Endoscopic ultrasound characteristics of pancreatic lymphoepithelial cysts: A case series from a large referral center.

BACKGROUND AND OBJECTIVES: Lymphoepithelial cysts (LECs) of the pancreas are benign lesions that can mimic cystic neoplasms on imaging. Endoscopic ultrasound (EUS) features have not been well described. We aimed to describe the clinical and EUS characteristics of LECs and the present outcomes of management at a high-volume referral center. MATERIALS AND METHODS: We identified patients who underwent EUS and were found to have LECs based on fine-needle aspiration (FNA) cytology or surgical pathology from existing databases. EUS features, imaging characteristics, and pathology results were described. RESULTS: Sixteen patients were found to have 17 LECs. The mean size was 33 mm ± 15 mm. Locations within the pancreas included 10 lesions in the tail, 3 in the body, 1 in the uncinate process; the remaining 3 were exophytic. Six lesions were anechoic, 6 were hypoechoic, and 5 had mixed echogenicity. Nine lesions had mixed solid/cystic components, 7 were purely cystic, and 1 was solid. Cyst fluid was thick or viscous in six cases and thin in three. Eleven patients had diagnostic cytopathology. Six patients ultimately underwent surgery due to symptoms, nondiagnostic FNA, or other clinical concerns for malignancy. CONCLUSIONS: Pancreatic LECs have variable morphology and echogenicity on EUS, but the appearance of a cyst with variable solid and cystic components combined with the appearance of thick, turbid, and viscous aspirate should raise suspicion for an LEC. The majority of patients with LECs at our center avoided surgery for LECs on the basis of diagnostic EUS-FNA

Two cases of lymphoepithelial cyst of the pancreas

A 35-year-old man was found to have a cystic mass in the pancreatic body on a routine health examination ; high serum CA19-9 was also detected. The enucleated cyst was diagnosed as a lymphoepithelial cyst (LEC). A 74-year-old man found to have a cystic mass in the pancreatic head by computer tomography as well as high serum CA19-9 was suspected of a cystic neoplasm of the pancreas (IPMN), and pylorus-preserving pancreaticoduodenectomy (PPPD) was performed. Pathologically, the cyst was found to be LEC. It is often difficult to diagnose pancreatic cyst as LEC preoperatively. Care should be taken not to do over-surgery for benign disease LEC

Two cases of lymphoepithelial cyst of the pancreas

A 35-year-old man was found to have a cystic mass in the pancreatic body on a routine health examination ; high serum CA19-9 was also detected. The enucleated cyst was diagnosed as a lymphoepithelial cyst (LEC). A 74-year-old man found to have a cystic mass in the pancreatic head by computer tomography as well as high serum CA19-9 was suspected of a cystic neoplasm of the pancreas (IPMN), and pylorus-preserving pancreaticoduodenectomy (PPPD) was performed. Pathologically, the cyst was found to be LEC. It is often difficult to diagnose pancreatic cyst as LEC preoperatively. Care should be taken not to do over-surgery for benign disease LEC

Comparison of the diagnostic accuracy of three current guidelines for the evaluation of asymptomatic pancreatic cystic neoplasms.

Asymptomatic pancreatic cysts are a common clinical problem but only a minority of these cases progress to cancer. Our aim was to compare the accuracy to detect malignancy of the 2015 American Gastroenterological Association (AGA), the 2012 International Consensus/Fukuoka (Fukuoka guidelines [FG]), and the 2010 American College of Radiology (ACR) guidelines.We conducted a retrospective study at 3 referral centers for all patients who underwent resection for an asymptomatic pancreatic cyst between January 2008 and December 2013. We compared the accuracy of 3 guidelines in predicting high-grade dysplasia (HGD) or cancer in resected cysts. We performed logistic regression analyses to examine the association between cyst features and risk of HGD or cancer.A total of 269 patients met inclusion criteria. A total of 228 (84.8%) had a benign diagnosis or low-grade dysplasia on surgical pathology, and 41 patients (15.2%) had either HGD (n = 14) or invasive cancer (n = 27). Of the 41 patients with HGD or cancer on resection, only 3 patients would have met the AGA guideline\u27s indications for resection based on the preoperative cyst characteristics, whereas 30/41 patients would have met the FG criteria for resection and 22/41 patients met the ACR criteria. The sensitivity, specificity, positive predictive value, negative predictive value of HGD, and/or cancer of the AGA guidelines were 7.3%, 88.2%, 10%, and 84.1%, compared to 73.2%, 45.6%, 19.5%, and 90.4% for the FG and 53.7%, 61%, 19.8%, and 88% for the ACR guidelines. In multivariable analysis, cyst size \u3e3 cm, compared to ≤3 cm, (odds ratio [OR] = 2.08, 95% confidence interval [CI] = 1.11, 4.2) and each year increase in age (OR = 1.07, 95% CI = 1.03, 1.11) were positively associated with risk of HGD or cancer on resection.In patients with asymptomatic branch duct-intraductal papillary mucinous neoplasms or mucinous cystic neoplasms who underwent resection, the prevalence rate of HGD or cancer was 15.2%. Using the 2015 AGA criteria for resection would have missed 92.6% of patients with HGD or cancer. The more inclusive FG and ACR had a higher sensitivity for HGD or cancer but lower specificity. Given the current deficiencies of these guidelines, it will be important to determine the acceptable rate of false-positives in order to prevent a single true-positive

Differentiation of mucinous from non-mucinous pancreatic cyst fluid using dual-stained, 1 dimensional polyacrylamide gel electrophoresis

BACKGROUND: Pancreatic cysts are being increasingly identified in patients. Mucinous cysts have malignant potential whereas non-mucinous cysts do not. Distinguishing potentially malignant cysts from harmless ones by the characterization of cyst fluid contents remains a difficult problem. This study was undertaken to determine whether cyst fluid mucin glycoprotein analysis could differentiate mucinous from non-mucinous pancreatic cysts. METHODS: Cyst fluid from 28 patients who underwent resection of a pancreatic cyst was used for the study. In each case the type of cyst was histologically identified. One dimensional SDS polyacrylamide gel electrophoresis (1D-SDS PAGE) was performed on cyst fluid samples. For the detection of the separated proteins, we employed a novel dual staining technique. The gel was first stained with periodic acid Schiff (PAS), a mucin histochemical stain followed by a secondary protein staining with Simply Blue Safestain (Invitrogen). RESULTS: Visual scoring (based on the presence of mucins) gave a sensitivity of 95%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 88% for prediction of mucinous histology. CONCLUSIONS: One dimensional SDS polyacrylamide gel electrophoresis of pancreatic cyst fluid, followed by mucin (PAS) and protein (Simply Blue Safestain) staining, provides a means of concentrating and visualizing mucins, which allows the accurate differentiation of mucinous from non-mucinous histology in pancreatic cysts

Juvenile parotitis

In parotitis, one or both of the parotid glands swell, causing pain while eating, reduced mouth opening, and in some cases fever. Before the vaccination era, mumps was the commonest cause of childhood parotitis. Nowadays acute pediatric parotitis is rare, and the causative agent(s) are not fully known. It is assumed that other viruses in addition to mumps virus are capable of causing similar symptoms. Some children develop recurrent symptoms i.e. juvenile recurrent parotitis (JRP). If symptoms are frequent, this condition can be quite life-disruptive. Fortunately, JRP often resolves in puberty. The etiology and pathophysiology of this juvenile recurrent parotid inflammation are other aspects currently not completely understood. The aim of the present study was to assess the epidemiology, etiology, clinical picture, and outcome for pediatric parotitis at present. In addition, it addresses differential diagnosis and complications. A group of 41 children aged ≤17 with acute parotid inflammation was collected prospectively for this study that reported clinical characteristics, treatment, outcome and complications. Another group of 133 children was collected retrospectively with the clinical picture of their disease reported, as well. The serine protease inhibitor Kazal-type 1 (SPINK-1) genotype was tested in 88 parotitis patients, since mutation of this gene disposes to pancreatitis, and salivary glands bear some resemblance to the pancreas in function. To map the etiology of parotitis, a questionnaire about history of parotitis, and parotid gland -related symptoms went to 1,000 adolescents randomly selected. In addition, human herpes viruses (HHVs) from saliva samples of children with acute parotid inflammation, and from healthy controls were tested. To assess the differential diagnosis and complications of parotitis, the database of Helsinki University Central Hospital, Department of Otorhinolaryngology - Head and Neck Surgery, was searched according to ICD-10 codes in order to find all children diagnosed and treated due to osteomyelitis or parotid abscess. All prospectively studied children with acute parotitis were in good general condition, and most episodes of parotitis in childhood seem to have a benign course. Half these children were treated only with non-steroidal anti-inflammatory drugs. However, parotid symptoms have a tendency to recur in about half the cases. About 1% of the respondents to the epidemiologic survey had suffered from parotitis. Heredity similar to pancreatitis could not be shown, since no difference emerged in SPINK-1 genotype in children with parotitis compared to controls. HHVs seem to play no role in acute juvenile parotitis, but are instead common findings in saliva. Osteomyelitis of the head and neck region is rare, but important in differential diagnosis of children with recurrent parotid symptoms. Parotitis-related complications are rare. Parotid abscesses are multi-bacterial infections with intravenous antibiotic therapy being the cornerstone of treatment. Surgical drainage assists in recovery and does not lead to fistula formation. In conclusion, according to this study juvenile parotitis has a frequency close to 1%, it has a tendency to recur, and in most cases the overall condition of the child is good during the infection. Osteomyelitis as a differential diagnosis must be kept in mind when treating recurrent symptoms of the parotid area. Abscesses related to parotitis are rare. The full etiology of juvenile parotitis still remains to be discovered.Korvasylkirauhastulehduksessa poski on kipeä ja turvonnut. Suun aukaiseminen on usein rajoittunutta ja syöminen pahentaa kipua. Tautiin voi liittyä kuumetta. Ennen kattavia kansallisia rokotuksia sikotauti oli yleinen ja tavallisin korvasylkirauhastulehduksen aiheuttaja. Nykyään lasten korvasylkirauhastulehdukset ovat harvinaisia eikä kaikkia taudinaiheuttajia tunneta. Sikotautiviruksen lisäksi myös muut virukset voivat aiheuttaa korvasylkirauhastulehduksen. Osa lapsista kärsii toistuvasta korvasylkirauhastulehduksesta, jonka oireet helpottavat tai häviävät yleensä murrosiässä. Myöskään toistuvan korvasylkirauhastulehduksen etiologiaa tai patofysiologiaa ei tällä hetkellä tunneta tarkasti. Tämän väitöskirjatyön tarkoituksena oli selvittää lasten korvasylkirauhastulehdusten epidemiologiaa, etiologiaa, taudin kuvaa ja hoitoa. Lisäksi tutkittiin erotusdiagnostiikkaa ja komplikaatioita. Prospektiivinen tutkimusryhmä koostui 41 korvasylkirauhastulehdusta sairastavasta alle 17-vuotiaasta lapsesta. Taudinkuva, hoito ja komplikaatiot selvitettiin. Toinen tutkimusryhmä koostui 133 retrospektiivisesti kerätystä lapsesta, joiden taudinkuva ja hoito rekisteröitiin. Seriiniproteaasin estäjä Kazal tyyppi 1:n (SPINK-1) genotyyppi testattiin 88 lapselta, koska tiedetään, että tämän geenin mutaatiot altistavat haimatulehduksille. Sylkirauhasten ja haiman toiminnassa on paljon samankaltaista. Epidemiologian selvittämiseksi tuhannelle satunnaisesti valitulle nuorelle lähetettiin kysely sairastetuista korvasylkirauhastulehduksista ja muista mahdollisista korvasylkirauhasoireista. Lisäksi korvasylkirauhastulehdusta sairastavien lasten, verrokkilasten ja terveiden aikuisverrokkien syljestä testattiin herpesviruksia osana etiologisia selvittelyjä. Helsingin yliopistollisen keskussairaalan Silmä-korvasairaalan potilastietokannasta etsittiin kaikki lapset ja nuoret, jotka olivat olleet hoidossa pään ja kaulan alueen luutulehduksen tai korvasylkirauhaspaiseen vuoksi. Pään ja kaulan alueen luutulehduksen ja korvasylkirauhastulehduksen oireet voivat muistuttaa toisiaan, ja paise on korvasylkirauhastulehduksen harvinainen komplikaatio. Kaikkien 41 prospektiivisesti tutkitun lapsen yleistila oli korvasylkirauhastulehduksen aikana hyvä. Suurin osa lasten tulehduksista parantui hyvin, vaikka noin puolet lapsista hoidettiin pelkällä tulehduskipulääkityksellä. Noin puolella lapsista korvasylkirauhastulehdus uusi. Noin joka sadannella kyselytutkimukseen osallistuneesta lapsesta oli ollut korvasylkirauhastulehdus. Tässä tutkimuksessa ei pystytty osoittamaan korvasylkirauhastulehduksissa samanlaista SPINK-1 genotyyppiin liittyvää perinnöllisyyttä kuin haimatulehduksissa. Herpesvirukset olivat yleisiä kaikkien testiryhmien syljessä, eikä yhteyttä äkilliseen korvasylkirauhastulehdukseen löydetty. Pään ja kaulan alueen luutulehdus on harvinainen, mutta tärkeä erotusdiagnostinen vaihtoehto. Korvasylkirauhastulehduksiin liittyvät komplikaatiot ovat harvinaisia. Korvasylkirauhasen paiseet ovat usean bakteerin aiheuttamia infektioita, joiden hoidon perusta on suonensisäinen antibioottilääkitys. Paiseen puhkaisu tai avaaminen on usein välttämätöntä, eikä johda sylkifistelin muodostumiseen. Tämän tutkimuksen perusteella lasten korvasylkirauhastulehdukset ovat luultua yleisempiä, niillä on taipumus uusiutua, ja lapsen yleistila on tulehduksen aikana yleensä hyvä. Komplikaatiot ovat harvinaisia. Toistuvia korvasylkirauhastulehduksia hoidettaessa on muistettava myös pään ja kaulan alueen luutulehduksen mahdollisuus. Kaikkia korvasylkirauhastulehduksen aiheuttajia ei tunneta

Pancreatic lymphoepithelial cyst with concurrent HIV infection: A case report and review of the literature

Pancreatic lymphoepithelial cysts are rare, benign, non-neoplastic unilocular or multilocular cystic lesions. These circumscribed pancreatic lesions are filled with keratinous material grossly and exhibit distinct microscopic features. Pancreatic lymphoepithelial cysts are like the more common lymphoepithelial cysts of the parotid glands, which have been associated with the diffuse infiltrative lymphocytosis syndrome often seen in patients with HIV infection. However, pancreatic lymphoepithelial cysts are rare and their association with HIV infection has not been established. The presence of secondary changes in non-neoplastic cysts such as goblet cell metaplasia that was present in our case is an important feature to be included in the differential diagnosis and not to be interpreted as a mucinous neoplasm, particularly on fine-needle aspiration specimen microscopic evaluation that would impact further management. Here we describe the diagnosis and treatment of lymphoepithelial cysts in a patient who was on highly active antiretroviral therapy for HIV infection and we provide a brief literature review. Defining the clinical characteristics of lymphoepithelial cysts in patients with HIV and determining accurate preoperative diagnostic procedures will be critical for establishing effective surgical and medical approaches to treating these cysts, which differ substantially from other more serious pancreatic cystic lesions

Lymphoepithelial Cyst of the Pancreas: Serum Markers do not Help

We report a case of lymphoepithelial cyst of the pancreas with non-specific elevation of CA 19.9 and CEA. Pre-operative diagnosis by conventional means proved elusive, and only surgical resection and histopathology revealed the diagnosis. The origin and diagnosis are discussed by literature review