Full-term pregnancy with retroperitoneal giant mucinous cyst: A case report and literature review

RATIONALE

Retroperitoneal benign cysts during pregnancy are extremely rare and often remain asymptomatic until they attain a very large size. Diagnosis typically relies on a pathological tissue biopsy. The decision to pursue 1-step or 2-step surgical treatment should be tailored to each individual case rather than generalized.

PATIENT CONCERNS

This case report presents the unique scenario of a pregnant woman with a confirmed pregnancy complicated by a large retroperitoneal cyst. The patient had a retroperitoneal cyst during her initial pregnancy, which went undetected during the first cesarean section. However, it was identified during her second pregnancy by which time it had grown to 13.0 cm × 15.0 cm × 25.0 cm, and extended from the liver margin to right ovarian pelvic infundibulopelvic ligament. Consequently, it was removed smoothly during her second cesarean section.

DIAGNOSES

Postoperative pathology results indicated a massive retroperitoneal mucinous cystadenoma.

INTERVENTIONS

The giant retroperitoneal cyst was smoothly excised during the second cesarean delivery for 1-step surgical treatment.

OUTCOMES

Under the combined spinal and epidural anesthesia, a live female infant was delivered at 38 3/7 gestational weeks and the neonatal weight was 3200g. Under general anesthesia with endotracheal intubation, the giant retroperitoneal cyst was excised smoothly without complications.

LESSONS

The findings of this case report contribute to the understanding of the diagnostic modalities, surgical approaches and postoperative considerations of giant retroperitoneal cysts associated with pregnancy.

[Pseudoascitis by giant ovaric cyst]

The term pseudoascitis is used in patients who give the false impression of ascites, with abdominal distension but without peritoneal free fluid. The case of a 66-year-old woman, hypertensive and hypothyroid with occasional alcohol consumption, who consults due to progressive abdominal distension of 6 months of evolution and diffuse percussion dullness is presented, in whom a paracentesis is performed with the wrong endorsement of examination ultrasound that reports abundant intrabdominal free fluid (Fig. 1), later finding in the CT scan of the abdomen and pelvis an expansive process of cystic appearance of 295mm x 208mm x 250mm. Left anexectomy is programmed (Fig. 2) with pathological report of mucinous ovarian cystadenoma. The case report refers to the availability of the giant ovarian cyst within the differential diagnosis of ascites. If no symptoms or obvious signs of liver, kidney, heart or malignant disease are found and / or ultrasound does not reveal typical signs of intra-abdominal free fluid (fluid in the bottom of the Morrison or Douglas sac, presence of floating free intestinal handles), a CT scan and / or an RMI should be requested before performing paracentesis, which could have potentially serious consequences.

Postmenopausal woman with 24 kgs ovarian mucinous cystadenoma: a rare case report

A case of a 53-year-old postmenopausal woman presenting a giant ovarian cystic mucinous tumor weighing 24 kg is reported here. When she was seen first at our outpatient clinic, she had gross abdominal distension since 2 years, and she complained of unbearable aggressive pain. Her computed tomography (CT) scan was done which came suggestive of ovarian serous cystadenoma of large massive size 35 x 40 x 32 cm with moderate ascites. On exploratory laparotomy, a giant, totally cystic, vascularized and smooth mass attached to the right ovary was encountered. On the postoperative tenth day, she was discharged without any problem. Histopathology report of the right ovarian cystic mass came suggestive of multiloculated cyst with capsule intact with Borderline Mucinous tumor of right ovary weighing 24 kg. This is both one of the largest known examples in the literature and the largest ovarian cyst ever seen at our institution.

Neuroendocrine Tumor Arising within Mature Cystic Teratoma of the Pancreas: Literature Review and Case Report

Cystic teratomas are germ cell tumors most commonly found in the ovaries and testes. The pancreas, however, is very rare as a site of occurrence. Moreover, only two cases of cystic teratoma with concomitant neuroendocrine tumor have been reported to date. We report the case of a 33-year-old female who presented with abdominal pain. Computed tomography and magnetic resonance imaging of the upper abdomen revealed an 85 mm cystic tumor in the head of the pancreas. Cystic teratoma and mucinous cystadenoma were suggested as differential diagnoses. Cytopathologic analysis of endoscopic ultrasound-guided fine needle aspiration was consistent with mucinous cystadenoma. Therefore, the patient underwent surgical resection. Histologic analysis revealed a mature cystic teratoma of the pancreas with a concomitant neuroendocrine tumor. The patient is in great condition at 8 months follow-up. Cystic teratoma of the pancreas with a concomitant neuroendocrine tumor is an extremely rare condition. Surgical resection remains the mainstay of treatment as it provides a definitive diagnosis and no recurrences have been reported to date.

Computed Tomography and Clinical Analysis of Ovarian Mucinous Tumors in Adolescent Patients

STUDY OBJECTIVE

To investigate the clinical and computed tomography features of ovarian mucinous tumors in children and adolescents.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective analysis of clinical and preoperative computed tomography (CT) data was performed in 59 patients who were 20 years or younger with ovarian mucinous tumors confirmed by histopathology. Patients' age, medical history, symptoms, tumor marker levels, and CT imaging findings were recorded.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Identification of the clinical and CT features of ovarian mucinous tumors in pediatric and adolescent patients.

RESULTS

There were 41 mucinous cystadenomas in 39 cases, 12 borderline mucinous cystadenomas in 11 cases, and 9 mucinous cystadenocarcinomas in 9 patients. A total of 55 tumors were multilocular (55/62, 88.7%), including fewer than 10 loculations in 23 tumors, 10-20 loculations in 17 tumors, and over 20 loculations in 15 tumors. Eleven borderline mucinous cystadenomas were multilocular (11/12, 91.7%), with over 10 loculations in 7 tumors (7/12, 58.3%). Twelve tumors appeared as multilocular cystic-solid (12/62, 19.4%), and a case of mucinous cystadenocarcinoma was predominantly solid (1/62, 1.6%). Seventeen tumors showed honeycomb sign and stained glass appearance. Six mural nodules, with sizes ranging from 1.1 to 3.5 cm (average: 2.8 cm), were found in borderline mucinous cystadenoma and mucinous cystadenocarcinoma.

CONCLUSIONS

The CT findings of ovarian mucinous tumors in children are characteristic. The preoperative CT is helpful in making differential diagnoses.

Müllerian Mucinous Cystadenomas of the Ovary: A Report of 25 Cases of an Unheralded Benign Ovarian Neoplasm Often Associated With Endometriosis and a Brief Consideration of Neoplasms Arising From the Latter

A subset of ovarian mucinous tumors demonstrates müllerian-type epithelium, with such lesions variably designated "endocervical-like" and seromucinous since their popularization based on a report of borderline examples in 1989. While müllerian mucinous borderline tumors and carcinomas have been highlighted in the literature, there has been minimal attention given to benign müllerian mucinous tumors, particularly müllerian mucinous cystadenomas. Given the paucity of literature describing the features of müllerian mucinous cystadenomas/cystadenofibromas, diagnostic difficulties may arise when papillary features are present and in cases that show a subtle transition from endometriosis. We thus reviewed 25 cases of müllerian mucinous cystadenoma/cystadenofibroma to highlight the notable characteristics of this entity, including gross, cytologic, and architectural features that aid in the distinction from müllerian mucinous borderline tumors as well as, rarely, metastatic tumors. The patients ranged in age from 26 to 85 yr old. Bilateral ovarian involvement was frequent (40%). The ovaries ranged from 2.3 to 26 cm in greatest dimension. Most were multicystic (18 cases) and contained tenacious mucoid material (14 cases). All cases demonstrated predominantly columnar mucinous epithelium with abundant pale-pink cytoplasm. A minor component of ciliated and endometrioid epithelium was seen in 15 and 2 cases, respectively. Broad papillary formations were frequently encountered (9 cases) as was epithelial papillary tufting comprising <10% of the tumor (6 cases). Endometriosis was present in 9 cases, with a transition from endometriosis to mucinous epithelium noted in 8 cases. This series highlights the morphologic features of a relatively uncommon, benign, endometriosis-associated ovarian tumor that may be confused with a müllerian mucinous borderline tumor or bland metastatic mucinous tumors. It also provides an argument for the terminology "müllerian mucinous cystadenoma" or "cystadenofibroma" rather than "seromucinous cystadenoma" due to the frequent association with endometriosis as well as the dominant mucinous epithelium.

Perioperative management of a patient with a giant ovarian tumor: A case report

RATIONALE

Giant ovarian tumors are very rare. Patients with large ovarian tumors appear similar to pregnant women and morbidly obese patients. The management of such patients is associated with significant mortality. Therefore, additional clinical research is essential to understanding the perioperative complications of this disease.

PATIENT CONCERNS

We report the perioperative management of a patient with a giant ovarian tumor that contained 23 L of fluid who underwent tumor resection. Given the infrequency of these giant ovarian tumors, a detailed anesthetic plan and postoperative respiratory support strategy were tailored to address the patient's hemodynamic and respiratory risks, as well as to minimize potential complications, including supine hypotensive syndrome, re-expansion pulmonary edema, and postoperative intestinal ileus. To prevent supine hypotensive syndrome, the patient used a mild left-sided position (10∼20°) after admission until the tumor was removed. In order to prevent re-expansion pulmonary edema (RPE), the intraoperative ventilator mode was set to pressure-controlled ventilation (PCV), with the addition of 8 cmH2O positive end-expiratory pressure (PEEP). The airway pressure was lower while maintaining a certain tidal volume. In the ICU, in the ventilator mode, we use pressure support ventilation as well as PEEP and adjust it according to the patient's spontaneous breathing situation and blood gas analysis to prepare for further detach from the respirator and extubation. And we prevent the occurrence of postoperative intestinal ileus by placing the abdominal binder after the operation.

DIAGNOSIS

Mucinous cystadenoma of the left ovary.

INTERVENTIONS

The patient underwent exploratory laparotomy with debulking of the left ovarian mass, transabdominal hysterectomy with bilateral salpingo-oophorectomy, complete omentectomy with appendectomy, and pelvic lymphadenectomy.

OUTCOMES

After surgery, the patient experienced intestinal distention. Up to now, the patient has recovered well.

LESSONS

A multidisciplinary approach is essential. Knowing the possibility of complications and choices for management can lead to favorable outcomes in such rare cases. This case reminds us that postoperative complications such as postoperative intestinal ileus may be fatal.

[Mucinous cystadenoma of the ileocecal valve. Uncommon intestinal tumor in a oneyear-old boy. Case report]

Mucinous cystadenoma is usually found in the ovary, pancreas and appendix but its presentation in the intestine is extremely rare. In this case report we present an infant with partial intestinal occlusion due to a mucinous cystadenoma of the ileocecal valve. We performed an excision of the terminal ileum, ileocecal valve, cecum and appendix, followed by ileocolic anastomosis. The patient did well after the procedure and recovered uneventfully. To our knowledge, this is the first case report of this tumor in this location.

An Ex-Vivo Culture System of Ovarian Cancer Faithfully Recapitulating the Pathological Features of Primary Tumors

The success rate of establishing human cancer cell lines is not satisfactory and the established cell lines often do not preserve the molecular and histological features of the original tissues. In this study, we developed a novel culture method which can support proliferation of almost all primary epithelial ovarian cancer cells, as well as primary normal human oviductal epithelial cells. Cancer cells from fresh or frozen specimens were enriched by the anti-EpCAM antibody-conjugated magnetic beads, plated on Matrigel-coated plate and cultivated under the optimized culture conditions. Seventeen newly established ovarian cancer cell lines, which included all four major histotypes of ovarian cancer, were confirmed to express histotype-specific markers in vitro. Some of the cell lines from all the four histotypes, except mucinous type, generated tumors in immune-deficient mice and the xenograft tumor tissues recapitulated the corresponding original tissues faithfully. Furthermore, with poorly tumorigenic cell lines including mucinous type, we developed a novel xenograft model which could reconstruct the original tissue architecture through forced expression of a set of oncogenes followed by its silencing. With combination of the novel culture method and cell-derived xenograft system, virtually every epithelial ovarian cancer can be reconstituted in mice in a timely fashion.

Mucinous Ovarian Tumors

Ovarian mucinous tumors range from benign cystadenomas to borderline tumors to frankly malignant adenocarcinomas, and may display either intestinal-type morphology or, less frequently, endocervical-type differentiation. The latter category has been the subject of recent controversy owing to its morphologic overlap with so-called "seromucinous" ovarian tumors, a group that shares more molecular features with endometrioid tumors than it does with either serous or mucinous ovarian neoplasias. Endocervical-type differentiation in ovarian mucinous tumors may also represent an endocervical metastasis. Distinction of primary ovarian mucinous tumors from gastrointestinal metastases can be difficult, as the morphology of intestinal-type ovarian mucinous primaries sometimes differs only subtly if at all from gastrointestinal metastases.

An osteoclast-like giant cell tumor embedded in the mural nodule of a pancreatic mucinous cystic neoplasm: A case report and literature review

RATIONALE

Mucinous cystic neoplasms (MCNs) are relatively rare lesions, accounting for 2%-5% of all exocrine pancreatic neoplasms. MCNs mainly occur in women (female:male ratio = 20:1), with a peak incidence in the 5th decade of life. Osteoclast-like giant cell tumors (OGCTs) are rare and relatively aggressive neoplasms, comprising <1% of all pancreatic carcinomas. Herein, we present a rare "combination tumor" case and discuss the impact of mural nodules in pancreatic MCNs considering malignant transformation.

PATIENT CONCERNS

A 54-year-old Mongolian man, without vomiting, nausea or jaundice, presented with abdominal distention since 3 months. He had a 7-year history of diabetes. Physical examinations indicated slight middle abdominal tenderness without rebound tenderness or rigidity. Laboratory results revealed that the level of carcinoembryonic antigen (CEA) was 1.16 ng/ml (normal: <5 ng/ml); CA-199: 30.02 U/ml (normal: <27 U/ml); hemoglobin: 143 g/L; fasting glucose: 7.71 mmol/L; and albumin: 43 g/L. Abdominal enhanced computed tomography revealed a 7 × 6 cm solid neoplasm in the pancreatic body with partial enhancement and heterogeneity. Endoscopic ultrasound revealed a solid-cystic space-occupying lesion in the pancreatic body.

DIAGNOSIS

The preoperative preliminary diagnosis was pancreatic solid-cystic tumor, possibly a solid pseudopapillary tumor. Postoperative pathological findings revealed a pancreatic borderline MCN with an OGCT embedded in a mural nodule of the capsule. Immunohistochemical results indicated a simultaneous dual origin from the epithelium and stroma.

INTERVENTIONS

The patient underwent open distal pancreatectomy and splenectomy. Postoperative blood glucose levels were closely monitored and regulated. We intravenously administered single-agent gemcitabine (1400 mg on day 1) as the first-time chemotherapy, 1 month after surgery. After the first chemotherapy, the patient refused to receive further treatment owing to personal reasons.

OUTCOMES

The patient showed uneventful recovery and was discharged 13 days after the initial surgery. Follow-up was performed 1, 3 and 6 months after surgery. At 6 months, abdominal computed tomography scan showed no signs of recurrence, regional lymphadenopathy, or other abnormalities. And laboratory tests showed a platelet count of 301 × 10/L, postprandial blood glucose of 12.9 mmol/L and CA-199 level of 20 U/ml. The patient had no obvious discomfort.

LESSONS

Although pancreatic MCNs are widely accepted as borderline tumors, malignant transformations may occur due to various risk factors (cyst size, mural nodules, septations, and tumor location). The combination tumor in this case was more likely to increase the possibility of malignant biological behavior, thereby worsening overall prognosis. Therefore, long-term follow-up must be maintained with strict monitoring.

Report: Laparoscopic management for coexistent parasitic ovarian teratoma of the omentum and ovarian mucinous cystadenoma: A case report

We report a case of a 34-year-old woman who underwent laparoscopy for her adnexal tumor. Coexistence of ovarian mucinous cystadenoma and parasitic ovarian teratoma of the omentum was found and successfully treated by laparoscopic surgery. As our case presented, it is thought that the omental teratomas could be resulting from the auto-amputation and re-implantation of a dermoid cyst of the ovary.

Ovarian mucinous cystic tumor associated with sarcomatous mural nodule and benign Brenner tumor: A case report and literature review

RATIONALE

Ovarian mucinous tumor with malignant mural nodule is exceedingly rare. We report a case of ovarian mucinous cystic tumor associated with sarcomatous mural nodule and benign Brenner tumor and accompanied by nodular histiocytic aggregates in the greater omentum.

PATIENT CONCERNS

A 60-year-old postmenopausal woman was presented with a history of one month of lower abdominal discomfort, abdominal distension, nausea, and vomiting. A physical examination revealed a hard, palpable mass with mild tenderness in her right lower abdomen.

DIAGNOSES

The mucinous tumor was solid and cystic and contained benign, borderline, and malignant elements. Within the solid areas, two nodules representing pleomorphic undifferentiated sarcoma and benign Brenner tumor were identified. The diagnosis of malignant mural nodule was based on vascular invasion and marked nuclear atypia, including atypical mitoses and mitotic activity.

INTERVENTIONS

Bilateral salpingo-oophorectomy and partial omentectomy were performed. Malignant cells were not found on cytologic examination of the peritoneal washing fluid. The patient underwent three cycles of chemotherapy with 210 mg paclitaxel liposome via an intravenous drip, 20 mg nedaplatin via an intravenous drip, and 80 mg nedaplatin via intraperitoneal perfusion.

OUTCOMES

The patient has been followed up for 3 years without evidence of tumor recurrence and metastasis.

LESSONS

Careful classification of a mural nodule is important to triage patients in need of aggressive adjuvant treatment.

Pancreatic mucinous cystadenoma doubly complicated by acute pancreatitis and retroperitoneal rupture

Mucinous cystadenomas are the most frequent cystic benign tumors of the pancreas. They are characterized by a malignant potential. Acute pancreatitis is their most common complication. This manuscript reports a unique complication of mucinous cystadenomas of the pancreas: retroperitoneal rupture associated to acute pancreatitis. After resuscitation, the patient underwent surgery. A cystic mass of the pancreas tail with retroperitoneal rupture was found. Splenopancreatectomy was performed. Outcomes were straightforward. After 3 years of follow-up, no signs of recurrence are highlighted.

Clinicopathological Features and Management of Appendiceal Mucoceles: A Systematic Review

Appendiceal mucoceles (AMs) are rare mucin-containing neoplasms with malignant potential. Lack of evidence-based data exists defining clinicopathological features for management. MEDLINE search between 1995 and 2015 was performed using search criteria "Appendix mucocele." Systematic review of patient-, pathologic-, and treatment-related characteristics was performed and data analyzed. Among 276 cases of non-perforated AMs, 163 (59%) patients were female, with variable and nonspecific presentation. Patients were treated with appendectomy (52.1%), right hemicolectomy (17.6%), partial cecectomy (17.2%), and ileocecetomy (13.1%). Pathologic evaluation revealed the following: cystadenoma/low-grade appendiceal mucinous neoplasm (54%), unspecified/benign (25%), retention cyst (14.1%), cystadenocarcinoma (4.2%), and mucosal hyperplasia (2.9%). All 11 (4.2%) patients with cystadenocarcinoma were female (P = 0.004), odds ratio for malignancy 1.07 times higher for women. Synchronous colonic malignancy was reported in three patients (27%) with cystadenocarcinoma (P = 0.007), odds ratio of 12.1. AMs have low risk for malignancy. Treatment should begin with appendectomy-only and subsequently guided by pathologic diagnosis.

Diagnosis, morphopathological profile and treatment of mucinous cystadenoma of the pancreas - a single center experience

AIM

Pancreatic mucinous cystadenoma (MCA) occurs almost exclusively in perimenopausal women and represents between 10% and 45% of cystic neoplasm of the pancreas, being considered a premalignant lesion.

MATERIALS AND METHODS

From 1983 to 2017, 31 patients underwent surgery for MCA of the pancreas in our Center. The median age was 47 years (range 17-81 years). All data were obtained retrospectively.

RESULTS

The female∕male gender ratio was 14.5∕1. Most of the patients (90.3%) were symptomatic. The most common clinical manifestation was non-specific abdominal pain (58.06%), followed by fatigue and vomiting. The median cyst size was 7 cm, with a range between 2 cm and 15 cm. There were 35 procedures in 31 patients (in four patients the resection was preceded by a drainage procedure). From the 28 resections, most of them (89.28%) were performed by an open approach; a minimal invasive approach was used in three patients (robotic - two; laparoscopic - one). Most of the resections (82.14%) were distal pancreatectomies. In all cases, the final diagnosis was based on histological examination that revealed columnar epithelium and ovarian-type stroma. Postoperative complications occurred in 10 (34.48%) patients. Postoperative mortality was 3.44% (one patient) by septic shock secondary to acute postoperative pancreatitis.

CONCLUSIONS

MCAs represent a rare pancreatic pathology with challenging diagnostic and therapeutic implications. Multi-detector computed tomography (MDCT) scan, endoscopic ultrasound (EUS) and magnetic resonance imaging (MRI)∕magnetic resonance cholangiopancreatography (MRCP) are useful in the differential diagnosis with other pancreatic fluid collections and treatment. Oncological surgical resections are recommended. Histopathological examination establishes the final diagnosis. The most common postoperative complication is pancreatic fistula.

Results of Fertility-Sparing Surgery for Expansile and Infiltrative Mucinous Ovarian Cancers

BACKGROUND

No series had been reported focusing on the results of fertility-sparing surgery in stage I mucinous ovarian cancers according to histotype (infiltrative vs. expansile). Investigating such outcomes was the aim of the present study.

MATERIALS AND METHODS

The present study was a retrospective analysis of patients treated conservatively with preservation of the uterus and contralateral ovary from 1976 to 2016. The pathology of the tumors was reviewed by two expert pathologists according to the 2014 World Health Organization (WHO) classification criteria. Oncologic and fertility results were analyzed.

RESULTS

Twenty-one patients fulfilled the inclusion criteria, twelve with expansile and nine with infiltrative cancer. All patients had a unilateral tumor and underwent unilateral salpingo-oophorectomy in one-step (n = 6) or two-step (n = 15) surgeries. All but one had complete peritoneal staging surgery based on cytology, omentectomy, and random peritoneal biopsies. Ten had nodal staging surgery. The International Federation of Gynecology and Obstetrics stages were IA (n = 9), IC1 (n = 6), and IC2 (n = 6); the nuclear grades were grade 1 (n = 9), grade 2 (n = 5), and grade 3 (n = 1). Two patients recurred (one expansile and one infiltrative type) 19 and 160 months after surgery, respectively. One stage IA, nuclear grade 2 expansile tumor recurred on the spared ovary; the patient remains alive. The other stage IA infiltrative tumor recurred as peritoneal spread; the patient is alive with disease. Six patients became pregnant; four with expansile tumors and two with infiltrative tumors.

CONCLUSION

The type of mucinous cancer has no impact on the oncologic outcome in this series of patients treated conservatively. Fertility-sparing surgery should be considered for early-stage infiltrative-type tumors.

IMPLICATIONS FOR PRACTICE

According to the most recently updated World Health Organization classification guidelines, mucinous cancers should be classified as either expansile or infiltrative. The infiltrative type has a poorer prognosis, but there are no data about the safety of fertility-sparing surgery (FSS) in this context. A collection of 21 cases reviewed by two expert pathologists this study is the first devoted to the conservative treatment of mucinous tumors according to both subtypes. The key result was that the type of mucinous cancer has no impact on the oncologic outcome; thus, FSS may be considered in both subtypes.

Urachal borderline mucinous cystadenoma: A rare case report and literature review

RATIONALE

Urachal borderline mucinous cystadenoma is very rare and has only 9 cases in the current literature with the biological behavior between adenoma and adenocarcinoma.

PATIENT CONCERNS

We reported a 41-year-old man with moderate lower abdominal pain, and the imaging examination found an irregular cystic lesion extending from umbilicus to the dome of urinary bladder with significant separations and calcifications.

DIAGNOSES

The diagnosis was confirmed according to the specific anatomical location and pathological examination which was proved as mucinous cystadenoma with low malignant potential.

INTERVENTIONS

The patient undertook radical excision and partial cystectomy.

OUTCOMES

His postoperative condition was good.

LESSONS

Urachal borderline mucinous cystadenoma can be located by image examination, which may also offer several diagnostic tips according to separation, calcification, and enhancement in computed tomography scan. When combined with pathological findings, qualitative diagnosis can be determined. Surgical resection should be chosen as an optimal treatment. Our present study reviewed the clinical and biological information of all previous cases which were diagnosed as urachal borderline mucinous cystadenoma and we supplemented more data for further study.

Benign, premalignant and malignant pancreatic cystic lesions: the pathology landscape

Pancreatic cystic lesions are being increasingly detected in last years. Pancreatic cysts can be classified grossly into pseudocysts and true cysts. In the true cysts group, it is important to distinguish mucinous from non-mucinous cysts because the former are considered being premalignant lesions. In this article the major types of pancreatic cysts are reviewed, with emphasis on the histopathological aspects. Molecular markers in the cyst fluid are being increasingly studied in recent years ; the clinical utility of such biomarkers should be addressed in future studies.

Intraductal papillary mucinous tumors of the pancreas

Purpose: To compare the effectiveness of thin-section helical CT and MR imaging with gadolinium-enhanced dynamic technique and MR cholangiopancreatography (MRCP) in the examination of patients with intraductal papillary mucinous tumors.

Material and Methods: Helical CT, dynamic MR imaging, and MRCP of 25 intraductal papillary mucinous tumors were compared with ERCP and surgical findings.

Results: The duodenal papilla was identified by helical CT and dynamic MR imaging in 11 (44%) and 20 (80%) of the 25 patients, respectively ( p<0.05). The main pancreatic duct was visualized on helical CT, dynamic MR imaging, and MRCP in all patients (100%): 25 (96.2%), 24 (92.3%), and 26 (100%) cystic lesions were depicted, respectively. A communicating duct between the main pancreatic duct and the cystic lesion was visualized on helical CT, dynamic MR imaging, and MRCP in 14 (53.8%), 11 (42.3%), and 15 (55.7%) lesions, respectively. The papillary projections corresponding to 3 mm or larger papillary neoplasms were depicted on helical CT and MR imaging in 7 patients (25%).

Conclusion: MR imaging was equal or slightly superior to thin-section helical CT in the evaluation of intraductal papillary mucinous tumors.

Sarcoma-Like Mural Nodule in a Borderline Mucinous Tumour of Ovary

A 37-year female presented with complaint of lower abdominal pain and amenorrhoea to the Military Hospital, Rawalpindi. Ultrasound of pelvis showed a right adnexal cystic lesion. On investigation, CA-125 was raised. Her MRI scan of pelvis revealed a right adnexal mass of fluid intensity measuring 15.2 x 12.9 x 9.2 cm. Right ovarian cystectomy was performed and the specimen was sent for histopathological examination. Grossly, the mass was cystic in appearance and measured 13.5 x 10 x 10 cm. On sectioning, it was unilocular and filled with turbid material. The cyst wall showed multiple papillary structures along with a nodule measuring 1.1 x 1 cm. Microscopically, the sections revealed borderline mucinous tumour with a sarcoma-like mural nodule composed of spindle shaped cells and epulis-like giant cells. Sarcoma-like mural nodules are rare nodules which are associated with mucinous tumours of the ovary. However, they have excellent prognosis and should not be interpreted as malignant.

Heterotopic ossification in appendiceal mucinous neoplasms: clinicopathological characteristics of 3 cases

Heterotopic bone formation is a very rare event in the gastrointestinal tract including in the appendix. Here we report three cases of heterotopic ossification in appendiceal mucinous neoplasms, one occurring in an appendiceal mucinous cystadenoma, another in a low-grade appendiceal mucinous neoplasm, and the third occurring in an appendiceal mucinous adenocarcinoma. The clinicopathologic characteristics of these three present cases and two previously reported cases are discussed in detail. The mechanism of heterotopic ossification in appendiceal mucinous neoplasm is still unclear, but mucin extravasation and subsequent calcification may be predisposing events.

Resection of the main trunk of the superior mesenteric vein without reconstruction during surgery for giant pancreatic mucinous cystadenoma: A case report

Pancreatic tumors, with peri-pancreatic main vascular invasion, especially the superior mesenteric vein (SMV) or the portal vein, are very common. In some cases, vascular resection and reconstruction are required for complete resection of pancreatic tumors. However, the optimum surgical method for venous management is controversial. Resection of the SMV without reconstruction during surgery for pancreatic tumors is rarely reported. Here we present the case of a 58-year-old woman with a giant pancreatic mucinous cystadenoma adhering to the SMV, who underwent an en bloc tumor resection, including the main trunk of the SMV and the spleen. No venous reconstruction was performed during surgery. No ischemic changes occurred in the bowel. The presence of several well-developed collateral vessels was shown by 3-dimensional computed tomography examination. The patient had an uneventful postoperative period and was discharged. This case indicated that the main trunk of the SMV can be resected without venous reconstruction if adequate collateralization has formed.

Primary retroperitoneal mucinous cystadenoma: A case report

Primary retroperitoneal mucinous cystic tumors are extremely rare. These tumors can be classified as a primary retroperitoneal mucinous cystadenoma with or without borderline malignancy or primary retroperitoneal mucinous cystadenocarcinoma. The most common of these is primary retroperitoneal mucinous cystadenoma, which almost always occurs in female patients; only ten cases have been reported in males. The most common clinical findings for this tumor type include nonspecific abdominal pain and a palpable abdominal mass. A definitive diagnosis is usually obtained from histopathology after surgical excision. Here, we report the case of a 60-year-old female patient who complained of abdominal pain that had been present for 3 mo and presented with a palpable abdominal mass. Multidetector computed tomography scanning revealed a large, unilocular cystic mass in the left retroperitoneal space. Surgical intervention was performed and the tumor was completely removed. Histopathologic examination confirmed that the tumor was a primary retroperitoneal mucinous cystadenoma. Two years after surgery, the patient remains disease free.

[A large abdomen can camouflage the symptoms of an ovarian tumour]

Mucinous cystadenomas of the ovaries are benign tumours which can grow to sometimes gigantic proportions. Symptoms may be vague and due to complications hence the tumour can go undiagnosed for several years. This is a case report of a 48-year-old woman with a 40-kg ovarian tumour developed through 19 years. In spite of discomfort and complaints of the very large abdomen she had not received thorough examination previously. A large abdomen and discomfort should always lead to transabdominal ultrasound when transvaginal ultrasound - as in this case - does not diagnose the condition.

Pancreatic mucinous cystadenoma with serum CA 19-9 over 1,000,000 U/mL: a case report and review of the literature

BACKGROUND

The diagnosis of pancreatic cystic neoplasms has become more accurate recently. In some cases, however, doubt remains regarding the lesion's malignant potential. CA 19-9 has long been identified as a reliable biomarker in differentiating pancreatic benign and malignant lesions, especially in non-jaundiced patients.

CASE REPORT AND DISCUSSION

We report a case of a young female who presented with a mucinous lesion in the tail of the pancreas and a serum CA 19-9 over 1,000,000 U/mL. She was taken to surgery and had a distal pancreatectomy and splenectomy. Pathology reports showed only a mucinous cystadenoma. After 1 year of follow-up, her serum CA 19-9 was normal. Following that, the work-up in these lesions, the role of the biomarker in pancreatic adenocarcinoma and in the differentiation between benign and malignant lesions is discussed.

A successful management of a giant mucinous ovarian tumor with intraoperative controlled fluid aspiration

BACKGROUND

The aim of this article was to present management of a giant ovarian mass.

CASE REPORT

A 61-year-old patient was admitted with compliants of abdominal swelling and dyspnea. Ultrasound revealed a giant ovarian mass with dimesnions 47x43x30 cm. The patient underwent laparatomy and the cyst's content was aspirated before total cyst excision. The total weight of the mass was calculated to be 42.5 kg. Postoperatively, the patient was discharged on her postoperative seventh day.

CONCLUSION

Giant ovarian cysts can be managed with controlled aspiration before total cyst excision.

Different staining patterns of ovarian Brenner tumor and the associated mucinous tumor

The association of ovarian Brenner tumors and adjacent mucinous tumors is well known but not completely understood. In this study, we analyzed immunohistochemical markers on Brenner tumors and their associated mucinous tumor to explore Mullerian as well as Wolffian and germ cell derivation and determine if the mucinous component is independent or related to the Brenner tumor. Of 32 consecutive cases of Brenner tumors, 8 were identified with significant mucinous component, and 7 additional cases included foci of mucinous epithelium within the Brenner transitional nests. All Brenner tumors were diffusely positive for GATA3 and negative for Paired box gene 8, PAX2, and Sal-like protein 4. Interestingly, the areas of mucinous epithelium as well as mucinous tumors, intermixed and adjacent to the Brenner tumor, were negative for all 4 markers; however, occasional basal-like cells retained expression of GATA3. The immunoprofile of mucinous tumors associated with Brenner tumors shares the lack of Mullerian markers PAX2 and Paired box gene 8 with the Brenner tumor but differs in the expression of GATA3 only in the Brenner tumor component.

Cystic pancreatic tumors: should we resect all of them?

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.

Duodenum-preserving resection and Roux-en-Y pancreatic jejunostomy in benign pancreatic head tumors

This study was conducted to explore the feasibility of partial pancreatic head resection and Roux-en-Y pancreatic jejunostomy for the treatment of benign tumors of the pancreatic head (BTPH). From November 2006 to February 2009, four patients (three female and one male) with a mean age of 34.3 years (range: 21-48 years) underwent partial pancreatic head resection and Roux-en-Y pancreatic jejunostomy for the treatment of BTPH (diameters of 3.2-4.5 cm) using small incisions (5.1-7.2 cm). Preoperative symptoms include one case of repeated upper abdominal pain, one case of drowsiness and two cases with no obvious preoperative symptoms. All four surgeries were successfully performed. The mean operative time was 196.8 min (range 165-226 min), and average blood loss was 138.0 mL (range: 82-210 mL). The mean postoperative hospital stay was 7.5 d (range: 7-8 d). In one case, the main pancreatic duct was injured. Pathological examination confirmed that one patient suffered from mucinous cystadenoma, one exhibited insulinoma, and two patients had solid-pseudopapillary neoplasms. There were no deaths or complications observed during the perioperative period. All patients had no signs of recurrence of the BTPH within a follow-up period of 48-76 mo and had good quality of life without diabetes. Partial pancreatic head resection with Roux-en-Y pancreatic jejunostomy is feasible in selected patients with BTPH.

Mucinous cystic neoplasms of the pancreas: are we overestimating malignant potential?

Surgical resection is recommended for all mucinous cystic neoplasms (MCNs) of the pancreas as a result of: 1) lack of an accurate tumor marker for invasive cancer; 2) young age at diagnosis; and 3) historical studies revealing 36 per cent incidence of malignancy in resected lesions. This study compares the clinicopathologic and prognostic features of our series of resected MCNs to recent studies using the current International Association of Pancreatology (IAP) system. Thirty-eight resected MCNs were identified. Almost all patients were female (97.4%); median age at diagnosis was 53.5 years (interquartile range [IQR], 41.3 to 61.0). The majority occurred in the body/tail of the pancreas (86.8%); median size on computed tomography/magnetic resonance imaging was 5.0 cm (IQR, 3 to 8.8). Comparison of the five high-grade (HG, 13.2%) and 33 low-grade (86.8%) MCNs revealed that 1) patients were similar in age (55.0 vs 52.0 years, respectively) and 2) HG lesions were significantly larger on preoperative imaging (9.9 vs 3.5 cm) and final pathology (10.9 vs 3.5 cm). These data, taken together with five recent studies that adhere to the 2012 IAP criteria (385 total MCNs), reveal that a cutoff of less than 3 cm without mural nodules would have only missed one (0.26%) HG lesion. Surveillance of these lesions may be appropriate for some patients.

Complex mucinous cystadenoma of undetermined malignant potential of the urachus: a rare case with review of the literature

Urachal carcinoma is an uncommon neoplasm. Benign urachal tumours are extremely rare. All urachal mucinous tumours, regardless of tumour type, have the potential to behave in an aggressive clinical manner that includes the development of pseudomyxoma peritonei. We report a 58-year-old man who presented with lower abdominal pain. Ultrasound and CT imaging defined a large lobulated cystic mass superior to the urinary bladder. At laparotomy, the multiloculated cystic mass, 10 x 8 x 6 cm, could be completely separated from the bladder and was excised. It was smooth-walled and filled with thick mucinous fluid. Histology revealed a complex mucinous cystadenoma of undetermined malignant potential of the urachus. The cystic spaces were lined by mucin-secreting columnar epithelium that showed focal areas of mild atypia. The epithelium lacked architectural features of villous adenoma. There was no stromal invasion to support an invasive neoplastic process. No pseudomyxoma peritonei was present. The patient was well, with no tumour recurrence, at 6 months follow-up.

Association of pancreatic adenocarcinoma up-regulated factor expression in ovarian mucinous adenocarcinoma with poor prognosis

Pancreatic adenocarcinoma up-regulated factor (PAUF) expression is elevated in both ovarian tumors and pancreatic adenocarcinoma. However, PAUF expression in ovarian tumors according to histologic subtype and grade has not been investigated. In this study, we examined various clinicopathologic features of 24 patients with mucinous cystadenoma (MCA), 36 with mucinous borderline tumors (MBTs), and 46 with mucinous adenocarcinomas (MACs) according to PAUF expression status assessed using immunohistochemistry. We found that MACs more frequently stained positive for PAUF than did MCAs and MBTs (P < 0.0001). Although there was no significant differences with respect to other clinicopathologic characteristics of MACs according to PAUF expression status, patients with PAUF-weakly positive and PAUF-strongly positive MACs tended to have a shorter overall survival (OS) than those with PAUF-negative MAC, determined using a Kaplan-Meier analysis (P = 0.1885). After adjusting for various clinicopathologic parameters, PAUF positivity of MACs was a significant predictive factor for disease-free survival (DFS) (negative vs. weakly positive: P = 0.045, hazard ratio [HR] = 57.406, 95% confidence interval [CI]: 1.090-3022.596; and negative vs. strongly positive: P = 0.034, HR = 97.890, 95% CI: 1.412-6785.925). In conclusion, PAUF was more frequently expressed in MAC than in its benign and borderline counterparts, and was associated with a poor OS and DFS in MAC patients. Therefore, we suggest that PAUF may be a practical biomarker for histopathological categorization and a prognostic marker for patients with an ovarian mucinous tumor.

Inhibitory role of prohibitin in human ovarian epithelial cancer

OBJECTIVES

To characterize the exact individual roles of gonadotropins on ovarian epithelial carcinogenesis, an earlier study showed that prohibitin was significantly up-regulated by luteinizing hormone (LH). To further clarify the role of prohibitin in ovarian carcinogenesis and its association with LH, herein we studied the expression of prohibitin in various ovarian tissues including different developmental stages of ovarian epithelial tumors.

METHODS

A total of 135 samples were studied by immunohistochemistry. These included benign ovarian cases with follicles, ovarian surface epithelia and ovarian epithelial inclusions (OEI) (n=30), serous cystadenoma (n=14), serous borderline tumor (n=12), serous carcinoma (n=20), mucinous cystadenoma (n=10), mucinous borderline tumor (n=10), mucinous carcinomas (n=10), endometrioid carcinomas (n=12), poorly/undifferentiated carcinomas (n=5), and fallopian tube (n=12).

RESULTS

Strong and diffuse staining of prohibitin was detected in luteinized ovarian stromal cells, follicular cells, fallopian tube, and OEI with serous differentiation. A significantly higher prohibitin expression in luteinized stromal cells than in non-luteinized stromal cells was observed (P<.01). Within the ovarian epithelium, the level of prohibitin expression was basically negative in ovarian surface epithelia, but highly expressed in OEI. However, compared to the level of prohibitin expression in OEI, it showed a trend of gradual loss from benign ovarian tumors, to borderline tumors and to carcinomas (P<.0001). Compared to the serous tumors, epithelial tumors with mucinous differentiation showed a significant lower level of prohibitin (P<.0001). An inverse correlation was noted between prohibitin expression and cancer grade. It is interesting to note that a high prohibitin expression level was seen in the fallopian tube, which is similar to OEI.

CONCLUSIONS

These data further suggest that prohibitin plays a tumor suppressing role, which is probably associated with LH mediated protection role against ovarian epithelial carcinoma. In addition to the tumor suppressive role of prohibitin, it also plays a role in cellular differentiation, which may be helpful to differentiate ovarian mucinous tumors from the tumors with serous differentiation in clinical settings. More importantly, our findings are supportive that the ovarian epithelial cancers, particularly the serous cancers including those precursors with serous differentiation are likely to be derived from fallopian tube instead of ovarian surface epithelia.

Mucinous cystic neoplasm of pancreas in a male patient: a case report and review of the literature

Mucinous cystic neoplasms (MCNs) are among the most common primary cystic neoplasms of pancreas. These lesions usually occur in body and tail of the pancreas and are characterized by the presence of ovarian type stroma in the pathological evaluation. Mucinous cystic neoplasms have significant malignant potential; therefore, their diagnosis and resection is of utmost importance. Mucinous cystic neoplasms typically occur in women. Only a few cases have been previously reported in male patients. In this case report, we present a 48-year-old man who was referred to our center due to an incidentally found cystic lesion in the tail of the pancreas that was increasing in size in serial evaluation. The patient underwent open distal pancreatectomy. The pathology showed mucinous cystic neoplasm with characteristic ovarian type stroma and positive staining for estrogen and progesterone receptors. This case report shows that mucinous cystic neoplasms can occur in men and should be considered in differential diagnosis of cystic pancreatic lesions in this population.

[Heterogeneity of epithelial ovarian carcinomas and their clinical significance]

Epithelial ovarian cancer is one of the most lethal gynecological malignant tumors despite improvement of the treatment. Recent molecular studies show that ovarian cancer is a heterogeneous disease which is reflected by different histologic types. These subtypes differ from their origin, pathogenesis and molecular alterations and can be divided in two major groups. The type I cancer (low grade) evolves from precursor lesions in a step-wise process. In contrast, the type II cancer (high grade) grows rapidly without any identifiable precursors. Among all subtypes is heterogeneity in the biological behavior which has implications in patient prognosis and treatment especially for individualized therapies in the future.

Giant ovarian mucinous cystadenoma with borderline areas: a case report

Nowadays, giant ovarian mucinous cystadenomas are a rare condition, due to early diagnose and treatment. We report the case of a 44-year-old patient, who was diagnosed and admitted in our department with a giant pelvi-abdominal mass. The patient was operated with very high-risk consent, thus an enormous ovarian cyst of approximately 30 kg was extirpated. Afterwards, an extensive histopathological analysis was performed in order to determine the exact clinicopathological entity of the giant tumor-enteric type of multilocular mucinous ovarian cyst adenoma with borderline areas, with benign proliferation. Although giant ovarian mucinous cyst adenoma with borderline areas is an extremely rare condition, when encountered it is a real challenge for both surgeon and pathologist.

Comparison of pelvic masses score (PMS) and Risk of Malignancy Index (RMI 3) in the evaluation of pelvic masses

PURPOSE

Ovarian cancer is the fourth cause of death from cancer in women worldwide and the majority of its diagnoses is made in an advanced stage of the disease. Several sonographic scoring systems have been created for a better preoperative discrimination between benign and malignant pelvic masses. The aim of this study was to evaluate the performances of the Risk of the Malignancy Index 3 (RMI 3) and the Pelvic Masses Score (PMS).

MATERIALS AND METHODS

This retrospective study was performed in 55 women admitted to the department of Obstetrics and Gynecology of University of Udine for surgical exploration of pelvic masses between 2009 and 2012. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for both the scores.

RESULTS

PMS showed a sensitivity of 100%, a specificity of 93.8%, a PPV of 70%, and a NPV of 100%, while RMI 3 yielded a sensitivity of 85%, a specificity of 91%, a PPV of 60%, and a NPV of 97.8%.

CONCLUSION

The authors found that, in discriminating between benign and malignant pelvic disease, the PMS method was more reliable than RMI3. PMS is a simple scoring system which can be used in clinical practice.

Appendectomy with cytoreductive surgery for ovarian and type 2 endometrial carcinoma

There is considerable variation within and between cancer centers in the practice of appendectomy as part of cytoreductive surgery for ovarian carcinoma and in the surgical staging of endometrial carcinoma. The purpose of this study was to determine the prevalence and the type of appendiceal pathology, the morbidity associated with appendectomy in gynaecologic cancer surgery.

MATERIALS AND METHODS

This is a retrospective review of all cytoreductive surgery for ovarian carcinoma and surgical staging for endometrial carcinoma with appendectomy over a four year period.

RESULTS

Two hundred and fifty-one patients (38 patients for endometrial carcinoma surgery and 213 patients for ovarian cytoreduction) had an appendectomy performed. Metastases to the appendix was present in 46 (23.2%) of primary ovarian carcinoma and one (2.6%) primary endometrial carcinosarcoma. The appendix was more likely to be involved in advanced stage ovarian cancer with positive peritoneal washings, omental deposits, grade 3 differentiation, and papillary serous histology. Sixteen (6.4%) co-incidental primary appendiceal tumours were detected. No postoperative morbidity specific to appendectomy was identified. One case of ovarian carcinoma was upstaged from IC to IIIA by the appendiceal metastases. There was no upstaging of disease in the endometrial carcinoma group.

DISCUSSION

Appendectomy is an integral part of ovarian cytoreductive surgery but the authors found it did not upstage the disease in a clinically significant manner. The incidence of co-incidental appendiceal primary tumours was high in this series and may add value to the procedure in preventing further surgeries. The absence of procedure related morbidity is reassuring. The authors recommend appendectomy for all ovarian staging surgery and its consideration in type 2 endometrial cancer.

Primary retroperitoneal mucinous tumor of low malignant potential in a Persian woman

Primary retroperitoneal mucinous tumor (PRMT) of low malignant potential (border line) is an uncommon neoplasm with fewer than 50 reported cases. Uncertain diagnostic imaging results make diagnosis of its origin difficult, preoperatively. Later treatment planning and prognosis would be affected by exact diagnosis of the tumor origin. This study presents a case of Persian woman with diagnostic, histological and immunohistochemical specifications.

Differentiation of mucinous cystic neoplasm and cystic changes associated with pancreatic adenocarcinoma

A 63-year-old woman presented to the hospital with persistent nausea, dyspepsia and weight loss for 6 months. Abdomen CT showed a low-attenuation mass, approximately 7.6 cm diameter, in the region of the body and tail of the pancreas. Cystic lesions, 5.5×4.9 cm and 4.6×3.7 cm in size, were observed in the body and tail of the pancreas, respectively, associated with the low-attenuation mass. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) revealed fetal carcinoembryonic antigen levels of >1000 ng/mL and necrotic cells with no malignant cells. On the basis of the imaging and EUS-FNA results, a putative diagnosis of mucinous cystadenoma accompanying pancreatic adenocarcinoma was made, and distal pancreatectomy and splenectomy were performed. Final biopsy using the surgical specimen confirmed pancreatic adenocarcinoma with moderate differentiation accompanied by degenerative cystic changes.

Giant biliary mucinous cystadenoma of the liver

Biliary mucinous cystadenomas (BMC) of the liver are rare benign cystic tumors, however an estimated 20% undergo malignant transformation. They have recently been redefined as mucinous cystic neoplasms in the 2010 WHO classification. The preferred treatment is through radical resection, as there are high recurrence rates with other treatment modalities; however this is often not possible in patients with bilobar or giant cysts, and liver transplantation may be indicated. We present a patient with a giant biliary mucinous cystadenoma of the liver and discuss the management with reference to the literature. A 47 year-old woman presented with a 6-week history of moderate epigastric discomfort on a background of 12 months of symptom-free abdominal distension. A giant cystic bilobar tumor of the liver measuring 22 x 23 x 17 cm was diagnosed and characterised by ultrasound scan and magnetic resonance imaging. Serum bilirubin, alkaline phosphatase and gamma-glutamyl transpeptidase were elevated, though other laboratory data including tumor markers (CEA, aFP, CA19-9) were within normal limits. Total excision of the cyst was not possible due to its size and position, and the patient underwent cyst drainage, a sub-total cyst excision and omentoplasty. Histology confirmed a benign biliary mucinous cystadenoma with an ovarian stroma. Though the patient remained clinically well, routine post-operative computed tomography (CT) surveillance showed an 11 cm recurrent cyst at 6 months. A partial cyst resection with close follow-up, regular CA19-9 serology and ultrasound/CT imaging, may be a reasonable alternative for bilobar or giant cysts. However should any features pathognomonic of malignancy develop, then a liver transplantation is indicated.

Male primary retroperitoneal mucinous cystadenoma

Primary retroperitoneal mucinous cystadenoma of borderline malignancy is a rare disease, especially in male patients. Often these tumors are not incidentally found due to abdominal symptoms. We present the radiologic abdominal computed tomography scan, surgical, and pathologic images of this unique, rare condition in a male patient. Surgical treatment is recommended to establish diagnosis and treatment.

Increased risk of mucinous neoplasm of the appendix in adults undergoing interval appendectomy

IMPORTANCE

The role of interval appendectomy after conservative management of perforated appendicitis remains controversial. Determining the etiology of perforated appendicitis is one reason to perform interval appendectomies.

OBJECTIVE

To determine whether adult patients undergoing interval appendectomy experience an increased rate of neoplasms.

DESIGN

Retrospective study.

SETTING

A single tertiary care institution.

PARTICIPANTS

All patients 18 years or older who underwent appendectomy for presumed appendicitis from January 1, 2006, through December 31, 2010. EXPOSURES Appendectomy for presumed appendicitis.

MAIN OUTCOMES AND MEASURES

Underlying neoplasm as the cause of presentation for presumed appendicitis. Demographic data, clinicopathologic characteristics, interval resection rate, and complication data were collected and analyzed.

RESULTS

During the study period, 376 patients underwent appendectomies. Interval appendectomy was performed in 17 patients (4.5%). Neoplasms were identified in 14 patients (3.7%); 5 of those tumors occurred in patients who had undergone interval appendectomy (29.4%). Nine neoplasms were mucinous tumors (64.3%), including all neoplasms associated with interval appendectomies. The mean age of all patients with appendiceal tumors was 49 years (range, 35-74 years).

CONCLUSIONS AND RELEVANCE

Mucinous neoplasms of the appendix were found in 5 of 17 patients (29.4%) undergoing interval appendectomy. Interval appendectomies should be considered in all adult patients, especially those 40 years or older, to determine the underlying cause of appendicitis. A multi-institutional study to determine the generalizability of these findings is warranted.

Hemolymphangioma: A rare differential diagnosis of cystic-solid or cystic tumors of the pancreas

We report a case of pancreatic hemolymphangioma. Hemolymphangioma is a malformation of both lymphatic vessels and blood vessels. The incidence of this disease in the pancreas is extremely rare. To the best of our knowledge, only seven cases have been reported worldwide (PubMed). A 39-year-old woman with a one-day history of abdominal pain was admitted to our hospital. There was no obvious precipitating factor. The preoperative examination, including ultrasonography and computed tomography, showed a cystic-solid tumor in the pancreas, and it was considered to be a mucinous cystadenoma or cystadenocarcinoma. Pancreatic body-tail resection combined with splenectomy was performed. After the operation, the tumor was pathologically demonstrated to be a pancreatic hemolymphangioma. Although pancreatic hemolymphangioma is rare, we believe that it should be considered in the differential diagnosis of cystic-solid tumors of the pancreas, particularly when there is no sufficient evidence for diagnosing cystadenoma, cystadenocarcinoma or some other relatively common disease of the pancreas.