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A 60-year-old woman was investigated for abdominal pain and increasing asthenia. Abdominal CT revealed a 25 mm hypodense cystic lesion in the tail of the pancreas. MRI showed a multiloculated cystic lesion, T1-hypointense and T2-hyperintense lesion, without wall enhancement. Endoscopic ultrasound detected a 25 mm multi-loculated cystic lesion, with regular margin and without pancreatic duct communication. Diagnosis of pancreatic mucinous cystadenoma was discussed and the patient was referred to surgery. She underwent distal pancreatectomy with spleen preservation. Pathological examination revealed the diagnosis of pancreatic mesothelial cyst. Histologically, the cyst was multiloculated, lined by cuboidal epithelium, ovoid nuclei and amphophilic cytoplasm, without mucin deposition or cytological atypia. Immunohistochemistry examination revealed positive staining for cytokeratin 5/6, vimentin and calretinin. At 1-year follow-up, she is in her usual health, without any symptoms., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The prevalence of undefined pancreatic cystic neoplasms (PCNs) is high in the general population, increasing with patient age. PCNs account for different biological entities with different potential for malignant transformation. The clinician must balance his or her practice between the risk of surgical overtreatment and the error of keeping a malignant lesion under surveillance., Methods: We review and discuss the clinical management of PCNs. Specifically, we analyze the main features of PCNs from the surgeon's point of view, as they present in the outpatient clinic. We also review the different consensus guidelines, address recent controversies in the literature, and present the current clinical practice at 4 different European Centers for pancreatic surgery., Results: The main features of PCNs were analyzed from the surgeon's point of view as they present in the outpatient clinic. All aspects of surgical management were discussed, from indications for surgery to intraoperative management and surveillance strategies., Conclusions: Management of PCNs requires a selective approach with the aim of minimizing clinically relevant diagnostic mistakes. Through the evaluation of clinical and radiological features of a PCN, the surgeon can elaborate on a diagnostic hypothesis and assess malignancy risk, but the final decision should be tailored to the individual patient's need., (© 2019 S. Karger AG, Basel.)

Competing Interests: Dr. Thompson is a consultant for Boston Scientific, Olympus, Medtronic, Apollo Endosurgery, and USGI Medical.All other authors have no conflict of interest.

Rationale: Mucinous cystic neoplasms (MCNs) are pancreatic mucin-producing cystic lesions with a distinctive ovarian-type stroma. The diagnosis is generally easy in typical cases; however, differential diagnosis is difficult in others such as in the case we report herein., Patient Concerns: A 27-year-old woman with sudden onset of epigastric pain was referred to our hospital for suspected acute pancreatitis. Contrast-enhanced computed tomography revealed a 25-mm cystic lesion in the pancreas and a low density area with delayed enhancement at the right upper side of the cystic lesion., Diagnoses: During its clinical course, the cystic lesion underwent various morphological changes. Eventually, it presented typical findings of MCNs, and could be accurately diagnosed., Interventions: Laparoscopic distal pancreatectomy was performed on the patient by preserving the spleen., Outcomes: The patient revealed no symptoms till 1 year after the operation., Lessons: This case of MCN with intriguing short-term morphological changes was associated with recurrent pancreatitis. A combination of imaging modalities is essential for accurate diagnosis of MCNs, and follow-up with serial imaging might be useful for certain unusual lesions.

Pancreatic cysts are common and are incidentally detected in up to 13.5% of individuals. Intraductal papillary mucinous neoplasm (IPMN) and mucinous cystic neoplasm (MCN) are precursors to pancreatic adenocarcinoma. Most will never develop into pancreatic cancer. Several types of pancreatic cysts have no malignant potential. Solid tumors can present as a pancreatic cysts. Guidelines recommend surveillance. Management includes differentiating IPMNs and MCNs from other types, identifying those at highest risk of harboring pancreatic cancer or high-grade dysplasia, and referral to a multidisciplinary group for evaluation and consideration of surgical resection., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Since the original description of pancreatic fluid collections (PFC) in 1761 by Morgagni, their diagnosis, description, and management have continued to evolve. The mainstay of therapy for symptomatic PFCs has been the creation of a communication between a PFC and the stomach, to enable drainage. Surgical creation of these drainage conduits had been the gold standard of therapy; however, there has been a paradigm shift in recent years with an increasing role of endoscopic drainage. The techniques of endoscopic drainage have evolved from blind fluid aspiration to include endoscopic necrosectomy and the placement of lumen-apposing metal stents., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Pancreatic cystic lymphangioma is an extremely rare tumor. The characteristic imaging findings are poorly defined, and distinguishing between this disease and other pancreatic cyst-related tumors is very difficult. We herein report a case of a Japanese woman in her 50s with this lesion, located in the tail of the pancreas. Pancreatic cystic lymphangioma should therefore be considered in the differential diagnosis of pancreatic cystic lesions. Laparoscopic resection can be a useful, minimally invasive surgical approach for treating these cysts as well as for the treatment of benign or low-grade malignant tumors located in the pancreatic body or tail.

Chronic pancreatitis and incidentally discovered pancreatic lesions present significant diagnostic and therapeutic challenges for surgeons. While both decompressive and resection procedures have been described for treatment of chronic pancreatitis, optimal management must be tailored to each patient's individual disease characteristics, parenchymal morphology, and ductal anatomy. Surgeons should strive to achieve long-lasting pain relief while preserving native pancreatic function. For patients with incidentally discovered pancreatic lesions, differentiating benign, pre-malignant, and malignant lesions is critical as earlier treatment is thought to result in improved survival. The purpose of this evidence-based manuscript is to review the presentation, workup, surgical management, and associated outcomes for patients with chronic pancreatitis or incidentally discovered solid and cystic lesions of the pancreas.

Background: The aim of this study was to compare the American Gastroenterological Association guidelines (AGA criteria), the 2012 (Fukuoka criteria), and 2006 (Sendai criteria) International Consensus Guidelines for the diagnosis of advanced pancreatic cystic neoplasms., Methods: All patients who underwent surgical resection of a pancreatic cyst from August 2007 through January 2016 were retrospectively analyzed at a single tertiary academic center. Relevant clinical and imaging variables along with pathology results were collected to determine appropriate classification for each guideline. Advanced pancreatic cystic neoplasms were defined by the presence of either high-grade dysplasia or cystic adenocarcinoma. Diagnostic accuracy was measured by ROC analysis., Results: A total of 209 patients were included. Both the AGA and Fukuoka criteria had a higher diagnostic accuracy for advanced neoplastic cysts than the Sendai criteria: AGA ROC 0.76 (95% CI 0.69-0.81), Fukuoka ROC 0.78 (95% CI 0.74-0.82), and Sendai ROC 0.65 (95% CI 0.61-0.69) (p < 0.0001). There was no difference between the Fukuoka and the AGA criteria. While the sensitivity was higher in the Fukuoka criteria compared to the AGA criteria (97.7 vs. 88.6%), the specificity was higher in the AGA criteria compared to the Fukuoka criteria (62.4 vs. 58.2%)., Conclusions: In a surgical series of patients with pancreatic cysts, the AGA and Fukuoka criteria had superior diagnostic accuracy for advanced neoplastic cysts compared to the original Sendai criteria.

Epidermoid cysts arising from both the pancreas and spleen are rare. We herein report a case of a surgically resected epidermoid cyst in the pancreatic tail invaginated from the spleen. A multi-locular cyst, 2 cm in diameter, without a solid component was discovered incidentally in the pancreatic tail. During the 11-year follow-up, the emergence of satellite cystic lesions with distinct appearances was seen, and surgical resection was selected despite the lack of any associated symptoms or evidence of cytological abnormalities. Histologically, these cysts were lined with benign multi-layered flattened epithelium surrounded by a thin layer consisting of cells positive for CD8 and CD68 and connecting to the spleen.

Background & Aims: The management of pancreatic cysts poses challenges to both patients and their physicians. We investigated whether a combination of molecular markers and clinical information could improve the classification of pancreatic cysts and management of patients., Methods: We performed a multi-center, retrospective study of 130 patients with resected pancreatic cystic neoplasms (12 serous cystadenomas, 10 solid pseudopapillary neoplasms, 12 mucinous cystic neoplasms, and 96 intraductal papillary mucinous neoplasms). Cyst fluid was analyzed to identify subtle mutations in genes known to be mutated in pancreatic cysts (BRAF, CDKN2A, CTNNB1, GNAS, KRAS, NRAS, PIK3CA, RNF43, SMAD4, TP53, and VHL); to identify loss of heterozygozity at CDKN2A, RNF43, SMAD4, TP53, and VHL tumor suppressor loci; and to identify aneuploidy. The analyses were performed using specialized technologies for implementing and interpreting massively parallel sequencing data acquisition. An algorithm was used to select markers that could classify cyst type and grade. The accuracy of the molecular markers was compared with that of clinical markers and a combination of molecular and clinical markers., Results: We identified molecular markers and clinical features that classified cyst type with 90%-100% sensitivity and 92%-98% specificity. The molecular marker panel correctly identified 67 of the 74 patients who did not require surgery and could, therefore, reduce the number of unnecessary operations by 91%., Conclusions: We identified a panel of molecular markers and clinical features that show promise for the accurate classification of cystic neoplasms of the pancreas and identification of cysts that require surgery., (Copyright © 2015 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Objectives: To evaluate secretin-enhanced MRCP (S-MRCP) findings of patients with pancreas divisum and Santorinicele, before and after minor papilla sphincterotomy., Methods: S-MRCP examinations of 519 patients with suspected pancreatic disease were included. Size of the main pancreatic duct, presence and calibre of Santorinicele were evaluated. Duodenal filling was assessed on dynamic images. After sphincterotomy the same parameters and the clinical findings were re-evaluated., Results: Pancreas divisum was depicted in 55/519 patients (11 %) by MRCP and an additional 26/519 by S-MRCP (total 81/519, 16 %). Santorinicele was detected in 7/81 patients (8.6 %) with pancreas divisum by MRCP and an additional 20/81 by S-MRCP (total 27/81, 33 %). Dorsal duct in patients with Santorinicele was significantly larger in the head compared with patients with only pancreas divisum (p < 0.01), in basal conditions (average 2.4 versus 1.9 mm) and after secretin administration (average 3.0 versus 2.4 mm). Duodenal filling was impaired in 11/27 patients (41 %) with Santorinicele. After sphincterotomy significant reduction in size of Santorinicele (-33 %) and dorsal duct (-17 %), increase of pancreatic juice and symptoms improvement were observed., Conclusion: Secretin administration increases the accuracy of MRCP in detecting Santorinicele and demonstrates the impaired duodenal filling. S-MRCP is useful to assess results of sphincterotomy., Key Points: • Secretin-enhanced MRCP gives anatomical and functional information on pancreatic outflow dynamics. • Santorinicele is a cystic dilatation of the termination of the Santorini duct. • S-MRCP images are the most useful to recognize the presence of Santorinicele. • Minor papilla sphincterotomy during ERCP is indicated in patients with Santorinicele.

Reports of combined congenital abnormalities of gastric duplication cysts and accessory pancreatic lobes are rarely reported. Patients with such anomalies may require appropriate surgical intervention tailored to the individual patient for complete cure. A multimodality diagnostic approach using ultrasonography, CT and MRI is useful for appreciation of the relevant anatomy of the congenital abnormality and for proper surgical planning. We present a case of a gastric duplication cyst with accessory pancreatic lobe and ectopic pancreatic rest in a 5-year-old child presenting with symptoms of recurrent pancreatitis., (2015 BMJ Publishing Group Ltd.)

Squamous-lined cysts (SLC) in the pancreas are rare and include lymphoepithelial cysts (LEC), dermoid cysts (DC), and epidermoid cysts in heterotopic spleen (EC). Previously only rare case reports and small case series have been published describing the FNA findings in these entities. The departmental archives were searched for surgically excised SLC from the pancreas. Twenty-five specimens were identified: 20 LEC, four EC, and one DC. Eight corresponding FNA specimens taken prior to resection were identified and available for review: seven LEC and one EC. A junior and senior pathologist reviewed the cases individually and then together for consensus. On morphological review, all lesions contained single nucleated and anucleated mature squamous cells, macrophages, and varying amounts of lymphocytes. Benign squamous fragments were found in half of all specimens. Amorphous debris was found in all cases. Keratin was found in all but two cases and its appearance varied among cases. Half of all cases contained cholesterol crystals. No nuclear atypia or necrosis was noted. Inspissated mucin, a potentially misleading finding, was seen in three cases. The most important goal in evaluating pancreatic cystic lesions is to exclude a mucin-producing neoplasm. If features of a SLC are present, the differential diagnosis should include LEC, DC, and EC. Only 38% (3/8) cases had the most specific features of an SLC present (squamous fragments, cholesterol crystals, keratin, and squamous cells), which suggests that most cases will not be specifically identified on FNA even by experienced cytopathologists., (© 2013 Wiley Periodicals, Inc.)

Pancreatic surgery has undergone significant progress during recent years. Specialised centres with interdisciplinary expertise have led to improved patient care with decreased morbidity and mortality. Regarding evidence-based medicine, consensus definitions on morbidity as well as high-quality studies, systematic reviews and meta-analyses on different topics of pancreatic surgery have been published. In acute pancreatitis paradigms have shifted towards conservative management, in chronic pancreatitis parenchyma-sparing resection techniques have widely become accepted. Management of cystic lesions - especially intraductal papillary mucinous neoplasms (IPMN) - has attracted great interest in surgical practice. In pancreatic cancer treatment not only surgical resection techniques have improved but also the central impact of adjuvant treatment has been demonstrated in large multicentre trials., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Diagnostic errors in the evaluation of cystic neoplasms of the pancreas (PCNs) are quite common. Few data are available regarding the impact of these errors on clinical management. The aim of this study was to determine the accuracy of a pancreatic multidisciplinary conference in diagnosing PCNs, to assess the potential risk of misdiagnosis, and to evaluate the clinical impact of these errors., Methods: A retrospective consecutive series of patients undergoing surgery for PCNs at Karolinska University Hospital between 2004 and 2012 was analyzed., Results: During the study period, a total of 141 patients had undergone pancreatic resection for PCN. The overall accuracy of the preoperative diagnosis was 60.9 %. The rate of concordance between preoperative diagnosis and histology was similar for asymptomatic and symptomatic lesions (62.8 vs. 59.1 %; p = NS). The rate of correct diagnosis increased over time (54.5 % in 2004-2006, 61.7 % in 2007-2012, 63.5 % in 2010-2012). Univariate analysis identified the location of the lesion (diffuse pancreatic involvement) and a mucinous nature of the lesion as factors conducive to a correct diagnosis. Reevaluation of the original indication for surgery in light of the exact diagnosis showed that a surgical procedure should not have been performed in 12 patients (8.5 %)., Conclusions: This study confirms that diagnostic errors are fairly common in the preoperative assessment of PCNs, but the errors are clinically relevant in <10 % of patients.

Context: PAM4 is a monoclonal antibody that shows high specificity for pancreatic ductal adenocarcinoma (PDAC) and its neoplastic precursor lesions. A PAM4-based serum immunoassay is able to detect 71% of early-stage patients and 91% with advanced disease. However, approximately 20% of patients diagnosed with chronic pancreatitis (CP) are also positive for circulating PAM4 antigen. The specificity of the PAM4 antibody is critical to the interpretation of the serum-based and immunohistochemical assays for detection of PDAC., Objective: To determine whether PAM4 can differentiate PDAC from nonneoplastic lesions of the pancreas., Design: Tissue microarrays of PDAC (N = 43) and surgical specimens from CP (N = 32) and benign cystic lesions (N = 19) were evaluated for expression of the PAM4 biomarker, MUC1, MUC4, CEACAM5/6, and CA19-9., Results: PAM4 and monoclonal antibodies (MAbs) to MUC1, MUC4, CEACAM5/6, and CA19-9 were each reactive with the majority of PDAC cases; however, PAM4 was the only monoclonal antibody not to react with adjacent, nonneoplastic parenchyma. Although PAM4 labeled 19% (6 of 32) of CP specimens, reactivity was restricted to pancreatic intraepithelial neoplasia associated with CP; inflamed tissues were negative in all cases. In contrast, MUC1, MUC4, CEACAM5/6, and CA19-9 were detected in 90%, 78%, 97%, and 100% of CP, respectively, with reactivity also present in nonneoplastic inflamed tissue., Conclusions: PAM4 was the only monoclonal antibody able to differentiate PDAC (and pancreatic intraepithelial neoplasia precursor lesions) from benign, nonneoplastic tissues of the pancreas. These results suggest the use of PAM4 for evaluation of tissue specimens, and support its role as an immunoassay for detection of PDAC.

Context: Lymphoepithelial cysts with sebaceous glands of the pancreas are extremely rare, with only 7 cases, including this case, published in English literature., Case Report: We herein present the case of a 67-year-old Asian man who underwent a resection of a lymphoepithelial cyst of the pancreas during the follow up care for lung cancer. Fourteen years previously he underwent a right lower lobectomy at the right segment nine for lung cancer. A 20 mm mass in the body of the pancreas was identified by CT scan 4 years ago, and the diagnosis was intraductal papillary mucinous neoplasm (IPMN) at that time. Over a 5-year period, this mass grew to 42 mm without dilatation of the main pancreatic duct. The preoperative evaluation, including endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), indicated a cystic neoplasm with suspicion of malignancy. Intraoperative frozen section revealed a squamous-lined cyst accompanied by sebaceous glands without any malignant findings. Following this pathological finding, resection of the cyst was performed. Consequently, microscopic examination revealed that it was a lymphoepithelial cyst with sebaceous glands of the pancreas., Conclusions: Pancreatic lymphoepithelial cysts can be cured by conservative resection, but if they are asymptomatic and are diagnosed before surgery, no treatment is necessary. To our knowledge, this is the first ever published case of a lymphoepithelial cyst with sebaceous glands of the pancreas, which was found during the follow up care for lung cancer.

Context: Lymphoepithelial cysts of the pancreas are a rare disease of true pancreatic cysts, the cause of which is unknown. The differential diagnosis is broad and includes many benign and malignant cystic lesions of the pancreas and surrounding organs. A combination of imaging modalities and fine needle aspiration might narrow the differential diagnosis. However, the final diagnosis can only be achieved with certainty after resection of the cyst., Case Report: The present case report is a lymphoepithelial cyst of the pancreas that was resected laparoscopically. A 53-year-old man was incidentally found to have a cystic tumor in the tail of the pancreas after undergoing an abdominal ultrasound, which showed a 41x33 mm cystic mass in the pancreatic tail. He had no abdominal symptoms. Laparoscopic distal pancreatectomy and splenectomy were performed. Histologic examination revealed a lymphoepithelial cyst., Conclusion: Herein, we discuss the diagnostic difficulties and management decisions that face surgeons treating pancreatic cysts.

Introduction: Pancreatic enucleation is associated with a low operative mortality and preserved pancreatic parenchyma. However, enucleation is an uncommon operation, and good comparative data with resection are lacking. Therefore, the aim of this analysis was to compare the outcomes of pancreatic enucleation and resection., Material and Methods: From 1998 through 2010, 45 consecutive patients with small (mean, 2.3 cm) pancreatic lesions underwent enucleation. These patients were matched with 90 patients undergoing pancreatoduodenectomy (n = 38) or distal pancreatectomy (n = 52). Serious morbidity was defined in accordance with the American College of Surgeons-National Surgical Quality Improvement Program. Outcomes were compared with standard statistical analyses., Results: Operative time was shorter (183 vs. 271 min, p < 0.01), and operative blood loss was significantly lower (160 vs. 691 ml, p < 0.01) with enucleation. Fewer patients undergoing enucleation required monitoring in an intensive care unit (20% vs. 41%, p < 0.02). Serious morbidity was less common among patients who underwent enucleation compared to those who had a resection (13% vs. 29%, p = 0.05). Pancreatic endocrine (4% vs. 17%, p = 0.05) and exocrine (2% vs. 17%, p < 0.05) insufficiency were less common with enucleation. Ten-year survival was no different between enucleation and resection., Conclusion: Compared to resection, pancreatic enucleation is associated with improved operative as well as short- and long-term postoperative outcomes. For small benign and premalignant pancreatic lesions, enucleation should be considered the procedure of choice when technically appropriate.

Objectives: The aim of the study was to assess the diagnosis and management of solid pancreatic neoplasm in children and the type of surgical treatment, focusing on short- and long-term outcomes., Methods: We retrospectively reviewed the charts of all children who had undergone pancreatic resection for suspicion of pancreatic tumor in Kremlin Bicêtre Hospital, Paris, between 1986 and 2008. We studied the symptoms at diagnosis, the type of surgery, and the short- and long-term morbidity and mortality., Results: Of 18 patients identified, there were 7 pseudopapillary tumors, 3 neuroblastomas, 2 rhabdomyosarcomas, 1 acinar cell carcinoma, 1 endocrine cell carcinoma, 1 renal angiomyolipoma, and 3 pancreatic cysts. Symptoms at diagnosis were abdominal trauma, abdominal mass, and jaundice. Operative procedures were duodenopancreatectomy (11), mid-pancreatic resections (2), splenopancreatectomy (2), distal pancreatectomy (1), and tumorectomy (2). There were no deaths related to surgery. The postoperative morbidity rate was 45%, including 2 cases of fistula (11%) occurring after a mid-pancreatic resection and a pancreaticoduodenectomy. The median follow-up was 4.2 years (range 2-11). There was no diabetes mellitus, but there was 1 case of fat diet intolerance requiring pancreatic enzyme substitution. All of the children had a growth curve within normal limits., Conclusions: In this experience, pancreatic resections have proven to be a safe and efficient procedure, with low long-term morbidity, for the treatment of tumoral and selected nontumoral pancreatic masses.

Context: Pancreatic cystic lesions are increasingly recognized and comprise different pathological entities. The management of these lesions is challenging, because of inadequate preoperative histological diagnosis. Among this family of lesions, mature cystic teratomas are an extremely rare finding., Case Report: We present the case of a 61-year-old man with a mature cystic teratoma of the pancreas' uncinate process, incidentally discovered at diagnostic imaging., Conclusions: This case highlights the difficulty to obtain a preoperative diagnosis of this pathological entity and the need of increased awareness about mature cystic teratoma when examining a pancreatic cystic lesion.

An 11-day-old neonate presents with worsening nonbilious emesis and radiographic findings suggestive of pyloric stenosis. Using a laparoscopic approach, a slightly asymmetric and hypertrophied pylorus was visualized. The unusual age of presentation and appearance of the pylorus led to the decision to perform an open exploration for suspicion of a pyloric duplication. An incision of the pyloric muscle exposed and confirmed a duplication cyst. Further exposure revealed accessory pancreatic tissue communicating from the cyst to the main body of the pancreas. The duplication cyst and accessory pancreas were resected, and the patient had an uneventful recovery. Pyloric duplication is a rare cause of congenital extrinsic obstruction in the newborn. Even rarer is a communication of the duplication cyst with the pancreas. Resection of the duplication cyst and the aberrant pancreatic tissue and duct is recommended., (Copyright © 2011 Elsevier Inc. All rights reserved.)

We report a rare case of a foregut duplication cyst of the pancreas containing respiratory epithelium in a healthy adolescent male who presented with recurrent abdominal pain secondary to pancreatitis. The abnormality was revealed on computed tomography performed to evaluate severe abdominal pain radiating to the back. Further imaging (ultrasound and magnetic resonance imaging) confirmed that the lesion was a cyst with no apparent pancreatic ductal communication. Elective laparoscopic resection of the cyst was performed with complete resolution of the patient's symptoms., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Context: Solitary true cysts of the pancreas in adults are extremely rare and only few cases have been reported in the literature. The etiology and natural history of these lesions remain unknown and treatment is not standardized. We describe two additional resected cases., Case Reports: The first patient was a young woman with an incidental 3 cm cyst located in the pancreatic head who underwent enucleation. The second patient was a young woman with a large 8 cm symptomatic cyst located in the pancreatic tail who underwent a laparoscopic spleen-preserving distal pancreatectomy. Histological examination revealed fibrous walls lined by a monolayer of cuboidal epithelium in both cases., Conclusions: A preoperative work-up alone does not always allow an accurate diagnosis, but it is useful in determining lesion characteristics and guiding therapeutic decision making. When surgery is indicated, a limited resection is warranted in most cases.

Background and Aims: Early diagnosis of cancer in pancreatic cysts is important for timely referral to surgery. The aim of this study was to develop a predictive model for pancreatic cyst malignancy to improve patient selection for surgical resection., Methods: We performed retrospective analyses of endoscopic ultrasound (EUS) and pathology databases identifying pancreatic cysts with available final pathological diagnoses. Main-duct intraductal papillary mucinous neoplasms (IPMNs) were excluded due to the clear indication for surgery. Patient demographics and symptoms, cyst morphology, and cyst fluid characteristics were studied as candidate risk factors for malignancy., Results: 270 patients with pancreatic cysts were identified and analyzed (41% men, mean age 61.8 years). Final pathological diagnoses were branch-duct IPMN (n = 118, 50% malignant), serous cystadenoma (n = 71), pseudocyst (n = 37), mucinous cyst adenoma/adenocarcinoma (n = 36), islet cell tumor (n = 4), simple cyst (n = 3), and ductal adenocarcinoma with cystic degeneration (n = 1). Optimal cut-off points for surgical resection were cyst fluid carcinoembryonic antigen (CEA) > or =3,594 ng/ml, age >50, and cyst size >1.5 cm. Cyst malignancy was independently associated with white race (OR = 4.1, p = 0.002), weight loss (OR = 3.9, p = 0.001), cyst size >1.5 cm (OR = 2.4, p = 0.012), and high CEA > or =3,594 (OR = 5.3, p = 0.04). In white patients >50 years old presenting with weight loss and cyst size >1.5 cm, the likelihood of malignancy was nearly sixfold greater than in those patients who had none of these factors (OR = 5.8, 95% CI = 2.1-16.1, p = 0.004)., Conclusions: Risk factors other than cyst size are important for determination of malignancy in pancreatic cysts. Exceptionally high cyst fluid CEA levels and certain patient-related factors may help to better predict cyst malignancy and the need for surgical treatment., (Copyright 2009 S. Karger AG, Basel.)

This article presents the study of a 66-year-old man with an asymptomatic pancreatic mass detected incidentally 4 months earlier. A magnetic resonance imaging scan revealed 2 distinct cystic masses in the pancreas and the gastric antrum. Microscopically, the pancreatic lesion showed dilated cysts containing papillary structures lined by mucinous epithelium, which showed a loss of polarity, an increased nucleus-to-cytoplasm ratio, a prominent nucleolus, and high proliferation on immunostaining for Ki-67. The gastric lesion was composed of heterotopic pancreatic tissue surrounding a large dilated cyst that was lined with mucinous epithelium and contained a few intraluminal papillae.

Cytology frequently has some role in preoperatively distinguishing pancreatic mucus-producing neoplasia (intraductal papillary mucinous neoplasms [IPMNs] and mucinous cystic neoplasms [MCNs]) from other pancreatic cysts. We evaluated all cytologic specimens at our institutions from resected pancreatic cystic lesions for lesional extracellular and cellular material. Lesional extracellular material was identified in 32 of 38 of the cytologic samples from cystic pancreatic mucus-producing neoplasms (28 of 31 IPMNs and 4 of 7 MCNs). Lesional cellular material was seen in 22 of 38 cases (17 of 31 IPMNs and 5 of 7 MCNs). Lesional material was more commonly identified in higher grade and invasive lesions. Lesional extracellular material was seen in 3 of 14 samples of other pancreatic cysts, and lesional cellular material was seen in 6 of 14 cases.

We report a case of groove pancreatitis (GP) associated with a true pancreatic cyst. An 81-year-old man who had suffered epigastric pain for 4 months was referred to Saisekai Kure Hospital. Computed tomography and endoscopic retrograde pancreatography showed a cystic lesion in the groove area of the pancreas. Serum amylase elevation and imaging findings suggested GP due to the cyst. Six weeks of medical treatment did not improve the clinical symptoms. Therefore, pancreatoduodenectomy was performed. Histologic examination revealed a true cyst with intraluminal necrosis, which produced a protein plug that obstructed the Santorini duct. The parenchyma surrounding the groove area showed marked fibrosis and inflammatory cell infiltration. GP due to true pancreatic cyst was diagnosed. Although GP is usually caused by overconsumption of alcohol, which leads to changes in the pancreatic juice and the ultimate blockage of pancreatic outflow, the histologic features in our patient suggest that true pancreatic cyst stands as a secondary cause of GP.

Objective: To evaluate ancillary biochemical testing after pancreatic cyst fine needle aspiration (FNA) in the clinical setting., Study Design: Findings from 110 pancreatic guided FNA were reviewed cysts evaluated by image- and correlated with histology, clinical follow-up and biochemical analysis of cyst fluid and serum. Adequate followup was available for 95., Results: In terms of identifying cysts requiring surgery, FNA showed 55.3% sensitivity, 95% specificity, 92.9% positive predictive value (PPV) and 64.4% negative predictive value (NPV). FNA showed only nonspecific cyst contents in 51% of cases, but 40% of those patients proved to be surgical candidates at follow-up. Overall, patients with lesions requiring surgery were younger (p = 0.14), more often presented with pain (p = 0.006), had larger cysts (p = 0.05) and less often had a history of chronic pancreatitis (p = 0.12). Among cases in which FNA showed only nonspecific cyst contents, patients with lesions requiring surgery were more often female (p = 0.08), were younger (p = 0.10), had larger cysts (p = 0.06) and had pain at presentation (p = 0.02). Differences in fluid and serum analytes were not statistically significant., Conclusion: FNA of pancreatic cysts shows high specificity but poor sensitivity, even with cyst fluid and serum biochemical analysis. FNA of cysts requiring surgery often yielded nonspecific cyst cytology and causing a misinterpretation as pseudocysts. Ancillary biochemical analysis of cyst fluid remains problematic in the clinical setting.

Heterotopic pancreas is normal pancreatic tissue located in an abnormal location. Heterotopic pancreas in the esophagus is a rare congenital anomaly. We present a unique case of pancreatitis and retention cyst in a heterotopic pancreas in the esophagus, outline the investigation and management of cystic lesions of the distal esophagus, and review the literature.

Background: The pancreas is a rare primary location of hydatid disease. The purpose of our study is to gain more insight into this entity and to focus on the management and the diagnostic approach to the disease., Methods: The medical records of 5 patients with hydatid cysts of the pancreas were reviewed., Results: Four of the cysts were primary, while in 1 case a coexisting cyst was found in the liver. The body and tail of the pancreas were the most common locations. Clinical presentation varied according to the anatomic location of the cyst. Abdominal pain, discomfort and vomiting were the main clinical symptoms. One patient presented with obstructive jaundice, while another patient manifested a mild episode of anaphylactic shock. The indirect hemagglutination test was positive in 3 of 4 cases. A computed tomography scan successfully imaged all cysts and calcification of the cystic wall was found in 3 of 4 cases. All patients underwent surgical therapy. Hydatid cysts in the tail of the pancreas were successfully treated with distal pancreatectomy, while cysts in the body and head of pancreas were treated with proper evacuation, pericystectomy and omentoplasty. The postoperative course was uneventful in all patients except 1 who presented a pancreatic fistula and was re-operated. The mean length of hospitalization after surgery was 11-12 (range 10-13) days, except for the patient who needed to be re-operated. No evidence of cyst recurrence was observed during the follow-up period., Conclusions: Hydatid cystic masses of the upper abdomen might also originate from the pancreas especially in endemic countries. Surgical excision of the entire cystic lesion remains the optimal treatment, offering hope for a complete cure., (Copyright 2005 S. Karger AG, Basel and IAP.)

Enteric duplication cysts are rare congenital anomalies of the GI tract. We present a most unusual case presenting as a cystic lesion on the pancreas simulating a cystic pancreatic neoplasm. The differential diagnosis of cystic pancreatic lesions as well as duplication cysts is discussed.

Duodenal cystic dystrophy due to ectopic pancreas deposit is an uncommon pathology. Diagnosis is made by modern imaging techniques, mainly endoscopic ultrasound which localizes precisely cysts in duodenal wall. The most frequent clinical symptoms are pain, duodenal obstruction, and weight loss. We report the case of a 40 year-old man with cystic dystrophy of the 2nd part of the duodenum, without chronic pancreatitis, treated by a conservative surgical procedure including segmental duodenal resection. This original approach is an alternative to the Whipple procedure.

Results of endoscopic drainage of postnecrotic pancreatic cysts in 12 patients were analyzed. Possibilities of the method are limited by location of the cysts in pancreatic head and corpus. Clear visualization of the cysts on the gastric or duodenal wall is the main condition for this procedures feasibility. Surgery must be started with point burning in the wall that is safe and permits the surgeon to stop procedure when cyst is not found. When the cyst is drained through the duodenal lumen, it is necessary to visualize Veter's papilla and perform the procedure below it to prevent lesion of a distal part of the common bile duct. Section of the cyst with wall thickness to 3-4 mm from the duodenal lumen and the ikness to 6-7 mm from the stomach is safe enough. Endoscopic procedures are not indicated in hypertension in the bile ducts.

A peculiar 6 x 5 x 3 cm, multilobed, septated, cystic tumor presented in the tail of the pancreas in a 5-month-old infant with left ear pit, bilateral cleft palate, brachydactyly type B, and familial ear pits. This combination was not found previously reported. The cysts were lined by attenuated epithelium and PAS-positive, mucus-containing cells. These were keratin 8-, 18-, and 19-positive and CA 19.9-negative. Ductuloinsular complexes were present in the adjacent pancreatic tissue. Pancreatic cystic dysplasia (dysgenesis) may associate with several malformation syndromes. A similar lesion may present isolated as a tumor in the first year of life and has been reported under a variety of names (hamartoma, cystadenoma, and cyst). The lesion does not fit with the criteria of cystadenomas as seen in adults.

A rare case of a gastric duplication in the tail of the pancreas in a child presenting with recurrent abdominal pain and evidence of pancreatic calcification suggesting pancreatitis was cured by excision of the cyst and adjacent pancreas. Congenital causes of pancreatitis are rare, but are curable with surgery. These lesions are often misdiagnosed, and patients may be subjected to inappropriate surgery. Imaging is sensitive in the detection of such lesions, but the lack of specific features necessitates an index of suspicion. Similar cases have been described previously, but the pancreatic tail is rarely involved.