Lymphoepithelial cyst of the pancreas

A case of lymphoepithelial cyst (LEC) of the pancreas is presented. A 48-year-old man complaining of general fatigue was found to have a heterogeneous water-dense mass protruding from the surface of the pancreas on plain computed tomography (CT). Dynamic CT disclosed septa within the mass. Magnetic resonance imaging (MRI) showed a hypoiintense mass on T1-weighted imaging, and a hyperintense mass on T2-weighted imaging. MRI with gadolinium enhancement revealed septa within the mass. Endoscopic ultrasonography showed septa and fine echogenic structures within the cystic echoic lesion. Endoscopic retrograde pancreatecraphy showed a normal duct system. Distal pancreatectomy with splenectomy was performed, with a suspected diagnosis of cystic neoplasms of the pancreas. Histopathologic examination disclosed LEC of the pancreas. Our case suggests that LEC should be considered in the differential diagnosis of cystic neoplasms of the pancreas.     

Lymphoepithelial cyst of the pancreas

We experienced a rare case of lymphoepithelial cyst of pancreas. The patient was a 68-year-old man in whom a cystic lesion in the pancreas was detected when he was admitted for chronic renal failure. On ultrasonography, we detected a cystic lesion, 3 cm in diameter, with a septum, in head and body of the pancreas. On both computed tomography and magnetic resonance imaging, the cystic lesion did not show solid components. Endoscopic retrograde cholangiopancreatography showed no abnormality in the pancreatic duct and did not detect the cystic lesion. Although the lesion showed no evidence of malignancy on the images, we could not rule out malignancy, since high levels of carcinoembryonic antigen and carbohydrate antigen 19-9 were detected. We therefore performed a pancreatoduodenectomy. In the resected specimen, the lesion was a well-circumscribed and multilocular cyst that contained yellowish-white keratinous material and had no solid components. Histologically, the cyst wall was composed of mature keratinizing squamous epithelium and lymphoid tissue; it was diagnosed as a benign lymphoepithelial cyst of the pancreas.     

Lymphoepithelial cyst in the pancreas: A case report

A case of lymphoepithelial cyst in the pancreas was reported. A 64-year-old man without any specific compalints was found to have a cystic lesion in the anterior portion of the pancreas, as revealed by ultrasonography of the abdomen at an annual medical examination in 1988. This was dissected easily from the pancreas. Histologically, it was diagnosed to be a benign lymphoepithelial cyst in the pancreas. Cysts of this type are rare, and their histogenesis is also not well understood.     

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.     

Biliary cystadenoma of the liver with elevated CA 19-9

ABSTRACT: A case of intrahepatic biliary cystadenoma with mesenchymal stroma is reported. The tumor was associated with strikingly elevated serum and intracystic levels of the tumor-associated antigen CA19-9. Two months after surgical enucleation, serum CA 19-9 levels returned to normal.     

Extrapancreatic lymphoepithelial cyst of the pancreas

A lymphoepithelial cyst is reported. A 68-year-old man consulted a surgeon, presenting with a sense of abdominal fullness. Ultrasonography and computed tomography revealed a large tumor, 10 cm in diameter, behind the head of the pancreas. Celiac arteriography at our hospital showed feeding arteries from the dorsal pancreatic artery and the pancreatic arcades. CA19-9 was elevated to 178 U/ml. Laparotomy was performed. The tumor was well demarcated from the surrounding tissue by a fibrous capsule and there was no continuity to the pancreatic parenchyma. Simple tumorectomy and distal gastrectomy for peptic gastric ulcer disease were performed. The cut surface revealed a multicystic lesion containing atheromatous substances. Histopathologically, the internal surface of the cyst was lined with stratified squamous epithelium containing mucin-producing cells; many germinal centers were observed in the cyst wall.     

Lymphoepithelial cyst of the pancreas with sebaceous differentiation

We recently encountered a patient with a lymphoepithelial cyst of the pancreas with sebaceous differentiation. We sought to compare the characteristics of this patient with those previously reported in order to foster a keener understanding of this rare clinical entity. After reviewing the present patient's case in detail, we conducted a comprehensive review of the English-language literature and analyzed the clinical characteristics of reported cases of lymphoepithelial cysts. Our patient was an asymptomatic 60-year-old man who presented with an incidental finding of a cystic lesion in the tail of the pancreas documented by computed tomography. The cyst was enucleated, and was found to contain keratinized material. It was lined by squamous epithelium with small sebaceous glands, and surrounded by lymphoid tissue with germinal centers. Of 33 reported cases, only 6 (18%) contained sebaceous glands. In all patients who underwent operation, the cysts were easily resected, and the outcome was favorable. Lymphoepithelial cyst of the pancreas is rare, and may be difficult to differentiate from cystic neoplasms preoperatively. Therefore resection is indicated. The diagnosis, however, can be confirmed by careful histologic review, and the prognosis is excellent. Received: March 8, 1999 / Accepted: October 22, 1999     

Epidermoid cyst of the intrapancreatic accessory spleen producing CA19‐9

We report a rare case of an epidermoid cyst in an accessory spleen at the pancreatic tail with producing CA19‐9. A 55‐year‐old female was admitted to our hospital, Cancer Research Institute, Kanazawa University, for close examination of a cystic lesion at the pancreatic tail and a high serum CA19‐9‐value (176 U/mL). There were almost no abdominal symptoms related to the cystic lesion. A cystic tumor approximately 3 cm in diameter and composed of multilocular cysts without a protruding portion of the inner surface was found at the pancreatic tail by ultrasound sonography, computed tomography, and magnetic resonance imaging. Endoscopic retrograde pancreatography revealed that the main pancreatic duct shifted at the pancreatic tail and there was no communication between the main pancreatic duct and cystic lesion. Based on a preoperative diagnosis of mucinous cystic tumor, distal pancreatectomy with splenectomy was performed. Histological ?ndings suggested an epidermoid cyst (3.5 × 3.0 cm) originating from an intrapancreatic accessory spleen. Immunohistochemical analysis of CA19‐9 in the epidermoid cyst showed clear staining of the inner epithelium of the cyst and amorphous or hyalinous cystic contents. The serum CA19‐9 value was con?rmed to decline to normal 2 months after resection. Physicians should not forget this disease during differential diagnosis related to pancreatic cystic lesions with elevated levels of serum tumor markers, such as CA19‐9 or carcinoembryonic antigen, although this disease is extremely rare.     

胆总管结石对血清CA19-9的影响

目的:探讨胆总管结石对血清CEA、CA19-9的影响.方法:回顾经ERCP或手术证实、治疗的胆总管结石患者68例,分析血清CEA,特别是血清CA19-9与胆总管结石患者总胆红素、直接胆红素的相关性:并对20例血清CA19-9值超过正常上限两倍以上的患者统一时间进行随访,分析治疗前后血清CA19-9变化值与总胆红素、直接胆红素变化值的相关性.结果:血清CA19-9与总胆红素、直接胆红素存在明显相关性(r=0.813,0.786,均P=0.000);血清CEA与总胆红素、直接胆红素不存在相关性;治疗前后血清CA19-9变化值与总胆红素、直接胆红素变化值存在明显相关性(r=0.787,0.806,均P=0.000).结论:胆总管结石合并阻塞性黄疸时,可导致血清CA19-9升高,此时血清CA19-9作为肿瘤标志物的特异性差.     

胆胰疾病CA19-9升高相关因素及其临床价值研究

目的研究影响胆胰疾病CA19-9水平的因素,评价CA19-9升高在鉴别诊断消化道良恶性疾病中的临床价值。方法回顾性分析2003—2009年北京大学人民医院201例胆胰疾病(73例胰腺癌、45例胆管癌、83例胆总管结石),分析胆总管结石患者的CA19-9水平和胆汁淤积以及胆管炎症相关指标的相关性。分析胰腺癌、胆管癌患者CA19-9水平和肿瘤分期及分化程度的相关性。绘制胰腺癌、胆管癌CA19-9的ROC曲线。结果CA19-9升高组胆总管结石患者胆汁淤积以及胆管炎症相关指标均较CA19-9正常组高(P值均0.05),患者的CA19-9水平与上述指标呈正相关(P值均0.05)。胰腺癌患者的CA19-9水平与年龄和肿瘤分期呈正相关(P值均0.05)。CA19-9诊断胰腺癌的灵敏度(临界值为37kU/L)86.30%,特异度42.16%,据ROC曲线当临界值为42kU/L时灵敏度为86.30%,特异度为53.06%。CA19-9临界值为37kU/L诊断胆管癌的灵敏度95.56%,特异度42.16%,根据ROC曲线当临界值为63.14kU/L时,灵敏度95.56%,特异度60.24%。结论胆总管结石患者的CA19-9非特异性升高水平与胆汁淤积以及胆管炎症相关指标呈正相关。胰腺癌患者的CA19-9水平和肿瘤分期呈正相关。以CA19-9临界值为37kU/L诊断胰腺癌和胆管癌灵敏度较高,但是鉴别良恶性疾病的特异性不理想,提高临界值可以提高特异度。     

Dilemma of elevated CA 19-9 in biliary pathology

Carbohydrate antigen 19-9 (CA 19-9) is a tumor marker which has been extensively evaluated and widely utilized primarily in diagnosing and prognosticating pancreaticobiliary malignancies. Levels may be significantly influenced and elevated in cases of benign biliary conditions however, especially in obstructive jaundice, thereby posing difficulty in distinguishing between benign and malignant cholestasis. A myriad of studies have focused on elucidating proper use and interpretation of CA 19-9 in pancreatic cancer as well as in the setting of cholestasis. These studies have demonstrated that many factors influence CA 19-9 values and various methods for interpreting CA 19-9 in obstructive jaundice have been proposed. With improvements in diagnostic imaging, advancements in endoscopic modalities, and likelihood that management will not change based on the results of the test, clinicians should be cautious when ordering CA 19-9 and consider the reasons for measuring the tumor marker.     

Lymphoepithelial cyst of the pancreas

Summary Conclusion Lymphoepithelial cyst of the pancreas (LC) is a very rare benign lesion and preoperative diagnosis is difficult. Conservative surgery seems to be the appropriate therapy in symptomatic patients or when a precise preoperative diagnosis is not achieved. The benign behavior of all reported cases suggests that the asymptomatic patients with a certain morphological preoperative diagnosis might be clinically followed up. The histogenesis of LC remains to be elucidated. Background LC of the pancreas is a cyst that is histologically characterized by a fibrous tissue, a lymphoid component and a lining squamous epithelium. Methods Clinical and pathological findings of two personal cases are reported with review of the literature. Results A 56-yr-old man, complaining of epigastric pain, and a 47-yr-old man, with a history of alcohol abuse, were admitted to hospital. In both cases the lesion was detected with abdominal ultrasound but a certain diagnosis was obtained only after histological examination of the resected cysts.     

Intra-abdominal sequestration of the lung and elevated serum levels of CA 19-9: a diagnostic pitfall

Background

Extralobar pulmonary sequestration is an uncommon congenital abnormality that is rarely diagnosed after the age of 40 years. We describe a 64-year-old woman with an intra-abdominal sequestration of the lung and elevated carbohydrate antigen (CA) 19-9 serum levels.

Case outline

On abdominal ultrasound a semi-solid cystic tumour was demonstrated that showed tight connection to the tail of the pancreas according to computed tomography. Cytological examination of the percutaneous biopsy did not lead to a definitive diagnosis. CA 19-9 serum levels were repeatedly elevated >250 IU/ml. With a tentative diagnosis of a tumour of the tail of pancreas the semi-solid cystic mass was resected. Frozen section histology suggested the diagnosis of pulmonary sequestration, which was confirmed by definitive histological examination. Immunohistochemical staining of the specimen with a specific monoclonal antibody against CA 19-9 showed strong immunoreactivity. Three months later the elevated CA 19-9 serum levels returned to normal.

Discussion

Elevated CA 19-9 serum levels have been described in benign pulmonary and mediastinal cystic lesions and in one case of extralobar intrathoracic lung sequestration. Although there is evidence that malignancies may arise in congenital lung cysts, CA 19-9 serum levels have not been investigated in such cases. Based on our results elevated serum values of CA 19-9 in combination with a cystic semi-solid mass in the left subphrenic space should include the differential diagnosis of extralobar pulmonary sequestration.     

Type 2 diabetes mellitus and CA 19-9 levels

AIM： To prospectively investigate serum CA 19-9 levels in type 2 diabetic patients in comparison with age and gender-matched control subjects.
METHODS： We recorded duration of diabetes and examined fasting glucose levels, HbAlc levels and serum CA 19-9 levels in 76 type 2 diabetic patients and 76 controls. Abdominal CT was performed in order to eliminate abdominal malignancy in the diabetic and control groups.
RESULTS： The average CA 19-9 level was 46.0 ± 22.4 U/mL for diabetic patients whereas it was 9.97± 7.1 U/mL for the control group （P 〈 0.001 ）. Regression analysis showed a positive correlation between diabetes and CA 19-9 independent from age, gender, glucose level and HbAlc level （t = 8.8, P 〈 001 ）. Two of the diabetic patients were excluded from the study because of abdominal malignancy shown by CT at the initial evaluation. For all patients, abdominal CT showed no pancreatic abnormalities.
CONCLUSION： CA 19-9 is a tumor-associated antigen, which is elevated in pancreatic, upper gastrointestinal tract, ovarian hepatocellular, and colorectal cancers, as well as in inflammatory conditions of the hepatobiliary system, biliary obstruction and in thyroid diseases. Diabetes has been claimed to be a risk factor for pancreatic cancer, which is increasing its incidence and has one of the lowest survival rates of all cancers. CA 19-9 is used in the diagnosis of pancreatic cancer but is also a marker of pancreatic tissue damage that might be caused by diabetes. We propose that a higher cutoff value of CA 19-9 should be used in diabetics to differentiate benign and malignant pancreatic disease, and subtle elevations of CA 19-9 in diabetics should be considered as the indication of exocrine pancreatic dysfunction.     

Type 2 diabetes mellitus and CA 19-9 levels

AIM: To prospectively investigate serum CA 19-9 levels in type 2 diabetic patients in comparison with age- and gender-matched control subjects. METHODS: We recorded duration of diabetes and examined fasting glucose levels, HbA1c levels and serum CA 19-9 levels in 76 type 2 diabetic patients and 76 controls. Abdominal CT was performed in order to eliminate abdominal malignancy in the diabetic and control groups. RESULTS: The average CA 19-9 level was 46.0 ± 22.4 U/mL for diabetic patients whereas it was 9.97 ± 7.1 U/mL for the control group (P ＜ 0.001 ). Regression analysis showed a positive correlation between diabetes and CA 19-9 independent from age, gender, glucose level and HbA1c level (t = 8.8, P ＜ 001 ). Two of the diabetic patients were excluded from the study because of abdominal malignancy shown by CT at the initial evaluation. For all patients, abdominal CT showed no pancreatic abnormalities. CONCLUSION: CA 19-9 is a tumor-associated antigen, which is elevated in pancreatic, upper gastrointestinal tract, ovarian hepatocellular, and colorectal cancers, as well as in inflammatory conditions of the hepatobiliary system, biliary obstruction and in thyroid diseases. Diabetes has been claimed to be a risk factor for pancreatic cancer, which is increasing its incidence and has one of the lowest survival rates of all cancers. CA 19-9 is used in the diagnosis of pancreatic cancer but is also a marker of pancreatic tissue damage that might be caused by diabetes. We propose that a higher cutoff value of CA 19-9 should be used in diabetics to differentiate benign and malignant pancreatic disease, and subtle elevations of CA 19-9 in diabetics should be considered as the indication of exocrine pancreatic dysfunction.     

An elevated CA 19-9 is associated with invasive cancer and worse survival in IPMN

BackgroundCurrent guidelines for IPMN include an elevated serum carbohydrate antigen (CA) 19-9 among the worrisome features. However, the correlation of CA 19-9 with histological malignant features and survival is unclear. Serum CEA is also currently used for preoperative management of IPMN, although its measurement is not evidence-based. Accordingly, we aimed to assess the role of these tumor markers as predictors of malignancy in IPMN.MethodsIPMN resected between 1998 and 2018 at Massachusetts General Hospital were analyzed. Clinical, pathological and survival data were collected and compared to preoperative levels of CA 19-9 and CEA. Receiver operating characteristic (ROC) and Cox regression analyses were performed considering cut-offs of 37 U/ml (CA 19-9) and 5 μg/l (CEA).ResultsAnalysis of 594 patients showed that preoperative CA 19-9 levels > 37 U/ml (n = 128) were associated with an increased likelihood of invasive carcinoma when compared to normal levels (45.3% vs. 18.0%, P < 0.001), while there was no difference with respect to high-grade dysplasia (32.9% vs 31.9%, P = 0.88). The proportion of concurrent pancreatic cancer was higher in patients with CA 19-9 > 37 U/ml (17.2% vs 4.9%, P < 0.001). An elevated CA 19-9 was also associated with worse overall and disease-free survival (HR = 1.943, P = 0.007 and HR = 2.484, P < 0.001 respectively). CEA levels did not correlate with malignancy.ConclusionIn patients with IPMN, serum CA19-9 > 37 U/ml is associated with invasive IPMN and concurrent pancreatic cancer as well as worse survival, but not with high-grade dysplasia. Serum CEA appears to have minimal utility in the management of these patients.     

Multicystic biliary hamartoma with extremely elevated CA19-9: a case report

Multicystic biliary hamartoma (MCBH) is a rare cystic disease of the liver. We herein report a case of MCBH associated with extremely elevated levels of serum carbohydrate antigen (CA) 19-9. A 53-year-old man was referred to our hospital because of extremely elevated CA19-9 levels (more than 12,000?U/mL). Enhanced abdominal computed tomography and magnetic resonance imaging (MRI) revealed a multicystic tumor with a calcified wall in the left lobe of the liver, although no apparent intracystic nodule was detected. Because of the possibility of a malignant tumor, such as intraductal papillary neoplasm of the bile duct or cystadenocarcinoma, the patient underwent left hepatectomy. Based on the postoperative pathological findings, the lesion was diagnosed as MCBH. The serum CA19-9 level drastically decreased after surgery. We encountered a rare case of MCBH with extremely elevated CA19-9 levels.     

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.     

Extremely Elevated CA19-9 in Acute Cholangitis

A 68-year-old women was admitted with the chief complaints of epigastralgia with radiation to the back and jaundice. Fever and chills were also noted. The laboratory data showed alkaline phosphatase, 245 U/L (normal range: 28–94); Direct Bilirubin, 5.29 mg% (0–0.4); Total Bilirubin, 8.4 mg% (0.2–1.4). Surprisingly, the serum CA19-9 was 5673.8 U/ml (normal value: <37). Abdominal sonography showed dilated common hepatic duct. MRCP demonstrated diffuse biliary tree dilatation with a very low signal intensity in distal common bile duct. Surgical intervention reveled a black stone at distal common bile duct and was successfully retrieved. After operation, the CA19-9 fell to 63.1 u/ml two weeks later and returned to normal (10.4 U/ml) one month later.