Gastric duplication cyst: Evaluation by endoscopic ultrasonography and magnetic resonance imaging

Endoscopic ultrasonography (EUS) and magnetic resonance imaging (MRI) are becoming popular methods for examining tumorous lesions along the upper gastrointestinal tract. Though duplication cysts are uncommon. EUS findings from gastric duplication cysts have accumulated and proven very useful for preoperative diagnosis. There have been few reports, however, concerning MRI findings from these cysts. We report herein the case of a 25-year-old man with a gastric duplication cyst. EUS demonstrated a cystic mass adjacent to the fourth layer of the stomach wall. MRI revealed a cyst containing low signalintensity fluid and high signal-intensity fluid separated by levels. In addition to the characteristic findings from preoperative examinations, the unique histological findings from the cyst are also described.     

Endoscopic treatment of periampullary duodenal duplication cysts in children:Four case reports and review of the literature

BACKGROUND Duodenal duplications are rare congenital anomalies of the gastrointestinal tract. As the periampullary variant is much rarer, literature is scant and only few authors have reported their experience in diagnosis and treatment, particularly with operative endoscopy.CASE SUMARY To report our experience with the endoscopic treatment in a series of children with periampullary duodenal duplication cysts, focusing on the importance of obtaining an accurate preoperative anatomic assessment of the malformations. The pediatric periampullary duodenal duplication cyst literature is reviewed. We conducted a systematic review according to the PRISMA guidelines. The PubMed database was searched for original studies on "duodenal duplication", "periampullary duplication" or "endoscopic management" published since 1990, involving patients younger than 18 years of age. Eligible study designs were case report, case series and reviews. We analyzed the data and reported the results in table and text. Fifteen eligible articles met the inclusion criteria with 16 patients, and analysis was extended to our additional 4 cases. Median age at diagnosis was 13.5 years. Endoscopic treatment was performed in 10(50%) patients, with only 2 registered complications.CONCLUSION Periampullary duodenal duplication cysts in pediatric patients are very rare. Our experience suggests that an accurate preoperative assessment is critical. In the presence of sludge or stones inside the duplication, endoscopic retrograde cholangio-pancreatography is mandatory to demonstrate a communication with the biliary tree. Endoscopic treatment resulted in a safe, minimally invasive and effective treatment. In periampullary duodenal duplication cyst endoscopically treated children, long-term follow-up is still necessary considering the potential malignant transformation at the duplication site.     

Gastric duplication cyst: A rare endosonographic finding in an adult

Cystic lesions located in the gastric wall are a rare finding in endosonography of the gastrointestinal tract. Compared to all forms of benign and malignant tumours of the stomach, gastric duplication cysts are an uncommon anomaly – especially in adults. We report on a 59-year-old woman suffering from intermittent abdominal pain, weight loss and nausea. A gastric duplication cyst was identified by endoscopic ultrasound (EUS), but malignancy was excluded by EUS and fine-needle aspiration histology. Because of continuously increasing abdominal complaints, surgery was performed with partial resection of the gastric corpus and splenectomy. Gross anatomy and histology showed a gastric cyst measuring 150 mm in maximum diameter with no evidence of malignancy or inflammation. Following surgery, the patient's condition recovered fully.     

Recurrent acute pancreatitis secondary to a duodenal duplication cyst in an adult. A case report and literature review

Duodenal duplication cysts are rare congenital abnormalities that are most commonly diagnosed in infancy and childhood. However, in rare cases, the lesion can remain asymptomatic until adulthood. An extremely rare case of a previously healthy adult patient with recurrent acute pancreatitis, who was diagnosed with a duodenal duplication cyst is presented. At laparotomy, a duplication cyst measuring 4.8 cm × 4 cm × 4 cm was found adjacent to the ampulla of Vater. A partial cyst excision and marsupialization into the duodenal lumen was performed. The patient is healthy and asymptomatic four years after surgery. The present case illustrates the necessity of considering a duodenal duplication cyst in the differential diagnosis of recurrent acute pancreatitis in previously healthy adults.     

Neuroendocrine carcinoma of the stomach with peripancreatic lymph node metastases successfully treated with pancreaticoduodenectomy

Neuroendocrine carcinoma of the stomach is an uncommon tumor, usually associated with highly malignant biological behavior and extremely poor prognosis. In this report, we described a case of advanced neuroendocrine carcinoma of the stomach with the peripancreatic lymph node metastases which was treated with pancreaticoduodenectomy with extended lymphadenectomy. The patient was admitted to our hospital for anemia. An upper gastrointestinal endoscopy revealed a 4x4-cm fungating tumor with its fundus locating mainly in the duodenal bulbus and extending to the gastric antrum, and tumor biopsy revealed the histological findings of adenocarcinoma. Computed tomography (CT) showed a large mass in the duodenal bulbus with regional lymph node metastases. The patient's disease was diagnosed as primary duodenal cancer with regional lymph node metastases preoperatively. During the operation, an obviously swollen lymph node on the anterior surface of the head of the pancreas 4.0 x 3.5 cm in size was found growing into the parenchyma of the pancreas head and could not be separated from the pancreas, and the swollen lymph node along the superior mesenteric vein was also hard and suspected to be a metastatic node. A pancreaticoduodenectomy with extended lymphadenectomy was performed to achieve a radical resection. Histopathologically, the origin of the primary tumor was considered as a gastric origin, and the tumor was composed of diffused small cells with a moderate mitotic index and occasional rosette formation. Immunohistochemical investigations of the neoplastic cells confirmed the tumor to be neuroendocrine carcinoma. The obvious swollen lymph node on the anterior surface of the head of the pancreas and the swollen lymph node along the superior mesenteric vein were also identified as metastatic lymph nodes. Adjuvant chemotherapy with TS-1 was administered on an out-patient basis 6 weeks after the operation. The patient is well and has now been free of symptoms of recurrence and metastasis for 8 months.     

Rare adult gastric duplication cyst mimicking a gastrointestinal stromal tumor

Gastric duplication cyst is a very rare gastrointestinal tract malformation that accounts for 2%-4%of alimentary tract duplications.Most cases are diagnosed within the first year of life,following presentation of abdominal pain,vomiting,and weight loss and clinical discovery of an abdominal palpable mass.This case report describes a very uncommon symptomatic gastric duplication cyst diagnosed for the first time in adulthood.Only a few other case reports of similar condition exist,and all were identified by endosonography.The current case involves a 52-year-old male who presented with a onemonth history of progressive iron deficiency anemia without overt gastrointestinal bleeding.The patient underwent esophagogastroduodenoscopy,which revealed a 2.0 cm pinkish subepithelial lesion,suspected to be a gastrointestinal stromal tumor(GIST)and source of gastrointestinal bleeding.The endosonography showed inhomogeneous hypoechoic lesions with focal anechoic areas arising from a second and third layer of the gastric wall.Differential diagnoses of GIST,neuroendocrine tumor,or pancreatic heterotopia were made.The lesion was removed using an endoscopic submucosal resection technique.Histopathology revealed an erosive gastric mass composed of a complex structure of dilated gastric glands surrounded by fibro-muscular tissue,fibroblasts,and smooth muscle bundles,which led to the diagnosis of gastric duplication.     

Successful treatment of duodenal adenocarcinoma with multiple liver metastases by S-1?+?irinotecan (CPT-11)

Unresectable duodenal adenocarcinoma excluding the ampullary region is rare, and no standard chemotherapy has been defined for this disease. Although S-1-based chemotherapy is widely administered for advanced gastric cancer, few reports have described advanced duodenal cancer treated with S-1-based chemotherapy. We present herein a case of duodenal adenocarcinoma with liver metastases. The patient was a 72-year-old man with chief complaints of epigastralgia and fever. Gastroduodenal endoscopy revealed an ulcerative lesion on the upper wall of the duodenal bulb, and biopsy specimens showed well-differentiated adenocarcinoma. Computed tomography and ultrasonography showed multiple liver metastases. S-1 (80 mg/m² day⁻¹ on days 1–21) + irinotecan (80 mg/m² day⁻¹ on days 1 and 15) were administered in 4-week intervals as first-line chemotherapy. Tumor markers subsequently normalized, and liver metastases were diminished. The progression-free term was 6 months. Grade 3 neutropenia and diarrhea were observed as adverse events. S-1 + cisplatin and S-1 + docetaxel were administered as second- and third-line chemotherapies, respectively. The patient died due to hepatic failure, with an overall survival of 15 months. S-1-based regimens appear effective and well tolerated, and S-1 may thus represent a useful option for advanced duodenal cancer.     

Tonsillar metastasis of gastric cancer

Metastasis from a malignant tumor to the palatine tonsils is rare, with only 100 cases reported in the English-language literature. Tonsillar metastasis from a gastric cancer is very rare. We report here a case of palatine tonsillar metastasis after gastric cancer surgery. The patient was an 88-year-old woman who had gastric cancer with abdominal wall invasion. She had undergone a distal gastrectomy with abdominal wall resection and D2 lymph node dissection. Histologically, the tumor was primarily a moderately differentiated adenocarcinoma. It was stage IV (T4, N1, M0) using TNM clinical classification. The patient developed pharyngeal discomfort and abdominal pain and was hospitalized during the follow-up period, 1 year 9 months post-operatively. Multiple lung metastases, Virchow’s lymph node metastasis, and adrenal metastasis were observed. A mass of 2.5 cm was also observed in the right palatine tonsil. It was diagnosed as a moderately differentiated adenocarcinoma, a metastasis from gastric cancer. There was a concern of asphyxiation due to hemorrhage of the tumor; however, the tumor dislodged approximately 10 days after biopsy and tonsillar recurrence was not observed. The patient died 1 year 10 months post-operatively. In the literature there are cases with tonsillar metastases where surgical treatment, radiotherapy, and chemotherapy were performed and extension of survival was seen. Tonsillar metastasis is a form of systemic metastasis of a malignant tumor, and there is a high risk for asphyxiation from tumor dislodgement or hemorrhage. Thus, it is important to recognize tonsillar metastasis as an oncologic emergency.     

Successful endoscopic treatment of an esophageal duplication cyst

Duplication cysts of the gastrointestinal tract are rare, particularly in adults. Endoscopic minimally invasive treatment is still a challenging approach even in the endoscopically accessible sections of the gastrointestinal tract. In a 25-year-old patient suffering from dysphagia, an endoscopy and subsequent endosonography revealed a spherical duplication cyst in the lower third of the esophagus, which prompted us to puncture the cyst and subsequently to perform a fenestration (marsupialization; diameter 1 cm) in the anterior wall of the cyst, resulting in permanent drainage of the cystic fluid. Because of the recurrent complaints of the patient after 6 weeks, the anterior wall of the duplication cyst, the former esophageal wall, was partially resected, resulting in a permanent 4-cm opening including the cystic cavity into the esophageal lumen. Thereafter, there were no further complaints from the patient and the findings in the follow-up endoscopy were normal. A successful endoscopic intervention for this type of gastrointestinal duplication cyst is described for the first time. The minimally invasive resection of the anterior wall of the esophageal duplication cyst, simultaneously with the former regular wall at this segment of the esophagus, resulted in permanent inclusion of the cystic cavity into the esophageal lumen with no disadvantageous passage of fluid and food through the lower esophagus or changes in the former cystic epithelium. This method is considered to be feasible and a reasonable treatment alternative to the more invasive surgical approach.     

Subdiaphragmatic bronchogenic cyst of the esophagus masquerading as a metastatic lymph node of coexisting advanced gastric cancer

Esophageal bronchogenic cysts are rare bronchopulmonary foregut malformations, and those located in the abdominal cavity are particularly rare. Esophageal cysts are typically found incidentally; an exact preoperative diagnosis of bronchogenic cyst is difficult, and surgical resection is generally recommended. Here, we report a case in which a subdiaphragmatic bronchogenic cyst of the esophagus coexisted with advanced gastric cancer. A 44-year-old man was referred for the treatment of gastric cancer. A preoperative examination revealed a mass on the right side of the esophagogastric junction that was preoperatively diagnosed as a metastatic lymph node. Intraoperative exploration revealed that the mass had protruded from the abdominal esophageal wall, and was diagnosed as a cyst originating from the subdiaphragmatic esophagus. The cyst was completely resected with the whole stomach and abdominal esophagus. The histopathological findings of the cyst were specific for a bronchogenic origin. The patient has not shown any signs of disease recurrence.     

Gastric duplication cyst: a rare endosonographic finding in an adult

Cystic lesions located in the gastric wall are a rare finding in endosonography of the gastrointestinal tract. Compared to all forms of benign and malignant tumours of the stomach, gastric duplication cysts are an uncommon anomaly--especially in adults. We report on a 59-year-old woman suffering from intermittent abdominal pain, weight loss and nausea. A gastric duplication cyst was identified by endoscopic ultrasound (EUS), but malignancy was excluded by EUS and fine-needle aspiration histology. Because of continuously increasing abdominal complaints, surgery was performed with partial resection of the gastric corpus and splenectomy. Gross anatomy and histology showed a gastric cyst measuring 150 mm in maximum diameter with no evidence of malignancy or inflammation. Following surgery, the patient's condition recovered fully.     

Laparoscopic partial cystectomy with mucosal stripping of extraluminal duodenal duplication cysts

Duodenal duplication cysts are rare congenital anomalies.Duodenal duplication should be considered in the differential diagnosis of patients who present with abdominal symptoms with cystic structures neighboring the duodenum.Here,we present an 8-year-old girl with a duodenal duplication cyst treated with partial cystectomy with mucosal stripping performed laparoscopically.Laparoscopic surgery can be considered as a treatment option for duodenal duplication cysts,especially in extraluminal locations.     

Symptomatic Duodenal Duplication Cyst in an Adult Demonstrated by Endoscopic Retrograde Cholangiopancreatography

A patient with a symptomatic duodenal duplication cyst demonstrated by endoscopic retrograde cholangiopancreatography (ERCP) is presented. This lesion usually does not communicate with duodenal lumen but should be added to the list of eystic duodenal lesions demonstrable by ERCP. ERCP preoperatively is helpful to the surgeon in isolating adjacent duct structures but cyst wall histology is mandatory for correct anatomic diagnosis as this lesion has often been confused with Type III choledochal cysts.     

Esophageal duplication cyst continuously extending into the peritoneal cavity on the proximal portion of the stomach

Although bronchogenic or esophageal duplication cysts are foregut-derived developmental anomalies most commonly encountered in the mediastinum and rarely in the abdomen, a cyst continuously extending into the abdomen via the esophageal hiatus has not been reported previously. We report a case of esophageal duplication cyst that occurred in the distal esophagus and extended continuously into the proximal portion of the stomach via the esophageal hiatus. A 62-year-old Japanese man was admitted to a local hospital complaining of dysphagia and upper abdominal pain. Abdominal ultrasound and CT scan revealed a cystic mass dorsal to the lateral segment of the liver that extended continuously into the mediastinum via the hiatus. The upper gastrointestinal series and endoscopic examination revealed extramural compression of the distal esophagus without mucosal lesions. Resection of the cystic lesion was performed by thoracotomy followed by laparotomy. The upper part of the cyst originated in the submucosal layer, extending into the muscularis propria of the distal esophagus. Histology of the resected specimen indicated that the cystic wall was composed of two smooth muscle layers and that the inner cystic wall was lined with pseudostratified columnar ciliated and/or squamous epithelium associated without cartilage or respiratory gland, indicating esophageal differentiation. These histological characteristics indicated that the cyst was an esophageal duplication cyst, rather than a bronchogenic cyst. This is the first case of a large esophageal duplication cyst of the distal esophagus continuously extending into the abdomen via the esophageal hiatus. The atypical location of this esophageal duplication cyst provides an insight into the pathogenesis of esophageal duplication cysts.     

Symptomatic duodenal duplication cyst in an adult demonstrated by endoscopic retrograde cholangiopancreatography. Case report and literature review.

A patient with a symptomatic duodenal duplication cyst demonstrated by endoscopic retrograde cholangiopancreatography (ERCP) is presented. This lesion usually does not communicate with duodenal lumen but should be added to the list of cystic duodenal lesions demonstrable by ERCP. ERCP preoperatively is helpful to the surgeon in isolating adjacent duct structures but cyst wall histology is mandatory for correct anatomic diagnosis as this lesion has often been confused with Type III choledochal cysts.     

Gastric foregut cystic developmental malformation: Case series and literature review

Foregut cystic developmental malformation(FCDM) is a very rare lesion of the alimentary tract, especially in the stomach. We discuss the concepts of gastric duplication cyst, bronchogenic cysts, and FCDM. Nomenclature has been inconsistent and confusing, but, by some definitions, gastric duplication cysts involve gastric mucosa and submucosal glands, bronchogenic cysts involve respiratory mucosa with underlying cartilage and glands, and FCDM lacks gastric mucosa or underlying glands or cartilage but has pseudostratified ciliated columnar epithelium(PCCE). We searched our departmental case files from the past 15 years and identified 12 cases of FCDM in the alimentary tract. We summarize the features of these 12 cases including a report in detail on a 52-year-old man with a submucosal cyst lined with simple PCCE and irregular and stratified circular muscle layers that merged with gastric smooth muscle bundles near the lesser curvature of the gastric cardia. A literature review of cases with this histology yielded 25 cases. We propose the term gastric-FCDM for such cases. Our own series of 12 cases confirms that preoperative recognition of the entity is infrequent and problematic. The rarity of this developmental disorder, as well as a lack of understanding of its embryologic origins, may contribute to missing the diagnosis. Not appreciating the diagnosis preoperatively can lead to an inappropriate surgical approach. In contrast, presurgical recognition of the entity will contribute to a good outcome and reduced risk of complications.     

Bronchogenic cyst of the stomach involved with gastric adenocarcinoma

Bronchogenic cyst, a congenital anomaly mostly found in the mediastinum, rarely arises in the stomach. A 43-year-old man had epigastric pain and was diagnosed as having gastric adenocarcinoma. Abdominal ultrasonography showed hepatic cyst, and computed tomography and magnetic resonance imaging revealed a cystic lesion near the stomach. At surgery, the cystic lesion was found to be located at the lesser curvature of the stomach where the cancer invasion was seen. Total gastrectomy with combined resection of the cystic lesion was performed. Pathologically, the cyst wall was lined by pseudostratified ciliated columnar epithelium, subepithelial mixed seromucinous glands and smooth muscle bundles. The pathological diagnosis was bronchogenic cyst of the stomach involved with gastric adenocarcinoma. Based on a similar association between gastric diffuse submucosal cysts and gastric cancer in the previous reports, it is possible that chronic inflammation from bronchogenic cysts to the gastric mucosa may cause adenocarcinoma in the stomach. At surgery, complete combined resection without rupture of the bronchogenic cyst involved with the gastric adenocarcinoma is needed for treatment of gastric cancer to prevent dissemination of cancer cells considering when cancer cells have invaded beyond the pseudostratified ciliated columnar epithelium and within the bronchogenic cyst.     

Mixed adenocarcinoma and squamous cell carcinoma arising in a gastric duplication cyst

Malignant transformation of duplication cyst is a rare condition. The authors report the original case of a degenerated gastric duplication cyst in a 67-year-old patient. The histologic examination revealed a gastric duplication cyst infiltrated with both adenocarcinoma and squamous cell carcinoma. Local carcinomatosis was found at laparotomy. The patient died six months after complete macroscopic resection of the lesion, with metastatic disease.     

Endoscopic management of a duodenal duplication cyst associated with biliary obstruction in an adult

Duodenal duplication cysts are distinctly uncommon and most often present in infancy or early childhood. The clinical presentation is generally duodenal obstruction, hemorrhage, or pancreatitis. Duodenal duplication cysts rarely cause biliary obstruction in adults. So far, duodenal duplication cysts have been almost exclusively treated by surgical intervention. This report describes both endoscopic diagnosis and treatment of a large periampullary duodenal duplication cyst associated with biliary obstruction in an adult patient.     

A case of foregut gastric duplication cyst with pseudostratified columnar ciliated epithelium

Gastrointestinal duplication is a congenital rare disease. Duplication cyst of the stomach with pseudostratified columnar ciliated epithelium is extremely rare. A 44-year-old Japanese woman visited University of Yamanashi Hospital for evaluation of an abnormal tumor detected by abdominal ultrasonography at an annual general health examination. Abdominal computed tomography indicated a subserosal cystic lesion 6 cm in diameter on the posterior wall of the stomach. The cystic lesion was resected through partial resection of the stomach. Histopathology showed that the cyst did not communicate with the gastric lumen, was covered with gastric epithelium and pseudostratified columnar ciliated epithelium with circular muscle layers, and did not contain cartilaginous tissue. Consequently, the patient was diagnosed as having foregut duplication cyst of the stomach. Gastrointestinal duplication can occur in any region of the gastrointestinal tract, but foregut duplication cyst of the stomach is rare. The present case was a subserosal cyst on the greater curvature that did not communicate with the gastric lumen and was covered with gastric epithelium and pseudostratified columnar ciliated epithelium, suggesting a foregut cyst caused by an aberrant respiratory organ.