Lymphoepithelial cyst of the pancreas: a new case report

We report the case of a lymphoepithelial cyst of the pancreas discovered by chance on imaging in a 54-year old man. CT-scan showed a 10 cm hypodense multilocular cystic tumor of the pancreatic isthmus. Fine-needle aspiration did not provide further information. Due to the lack of preoperative diagnosis and mostly because it was not known if the cyst was malignant or benign, the patient underwent a cephalic duodenopancreatectomy. Lymphoepithelial cyst of the pancreas is a rare benign lesion which is difficult to diagnose before surgery. Histologically, the cyst wall is lined by mature keratinizing squamous epithelium and a distinct surrounding lymphoid tissue layer. The cysts are filled with keratin plugs that are not always visualized on imaging. Cytological and histological analysis of fine-needle aspiration material if the sample material is sufficient may help avoid extensive surgery.     

Lympho-epithelial cyst of the pancreas: a difficult diagnosis. About two cases

We report two cases of lymphoepithelial cyst of the pancreas discovered incidentally on imaging in two men aged 50 and 61 years. One cyst contained hyperdense spots on CT-scan and in this case the biochemical analysis of the cyst fluid revealed high level of CEA. The unilocular cysts measured 4 and 5 cm on the surgical specimen. On microscopic examination, the cysts were lined by squamous keratinized epithelium positive for CEA, with rare mucin-secreting cells, lining on lymphoid tissue. The lymphoepithelial cyst is a rare dysembryoplastic benign lesion of the pancreas difficult to diagnose before surgery. The presence of keratin plugs on imaging is inconstant and the biochemical analysis of the cyst fluid can mislead to a diagnosis of mucinous cystic tumour. Cytological and histological analysis of fine needle aspiration material is of diagnostic interest and can avoid surgical resection when patients are symptom-free.     

Lymphoepithelial cyst of the pancreas: report of a case

The aim of this report is to describe the clinical and pathological features of a lympoepithelial cyst of the pancreas and to recommend fine-needle aspiration biopsy for the differential diagnosis of this lesion. A 55-year-old man was incidentally diagnosed as having a pancreatic tumor by abdominal ultrasonography. A hypoechoic cystic lesion was detected on the surface of the pancreatic body. A computed tomography revealed a cystic lesion surrounded by a smooth, flat wall. Magnetic resonance imaging revealed that the lesion was a low-intensity mass on the T1-image and a slightly high-intensity mass on the T2-image. The lesion was diagnosed as a benign cystic tumor, and enucleation of the tumor was scheduled. The fine needle aspiration biopsy was performed after laparotomy, and cytology of the contents was negative for malignant cells. The postoperative pathological diagnosis was a lymphoepithelial cyst of the pancreas. This cyst is an unusual but benign mass that requires minimal surgery.     

Lymphoepithelial cyst of the pancreas. No evidence for Epstein-Barr virus-related pathogenesis.

Compared to pseudocyst formation after prior pancreatitis, true cysts of the pancreas are rare. Pancreatic cysts with irregular wall components or a mucinous content raise the suspicion for the presence of a cystic neoplasm, and surgical resection is recommended. A case of a patient with a history of prostate cancer is described in whom a cyst of the pancreatic tail was discovered incidentally. Based on the radiographic features, which did not support the presence of a serous cystadenoma, a spleen-preserving distal pancreatectomy was performed. Histologic features were characteristic for a lymphoepithelial cyst (LEC) of the pancreas, lined with thinned squamous epithelium surrounded by benign lymphoid tissue. Since LECs of the parotid gland, which are associated with acquired human immunodeficiency, are frequently related to Epstein-Barr virus (EBV) infection, EBV in situ hybridization was performed and did not reveal evidence for EBV. Twenty-eight instances of pancreatic LECs have been reported, primarily affecting adult males, without evidence of increased numbers of EBV-positive cells. The pathogenesis, differential diagnosis, and clinical implications of lymphoepithelial pancreatic cysts are discussed.     

Lymphoepithelial cyst of the pancreas

Summary  Compared to pseudocyst formation after prior pancreatitis, true cysts of the pancreas are rare. Pancreatic cysts with irregular wall components or a mucinous content raise the suspicion for the presence of a cystic neoplasm, and surgical resection is recommended. A case of a patient with a history of prostate cancer is described in whom a cyst of the pancreatic tail was discovered incidentally. Based on the radiographic features, which did not support the presence of a serous cystadenoma, a spleen-preserving distal pancreatectomy was performed. Histologic features were characteristic for a lymphoepithelial cyst (LEC) of the pancreas, lined with thinned squamous epithelium surrounded by benign lymphoid tissue. Since LECs of the parotid gland, which are associated with acquired human immunodeficiency, are frequently related to Epstein-Barr virus (EBV) infection, EBVin situ hybridization was performed and did not reveal evidence for EBV. Twenty-eight instances of pancreatic LECs have been reported, primarily affecting adult males, without evidence of increased numbers of EBV-positive cells. The pathogenesis, differential diagnosis, and clinical implications of lymphoepithelial pancreatic cysts are discussed.     

Lymphoepithelial cyst of the pancreas associated with elevated CA 19-9 levels

An extremely rare case of a lymphoepithelial cyst associated with persistent elevation of serum carbohydrate antigen (CA) 19-9 levels is described. A 72-year-old man was incidentally found to have a cystic tumor in the uncus of the pancreas and to have a high serum CA 19-9 level. At 2-year follow up, the tumor size had gradually increased and the high CA 19-9 level persisted. Because the malignant potential of the tumor could not be ruled out, a laparotomy was performed. The tumor was excised from the pancreas. On pathological examination, the tumor was proven to be a lymphoepithelial cyst. After the operation, the patient’s serum CA 19-9 level decreased to the normal range. Lymphoepithelial cysts of the pancreas are a rare, benign entity. They are true pancreatic cysts, characterized by a mature, keratinizing, squamous lining surrounded by lymphoid tissue. Because the treatment options and the prognosis of these entities are quite different from those of other cystic neoplasms of the pancreas, preoperative differential diagnosis is the main issue. Thus, although they are rare, lymphoepithelial cysts should be considered in the differential diagnosis of cystic tumors of the pancreas.     

Case of lymphoepithelial cyst of the pancreas]

We recently experienced a case of lymphoepithelial cyst of the pancreas, which is a rare benign pancreatic cystic tumor. A 59-year-old-man was pointed out as having a pancreatic tumor based on abdominal ultrasonography findings obtained during a medical check-up. Thereafter, abdominal ultrasonography, CT, and MRI studies revealed the presence of a multi-cystic tumor in the pancreas body to tail measuring 45 mm in size which had no infiltrating tendency. The operative findings showed a yellowish-white colored cystic tumor covered with a thin capsule, which could be easily extirpated from the pancreas. The dissected tumor, which contained a curd-like material and a condensed milky liquid, was diagnosed to be a lymphoepithelial cyst of the pancreas based on the pathological findings. Similar reports of lymphoepithelial cysts arising in the pancreas have recently been increasing.     

Lymphoepithelial cysts of the pancreas: The use of endoscopic ultrasound-guided fine-needle aspiration in diagnosis

Lymphoepithelial cysts (LECs) are rare non-neoplastic lesions that can appear as a complex cyst or a mass in the pancreas. Cytology from endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) can be helpful in making a diagnosis with the aim of avoiding unnecessary surgical resection. A case involving a 51-year-old woman with lower abdominal pain who was found to have a multiloculated cystic lesion at the junction of the pancreatic body and tail is described. Cytology from EUS-FNA was consistent with a pancreatic LEC. The lesion was managed conservatively and follow-up imaging of the cyst over the following two years was unchanged. The patient remains clinically well. Cytology from EUS-FNA can help distinguish LECs from cystic neoplasms, thus preventing radical surgical resection of this benign pancreatic cyst.     

Role of cystic fluid in diagnosis of the pancreatic cystadenoma and cystadenocarcinoma

BACKGROUND/AIMS: Early and accurate diagnosis of cystic neoplasm of the pancreas is difficult especially for the differentiation of benign or malignancy. In this study, we try to compare EUS-guided fine needle aspiration biopsy combined with measurement of the cyst fluid and serum levels of CEA, and CA19-9 for the preoperative diagnosis of pancreatic cystadenoma or cystadenocarcinoma. METHODOLOGY: Retrospective analysis was made on the clinical data of 37 patients with pancreatic cystadenoma and 48 patients with cystadenocarcinoma from 1998 to 2005. RESULTS: Carcinoembryonic antigen (CEA), and CA19-9 of the cyst fluid and serum combined with EUS-guided fine needle aspiration biopsy was made. Examination of serum CEA, and CA19-9 resulted in 21.0+/-18.0, 2.7+/-1.7 U/L and 18.7+/-17.5, 269.0+/-182.0 U/L for cystadenoma and cystadenocarcinoma respectively (P<0.05). The sensitivity of cyst fluid combined with biopsy was higher than that of a single marker. However, the sensitivity and specificity of tumor markers of cystic fluid were much higher than that of the serum (P<0.05). CONCLUSIONS: EUS-guided fine needle aspiration biopsy combined with examination of cyst fluid level of CEA and CA19-9 will be a credible means for early diagnosis of pancreatic cystadenoma and cystadenocarcinoma.     

Lymphoepithelial cysts of the pancreas a management dilemma

Pancreatic lymphoepithelial cysts (LECs) are rare, benign lesions that are typically unexpected post-operative pathological findings. We aimed to review clinical, radiological and pathological features of LECs that may allow their pre-operative diagnosis. Histopathology databases of two large pancreatic units were searched to identify LECs and notes reviewed to determine patient demographic details, mode of presentation, investigations, treatment and outcome. Five male and one female patients were identified. Their median age was 60 years. Lesions were identified on computed tomography performed for abdominal pain in two patients, and were incidentally observed in four patients. Five LECs were located in the tail and one in the body of the pancreas, with a median cyst size of 5 cm. Obtaining cyst fluid was difficult and a largely acellular aspirate was yielded. The pre-operative diagnosis was mucinous cystic neoplasm in all patients. This series of patients were treated distal pancreatectomy and splenectomy. A retrospective review of radiological examinations suggested that LECs have a relatively low signal on T2 imaging and a high signal intensity on T1 weighted images. LECs appear more common in elderly males, and are typically incidental, large, unilocular cysts. Close attention to signal intensity on MRI may allow pre-operative diagnosis of these lesions.     

Endosonography in the diagnosis and management of pancreatic cysts

Rapid advances in radiologic technology and increased cross-sectional imaging have led to a sharp rise in incidental discoveries of pancreatic cystic lesions. These cystic lesions include non-neoplastic cysts with no risk of malignancy, neoplastic non-mucinous serous cystadenomas with little or no risk of malignancy, as well as neoplastic mucinous cysts and solid pseudopapillary neoplasms both with varying riskof malignancy. Accurate diagnosis is imperative as management is guided by symptoms and risk of malignancy. Endoscopic ultrasound(EUS) allows high resolution evaluation of cyst morphology and precise guidance for fine needle aspiration(FNA) of cyst fluid for cytological, chemical and molecular analysis. Initially, clinical evaluation and radiologic imaging, preferably with magnetic resonance imaging of the pancreas and magnetic resonance cholangiopancreatography, are performed. In asymptomatic patients where diagnosis is unclear and malignant risk is indeterminate, EUSFNA should be used to confirm the presence or absence of high-risk features, differentiate mucinous from non-mucinous lesions, and diagnose malignancy. After analyzing the cyst fluid for viscosity, cyst fluid carcinoembryonic antigen, amylase, and cyst wall cytology should be obtained. DNA analysis may add useful information in diagnosing mucinous cysts when the previous studies are indeterminate. New molecular biomarkers are being investigated to improve diagnostic capabilities and management decisions in these challenging cystic lesions. Current guidelines recommend surgical pancreatic resection as the standard of care for symptomatic cysts and those with high-risk features associated with malignancy. EUSguided cyst ablation is a promising minimally invasive, relatively low-risk alternative to both surgery and surveillance.     

Improved early diagnosis of cystadenocarcinoma of the pancreas

IntroductionT here are great differences between the therapy for cystadenocarcinomas and benign pancreatic lesions. Early diagnosis is propitious to selecting the appropriate therapy, and may directly influence the prognosis.[1-4] Differential diagnosis between cystadenocarcinoma and benign pancreatic lesion is difficult, because they lack typical clinical symptoms in early stage. In the commonly used examinations, the specificity of B-ultrasonography (B-US) and CT is very poor; they are di…     

EUS diagnosis of cystic lesions of the pancreas

Summary Background. Cystic tumors of the pancreas are composed of benign, premalignant, malignant, and inflammatory lesions that are traditionally difficult to diagnose. Most of the tumors are initially detected on CT/US scanning, but often the morphological characteristics are insufficient for making a definitive diagnosis. Endoscopic ultrasound (EUS) may be an ideal tool for imaging of these lesions because it can provide highly detailed imaging without interference by bowel or air. Furthermore, EUS can direct fine needle aspiration of the lesions, providing cyst fluid for cytologic examination. The findings of cyst fluid cytology can be complemented by the use of cyst fluid tumor makers such as CEA. Using the morphologic appearance by endosonography, the results of cytology, and tumor marker analysis, EUS can often differentiate between benign, malignant, and inflammatory cystic lesions of the pancreas.     

Pseudocyst or cystic neoplasm? Differential diagnosis and initial management of cystic pancreatic lesions

Owing to advances in pancreatic imaging, cystic lesions of the pancreas are being recognized with increasing frequency. A presumptive diagnosis of "pseudocyst", based upon CT appearance alone, will prove to be in error in as many as one-third of patients. Neoplastic cysts of the pancreas are particularly susceptible to this misdiagnosis, which can result in inappropriate drainage rather than resection. Using a combination of historical features and computed tomography, the differential diagnosis between pseudocyst and cystic neoplasm can usually be made. In borderline patients transcutaneous aspiration for cytology, and analysis of the cyst fluid for neoplastic markers may prove helpful. Final resolution of doubtful cases is achieved by biopsy of the cyst wall.     

Current status on the diagnosis and management of pancreatic cysts in the Asia-Pacific region: role of endoscopic ultrasound

Endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) play increasingly prominent roles in the diagnosis and management of pancreatic cysts. The Asian Consortium of Endoscopic Ultrasound was recently formed to conduct collaborative research in this area. This is a review of literature on true pancreatic cysts. Due to the lack of systematic studies, there are no robust data on the true incidence of pancreatic cystic lesions in Asia and any change in over the recent decades. Certain EUS morphological features have been used to predict particular types of pancreatic cysts. Pancreatic cyst fluid viscosity, cytology, pancreatic enzymes, and tumor markers, in particular carcinoembryonic antigen, can aid in the diagnosis of pancreatic cysts. Hemorrhage and infection are the most common complications of EUS-FNA of pancreatic cysts. Pancreatic cysts can either be observed or resected depending on the benign or malignant nature, or malignant potential of the lesions. Guidelines from an international consensus did not require positive cytological findings to be present in their recommendation for resection, which included all mucinous cystic neoplasms, all main-duct intraductal papillary mucinous neoplasms (IPMN), all mixed IPMN, symptomatic side-branch IPMN, and side-branch IPMN larger than 3 cm. In patients with poor surgical risks, EUS-guided cyst ablation of mucinous pancreatic cysts is an alternative. As long-term prospective data on pancreatic cysts are still not available in Asia, management strategies are largely based on risk stratification by surgical risk and malignant potential. Gene expression profiling of pancreatic cyst fluid and confocal laser endomicroscopic examination of pancreatic cysts are novel techniques currently being studied.     

Cyst fluid glucose: An alternative to carcinoembryonic antigen for pancreatic mucinous cysts

Pancreatic cystic lesions(PCLs) have been increasingly recognized in clinical practice. Although inflammatory cysts(pseudocysts) are the most common PCLs detected by cross-sectional imaging modalities in symptomatic patients in a setting of acute or chronic pancreatitis, incidental pancreatic cysts with no symptoms or history of pancreatitis are usually neoplastic cysts. For these lesions,it is imperative to identify mucinous cysts(intraductal papillary mucinous neoplasms and mucinous cystic neoplasms) due to the risk of their progression to malignancy. However, no single imaging modality alone is sufficient for a definitive diagnosis of all PCLs. The cyst fluid obtained by endoscopic ultrasound-guided fine needle aspiration provides additional information for the differential diagnosis of PCLs. Current recommendations suggest sending cyst fluid for cytology evaluation and measurement of carcinoembryonic antigen(CEA) levels. Unfortunately, the sensitivity of cytology is greatly limited, and cyst fluid CEA has demonstrated insufficient accuracy as a predictor of mucinous cysts. More recently, cyst fluid glucose has emerged as an alternative to CEA for distinguishing between mucinous and nonmucinous lesions. Herein, the clinical utility of cyst fluid glucose and CEA for the differential diagnosis of PCLs was evaluated.     

Clinical and radiological feature of lymphoepithelial cyst of the pancreas

A lymphoepithelial cyst(LEC)of the pancreas is a rare benign lesion.Because patients with LEC of the pancreas have a good prognosis,it is important that these lesions are accurately differentiated from other more aggressive pancreatic neoplasms for an appropriate treatment strategy.Previous studies have reported that a definitive diagnosis of LEC often cannot be obtained based solely on the findings of preoperative imaging(e.g.,Computed tomography or Magnetic resonance imaging).In this study,we reviewed four cases of pancreatic LECs to investigate the feature of LECs.We reviewed these cases with regard to symptoms,imaging findings,surgical procedures,and other clinical factors.We found that LEC was associated with unique characteristics on imaging findings.A preoperative diagnosisof LEC may be possible by comprehensively evaluating its clinical and imaging findings.     

Macrocystic form of serous pancreatic cystadenoma

OBJECTIVES: Macrocystic serous cystadenoma of the pancreas are benign lesions with sometimes difficult diagnostic issues. We aimed to describe clinicopathological and imaging features with cyst fluid analysis in a series of patients undergoing surgery for macrocystic serous cystadenoma. METHODS: Eight patients underwent pancreatic resection for a macrocystic lesion of the pancreas diagnosed on ultrasonography or CT. Endoscopic ultrasonography and preoperative fine-needle aspiration were performed in seven patients. Immunohistochemical analysis of the surgical specimen with antibodies to carcinoembryonic-antigen (CEA), carbohydrate antigen (CA) 19-9, estrogen receptor, and progesterone receptor antibodies was performed in all cases. RESULTS: Patients included seven women and one man, with a mean age of 48 yr. Lesions were incidentally discovered on ultrasonography in six patients and had a mean size of 3 cm (range, 1.5-5 cm). Endoscopic ultrasonography revealed millimetric cysts in three cases. In the seven aspirated cysts, cytological analysis was non-contributive, but biochemical analysis showed low content of CEA (< 5 ng/ml) and CA72.4 (< 40U/ml) in all but two. At histology, cysts were lined by clear cuboidal cells. They focally expressed CA19-9 but were negative for anti-CEA, antiestrogen receptor, and antiprogesterone receptor antibodies. Microscopic cysts in the wall of the lesions were demonstrated in five cases. CONCLUSIONS: Macrocystic serous cystadenoma is a particular variant of pancreatic serous cystadenoma. Endoscopic ultrasonography may be useful in detecting peripherally located millimetric cysts in unilocular lesions, and measurement of enzymes and tumor markers in cyst fluid may also contribute to the diagnosis showing low concentrations.     

Lymphoepithelial cyst of the pancreas]

A 66-year-old woman presented with abdominal pain and weight loss. Ultrasonography and computed tomography demonstrated a cystic lesion of the pancreas. After surgical resection, the patient's symptoms disappeared. Microscopic examination of the cyst lining showed mature, keratinizing squamous epithelium, surrounded by lymphoid tissue. Only three cases of this type of lesion, called "lymphoepithelial cyst", have been described previously. Histogenesis of this particular type of cyst is not well know, but can be histologically differentiated from other pancreatic cysts.     

EUS-guided fine needle aspiration of pancreatic cysts: a retrospective analysis of complications and their predictors.

BACKGROUND AND AIMS: Endoscopic ultrasound-guided fine-needle aspiration (EUS FNA) of pancreatic cysts is considered safe, however, data are conflicting regarding complication rates. The aim of this study was to determine the complication rate of EUS-guided pancreatic cyst aspiration and predictors of these complications. METHODS: Results of pancreatic cyst EUS FNA at 2 academic institutions from March 1996 to October 2003 were reviewed. A total of 603 patients with 651 pancreatic cysts were evaluated. Complications were identified from clinic, emergency department, and discharge notes, and laboratory and radiologic data. Data collected were as follows: cyst size, location, septations, diagnosis, number of passes, needle size, status as inpatient or outpatient, performance of same-day endoscopic retrograde cholangiopancreatography (ERCP), and use of prophylactic antibiotics. RESULTS: Complications were identified in 13 patients (2.2%, 13 of 603): 6 patients had pancreatitis, 4 patients had abdominal pain, 1 patient had a retroperitoneal bleed, 1 patient had an infection, and 1 patient had bradycardia. Twelve patients required hospitalization, with an average length of stay of 3.8 +/- 1.1 days. Type of cyst, size, presence of septations or mass, and same-day ERCP were not predictors of complications. CONCLUSIONS: EUS-guided pancreatic cyst aspiration carries a low complication rate similar to that reported for solid pancreatic lesions. No patient or cyst characteristics appear to be predictive of adverse events.