Search

Introduction: The aim of this study was to determine if neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were predictive of malignancy in mucin-producing pancreatic cystic neoplasms (MpPCN)., Methods: One hundred and twenty patients with MpPCN were retrospectively reviewed. Malignant neoplasms were defined as neoplasms harbouring invasive carcinoma or high grade dysplasia. A high NLR and PLR were defined as ≥2.551 and ≥208.1, respectively., Results: High NLR was significantly associated with symptomatic tumors, larger tumors, solid component, main-duct IPMN, and Sendai high risk category. High PLR was significantly associated with jaundice and Sendai high risk category. On univariate analyses, symptomatic tumors, jaundice, solid component, dilated pancreatic duct, and both a high NLR and PLR were significant predictors of malignant and invasive MpPCN. On multivariate analyses, solid component and dilated pancreatic duct were independent predictors of malignant and invasive MpPCN. PLR was an independent predictor for invasive MpPCN. When MpPCN were stratified by the Fukuoka and Sendai Guidelines, both a high NLR and PLR were significantly associated with malignant neoplasms within the high risk categories., Conclusions: PLR is an independent predictor of invasive carcinoma. The addition of PLR as a criterion to the FCG and SCG significantly improved the predictive value of these guidelines in detecting invasive neoplasms., (© 2015 Wiley Periodicals, Inc.)

Background: The diagnosis of side-branch intraductal papillary mucinous neoplasms (IMPNs) is increasingly more common, but their appropriate management is still evolving. We recently began performing laparoscopic hand-assisted enucleation or duodenal-sparing pancreatic head resection for these lesions with vigilant postoperative imaging., Materials and Methods: Seventeen patients with pancreatic cystic lesions were included in this single-center retrospective review from January 1, 2008 to March 30, 2013. Indication for surgical intervention was growth in size of the cyst, symptoms, cyst size >3 cm, and/or presence of a mural nodule. Twelve patients underwent laparoscopic hand-assisted enucleation, and 5 patients underwent laparoscopic hand-assisted pancreatic head resection., Results: The mean age of patients was 64 years old. The most common presenting symptom was abdominal pain. The indication for surgical intervention was growth in the cyst or symptoms in the majority of patients. Fourteen lesions were in the head/uncinate, two were in the pancreatic body, and one was in the tail. Final pathology was consistent with side-branch IPMN in 13 patients (1 with focal adenocarcinoma). Three patients had serous cysts, and 1 had a mucinous cyst. Three patients developed pancreatic leaks, which were controlled with intraoperative placed drains, whereas 1 patient required additional drain placement. Median time from surgery to latest follow-up imaging is over 2 years. No patients have developed recurrent cysts or adenocarcinoma., Conclusions: Duodenal-sparing pancreatic head resection or pancreatic enucleation for patients with presumed side-branch IPMN is a safe and efficacious option, in terms of both operative outcomes and postoperative recurrence risk.

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.

Cystic teratomas are a rare type of germ cell neoplasms derived from one or more germ layers. They can be classified as mature and immature teratomas based on the maturity of neuroectodermal elements within the tumor. Mature teratomas are benign, well-differentiated lesions, which may be solid or cystic. Mature cystic teratomas (MCTs) are also called dermoid cysts - a term likely coming from early surgical literature when the resected cysts resembled skin. Immature teratomas are malignant, undifferentiated tumors and generally solid. The most common location for MCTs is sacrococcygeus followed by ovaries and testes. MCTs in the pancreas are extremely rare with only few published case reports. Diagnosis of teratomas is challenging since there are no definitive preoperative diagnostic tests or pathognomonic findings. Even though EUS is commonly used for diagnosis of pancreatic cysts, the imaging features and cyst fluid characteristics of MCTs on EUS FNA have not been described. We describe a challenging case of a 65-year-old patient who had a 9 cm × 7 cm MCT in the body of the pancreas and discuss the role of EUS in diagnosis and management of these rare lesions. Complete surgical removal seems to be the current standard of care., (Copyright © 2015 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

Background: In 2006, the Sendai Consensus Guidelines identified size >3.0 cm as the only independent predictor of malignancy in incidentally discovered pancreatic cysts. The 2012 updated guidelines increased emphasis on radiographic features over size. Earlier studies included patients with preoperatively diagnosed carcinoma or with a corresponding mass. In this report, we characterize the use of size and serum tumor markers in the initial evaluation of pancreatic cystic neoplasms without preoperatively diagnosed adenocarcinoma and correlate them with clinical and pathologic outcomes., Study Design: A retrospective cohort study was undertaken of 112 patients with a resected pancreatic cystic neoplasm. Patient demographics, cyst characteristics, preoperative serum tumor markers, morbidity, and mortality were captured. Statistical analysis included nonparametric tests of comparison, multivariate logistic regression, and receiver operating characteristic curve analyses., Results: One hundred and twelve pancreatic cystic neoplasms were resected; there was one perioperative death. Mucinous cysts were common (78%), followed by serous cysts (13%). In total, 17% of cysts harbored malignancy. On multivariate analysis, the risk of malignancy in cysts≥3 cm was more than 4 times that of smaller cysts (relative risk (RR)=4.32; 95% CI, 1.55-12.07). There was no significant difference in serum CEA, cancer antigen 19-9, or cyst-fluid CEA levels between the benign and malignant groups. At a median follow-up of 30 months, the incidence of diabetes was 15%., Conclusions: Surgical resection of pancreatic cysts can be performed with low perioperative mortality and acceptable long-term morbidity. Use of cyst size as a rationale for resection of cystic lesion, as per the Sendai criteria, is justified., (Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Without a reliable biopsy technique for pancreatic cysts, consensus-based guidelines are used to guide surgical utilization. The primary objective of this study was to characterize the proportion of operations performed outside of these guidelines., Methods: A 5-year retrospective review between July 1, 2007, and June 30, 2012, was performed of consecutive patients seen at a single tertiary medical center for a pancreatic cyst. Manual chart review for relevant clinical variables and cyst characteristics was performed., Results: During this period, 148 patients underwent surgery, and of these, 23 (16 %) patients had no high-risk criteria by the 2006 Sendai criteria. None of these harbored high-grade dysplastic or cancerous lesions. A high cyst carcinoembryonic antigen (CEA) level (35 %), patient anxiety (26 %), and physician concern (22 %) were explicit reasons to proceed to surgery. An elevated cyst CEA level >192 ng/ml was the most significant predictor (OR 5.14 (95 % confidence interval (CI) 1.47-18.0) for surgery without high-risk criteria., Conclusion: A high cyst CEA level was significantly associated with the decision to operate outside of consensus-based guidelines. The misuse of cyst CEA in the management of pancreatic cysts negatively impacts patient anxiety, increases physician uncertainty, and leads to surgery with minimal benefit.

Background: Pancreatic fluid collections can form after episodes of pancreatitis, either acute or chronic. The majority will resolve spontaneously but when decompression is mandated, endoscopic drainage is the method of choice. However, it is not void of complications., Methods: We retrospectively reviewed the charts of 65 patients who underwent endoscopic drainage of pancreatic fluid collections in our institution. The primary outcomes examined included the incidence and type of complications associated with the endoscopic approach., Results: Endoscopic ultrasound was utilized in 86.2% and transgastric approach was used in 81.5% of the cases. The complication rate was 17%. Specifically, complications recorded were infection (6%), perforation and acute abdomen necessitating surgical intervention (4.6%), pneumoperitoneum that was managed nonoperatively (3%), upper gastrointestinal bleed in the knife puncture site that resolved spontaneously (1.5%), and stent migration (1.5%). One patient died remotely to the endoscopic drainage after paracentesis of ascites that resulted in hemorrhagic shock., Conclusions: This study is one of the largest studies reporting the associated morbidity and mortality after endoscopic cyst-gastrostomy. Major and minor complications occurred at a rate of 17% in our study. Endoscopic approach is a safe draining method and should remain the approach of choice for pancreatic fluid collection decompression.

Objective: To assess the accuracy of pre-operative staging in patients with peripheral pancreatic cystic neoplasms (pPCNs)., Methods: From 2005 to 2011, 148 patients underwent a pancreatectomy for pPCNs. The pre-operative examination methods of computed tomography (CT), magnetic resonance imaging (MRI), endoscopic ultrasonography (EUS) were compared for their ability to predict the suggested diagnosis accurately, and the definitive diagnosis was affirmed by pathological examination., Results: A mural nodule was detected in 34 patients (23%): only 1 patient (3%) had an invasive pPCN at the final histological examination. A biopsy was performed in 79 patients (53%) during EUS: in 55 patients (70%), the biopsy could not conclude a diagnosis; the biopsy provided the correct and wrong diagnosis in 19 patients (24%) and 5 patients (6%), respectively. A correct diagnosis was affirmed by CT, EUS and pancreatic MRI in 60 (41%), 103 (74%) and 80 (86%) patients (when comparing EUS and MRI; P = 0.03), respectively. The positive predictive values (PPVs) of CT, EUS and MRI were 70%, 75% and 87%, respectively., Conclusions: Pancreatic MRI appears to be the most appropriate examination to diagnose pPCNs accurately. EUS alone had a poor PPV. Mural nodules in a PCN should not be considered an indisputable sign of pPCN invasiveness., (© 2015 International Hepato-Pancreato-Biliary Association.)

Background: Endoscopic ultrasound (EUS)-guided ethanol ablation has emerged as an efficacious and safe alternative management option for pancreatic cysts. We undertook a meta-analysis and systematic review to assess the overall safety and efficacy of EUS-guided ethanol ablation of pancreatic cysts., Method Study Selection Criteria: EUS-guided ethanol ablation of pancreatic cysts., Data Collection Extraction: Articles were searched in Medline, Pubmed, and Ovid journals., Statistical Method: Fixed and random effects models were used to calculate the pooled proportions., Results: Initial search identified 1,319 reference articles, in which 120 relevant articles were selected and reviewed. Data was extracted from seven studies (n = 152) of EUS-guided ethanol ablation of pancreatic cysts, which met the inclusion criteria. With EUS-guided ethanol ablation, the pooled proportion of patients with complete cyst resolution was 56.20 % (95 % CI = 48.16 to 64.08) and partial cyst resolution was 23.72 % (95 % CI = 17.24 to 30.89). Postprocedural complications after ablation were significant for abdominal pain in 6.51 % (95 % CI = 3.12 to 11.04) and pancreatitis in 3.90 % (95 % CI = 1.39 to 7.60) of the pooled percentage of patients. Publication bias calculated using Harbord-Egger bias indicator gave a value of -1.09 (95 % CI = 10.21 to 8.03, p = 0.77). The Begg-Mazumdar indicator gave a Kendall's tau b value of 0.05 (p ≥ 0.99)., Conclusions: EUS-guided ethanol ablation may be a safe alternative treatment modality for pancreatic cysts, with acceptable intraprocedural and postprocedural complications. However, due to the limited data available, prospective randomized controlled trials with a long follow up period are required in this area.

Two patients were referred to our hospital with cystic lesion (diameter 5 cm) of the pancreas and elevated serum CEA and CA19-9. We diagnosed them with malignant cystic neoplasms of the pancreas and performed distal pancreatectomy. Histologically, in both cases the cysts were lined with flat, transitional, squamoid cells without keratinization. Immunohistochemical staining confirmed two rare cases of squamoid cyst of the pancreatic ducts.

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.)

Background and Study Aims: Current diagnostic testing is inadequate to determine the malignant potential of pancreatic cysts, resulting in overcautious patient management. Integrated molecular pathology (IMP) testing combines molecular analysis with first-line test results (cytology, imaging, and fluid chemistry) to assess the malignant potential of pancreatic cysts. This multicenter study aimed to determine the diagnostic accuracy of IMP for pancreatic adenocarcinoma, and the utility of IMP testing under current guideline recommendations for managing pancreatic cysts., Patients and Methods: Patients who had undergone previous IMP testing as prescribed by their physician and for whom clinical outcomes were available from retrospective record review were included (n = 492). Performance was determined by correlation between clinical outcome and previous IMP diagnosis ("benign"/"statistically indolent" vs. "statistically higher risk [SHR]"/ "aggressive") or an International Consensus Guideline (Sendai 2012) criteria model for "surveillance" vs. "surgery." The Cox proportional hazards model determined hazard ratios for malignancy., Results: Benign and statistically indolent IMP diagnoses had a 97 % probability of benign follow-up for up to 7 years and 8 months from initial IMP testing. SHR and aggressive diagnoses had relative hazard ratios for malignancy of 30.8 and 76.3, respectively (both P < 0.0001). Sendai surveillance criteria had a 97 % probability of benign follow-up for up to 7 years and 8 months, but for surgical criteria the hazard ratio was only 9.0 (P < 0.0001). In patients who met Sendai surgical criteria, benign and statistically indolent IMP diagnoses had a > 93 % probability of benign follow-up, with relative hazard ratios for SHR and aggressive IMP diagnoses of 16.1 and 50.2, respectively (both P < 0.0001)., Conclusion: IMP more accurately determined the malignant potential of pancreatic cysts than a Sendai 2012 guideline management criteria model. IMP may improve patient management by justifying more relaxed observation in patients meeting Sendai surveillance criteria. IMP can more accurately differentiate between the need for surveillance or surgery in patients meeting Sendai surgical criteria., (© Georg Thieme Verlag KG Stuttgart · New York.)

Cystic lesions of the pancreas are increasingly diagnosed with a reported prevalence of 10 % in 70-year-old individuals. Despite their broad spectrum, most resected cystic lesions can be attributed to one of the following entities: intraductal papillary mucinous neoplasms (IPMN), mucinous cystic neoplasms (MCN), serous cystic neoplasms (SCN), neuroendocrine cystic tumors (NECT), and solid pseudopapillary neoplasms (SPN). Among them, IPMN and MCN represent precursors of ductal adenocarcinoma, NECT and SPN are low-grade, potentially malignant lesions, and SCN are usually benign. Due to the not negligible morbidity and mortality rates in pancreatic surgery, even in highly specialized centers, an interdisciplinary preoperative stratification of pancreatic cystic lesions into high- and low-risk tumors is necessary in order to accurately select those cases that need to undergo immediate resection. The role of the pathologist is fundamental in both the preoperative assessment and in the postoperative classification, which determines prognosis, further treatment, and follow-up.

Background: Preoperative diagnosis of pancreatic cystic lesions (PCLs) must be reliable as the current standard treatment, major or total pancreatectomy, dramatically affects quality of life. Additionally, early diagnosis of malignancy is essential to an improved prognosis. The diagnostic accuracy of fluid analysis using endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) has been demonstrated in pancreatic solid lesions. The utility of this technique in the diagnosis of PCLs is still unknown., Methods: A comprehensive search was performed in multiple databases. Studies differentiating benign and malignant PCLs via EUS-FNA were included in this meta-analysis. The quality of diagnostic accuracy studies (QUADAS) was adopted to evaluate the selected studies. Pooled sensitivity, specificity, likelihood ratio, diagnostic odds ratio, and summary receiver operating characteristic (sROC) curve analyses were conducted. Two main classification types of malignancy were characterized and analyzed. We also generated a subgroup analysis of available clinical factors. Publication bias was evaluated by Begg's and Egger's tests., Results: Sixteen studies containing 1024 subjects have been published. The pooled sensitivity for malignant cytology according to classification 1 was 0.51 (95% CI, 0.45-0.58), and pooled specificity was 0.94 (95% CI, 0.92-0.96). When the detected PCLs were identified as classification 2, suspicious malignancy or potential malignancy, sensitivity and specificity were similar, 0.52 (95% CI, 0.46-0.57) and 0.97 (95% CI, 0.95-0.98) respectively., Conclusion: This meta-analysis demonstrates that EUS-FNA is a reliable clinical tool for the diagnosis of PCLs. However, a more accurate algorithm is needed to reduce various biases and to improve the sensitivity of EUS-FNA in the detection of malignant PCLs., (© 2015 S. Karger AG, Basel.)

Pancreatic cystic lesions are being diagnosed with increasing frequency owing to the widespread use of cross-sectional imaging. Although most pancreatic cysts are detected incidentally, they represent a wide spectrum of histopathology, and neoplastic cysts appear to be more prevalent than previously estimated. Some histologic types have malignant potential. Considering the perioperative morbidity associated with surgical resection, deciding whether to operate or observe an indeterminate pancreatic cyst is challenging, and there is a strong clinical need to develop a minimally invasive approach. EUS-guided pancreatic cyst ablation has been investigated in several clinical trials, and may represent a viable alternative to surgical resection., (© 2014 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Pancreatic lymphoepithelial cysts (LECs) are rare benign pancreatic cystic lesions, the etiology of which is unknown. We report a case of a pancreatic LEC, discovered incidentally in a 63-year-old man during a follow-up clinic visit for an abdominal aneurysm. Computed tomography showed a multilocular cyst, 60-mm diameter in the body of the pancreas. This cyst increased from 6.0 to 6.5 cm during 12 months of observation. Part of the cyst was also visualized on positron emission tomography imaging. Since a pancreatic cystic neoplasm could not be ruled out, we performed distal pancreatectomy and postoperative pathological examination confirmed that the lesion was an LEC of the pancreas. Despite the conclusive postoperative findings, resection is unavoidable when a true pancreatic neoplasm cannot be excluded.

Introduction: In recent years, the practice of abdominal surgery marked increase in the number of patients with pancreatic cysts. Tactics of treatment of this disease is still disputable., Material and Methods: The article analyzes the treatment of 128 patients with formed pancreatic cysts. They were divided into three groups: 1) external drainage - 44 (34.4%); 2) internal drainage - 41 (32.0%); 3) resection surgery - 43 (33.6%)., Results: The duodenum resections were introduced for the treatment of the pancreatic head cysts - 21 (48.8%). Resection methods in the number of postoperative complications (23.3%) could be compared with the operations of the internal drainage of pancreatic cysts (19.5%), although the resection methods are technically more difficult and traumatic. 66 (51.6%) patients were observed in the long-term period. The number of postoperated disease recurrences was more in group 1 (28.6%). Quality of life indicators (SF-36) were higher in group 3. We marked the best results after resection operations., Conclusion: So this type of operation can be recommended for the treatment of patients with formed pancreatic cysts as the most radical method.

Objective: Pancreatic cystic tumors are relatively rare tumors and only 1% of them are malignant. They are often asymptomatic and detected as incidental findings through diagnostic imaging. Currently there are no universal guide lines for the correct clinical approach to pancreatic cystic lesions. Cross-sectional imaging demonstrates some typical morphological features that determine the pre-operative diagnosis of the pancreatic cystic lesions (serous or mucinous cystadenoma, intraductal papillary mucinous neoplasms). In addition, endoscopic ultrasonography permits the collection and analysis of the fluid content. The aim of this paper is to describe our case load in the management of pancreatic cystic neoplasms and propose some criteria for choosing between surgical or conservative approaches., Patients and Methods: 12 patients with pancreatic cystic neoplasms were retrospectively evaluated. They were studied using cross-sectional imaging modalities (computed tomography and magnetic resonance); endoscopic ultrasonography was performed in 7 patients., Results: In each patient a careful evaluation of several factors (age, comorbidity, imaging features, symptoms, life expectancy) conditioned our clinical decision. Among our 12 patients, surgical resection was performed in 7 cases., Discussion: The treatment of pancreatic cystic lesions is still a dilemma because even in the presence of malignant potential, pancreatic surgery remains very complicated and demolitive. Many factors need to be considered in the management of cystic pancreatic tumors. The most important include histological type, location, size, age and clinical condition of the patient., Conclusions: A correct multidisciplinary pre-operative diagnosis is mandatory. Surgery should only be performed in selected cases.

Background: Incidental pancreatic cysts are common, a small number of which are premalignant or malignant. Multidisciplinary care has been shown to alter management and improve outcomes in many types of cancers, but its role has not been examined in patients with pancreatic cysts. We assessed the effect of a multidisciplinary pancreatic cyst clinic (MPCC) on the diagnosis and management of patients with pancreatic cysts., Methods: The referring institution and MPCC diagnosis and management plan were recorded. Patient were placed into one of five categories-no, low, intermediate, or high risk of malignancy within the cyst, and malignant cyst-on the basis of their diagnosis. Patients were assigned one of four management options: surveillance, surgical resection, further evaluation, or discharge with no further follow-up required. The MPCC was deemed to have altered patient care if the patient was assigned a different risk or management category after the MPCC review., Results: Referring institution records were available for 262 patients (198 women; mean age 62.7 years), with data on risk category available in 138 patients and management category in 225. The most common diagnosis was branch duct intraductal papillary mucinous neoplasm. MPCC review altered the risk category in 11 (8.0%) of 138 patients. The management category was altered in 68 (30.2%) of 225 patients. Management was increased in 52 patients, including 22 patients who were recommended surgical resection. Management was decreased in 16 patients, including 10 who had their recommendation changed from surgery to surveillance., Conclusions: MPCC is helpful and alters the management over 30% of patients.

Objectives: Lymphoepithelial cyst (LEC) of the pancreas is an unusual and benign cystic tumor. Accurate preoperative diagnosis is difficult; hence, most of pancreatic LECs are resected. The aim was to describe clinicopathological features of pancreatic LEC to guide appropriate management., Methods: We retrospectively collected data about LEC patients treated in our department between 1987 and 2012 and added cases from review of the literature during the same period., Results: One hundred seventeen cases (3 from our institution and 114 from literature review) were identified. Most patients were men (78%). The discovery was generally fortuitous. Serum CA19-9 was elevated in half of the cases. No specific radiological feature was identified. Fine needle aspiration and cytologic analysis allowed a correct preoperative diagnosis in 21% of the patients, showing presence of squamous cells, lymphocytes, and keratinous debris. Half of them were treated conservatively, whereas other patients underwent surgery. Neither malignant transformation nor recurrence after resection was observed., Conclusions: The LEC of the pancreas is a rare benign tumor that could be treated conservatively. Fine needle aspiration is the only tool that can achieve a diagnosis without resection. If no certain diagnosis can be made, surgery is warranted to rule out a malignant differential diagnosis.

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.

Pancreatic cysts are increasingly being identified by cross-sectional imaging studies. Pancreatic cystic lesions comprise a spectrum of underlying pathologies ranging from benign and pre-malignant lesions to frank malignancies. Magnetic resonance imaging with cholangiopancreatography is a non-invasive imaging modality used for the characterization of cystic pancreatic lesions. This article will review the most common pancreatic cystic neoplasms and the utility of MR imaging in the characterization of these cysts.

Background: Endoscopic ultrasonography (EUS)-guided pancreatic cyst ablation is a minimally invasive treatment modality. Local injection of ablative agents may rarely cause systemic effects in patients., Aims: This study aimed to evaluate the systemic effect of ablative agents by analyzing the plasma drug concentration., Methods: Ten patients with pancreatic cysts were enrolled. Cyst ablation was performed by 99 % ethanol lavage (2.5-70 mL) and paclitaxel (Genexol-polymeric micelle, 6.0-24.0) injection. Blood samples were collected at 0, 2, 4, 7 and 24 h. Plasma paclitaxel concentration was analyzed by a liquid chromatography-tandem mass spectrometry with the lowest limit of quantitation of 0.1 ng/mL. Procedure-related complications were closely monitored., Results: Pancreatic cysts were located at the head in two, body in seven and tail in one patient. Eight cysts were septated. Median diameter and original volume were 39.5 mm (range 2.7-21.8) and 14.79 mL (3.42-343.30). Median cyst fluid CEA and amylase values were 17.10 ng/mL (0.5-14127.5) and 73.50 U/L (3.1-91,590). Peak plasma paclitaxel concentration values were observed between 2 and 7 h, ranging from 0.45 to 14.73 ng/mL. The highest concentration (17.10 ng/mL at 0 h) was observed in a patient who had intracystic bleeding. Mild abdominal pain occurred in five patients and vomiting in one patient during the first 48-h monitoring., Conclusion: Plasma paclitaxel concentration after EUS-guided pancreatic cyst ablation was nearly as low as the undetectable value and rarely caused systemic side-effect.

Objectives: The objectives of this study were to assess the long-term quality of life (QOL) after the resection of a primary pancreatic cyst and to determine predictors of outcome. Secondary outcomes were pancreatic function and survival., Methods: One hundred eight consecutive patients, who underwent resection between 1992 and 2007 and had nearly 60 months follow-up, were reviewed. Questionnaires and function tests were collected during scheduled outpatient clinic visits., Results: At follow-up, 20 patients had died. Five-year overall survival was 94% for benign and 62% for malignant neoplasia. Of 88 living patients, 65 (74%) returned questionnaires. Generic physical and mental QOL scores were equal or better compared with healthy references. None of the disease-specific symptom scales were above mean 50, implicating none to mild complaints. Independent predictors for good generic QOL were young age (P < 0.05) and resected malignancy (P < 0.05); predictors for good gastrointestinal QOL were male sex (P < 0.1), limited resection (P < 0.05), endocrine insufficiency (P < 0.05), and employment (P < 0.05). Endocrine insufficiency prevalence was 40%, and 59% for exocrine insufficiency., Conclusions: After cyst resection, long-term QOL is equal to healthy references, pancreatic insufficiency is prevalent but does not impair QOL, and survival relates positive compared with solid pancreatic adenocarcinoma. The excellent long-term outcome justifies proceeding with surgery once a medical indication for resection has been established.

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.)

Background and Study Aims: Endoscopic ultrasound (EUS)-guided ethanol lavage with paclitaxel injection has been shown to be effective for the treatment of pancreatic cystic neoplasms; however, the evidence for effectiveness is based primarily on cyst resolution on imaging. The aim of this study was to evaluate changes in pancreatic cyst fluid DNA following EUS-guided pancreatic cyst ablation (PCA) with ethanol and paclitaxel., Patients and Methods: In a single-center, prospective study, patients with suspected benign pancreatic cysts (15 - 50 mm in diameter; ≤ 5 compartments) underwent EUS-PCA with ethanol and paclitaxel followed 3 months later by repeat EUS-FNA, cyst aspiration for repeat DNA analysis, and possible repeat EUS-PCA. Abdominal imaging was repeated 3 - 4 months and 12 months after the second EUS. Changes in baseline pancreatic cyst fluid DNA, procedural complications, and radiographic changes in cyst volume were evaluated., Results: A total of 22 patients (median age 67 years; 15 women) with cysts in the head or uncinate (n = 10), body or neck (n = 8), and tail (n = 4), measuring a median diameter of 25 mm (range 15 - 43 mm), underwent one (n = 22) or two (n = 9) EUS-PCA procedures. Baseline cyst DNA included mutations in 11 patients (50 %). Postablation cyst fluid (n = 19) showed elimination of all baseline mutations in eight patients, new mutations in three, and no changes in eight without a baseline mutation. The largest per-protocol postablation image-defined volume change (n = 20) from either of the follow-up abdominal imaging studies (n = 20) demonstrated complete response ( < 5 % original volume) in 10 patients (50 %), partial response (5 % - 25 % original volume) in 5 (25 %), and a persistent cyst (> 25 % original volume) in 5 (25 %). During a median follow-up of 27 months (range 17 - 42 months), adverse events from all EUS-PCAs (n = 31) included abdominal pain alone in four patients (13 %), pancreatitis in three (10 %), peritonitis in one (3 %), and gastric wall cyst in one (3 %). The adverse events were classified as moderately severe in four patients (three with pancreatitis, one with peritonitis)., Conclusion: EUS-PCA with ethanol and paclitaxel may possibly eliminate mutant DNA in neoplastic pancreatic cysts. This technique leads to complete or partial image-defined resolution in 75 % of cysts but may lead to rare adverse events., Clinical Trial Registration: ClinicalTrials.gov (NCT01643460)., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Cystic pancreatic neuroendocrine tumors (cPanNETs) account for 13% to 17% of PanNETs. Although the value of endoscopic ultrasound (EUS) imaging and cyst fluid analysis (CFA) in their preoperative diagnosis has been well described, limited information is available about the diagnostic role of cytology samples obtained from fine-needle aspiration (FNA)., Methods: Cytopathology records between 1992 and 2013 were searched for all reports of cysts interpreted as PanNET. Patient demographics, clinical and radiologic information, CFA, histopathology, and cytopathology findings were recorded. Performance characteristics of cytology and EUS for the accurate diagnosis of cPanNET were calculated., Results: In total, 35 FNAs from 33 patients with cPanNETs were identified, and 34 EUS were performed. Cytology made a specific diagnosis of a cPanNET in 71% of the biopsies compared with a specific diagnosis by EUS in 38% of cases. An interpretation of suspicious for cPanNET was given in 77% of cases by cytology and in 47% by EUS. Cytology identified 86% of the lesions as high-risk pancreatic cysts compared with 56% by EUS. Diagnostic morphology was present on both cytology and cell block preparations in 60% of aspirates, on cytology only in 20%, and on cell block only in 20%. CFA was performed on 51% cyst fluids. All cysts but 1 revealed low carcinoembryonic antigen levels (range, 0.2 to >500 ng/mL; mean, 29.5 ng/mL), and amylase levels were <500 U/L in all but 2 cases (range, 16-1493 U/L; mean, 205 U/L)., Conclusions: Cytology is the most accurate test for preoperative diagnosis of cPanNETs. EUS is insufficiently accurate for independent diagnosis, and carcinoembryonic antigen and amylase analyses are noncontributory., (© 2014 American Cancer Society.)

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.

Background: Solitary true pancreatic cysts (STPCs), or epithelial cysts, are benign lesions that are extremely rare in adult patients. Advances in radiographic techniques have improved the ability to identify pancreatic cystic lesions. We report a case of a large and symptomatic STPC in a 47-year-old female patient who was treated successfully with spleen-preserving laparoscopic distal pancreatectomy. We also review the clinical and pathologic features of all reported STPCs within the past 25 years., Database: To compose the review, we did a search of the international literature for STPCs that had occurred in adults. Fourteen related articles were found describing cases of STPCs. Clinical and pathologic information was collected for all of the reported pancreatic cysts, and a database was formed. STPCs are detected more frequently in women than in men. The mean age of occurrence is 43.2 years, and the mean cyst size is 5.6 cm. Fifty percent of true cysts are located in the head of the pancreas. Size and site are responsible for the symptoms caused, although 22.8% were asymptomatic. Diagnosis was made postoperatively in all cases by histopathologic studies. No case of malignancy was reported in any STPC., Conclusions: STPCs are rare and benign lesions commonly discovered incidentally during abdominal imaging. Surgical treatment is considered the appropriate therapy for large and symptomatic STPCs. The definitive diagnosis is established by histopathologic and immunohistochemical studies.

Background: Mucinous pancreatic cysts (intraductal papillary mucinous neoplasm and mucinous cystic neoplasm) have the potential to progress to invasive pancreatic adenocarcinoma, presenting an opportunity for early detection, prevention, and cure. Serous cystic neoplasms (SCN) have no malignant potential, but can mimic mucinous pancreatic cysts on imaging. Therefore, identification of biomarkers that can distinguish between cystic lesions is critically important. We hypothesize that vascular endothelial growth factor (VEGF)-A levels in pancreatic fluid correlate with pathologic diagnosis., Study Design: Pancreatic cyst/duct fluid samples were prospectively collected from patients undergoing pancreatic resection and correlated with surgical pathology. VEGF levels were detected by ELISA. VEGF-A and VEGF receptor 2 expression in pancreatic tissue was localized by immunohistochemistry. Genetic alterations of the von Hippel-Lindau gene were determined by targeted next-generation sequencing., Results: Eighty-seven patients met inclusion criteria for enrollment. Final pathologic diagnoses included pseudocyst (n = 9), SCN (n = 17), mucinous cystic neoplasm (n = 24), low/moderate grade intraductal papillary mucinous neoplasm (n = 16), high-grade/invasive intraductal papillary mucinous neoplasm (n = 10), and pancreatic ductal adenocarcinoma (n = 11). VEGF-A was significantly upregulated in SCN cyst fluid compared with all other diagnoses (p < 0.0001). With a cut-off of 8,500 pg/mL, VEGF-A has 100% sensitivity and 97% specificity as an SCN biomarker. VEGF-A and VEGF receptor 2 are overexpressed in SCN cyst tissue. VEGF-C was also significantly elevated in SCN cyst fluid (p < 0.0001). With a cut-off set at 200 pg/mL, VEGF-C identifies SCN with 100% sensitivity and 90% specificity. The presence of a von Hippel-Lindau mutation in SCN cyst tissue correlates with elevated cyst fluid VEGF levels., Conclusions: This is the first report of a cyst fluid protein biomarker that can positively identify SCN. The ability to distinguish SCN from premalignant/malignant pancreatic cysts can spare the cost and risk of surveillance and surgical intervention in select patients., (Copyright © 2014 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Incipient intraductal papillary mucinous neoplasms (IPMNs) are poorly described subcentimeter pancreatic cysts with papillae and mucin similar to IPMNs. They are larger than pancreatic intraepithelial neoplasia but do not meet the cutoff size for IPMNs (≥ 1 cm). GNAS codon 201 mutations are hallmark genetic alterations of IPMNs. Hence, we sought to determine the GNAS status of incipient IPMNs to better classify these lesions. Incipient IPMNs from 3 institutions were histologically reassessed, manually microdissected, and the genomic DNA was extracted. Using a sensitive digital ligation technique, the mutational status of KRAS at codon 12 and GNAS at codon 201 was determined. We included 21 incipient IPMNs from 7 male and 12 female patients with a median age of 63 years (range, 40 to 76 y). Most patients underwent surgery for pancreatic ductal adenocarcinoma (N = 8) or ampullary adenocarcinoma (N = 3). The median incipient IPMN size was 4 mm (range, 2 to 7 mm), and a majority had gastric-foveolar (N = 11) or intestinal (N = 5) differentiation. The maximum dysplasia observed was intermediate, and most of the lesions had intermediate-grade dysplasia. Mutational analysis revealed KRAS codon 12 mutations in all 21 incipient IPMNs, whereas 7 lesions (33%) in 7 individual patients harbored GNAS codon 201 mutations. The presence of GNAS 201 mutations in incipient IPMNs suggests that a fraction of these cysts are in fact small IPMNs. Morphologically, incipient IPMNs do not appear to be high-risk lesions. Additional studies in a larger cohort are needed to define the relationship of incipient IPMNs to larger IPMNs and, more importantly, to determine their clinical significance.

Objectives: With the increased use of cross-sectional radiologic imaging in recent years, cystic lesions of the pancreas are being diagnosed with greater frequency. While pseuodocysts have historically accounted for the majority of benign pancreatic cysts, there are a number of rare, benign cystic lesions of the pancreas that can mimic neoplastic cysts. The objective of this study was to review a single institution's experience with these benign cystic lesions of the pancreas., Methods: We conducted a retrospective analysis of all patients who underwent surgical resection for pancreatic disease from 2005 to 2012 at our institution. Out of a total of 947 pancreatic resections, we identified those cases performed for cystic disease, and focused upon the clinicopathologic data of patients with non-neoplastic pancreatic cysts., Results: Of the 947 pancreatic resections, 256 (27%) were performed for cystic disease. Sixteen cases (6.3%) out of the total of 256 pancreatic operations performed for cystic disease were found to have non-neoplastic cystic lesions of the pancreas. Preoperative imaging revealed primary lesions in all patients, eight of which were found incidentally. Of these lesions, 14 were suspected preoperatively to be mucinous neoplasms and two to harbor pancreatic adenocarcinoma. However, postoperative pathology revealed eight patients with ductal retention cysts, three squamoid cysts, one mucinous non-neoplastic cyst, one congenital ciliated foregut cyst, one lymphoepithelial cyst, and two endometrial cysts. Two patients had complications postoperatively, one pancreatic fistula and one SMV thrombosis. Both complications resolved with conservative management., Conclusions: Non-neoplastic epithelial pancreatic cysts are rare, benign lesions. In our institutional experience, these lesions are often indistinguishable from cystic neoplasms of the pancreas preoperatively. As such, many of these lesions are resected unknowingly. It is important for the clinician to be well informed of the nature of these lesions, in the hopes to avoid unnecessary resection whenever possible.

Pancreatic pseudocysts are the most common cystic lesions of the pancreas and may complicate acute pancreatitis, chronic pancreatitis, or pancreatic trauma. While the majority of acute pseudocysts resolve spontaneously, few may require drainage. On the other hand, pancreatic cystic tumors, which usually require extirpation, may disguise as pseudocysts. Hence, the distinction between the two entities is crucial for a successful outcome. We conducted this study to highlight the fundamental differences between pancreatic pseudocysts and cystic tumors so that relevant management plans can be devised. We reviewed the data of patients with pancreatic cystic lesions that underwent intervention between June 2007 and December 2010 in our hospital. We identified 9 patients (5 males and 4 females) with a median age of 40 years (range, 30-70 years). Five patients had pseudocysts, 2 had cystic tumors, and 2 had diseases of undetermined pathology. Pancreatic pseudocysts were treated by pseudocystogastrostomy in 2 cases and percutaneous drainage in 3 cases. One case recurred after percutaneous drainage and required pseudocystogastrostomy. The true pancreatic cysts were serous cystadenoma, which was treated by distal pancreatectomy, and mucinous cystadenocarcinoma, which was initially treated by drainage, like a pseudocyst, and then by distal pancreatectomy when its true nature was revealed. We conclude that every effort should be exerted to distinguish between pancreatic pseudocysts and cystic tumors of the pancreas to avoid the serious misjudgement of draining rather than extirpating a pancreatic cystic tumor. Additionally, percutaneous drainage of a pancreatic pseudocyst is a useful adjunct that may substitute for surgical drainage.

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.

A 54-year-old man exhibited a pancreatic mass on abdominal ultrasonography. Diagnostic imaging with endoscopic ultrasonography, computed tomography, and magnetic resonance imaging revealed that the mass comprised various internal structures and was not connected to the pancreatic duct. Over a period of 4 years and 2 months, the mass increased from 22mm to 32mm in diameter. Laparoscopic enucleation was performed, and a histopathological diagnosis of a lymphoepithelial cyst (LEC) of the pancreas was obtained. LEC is rare and seldom reported in the literature. Although it is considered to be benign, most case reports indicate that they tend to increase in size. This indicates that LEC should be carefully monitored if surgery is not performed after diagnosis.

Context: The accuracy for determining pancreatic cyst volume with commonly used spherical and ellipsoid methods is unknown. The role of CT volumetry in volumetric assessment of pancreatic cysts needs to be explored., Objectives: To compare volumes of the pancreatic cysts by CT volumetry, spherical and ellipsoid methods and determine their accuracy by correlating with actual volume as determined by EUS-guided aspiration. Setting This is a retrospective analysis performed at a tertiary care center. Patients Seventy-eight pathologically proven pancreatic cysts evaluated with CT and endoscopic ultrasound (EUS) were included. Design The volume of fourteen cysts that had been fully aspirated by EUS was compared to CT volumetry and the routinely used methods (ellipsoid and spherical volume). Two independent observers measured all cysts using commercially available software to evaluate inter-observer reproducibility for CT volumetry., Main Outcome Measures: The volume of pancreatic cysts as determined by various methods was compared using repeated measures analysis of variance. Bland-Altman plot and intraclass correlation coefficient were used to determine mean difference and correlation between observers and methods. The error was calculated as the percentage of the difference between the CT estimated volumes and the aspirated volume divided by the aspirated one., Results: CT volumetry was comparable to aspirated volume (P=0.396) with very high intraclass correlation (r=0.891, P<0.001) and small mean difference (0.22 mL) and error (8.1%). Mean difference with aspirated volume and error were larger for ellipsoid (0.89 mL, 30.4%; P=0.024) and spherical (1.73 mL, 55.5%; P=0.004) volumes than CT volumetry. There was excellent inter-observer correlation in volumetry of the entire cohort (r=0.997, P<0.001)., Conclusions: CT volumetry is accurate and reproducible. Ellipsoid and spherical volume overestimate the true volume of pancreatic cysts.

Gastric duplication cysts are rare cystic neoplasms that are often difficult to distinguish from other entities. We describe a healthy 44-year-old woman who presented with acute right lower quadrant abdominal and flank pain as well as chronic nausea and constipation. Her physical examination was unremarkable but contrasted computed tomography revealed a 6 cm cystic lesion between the stomach and body of the pancreas. Endoscopic ultrasonography and fluid analysis were consistent with a mucinous cyst with a markedly elevated fluid carcinoembryonic antigen level. The patient subsequently underwent a laparoscopic distal pancreatectomy, which was converted to an open procedure when the lesion was noted to be adherent to the coeliac axis. Intraoperative endoscopy revealed no abnormality. Final pathology revealed a gastric duplication cyst. The patient recovered well and was asymptomatic on follow-up. In this report, we discuss the incidence, natural history and management of this rare entity.

A 70-year-old woman was found to have 2 cystic lesions in the head of the pancreas on abdominal ultrasonography during a routine medical examination. Endoscopic ultrasonography (EUS) and magnetic resonance cholangiopancreatography showed multilocular cysts in the head of the pancreas without dilation of the main pancreatic duct. The patient was followed-up semiannually with imaging studies for suspected branch duct-type intraductal papillary mucinous neoplasm (IPMN). At 3 years after initial presentation, hypoechoic lesions were observed around each pancreatic cyst by EUS. Diffusion-weighted imaging showed high-intensity regions corresponding to these lesions. Therefore, a diagnosis of invasive carcinoma derived from IPMN could not be excluded, and subtotal stomach-preserving pancreaticoduodenectomy was performed. The macroscopic examination of the surgical specimen showed whitish solid masses in the head of the pancreas, with multilocular cysts within each mass. Microscopically, each solid mass consisted of inflammatory cells such as lymphocytes and plasma cells. Furthermore, immunochemical staining revealed immunoglobulin G4-positive cells, and many obliterating phlebitides were observed. The cysts consisted of mucus-producing epithelial cells and showed a papillary growth pattern. Based on these findings, we diagnosed multiple localized type 1 autoimmune pancreatitis occurring only in the vicinity of the branch duct-type IPMN.

Introduction: Accessory spleen is a relatively common congenital defect with a 10% incidence in the population. Intrapancreatic accessory spleens are rare and cystic formation may mimic a hypervascular pancreatic tumour., Case Report: We present the case of a 27-year-old woman who underwent abdominal ultrasonography (USG) because of chronic abdominal discomfort. USG findings revealed a 20 mm cystic mass in the tail of the pancreas. Additional preoperative investigations showed a tumour in the tail of the pancreas suspected of being a non-active neuroendocrine tumour. The intraoperative finding was a hard mass in the tail of the pancreas and neither peritoneal dissemination nor metastasis was detected. Distal pancreatectomy was performed. Pathological examination described an epithelial cyst in an intrapancreatic accessory spleen., Discussion: Cyst formation in an intrapancreatic accessory spleen is extremely rare. Most patients with this condition have no clinical symptoms and it is often detected incidentally by imaging studies. It is difficult to differentiate an epithelial splenic cyst in the pancreas from a primary pancreatic neoplasm because it lacks particular characteristics on radiological examination; epithelial splenic cysts should be considered in the differential diagnosis of a cystic lesion in the tail of the pancreas. Key words: spleen - epithelial cyst - intrapancreatic accessory spleen.

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.