Lactoferrin amyloid presenting as a mural nodule in a pancreatic cystic lesion prompting pancreatoduodenectomy: a case report

Background Amyloid deposition in pancreas is rare. Lactoferrin amyloid deposition has not been reported in pancreas, till date. Presence of enhancing mural nodule in a cyst on imaging is a worrisome feature for malignancy, and warrants surgical resection in a surgically fit candidate, as per Fukuoka guidelines for management of cystic lesions in pancreas. Case report We report a case of localized amyloidosis presenting as a mural nodule in a 1.6 cm cyst located in the head of pancreas, which led to pancreatoduodenectomy in a 69 year old woman. Histological evaluation revealed a simple mucinous cyst with localized lactoferrin amyloid deposition corresponding to the mural nodule identified on imaging. Conclusions We report the first case of localized lactoferrin amyloid deposition in pancreas that presented as a mural nodule in a cystic lesion and prompted pancreatoduodenectomy. This unique case illustrates that on rare occasion mural nodule in a cyst can be benign. It adds amyloid deposition to the differential diagnosis of mural nodules in pancreatic cystic lesions seen on imaging.

Practical Applications of Molecular Testing in the Cytologic Diagnosis of Pancreatic Cysts

Mucinous pancreatic cysts are precursor lesions of ductal adenocarcinoma. Discoveries of the molecular alterations detectable in pancreatic cyst fluid (PCF) that help to define a mucinous cyst and its risk for malignancy have led to more routine molecular testing in the preoperative evaluation of these cysts. The differential diagnosis of pancreatic cysts is broad and ranges from non-neoplastic to premalignant to malignant cysts. Not all pancreatic cysts—including mucinous cysts—require surgical intervention, and it is the preoperative evaluation with imaging and PCF analysis that determines patient management. PCF analysis includes biochemical and molecular analysis, both of which are ancillary studies that add significant value to the final cytological diagnosis. While testing PCF for carcinoembryonic antigen (CEA) is a very specific test for a mucinous etiology, many mucinous cysts do not have an elevated CEA. In these cases, detection of a KRAS and/or GNAS mutation is highly specific for a mucinous etiology, with GNAS mutations supporting an intraductal papillary mucinous neoplasm. Late mutations in the progression to malignancy such as those found in TP53, p16/CDKN2A, and/or SMAD4 support a high-risk lesion. This review highlights PCF triage and analysis of pancreatic cysts for optimal cytological diagnosis.

Simple mucinous cyst: another potential cancer precursor in the pancreas? Case report with molecular characterization and systematic review of the literature

Cystic lesions of the pancreas may range from benign to precursors of pancreatic cancer. Simple mucinous cyst (SMC) is larger than 1 cm, has a gastric-type flat mucinous lining, and minimal atypia without ovarian-type stroma. We report a new case of pancreatic SMC, coupling a systematic review of the English literature mainly focused on their clinic-pathological features. We reviewed 103 cases of SMC in adults (73 women), averaging 57 (range, 26–70) years. The SMCs were located in the body-tail region of the pancreas in 60 (58%) cases, presenting as single cystic lesions in 94% of cases; 43% of patients were asymptomatic. A preoperative fine-needle aspiration of the cyst fluid detected amylase and carcinoembryonic antigen positivity in 71% and 76% of cases, respectively. Patients underwent surgery mostly for suspected malignancy; in 83% of cases, a standard pancreatic resection was performed. Mean SMC size was 4.9 (range, 1.5–12.0) cm. Mucins MUC5AC and MUC6 resulted positive in 77% and 81% of cases performed, respectively, whereas MUC2 was negative in all but one patient. The SMC from our institution was characterized by a KRAS somatic mutation. The diagnosis of SMC should be considered when a solitary pancreatic cyst larger than 1 cm is detected in asymptomatic patients. To establish a correct diagnosis, an extensive histologic/immunohistochemical analysis is essential. The presence of a KRAS mutation highlights that SMC may represent another potential pancreatic cancer precursor.

Ulnar Nerve Compression in Guyon’s Canal by Ulnar Artery Cystic Adventitial Disease: A Case Report

Cystic adventitial disease is a condition where mucinous cyst(s) develop within the adventitia of blood vessels, especially arteries. The most affected vessel is the popliteal artery while the upper limb vasculature is seldom involved. To our knowledge, there are only 2 articles reporting this disease in the ulnar artery. We present a case of a 52-year-old female patient, a manual worker in a clothing factory, with a month history of increasing pain in her right wrist and gradual weakness that incapacitated her for work activities. She was finally treated surgically and an adventitial cyst of the ulnar artery compressing the ulnar nerve was diagnosed.

Computed tomography features of benign adnexal mass lesions

Background: Adnexal masses originating from gynaecologic and nongynecologic sources may be benign or malignant. The objective of this study was to describe multi-detector computed tomography features of benign adnexal masses for diagnostic accuracy and disease understanding.Methods: Study retrospectively evaluates the multidetector computed tomography features of benign adnexal mass lesions, which were referred for MDCT examination with a primary diagnosis of adnexal masses on clinical or USG. Patients who underwent MDCT and subsequently underwent surgery and proved to benign adnexal mass lesion on histopathological examination were included in this study.Results: Forty five percent benign adnexal mass were in the age group of 36-50 years followed by 32.7% in the age group of 21-35 years. Common presenting symptoms of benign adnexal masses were pain abdomen or pelvic pain (65.5%) followed by mass abdomen (42%) while in one fourth of the patients it was asymptomatic and detected as incidental finding. Pathologic diagnosis of most common benign adnexal mass detected were serous cyst adenoma (54.5%), followed by mature cystic teratoma (18.2%), mucinous cyst adenoma (14.5%) and par ovarian cyst (9.1%). Benign ovarian mass had a characteristic CT appearance of cystic lesion (83.6%), unilocular (65.5%) with regular/well defined and thin wall (83.6%) with occasional septations (21.8%) and papillary projections (14.5%). Ascitis (5.5%) was an uncommon finding of a benign adnexal mass lesion. Computed tomography was most accurate to characterize mature cystic teratoma with a typical cystic lesion having fat deposition and calcifications. Serous cyst adenoma had a CT appearance of thin walled cyst mass with no septations or solid component. Mucinous cyst adenoma ovary had a characteristic multilocular cystic lesion with different fluid attenuation and thin septations. Endometrioma had a variable CT appearance with uni or multilocular cystic lesion and hyperdense lesion with focal calcifications.Conclusions: Multi detector computed tomography may provide accurate and valuable diagnostic information about benign nature of an adnexal mass lesion.

THE STUDY OF ADNEXAL MASSES IN PREGNANCY AT TERTIARY CENTER

BACKGROUND: Adnexal masses occur frequently during the reproductive age and during pregnancy. The management of adnexal masses during pregnancy presents a difficult clinical decision.The abdominal surgery during pregnancy is risky to the mother and the foetus. On contrary, conservative management may result in the spread of cancer or serious complication such as the torsion or rupture of ovarian cysts. METHODS:In observational study, 42 cases of adnexal masses in pregnancy were studied. These patients were evaluated with the respect to their size,tumor markers,histopathological report gestational age,and Perinatal outcome and treatment. RESULT: In present study 38 % patients were between the age of 25-30 years. It was seen commonly in multiparous women. It was commonly observed in second trimester,.40% cases were found to have adnexal mass between 6-10 cm. CA-125 was estimated for 30 patients in present study most commonly found adnexal mass was mucinous adenoma and dermoid cyst CONCLUSION:Majority of the adnexal masses are benign in nature.Dermoid cyst and mucinous cyst adenomas are the most common pathology foundin adnexal masses in pregnancy. Operative management for adnexal massis safe and hence most commonly performedin second trimester.