Metastatic adenocarcinoma arising in a congenital foregut cyst of the esophagus: a case report with review of the literature

Surgical esophageal diseases in children

Pediatric age esophageal diseases are rare and complex clinical conditions. Treatment options should be individually determined for the patient. The advances in the follow-up and treatment process is the most important reason for the increase in survival time, particularly for congenital pediatric surgical diseases. This study aimed to evaluate the general characteristics of pediatric surgical esophageal diseases in light of the literature.

Mucosal Soft Tissue Lesions

Mucosal soft tissue lesions are fairly common in the pediatric population. However, the precise prevalence is unknown. This is the result of the limited number of studies, the use of various diagnostic criteria in those studies, and the transient nature of commonly encountered lesions in this population. In this section, we seek to familiarize the pediatric pathologist with a sampling of mucosal soft tissue lesions encountered in pediatric patients, highlight key diagnostic features and correlations with systemic diseases should they exist.

A ciliated hepatic foregut cyst mimicking hydatid cyst treated with laparoscopic surgery; a case-report and review of literature

INTRODUCTION AND IMPORTANCE

Congenital hepatic foregut cyst (CHFC) is a rare condition that is derived from an abnormal detachment of esophageal buds during foregut embryonic development. Early treatment is generally recommended due to the potential of malignant transformation. In this study, we are reporting our experience with laparoscopic resection of CHFC in a female patient.

CASE PRESENTATION

A 41-year-old female farmer presented with a 5-month history of right upper quadrant (RUQ) pain with a palpable mass. Abdominal examination revealed a visible subhepatic large mass with an estimated size of 10 cm, which was horizontally mobile. Abdominopelvic ultrasonography showed a 76 ∗ 87 ∗ 15 cm single subhepatic cyst with internal septations. The patient was scheduled to undergo laparoscopic surgical resection of the cyst with an initial diagnosis of a hepatic hydatid cyst. Histopathologic evaluations showed that the cyst wall was composed of four layers consistent with the diagnosis of CHFC.

CLINICAL DISCUSSION

Due to the disease's rarity there have been various recommendations regarding treatment of CHFC in literature including observation with serial imaging, aspiration, and surgical excision. However, surgical excision is considered the most reasonable option given the chance of malignant transfusion, particularly in patients with enlarging cysts with size of more than 4 cm, cyst wall abnormality, abnormal liver function tests, and symptomatic cases.

CONCLUSION

Surgical resection is a feasible option for resection of CHFC given that the cyst wall is thick enough to be excised from the hepatic parenchyma and the lesion is situated on the surface of the liver.

A congenital cystic pulmonary airway malformation occurring together with both an extralobar pulmonary sequestration and an esophageal duplication cyst

A foregut duplication cyst occurring together with both a congenital cystic pulmonary airway malformation and extralobar pulmonary sequestration is an unusual combination. Prenatal ultrasound, MRI, and postnatal CT are helpful for operative planning. Surgical resection is the definitive management for all three anomalies.

Esophageal duplication and congenital esophageal stenosis

Esophageal duplication and congenital esophageal stenosis (CES) may represent diseases with common embryologic etiologies, namely, faulty tracheoesophageal separation and differentiation. Here, we will re-enforce definitions for these diseases as well as review their embryology, diagnosis, and treatment.

Surgical resolution of an oesophageal duplication cyst causing regurgitation in a domestic shorthair cat

CASE SUMMARY

An 18-month-old female domestic shorthair cat was referred for investigation of a 6 month period of regurgitation. Contrast radiography indicated an intramural oesophageal structure. Ultrasound-guided fine-needle aspiration of the area retrieved viscous fluid containing high numbers of squamous epithelial cells. Computed tomography disclosed a thin-walled contrast-enhancing structure containing non-enhancing homogenous contents. Exploratory thoracotomy confirmed an intramural cystic oesophageal structure, which was resected. Histopathological analysis of the resected tissue demonstrated an intramural oesophageal duplication cyst. A 12 month follow-up period has seen complete resolution of the cat's clinical signs.

RELEVANCE AND NOVEL INFORMATION

This is the first report of successful oesophageal duplication cyst removal in a cat. Oesophageal duplication cysts should be included on the differential list for dysphagia and regurgitation in cats. Complete surgical removal in this cat carried a good long-term outcome.

Esophageal cancer with esophageal duplication cyst

Esophageal duplication cysts are benign, asymptomatic anomalies of foregut formation. We report a case of esophageal duplication cyst with esophageal squamous cancer. An upper endoscopy visualized with esophageal scan disclosed a stenotic lesion in the lower esophagus. Computed tomography images revealed a cystic mass in the inferior mediastinum, which was on the right wall of the esophagus. The postoperative pathology report confirmed the diagnosis of esophageal squamous cancer (ulcer type) and esophageal duplication cyst with calcification.

Acute respiratory distress caused by esophageal duplication canceration in an adult

Esophageal duplication (ED) in adults is rare, and ED canceration is very rare. We report a case of acute respiratory embarrassment caused by ED with squamous carcinoma in a 39-year-old man and a review of the literature.

Foregut duplication cysts: A report of two cases with emphasis on embryogenesis

Duplication cyst of the stomach with a pseudostratified columnar ciliated epithelium is extremely rare. We describe two cases of these cysts, with emphasis on their immunophenotype and embryogenesis. The first patient was a 29-year-old man who presented with cramping abdominal pain in his left lower quadrant. The second patient was a 26-year-old woman who had a history, over several years, of chronic epigastric abdominal pain radiating to her back. Both lesions were surgically removed. They showed the same histomorphology. The cysts were lined by a pseudostratified respiratory epithelium with ciliated cells. The first cyst was connected to the stomach, while the second cyst was not connected. Both cysts expressed thyroid transcription factor-1 (TTF-1) and surfactant. In this report, we explore the possible embryogenesis of these lesions in the light of TTF-1 and surfactant expression.

Foregut duplication cysts in siblings: A case report

Enteric duplication cysts are rare congenital anomalies that result from heterotrophic rests of foregut-derived epithelium in the head, neck, thorax or abdomen. Typically, foregut duplication cysts of the head and neck are diagnosed in asymptomatic children. No single embryologic process has been identified to explain causation. In this case, we report a case of two siblings with foregut duplication cysts-one cyst occurring in the floor of mouth and the other occurring in the thorax as an esophageal duplication. To our knowledge, this is the first report of such an event in the literature. This case raises the question of a possibly inherited foregut cyst versus a spontaneous occurrence in first degree relatives.

Bronchogenic and Esophageal Cyst With Laryngeal Malformations in a Thoroughbred Foal

This report documents an unusual case of congenital foregut cyst with dysphagia and stridor in a Thoroughbred foal. Histologically, the bilocular cyst, near the junction of larynx and trachea, had an epithelial lining of bronchogenic and esophageal origin. Concomitant malformation of the laryngeal muscles and cartilage resulted in a combination of anomalies that have not been reported in the human or veterinary literature.

Infection after endoscopic ultrasound-guided aspiration of mediastinal cysts

Foregut duplication cysts are rare congenital anomalies of enteric origin that arise during early embryonic development. They are usually incidentally found on routine imaging studies. The diagnosis can usually be made by computed tomography (CT) and endoscopic ultrasound (EUS) appearance. On CT, cyst attenuation values usually measure 0+/-20 Hounsfield units (HU). Higher HU is possible with hemorrhage, proteinaceous material or septations. At EUS, characteristic location and anechoic as well as hypoechoic but not necessarily anechoic appearance may be suggestive of a foregut duplication cyst. EUS-guided fine needle aspiration (FNA) has been thought to provide a safe, minimally invasive approach to establish the diagnosis. The purpose of this report is to highlight the potential for infectious risk of EUS-FNA for these cysts, and to suggest CT and EUS features that can suggest this diagnosis without FNA. Three patients who underwent EUS-FNA for diagnosis of incidental mediastinal lesions developed cyst infection despite accepted techniques including prophylactic antibiotics. Combined CT and EUS appearance may be sufficient in making this diagnosis without FNA. IV antibiotics may not be completely protective against infectious complications of FNA of mediastinal duplication cysts.

Ciliated foregut cyst of the pancreas: preoperative diagnosis using endoscopic ultrasound guided fine needle aspiration cytology--a case report with a review of the literature

A 51-year-old male presented with a 4-month history of abdominal pain, decreased appetite, and postprandial bloating. A CT scan showed a solitary, 5.3 x 4.4 cm, cystic lesion in the body/tail of the pancreas. Endoscopic retrograde cholangiopancreatography did not show communication between the pancreatic duct and the cystic lesion. Endoscopic ultrasound (EUS) examination revealed a 6.9 x 2.4 cm cystic lesion in the body/tail region of the pancreas without septae or solid components. The pancreatic parenchyma, pancreatic duct, and common bile duct were unremarkable. EUS-guided fine needle aspiration (EUS-FNA) was performed using a 22-gauge EchotipTM needle. Only a few drops of viscous fluid could be aspirated. Papanicolaou-stained direct smears and SurePath (Autocyte) preparations were evaluated. The direct smears were hypocellular; however, the concentration method producing liquid-based cytology preparation showed detached ciliary tufts (degenerated debris with ciliated cellular fragments of cell tops without nuclei) and occasional intact ciliated cells consistent with a ciliated foregut cyst. Although benign, the cyst was resected to alleviate the symptoms. The surgical pathology confirmed the benign preoperative interpretation of the ciliated foregut cyst. To the best of our knowledge, this is the first case of pancreatic ciliated foregut cyst reported to be diagnosed preoperatively by EUS-FNA. For a proper preoperative cytologic diagnosis, the needle rinses should be processed adequately. Otherwise, these hypocellular specimens with mucin may be misinterpreted as mucinous cystic lesions.

Ciliated hepatic foregut cyst: an increasingly diagnosed condition

Ciliated hepatic foregut cyst is a rare foregut cystic developmental malformation. It presents as a solitary cystic lesion in segment four of the liver. Histologically, it consists of four distinct layers; namely, the inner ciliate columnar epithelium, subepithelial connective tissue, smooth muscle layer, and an outer fibrous layer. Usually asymptomatic and detected incidentally, other modes of presentation can include portal hypertension, obstructive jaundice, and development of malignancy. We present a case of a young asymptomatic woman with a complex cyst in segment four of the liver, who underwent a laparoscopic resection, focusing our discussion on the review of the literature and the diagnostic dilemma encountered in these rare cases.

Clinicopathologic demonstration of complex bronchopulmonary foregut malformation

Bronchopulmonary foregut malformations are rare and often prove to be extremely difficult to diagnose. The presented case is a 44-year-old man complaining about cough and hemoptysis. These symptoms continued despite medical treatment. A computed thorax tomographic scan depicted a paravertebral cystic lesion. The patient underwent surgical exploration, and communication between the cyst and the esophagus was found. A left lower lobectomy was performed. The pathologic result confirmed a duplication cyst of mixed bronchogenic and esophageal type with bronchiectasis of the lower lobe. We present this unusual malformation complex especially in an adult with the review of the literature.

Esophageal Duplication Cyst in a Dog

A cranial cervical mass was surgically removed from a dog. On histologic examination, the mass was consistent with an esophageal duplication cyst, a condition rare in humans and not reported in the dog.

Ciliated foregut cyst of pancreas: cytologic findings on endoscopic ultrasound-guided fine-needle aspiration

The cytologic findings of a ciliated foregut cyst of the pancreas diagnosed by endoscopic ultrasound-guided fine-needle aspiration (FNA) are described. Cytologic features of ciliated foregut cysts include the presence of ciliated columnar cells and detached ciliary tufts in a cystic fluid background with amorphous debris and rare macrophages. These cytologic findings are clearly distinct from those of cystic mucinous neoplasms and other pancreatic cysts with which the ciliated foregut cyst may be confused. To the best of our knowledge, this is the first case reporting the cytologic findings of a pancreatic ciliated foregut cyst sampled by endoscopic ultrasound-guided FNA. We believe that the distinctive and characteristic cytologic features can allow a preoperative cytologic diagnosis of this highly unusual pancreatic cystic lesion.

Partial laparoscopic resection of inflamed mediastinal esophageal duplication cyst

We present a case of a 54-year-old woman who underwent a successful partial laparoscopic resection of a secondary inflamed esophageal duplication cyst localized in the lower posterior mediastinum. Laparoscopic approach was used for the surgical treatment of the intrathoracic esophageal duplication cyst for the first time. The standard surgical treatment uses thoracotomy or thoracoscopy, but the localization of the cyst in the lower mediastinum enables also the laparoscopic approach as it is demonstrated. Moreover, laparoscopy minimizes the risk of postoperative inflammatory complications in the pleural cavity especially after the surgery of secondary inflamed cysts.

Cystic lesions of the mediastinum

Cysts of the mediastinum comprise a relatively diverse group of lesions that include neoplastic and nonneoplastic constituents, the latter of which are largely congenital in nature. Therefore, a grasp of their clinicopathologic characteristics is bolstered by knowledge of which tumors in the chest may undergo cystic change, as well as the embryologic development of the thoracic organs. That information, as well as radiological and pathologic features of these lesions, is discussed in this review.

Thoracoscopic resection of esophageal duplication cysts

Esophageal duplication is a rare congenital esophageal disorder. Surgical excision is the standard treatment for symptomatic esophageal duplication cysts. Traditionally, the resection is accomplished via thoracotomy; however, a minimally invasive approach is possible, avoiding the long hospital stay, the discomfort and the long recovery time due to a thoracotomy. The authors describe two cases of esophageal duplication resected via a left thoracoscopic approach.

Ciliated hepatic foregut cyst in a young child

Ciliated hepatic foregut cysts are a rare entity usually found in adults. We present a case of a 3-year-old boy incidentally noted to have a radiographically complex liver cyst on computed tomographic scan. Given the complex appearance, the cyst was excised. Pathology revealed a ciliated hepatic foregut cyst. This is the second child and youngest patient affected with this lesion reported in the literature. The etiology of the lesion and an argument for surgical removal in pediatric patients are presented.

Successful endoscopic treatment of an esophageal duplication cyst

Duplication cysts of the gastrointestinal tract are rare, particularly in adults. Endoscopic minimally invasive treatment is still a challenging approach even in the endoscopically accessible sections of the gastrointestinal tract. In a 25-year-old patient suffering from dysphagia, an endoscopy and subsequent endosonography revealed a spherical duplication cyst in the lower third of the esophagus, which prompted us to puncture the cyst and subsequently to perform a fenestration (marsupialization; diameter 1 cm) in the anterior wall of the cyst, resulting in permanent drainage of the cystic fluid. Because of the recurrent complaints of the patient after 6 weeks, the anterior wall of the duplication cyst, the former esophageal wall, was partially resected, resulting in a permanent 4-cm opening including the cystic cavity into the esophageal lumen. Thereafter, there were no further complaints from the patient and the findings in the follow-up endoscopy were normal. A successful endoscopic intervention for this type of gastrointestinal duplication cyst is described for the first time. The minimally invasive resection of the anterior wall of the esophageal duplication cyst, simultaneously with the former regular wall at this segment of the esophagus, resulted in permanent inclusion of the cystic cavity into the esophageal lumen with no disadvantageous passage of fluid and food through the lower esophagus or changes in the former cystic epithelium. This method is considered to be feasible and a reasonable treatment alternative to the more invasive surgical approach.

Ciliated hepatic foregut cyst: A rare but increasingly reported liver cyst

We report a case of a ciliated hepatic foregut cyst (CHFC) in the left lobe of the liver in a 42-year-old woman. To date, only 60 cases of these respiratory epithelial lined hepatic cysts have been reported since first described by Friedrich in 1857. CHFC are believed to be congenitally derived from the embryonic foregut and are considered benign lesions that are most often unilocular. Recently, however, there has been documented malignant transformation in these cysts. The majority of patients with a CHFC are asymptomatic and the cyst is usually an incidental finding during abdominal imaging studies or during surgical exploration. Interestingly, 85% of the total number of cases of CHFC have been reported within the last two decades. This recent rise in case reports is likely explained by greater detection because of the dramatic rise in the use of abdominal imaging. In our case, however, ultrasound failed to demonstrate any lesion within the liver and on computed tomography the cyst was more consistent with a soft tissue mass. Therefore, pathologic evaluation was necessary for the correct diagnosis of this liver lesion and to exclude malignancy.

Intestinal obstruction in neonatal/pediatric surgery

Intestinal obstruction in the newborn infant and older child may be due to a variety of conditions, including atresia and stenosis, annular pancreas, malrotation, duplication cyst, meconium ileus, meconium plug syndrome and neonatal small left colon syndrome, Hirschsprung's disease, neoplasia, trauma, and other rarer causes. The mode of presentation can be acute or more chronic with systemic upset due to shock. Neonates, more so than older children, with unrecognized intestinal obstruction deteriorate rapidly, show an increase of associated morbidity and mortality and appropriate surgical treatment becomes more hazardous. Early diagnosis depends largely on the prompt detection of obstructive manifestations by the clinician and the subsequent accurate interpretation of radiographic findings and other investigations, leading to definitive treatment, which should always be preceded by appropriate resuscitation/preparation of the infant/child. Management of intestinal obstruction will almost always be surgical, apart from some notable exceptions and all are discussed in more detail. With the advent of pediatric and neonatal intensive care and multidisciplinary care, the morbidity and mortality of cases of intestinal obstruction reported in current series is generally extremely low and mainly determined by the coexistence of other major congenital anomalies (eg, cardiac), delays in diagnosis and treatment or coexisting medical conditions. Newer treatments and future developments may reduce the residual mortality in such cases as ultrashort-bowel syndrome.

Case report: Squamous carcinoma in an oesophageal foregut cyst

Cysts within the oesophageal wall may represent inclusion cysts, retention cysts or developmental cysts. Foregut duplications are developmental anomalies, which occur as a result of abnormal canalization of the foregut during intrauterine life. Malignant transformation is an extremely rare event occurring within oesophageal cysts, adenocarcinoma being the most common histology. We report a case of squamous cell carcinoma arising within an oesophageal cyst affecting the upper third of the oesophagus. The malignant cyst was not amenable to primary surgical resection and hence was treated using chemo-radiotherapy. The treatment gave good disease control, at the expense of a high oesophageal stricture. Chemo-radiotherapy is an alternative treatment modality to achieve long-term disease control in squamous cell carcinoma complicating oesophageal foregut cyst when primary surgical resection is not possible.

Predictive factors for acute pancreatitis and hyperamylasemia after endoscopic papillary balloon dilation

BACKGROUND

Although endoscopic papillary balloon dilation may result in acute pancreatitis or hyperamylasemia, the risk factors for these complications have not been well documented. Risk factors predictive of acute pancreatitis and hyperamylasemia after endoscopic papillary balloon dilation were retrospectively analyzed.

METHODS

In 118 patients who underwent endoscopic papillary balloon dilation for choledocholithiasis, postendoscopic papillary balloon dilation acute pancreatitis and hyperamylasemia (at least 3-fold elevation) were investigated. A multivariate analysis was conducted for 20 potential risk factors related to clinical and procedure characteristics.

RESULTS

Bile duct clearance was achieved in 113 patients. Early complications in the form of mild pancreatitis occurred in 7 patients (6%). Multivariate analysis identified history of acute pancreatitis as the only risk factor for postendoscopic papillary balloon dilation pancreatitis. Postendoscopic papillary balloon dilation hyperamylasemia occurred in 30 patients (25%). Multivariate analysis identified 4 independent risk factors for hyperamylasemia: an age of 60 years or less, previous pancreatitis, bile duct diameter 9 mm or less, and difficult bile duct cannulation.

CONCLUSIONS

Endoscopic papillary balloon dilation is associated with a relatively low occurrence (6%) of pancreatitis but a high frequency (25%) of hyperamylasemia. The latter may represent pancreatic irritation or latent pancreatic injury. Particular care is necessary when endoscopic papillary balloon dilation is performed in younger patients, those with a history of pancreatitis, patients with a nondilated bile duct, and when cannulation is difficult.

Metastatic adenocarcinoma arising from a small bowel duplication cyst

A case report of adenocarcinoma arising from a small bowel mesenteric cyst is presented. A discussion and review of the relevant literature then follows.

Minimally invasive approaches to mediastinal neoplasms

The goal of minimal-access surgery is to cause the least trauma necessary to gain exposure for an operative procedure. Application of this principle to mediastinal neoplasms involves the use of small incisions with both mediastinoscopy and video-assisted thoracoscopic surgery (VATS). The mediastinum is divided into anterior, middle, and posterior compartments, and this anatomy provides a framework for discussion of diagnostic and therapeutic procedures. Neoplasms occur with a characteristic frequency that varies with age and location. Neurogenic tumors and thymic neoplasms account for one third of all masses. Knowledge of the potential cause of a neoplasm and the surrounding anatomy provides the context for determining the surgical approach. The operative indications and goals of a procedure should not be significantly affected by the operative approach. Conversion from a minimal-access approach to a more traditional incision should be an anticipated possibility that is often undertaken as the next logical step rather than an expression of exasperation.