CEA and CA 19-9 in benign pulmonary or mediastinal cystic lesions

Application of endoscopic ultrasound-guided-fine needle aspiration combined with cyst fluid analysis for the diagnosis of mediastinal cystic lesions

BACKGROUND

Mediastinal cystic lesions account for approximately 15-20% of all mediastinal masses and are difficult to differentiate because of similar imaging manifestation. The aim of this study was to differentiate mediastinum cystic lesions through endoscopic ultrasound-guided-fine needle aspiration (EUS-FNA) and parameters from cyst-fluid analysis.

METHODS

Over a period of eight years, 37 patients suspected with mediastinal cystic lesions were assessed. Cyst fluid was collected via EUS-FNA and further examined using cytological and biochemical techniques. Definitive diagnosis was established based on cytology, surgical pathology, and/or clinical follow-up.

RESULTS

Based on the final pathological reports or long-term follow-up, 19 patients were diagnosed with benign cysts, 14 with benign or malignant tumors, 2 with tuberculosis, 1 with an abscess, and 1 with a pancreatic pseudocyst. Computed tomography or magnetic resonance imaging mistakenly distinguished eight cases as solid masses (27.03%), but EUS revealed cystic characteristics. Carcinoembryonic antigen and lactate dehydrogenase (LDH) were evaluated from the cyst fluid obtained by EUS-FNA. There was no statistically significant difference in carcinoembryonic antigen values between benign and malignant cysts; however the average LDH value in the malignancy group was significantly higher than in the benign group.

CONCLUSION

EUS-FNA showed great potential for differentiating mediastinal lesions by combining imaging manifestation and cytological examination. The elevated LDH value from cyst fluid chemical analysis could be used as an auxiliary indicator for diagnosing malignancy.

Benign cystic mediastinal teratoma presenting as a massive pleural effusion in a 17-year-old boy

Mediastinal teratomas are a rare, albeit an important differential diagnosis of anterior/middle mediastinal masses in young adults and various atypical presentations have been reported. The authors report a case of a 17-year-old boy who presented with a 2-month history of worsening shortness of breath and pleuritic chest pain. A massive left-sided pleural fluid collection was seen on a chest radiograph (CXR). The pleural fluid was drained and a CT Thorax confirmed the presence of a cystic mass. Following re-accumulation of the fluid, thoracotomy was performed and a benign mediastinal teratoma excised. The patient remained well with no evidence of recurrence on follow-up CXRs a year post operatively.

Mature cystic teratoma of the pancreas: Role of endoscopic ultrasound

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.

[A case of atypical pericarditis]

INTRODUCTION

An acute viral pericarditis may reveal a congenital pericardial abnormality.

CASE HISTORY

We report the case of a young man of 29 years in whom the development of rapidly progressive dyspnoea and fever led to the echocardiographic diagnosis of a pericardial tumour. The thoracic CT scan showed a mass arising in the superior mediastinum with no evidence of spread. Surgical exploration allowed the excision of a soft mutilobular mass adherent only to the aorta. Histological examination revealed an intrapericardial bronchogenic cyst.

CONCLUSION

After a review of bronchogenic cysts we point out the properties of this rare intra-pericardial localisation, one of which is the frequently observed secretion of CA 19-9.

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

BACKGROUND

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

CASE OUTLINE

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

DISCUSSION

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

Subcarinal bronchogenic cyst with high carbohydrate antigen 19-9 production

In a rare case of bronchogenic cyst with high carbohydrate antigen (CA) 19-9 production, a 57-year-old man with coughing and chest pain was diagnosed with a subcarinal mediastinal tumor. Fiberoptic bronchoscopy showed an erosive mucosal lesion overlying the area of extrinsic compression at the membranous of the right mainstem bronchus. Serum carbohydrate antigen 19-9 was elevated at 1300 U/ml. Thoracotomy showed an encapsulated cyst tightly adhering to the right main bronchus. The cyst was extirpated after ablation at the adherent cystic wall by electrocautery. Although intracystic carbohydrate antigen 19-9 concentration was very high, serum carbohydrate antigen 19-9 and bronchoscopic findings returned to normal postoperatively. The histological diagnosis was consistent with a bronchogenic cyst and carbohydrate antigen 19-9 could be immunohistochemically demonstrated within its epithelium.

Mediastinal esophageal cyst causing unilateral hyperlucent lung

Unilateral emphysema secondary to bronchial obstruction by a foregut-derived mediastinal cyst is rare. Here we describe an infant with a unilateral hyperlucent lung due to compression on the left main bronchus by an esophageal cyst, visualized by chest computed tomography and magnetic resonance imaging. A chest roentgenogram and a perfusion scan presented the normalized left lung after resection of the cyst.

A high cervical intradural extramedullary bronchogenic cyst. Case report

This article describes a 16-year-old male patient, otherwise healthy, with intractable suboccipital pain due to an intradural, extramedullary bronchogenic cyst at C1 level. Computed tomographic and magnetic resonance imaging scans showed an extramedullary cystic lesion on the right anterolateral side of the spinal cord at C1 level. No other vertebral, spinal cord, or cutaneous abnormality was associated. The patient underwent posterolateral resection of the C1 bony ring on the right side, followed by complete removal of a cyst microsurgically. Histology suggested that the mass, with its contents of slightly viscous and opaque liquid, was an atypical form of bronchogenic cyst with abundant pseudostratified ciliated epithelial cells.

Case report: ciliated foregut cyst of the pancreas mimicking teratomatous tumour

A ciliated cyst of foregut origin is often found in relation to the tracheobronchial tree and the upper gastrointestinal tract, when it is called bronchogenic cyst and enterogenous cyst, respectively. Cysts of this type rarely occur in the pancreas. We report a case of ciliated foregut cyst involving the pancreas, and mimicking teratomatous tumour on radiology.

Immunohistochemical detection of carbohydrate determinant 19-9 (CA 19-9) in intracranial epidermoid and dermoid cysts

We evaluated carbohydrate antigen (CA) 19-9 levels of intracranial dermoid and epidermoid cyst in serum and intratumoral tissue. The preoperative serum levels were mildly to moderately higher than their normal ranges in four of seven patients. In four patients with high serum CA 19-9 levels, they returned to normal ranges in three who had the cyst resected totally and remained slightly high in one with residual cyst. Immunohistochemical studies using anti-CA 19-9 antibody demonstrated positively stained capsule and keratinous tissue. Serum CA 19-9 levels of intracranial dermoid or epidermoid cysts with more teratomatous components may be elevated above normal levels.

Giant hamartoma of the lung with a high production of carbohydrate antigen 19-9

A rare case of a giant pulmonary hamartoma with a high production of carbohydrate antigen (CA) 19-9 is presented. A 43-year-old woman with complaints of cough, fever, and chest pain was diagnosed as having a posterior mediastinal tumor with pneumonia. The serum CA 19-9 level was high. A thoracotomy revealed an intrapulmonary solid mass with a histologic diagnosis of cartilaginous hamartoma with no evidence of malignancy. The CA 19-9 concentration in the mucus of the tumor was high, and postoperatively the serum CA 19-9 level returned to normal. The CA 19-9 could be immunohistochemically demonstrated on the surface of the tumor.