing the ultrasound appearance of adnexal masses and in calculating the risk of malignancy using logistic regression models.

To estimate interobserver agreement with regard to describing adnexal masses using the International Ovarian Tumor Analysis (IOTA) terminology and the risk of malignancy calculated using IOTA logistic regression models LR1 and LR2, and to elucidate what explained the largest interobserver differences in calculated risk of malignancy. One hundred and seventeen women with adnexal masses were examined with transvaginal gray scale and power Doppler ultrasound by two independent experienced sonologists who described the masses using IOTA terminology. The risk of malignancy was calculated using LR1 and LR2. A predetermined risk of malignancy cutoff of 10% indicated malignancy. There were 94 benign, four borderline, and 19 invasively malignant tumors. There was substantial variability between the two sonologists in measurement results and some variability in assessment of categorical variables (agreement 40%-98%, Kappa 0.30-0.91). Interobserver agreement when classifying tumors as benign or malignant was 84% (98/117), Kappa 0.68 for LR1, and for LR2 85% (99/117), Kappa 0.68. When using LR1 and LR2, the interobserver difference in calculated risk was ≥ 25 percentage units in 9% (11/117) and 12% (14/117) of tumors, respectively. Differences in assessment of wall irregularity, acoustic shadowing, color score, and color flow in papillary projections explained most of these largest differences. Interobserver agreement in classifying tumors as benign or malignant using the risk of malignancy cutoff of 10% for LR1 and LR2 was good. However, because risk estimates may differ substantially between sonologists, one should be cautious with using the risk value for counseling patients about their individual risk.

Diagnosis of pancreatic cysts: EUS-guided, through-the-needle confocal laser-induced endomicroscopy and cystoscopy trial: DETECT study

The diagnosis of pancreatic cystic neoplasms (PCNs), which now depends on morphology, cytology, and fluid analysis, is still challenging. A novel confocal laser endomicroscopy probe that can be inserted through a 19-gauge FNA needle allows needle-based confocal laser endomicroscopy (nCLE), and the feasibility of nCLE has been reported in PCNs. The combination of cystoscopy by using a through-the-needle fiberoptic probe in combination with nCLE under EUS guidance may improve the diagnosis of PCNs. To assess the feasibility, safety, and diagnostic yield of the combination of cystoscopy and nCLE in the clinical diagnosis of PCNs. A prospective feasibility study. An academic tertiary referral center. Thirty patients with PCNs. EUS-guided dual through-the-needle imaging (cystoscopy and nCLE) for PCNs. Technical feasibility and safety. Associations of cystoscopy and nCLE findings with clinical diagnosis of PCNs. The procedure was technically successful with the exception of 1 probe exchange failure. In 2 patients (7%), postprocedure pancreatitis developed. Specific features associated with the clinical diagnosis of mucinous cysts were identified: mucin on cystoscopy and papillary projections and dark rings on nCLE. The sensitivity of cystoscopy was 90% (9/10), and that of nCLE was 80% (8/10), and the combination was 100% (10/10) in 18 high-certainty patients. A single-center study and lack of complete pathologic correlation. The combination of dual through-the-needle imaging (cystoscopy and nCLE) of pancreatic cysts appears to have strong concordance with the clinical diagnosis of PCN. ( NCT01447238.).

Outcome following Resection of Biliary Cystadenoma: A Single Centre Experience and Literature Review

Background. Biliary cystadenomas (BCAs) are rare, benign, potentially malignant cystic lesions of the liver, accounting for less than 5% of cystic liver tumours. We report the outcome following resection of biliary cystadenoma from a single tertiary centre. Methods. Data of patients who had resection of BCA between January 1993 and July 2014 were obtained from liver surgical database. Patient demographics, clinicopathological characteristics, operative data, and postoperative outcome were analysed. Results. 29 patients had surgery for BCA. Male : female ratio was 1 : 28. Clinical presentation was abdominal pain (74%), jaundice (20%), abdominal mass (14%), and deranged liver function tests (3%). Cyst characteristics included septations (48%), wall thickening (31%), wall irregularity (38%), papillary projections (10%), and mural nodule (3%). Surgical procedures included atypical liver resection (52%), left hemihepatectomy (34%), right hemihepatectomy (10%), and left lateral segmentectomy (3%). Median length of stay was 7 (IQ 6.5–8.5) days. Two patients developed postoperative bile leak. No patients had malignancy on final histology. Median follow-up was 13 (IQ 6.5–15.7) years. One patient developed delayed biliary stricture and one died of cholangiocarcinoma 11 years later. Conclusion. Biliary cystadenomas can be resected safely with significantly low morbidity. Malignant transformation and recurrence are rare. Complete surgical resection provides a cure.