Eur J Cardiothorac Surg 2001;19:514-515
© 2001 Elsevier Science NL
Ectopic mediastinal pancreas
Ufuk Cagiricia,
Mustafa Ozbaranb,
Ali Veralc,
Hakan Posacioglub
a Department of Thoracic Surgery, Ege University Medical Faculty, 35100, Bornova, Izmir, Turkey
b Department of Cardiovascular Surgery, Ege University Medical Faculty, 35100, Bornova, Izmir, Turkey
c Department of Pathology, Ege University Medical Faculty, 35100, Bornova, Izmir, Turkey
Received 7 August 2000;
received in revised form 21 December 2000;
accepted 25 January 2001.
Corresponding author. Ege Universitesi, Gö
üs Cerrahisi Anabilim Dali, 35100 Bornova, Izmir, Turkey. Tel.: +90-232-343-43-43; fax: +90-232-339-00-02
e-mail: cagirici{at}med.ege.edu.tr
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Abstract
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Ectopic localisation of the pancreas is not an uncommon entity, but it is mostly seen in the gastrointestinal tract. Herein we report a 45-year-old woman with a cyst containing pancreatic tissue in the mediastinum. The English literature reveals only three previous cases of this extremely rare localisation of the pancreas.
Key Words: Mediastinal cyst • Ectopic pancreas
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1. Case report
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A previously healthy 45-year-old housewife, was admitted to the hospital with complaints of mild non-productive cough, chest pain and headache. The patient had no history of smoking and she was not taking any medications. Physical examination was normal. Results of laboratory studies were unremarkable, except an elevated erythrocyte sedimentation rate of 45 mm/h. Computed tomography (CT) of the thorax showed a large cystic lesion in the anterior mediastinum (Fig. 1)
. The lesion measured 11x8 cm, which extended to the atrium by compressing adjacent vascular structures. The lung fields, as well as the other parts of the mediastinum were normal. A provisional diagnosis of cystic thymoma, or dermoid cyst was made. Abdominal ultrasonography and electromyography demonstrated nil pathology. Repeated serology for hydatidosis was negative. Since cystic nature of the lesion precluded the attempt for a CT-guided transthoracic fine needle aspiration biopsy, thoracotomy was advised for surgical resection.
Chest was opened by a median sternotomy incision. An encapsulated fluctable cystic lesion, posterior to the sternum and chest wall, extending to the ascending aorta and left main pulmonary artery, was noticed in the anterior mediastinum. It had firm adhesions with the adjacent vascularity and mediastinal pleura. Incising the mediastinal pleura, left thoracic cavity was opened and the cyst was excised totally after dividing the adhesions by sharp dissection or electrocautery. No further dissection was performed, since no malignancy was reported from the frozen-section of the cyst wall. After completion of the procedure, 28F and 32F chest tubes connected to an underwater seal system were placed in the left pleural cavity and anterior mediastinum, respectively. Postoperative recovery was uneventful and the patient was discharged on the 5th postoperative day. With a follow-up period of 2 years, she was doing well with no signs of previously treated disease.
Histopathological examination of the specimen revealed ‘pseudocyst of the mediastinum containing pancreatic tissue’. In macroscopic examination, the lesion measured 10 cm in maximal and contained dense, yellowy turbid fluid. The cyst wall was fibrotic and microscopically it consisted of pancreatic acinary and ductal structures, as well as pancreatic islets within mediastinal adipose tissue (Fig. 2)
. Presence of pancreatic islets was verified by immunohistochemical study, in which these cells stained positively with synaptophysin and chromogranin.
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Fig. 2. Acinary structures of the pancreatic tissue in the cyst wall surrounded by inflammatory cells. (Hematoxlyin and eosin stain; original magnification x40).
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2. Discussion
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Ectopia of the pancreatic tissue is a developmental anomaly found in approximately 2% of all autopsies [1], and 70–90% of this anomaly is located in the gastrointestinal tract [2]. Mediastinal localisation of ectopic pancreatic tissue is very rare. To our knowledge, there are only three examples of this kind of heterotopia. The second documented case of mediastinal ectopic tissue presented as a mediastinal mass [3], and the third case in the literature, a previously healthy 16-year-old girl, was found to have a cystic lesion in the anterior mediastinum during evaluating of an asymptomatic heart murmur [1]. These cases were treated surgically and no recurrence was reported during follow-up period.
Mediastinal cyst containing pancreatic tissue may lead some thoracic symptoms [4], but in most of these cases a communication is usually present between the mediastinal cyst and the pancreas, unlike the present case [5]. Our patient had a mild non-productive cough and chest pain, attributable to the compressing effect of the mediastinal cyst, since the patient remained asymptomatic after the operation.
The histogenesis of this lesion is not clear. There are mainly two different theories on the embryogenesis of this anomalous development. First, abnormal differentiation of the pluripotent epithelial cells of the ventral primary foregut, so to say heteroplasia, may lead the formation of ectopic pancreatic tissue in the mediastinum. Second, some cells from the pancreatic bud may migrate and locate at a different site [2]. Further studies on embryogenesis may be informative on the ectopic localisation of the pancreatic tissue.
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References
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Perez-Ordonez B., Wesson D.E., Smith C.R., Asa S.L. A pancreatic cyst of the anterior mediastinum. Mod Pathol 1996;9:210-214.[Medline]
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von Schweinitz D., Wittekind C., Freihorst J. Mediastinaler sequester mit ektopem pankreasgewebe. Z Kinderchir 1990;45:249-250.[Medline]
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Carr M.J., Deiraniya A.K., Judd P.A. Mediastinal cyst containing mural pancreatic tissue. Thorax 1977;32:512-516.[Abstract]
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Furst H., Schmittenbecher P.P., Dienemann H., Berger H. Mediastinal pancreatic pseudocyst. Eur J Cardio-thorac Surg 1992;6:46-48.[Abstract]
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Beauchamp R.D., Winsett M., Nealon W.H. Operative strategies in the management of mediastinal pancreatic pseudocyst. Surgery 1989;106:567-570.[Medline]
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Abstract
1. Case report
