Cyst Type Differentiates Rathke Cleft Cysts From Cystic Pituitary Adenomas

PurposeA classification system for cystic sellar lesions does not exist. We propose a novel classification scheme for these lesions based on the heterogeneity of the cyst wall/contents and the presence of a solid component on imaging.MethodsWe retrospectively reviewed 205 patients’ medical records (2008–2020) who underwent primary surgery for a cystic sellar lesion. Cysts were classified a priori into 1 of 4 cyst types based on the heterogeneity of the cyst wall/contents and the presence of a solid component imaging. There was high interrater reliability. Univariable and multivariable models were used to estimate the ability of cyst type to predict the two most common diagnoses: Rathke cleft cyst (RCC) and cystic pituitary adenoma.ResultsThe frequencies of RCC and cystic pituitary adenoma in our cohort were 45.4% and 36.4%, respectively. Non-neoplastic lesions (e.g., arachnoid cysts and RCC) were more likely to be Type 1 or 2, whereas cystic neoplasms (e.g., pituitary adenomas and craniopharyngiomas) were more likely to be Type 3 or 4 (p<0.0001). Higher cyst types, compared to Type 1, had higher odds of being cystic pituitary adenomas compared to RCCs (OR: 23.7, p=0.033, and 342.6, p <0.0001, for Types 2 and 4, respectively). Lesions with a fluid-fluid level on preoperative MRI also had higher odds of being pituitary adenomas (OR: 12.7; p=0.023). Cystic pituitary adenomas were more common in patients with obesity (OR: 5.0, p=0.003) or symptomatic hyperprolactinemia (OR: 11.5; p<0.001, respectively). The multivariable model had a positive predictive value of 82.2% and negative predictive value of 86.4%.ConclusionWhen applied to the diagnosis of RCC versus cystic pituitary adenoma, higher cystic lesion types (Type 2 & 4), presence of fluid-fluid level, symptomatic hyperprolactinemia, and obesity were predictors of cystic pituitary adenoma. Further validation is needed, but this classification scheme may prove to be a useful tool for the management of patients with common sellar pathology.

Biliary cystadenoma masquerading as an adnexal cyst in pregnancy

The aetiological diagnosis of cystic masses detected on routine ultrasound during pregnancy can be challenging. Unless approached cautiously with a detailed history and adequate use of imaging techniques, misdiagnosis of these cystic masses are not uncommon. Cystic masses diagnosed during pregnancy are mostly of ovarian origin; however, other non-ovarian cystic masses are also detected incidentally or at laparotomy/laparoscopy. We report a rare case of ruptured biliary cystadenoma in a pregnant woman diagnosed at emergency laparotomy. She was taken up for surgery with a provisional impression of ruptured adnexal cyst. However, the cyst was found to be arising from the liver and the histology of the cyst wall was reported as biliary cystadenoma.

Radiologic Reporting of Simple Hepatic Cyst Versus Biliary Cystadenoma May Lead to Unnecessary Surgery

Background and Aims Simple liver cyst (SHC) is a benign condition with no malignant potential. They are typically discovered incidentally due to the increased use of abdominal imaging, but some patients may present with abdominal pain. A radiologist’s differential diagnosis in cases of SHC will often include “rule out biliary cystadenoma.” Under these circumstances, patients and surgeons are more likely to pursue surgical options even in asymptomatic cases. The aim of this study is to conduct a retrospective analysis of presentation, radiologic reporting, management plan, and histopathology of patients referred to a tertiary hospital in order to determine the correlation between radiology and histology. Methods We retrospectively analyzed the clinical, radiological, and histopathological data of 20 patients operated for a diagnosis of a cystic lesion in the liver. Result The CT/MRI of 6 (30%) patients was reported as a biliary cystadenoma, 13 (65%) were reported as a simple hepatic cyst and 1 patient (5%) had hepatocellular carcinoma (HCC) with the additional diagnosis of multiple hepatic cysts. The lesion reported as HCC on the scan was separate from the cystic lesions. The modality of imaging for these cysts was evenly split, 50% of patients had a CT scan, and 50% had an MRI performed. All imaging studies were interpreted by an attending radiologist and most of them were discussed in multidisciplinary meetings. Nineteen patients (95%) had an intraoperative diagnosis of a simple liver cyst based on its visual appearance and clear fluid within the cyst. These patients underwent cyst wall fenestration and de-roofing with the cyst wall sent for histopathology. One patient (5%) with HCC underwent a non-anatomical liver resection. Histopathology was conclusive for a benign hepatic cystic lesion from the cyst wall biopsy. All 20 patients in this study underwent surgery, either due to symptoms or due to radiologic diagnosis of BCA. Four of the 20 cases (20%) were asymptomatic and out of these four cases, 3 (75%) were diagnosed as cystadenoma on the preoperative imaging studies. All 19 cases were diagnosed as a simple liver cyst on pathology. Conclusion In summary, there is a growing trend of “ruling-out the diagnosis of biliary cystadenoma” in patients who present with liver cysts. Patients are appropriately more anxious after this preoperative diagnosis and the treating surgeons have medico-legal concerns regarding conservative management in asymptomatic patients diagnosed as BCA. This single center experience draws attention to the radiology criteria utilized for diagnosing a biliary cystadenoma and suggests that it is time to revisit the imaging interpretation and differential diagnosis.

A Novel Spo11 Homologue Functions as a Positive Regulator in Cyst Differentiation in Giardia lamblia

Giardia lamblia persists in a dormant state with a protective cyst wall for transmission. It is incompletely known how three cyst wall proteins (CWPs) are coordinately synthesized during encystation. Meiotic recombination is required for sexual reproduction in animals, fungi, and plants. It is initiated by formation of double-stranded breaks by a topoisomerase-like Spo11. It has been shown that exchange of genetic material in the fused nuclei occurs during Giardia encystation, suggesting parasexual recombination processes of this protozoan. Giardia possesses an evolutionarily conserved Spo11 with typical domains for cleavage reaction and an upregulated expression pattern during encystation. In this study, we asked whether Spo11 can activate encystation process, like other topoisomerases we previously characterized. We found that Spo11 was capable of binding to both single-stranded and double-stranded DNA in vitro and that it could also bind to the cwp promoters in vivo as accessed in chromatin immunoprecipitation assays. Spo11 interacted with WRKY and MYB2 (named from myeloblastosis), transcription factors that can activate cwp gene expression during encystation. Interestingly, overexpression of Spo11 resulted in increased expression of cwp1-3 and myb2 genes and cyst formation. Mutation of the Tyr residue for the active site or two conserved residues corresponding to key DNA-binding residues for Arabidopsis Spo11 reduced the levels of cwp1-3 and myb2 gene expression and cyst formation. Targeted disruption of spo11 gene with CRISPR/Cas9 system led to a significant decrease in cwp1-3 and myb2 gene expression and cyst number. Our results suggest that Spo11 acts as a positive regulator for Giardia differentiation into cyst.

Endoscopic Endonasal Resection of Symptomatic Rathke Cleft Cysts: Total Resection or Partial Resection

Objective: Rathke cleft cysts (RCC) are benign sellar lesions, and endoscopic endonasal surgery (EES) for symptomatic RCC is becoming increasingly popular, but total resection or partial resection (TR or PR) of the cyst wall is still inconclusive. The aim of this study was to review the complications and clinical prognoses associated with total and partial resection of the cyst wall by EES.Methods: We retrospectively analyzed a series of 72 patients with symptomatic RCC treated by EES from -January 2011 to June 2019 at Shenzhen University First Affiliated Hospital. For these 72 cases, 30 were treated with TR and 42 were treated with PR. Intra- and post-operative complications and clinical prognosis were investigated.Results: All 72 patients underwent a pure EES. In the TR group, 10 patients (33.3%) had intraoperative cerebrospinal fluid leakage (CSF leak), three patients (10%) had postoperative CSF leak, eight patients (26.7%) had postoperative diabetes insipidus (DI), eight patients (26.7%) had postoperative electrolyte disturbance, and 12 patients (40%) had temporary hypopituitarism postoperatively. While in the PR group, three patients (7.1%) had intraoperative CSF leak, two patients (4.8%) had postoperative DI, three patients (7.1%) had postoperative electrolyte disturbance, four patients (9.5%) had temporary hypopituitarism postoperatively, and no cases experienced postoperative CSF leak. The intra- and post-operative complications were significantly higher in TR group then PR group (P IntraoperativeCSFleak = 0.004, P Post−operativeCSFleak =0.036, P TransientDI = 0.008, P Temporaryhypopituitarism = 0.002, P Permanenthypopituitarism = 0.036, P Electrolytedisturbance = 0.023). No significant differences in post-operative improvement and recurrence.Conclusions: EES is a safe and effective approach for the treatment of symptomatic RCC. Complete sucking out the cyst contents and partial resection of the cyst wall may be sufficient for treatment, and total resection of the cyst wall is associated with a higher incidence of complications.

A clinicopathological study of ovarian endometriotic cysts

Endometriosis is an important gynecologic disorder with multifactorial causes, primarily affecting women during their reproductive years. Pathologically, it is the result of functional endometrium located outside the uterus which may vary from microscopic endometriotic implants to large cysts. Endometriotic cysts and infertility is a well-known association. Some patients are asymptomatic while others present with disabling pelvic pain, infertility, or adnexal masses. Cyst aspiration, fenestration and ablation of cyst wall are commonly performed surgical procedures. Excision of the cyst wall is an accepted surgical treatment owing to the low recurrence rates. A total of 35 patients who underwent ovarian cystectomy for endometriotic cysts between January 2019 and December 2020 were retrospectively identified. The clinical findings, gross and histopathological features were noted in each case. Microscopically, the presence or absence of ovarian tissue adjacent to the cyst wall was evaluated. If ovarian tissue was present, the morphologic characteristics were graded on a semi-quantitative scale of 0-4 as described by Muzii et al. The age group of patients ranged between 22-28yrs. Right side cysts accounted for the majority, however 6 cases had bilateral endometriotic cysts. Majority of patients presented with primary infertility (46.2%). The maximum weight recorded for these cysts was 35gm, size ranging between 4.5 to 18cm and median thickness of the cyst wall being 0.7cm. 68% of the cysts showed a lining epithelium, few showing atypia and oncocytic change. Fibrosis and hemosiderin laden macrophages were present in more than 70% of cases and endometrial glands and stroma in more than 50%. Inflammation when present was predominantly lymphocytic. On evaluation of the ovarian tissue, 42.8% of cases showed no follicles and the rest showing grades ranging from 1 to 4, with grade 1 accounting for majority. The present study further emphasizes endometriosis to be an important cause of primary infertility which needs to be recognized and treated appropriately. Recognition of these cysts on histopathological examination can be challenging at times when endometrial stroma is scant and in cases of tubo-ovarian masses where these lesions could mimic malignancy. The excision of endometriotic cyst wall may cause loss of functional ovarian tissue in patients with primary infertility and thus could effect the response to ovarian stimulation, ocyte recovery, implantation and fertilization rates in these patients.

Cystic Encapsulated Papillary Carcinoma in the Male Breast: An Unusual Feature With a Diagnostic Challenge

Papillary carcinoma in the male breast is uncommon. Here, we report a case of a large encapsulated papillary carcinoma (EPC) in a 62-year-old male. The patient presented with a left breast mass of 1-year duration and bloody nipple discharge for several days. Mammography and breast ultrasonography showed a large left breast mass. The initial biopsy demonstrated fat necrosis with acute and chronic inflammation only. Due to clinical suspicion, a repeat biopsy was performed and revealed scant fragments of papillary carcinoma in a background of inflammation. The patient underwent left total mastectomy. Grossly, the breast contained a 9.0 cm entirely cystic lesion lined by a hemorrhagic thick fibrotic wall. No solid area was identified in the cyst. The entire cyst wall was examined under microscopy; only a few sections with papillary carcinoma were identified. The lesion was confined to the cyst wall; so, a diagnosis of EPC was made. Compared to the previously reported EPC cases of male breast, the lesion of this case was unusually cystic, which making the diagnosis challenging. Therefore, awareness of this unusual feature, repeat biopsy when the pathology result is discordant, and extensive sampling of the lesion are essential for making the correct diagnosis and guiding patient management.