Lymphoepithelial Cyst of the Pancreas Tail

Eldo E Frezza
1
, Mitchell S Wachtel
2
1
Division of General Surgery, Department of Surgery, and
2
Department of Pathology,
Texas Tech University Health Sciences Center. Lubbock, TX, USA
ABSTRACT
Context Lymphoepithelial cyst of the
pancreas is a lesion that comprises a stratified
squamous epithelial lining atop dense
lymphoid tissue.
Case report We report our case of a 56-year-
old man presented with recurrent abdominal
pain. A CT scan showed a cystic lesion
between the spleen and the pancreas. A distal
pancreatectomy with splenectomy was
performed. All pancreatic tissue was
submitted for histologic examination. The
patient recovered on the ward. On
postoperative day two, the patient started
eating an advanced diet. He was discharged
on postoperative day four. The cyst is
comprised of benign stratified squamous
epithelium atop dense lymphoid tissue, which
was consistent with cyst.
Conclusion Good preoperative radiological
anatomical mapping, good communication
and good cooperation between the pathologist
and the surgeon are essential to resect the
lymphoepithelial cyst and exclude
malignancy.
INTRODUCTION
In 1987, Truong et al. coined the name of
lymphoepithelial cyst of the pancreas [1],
even though it had been described earlier.
About 88 cases have been previously
described [2, 3]. Pathologically, the lesion is
comprised of a stratified squamous epithelial
lining atop dense lymphoid tissue. The
present case report is that of a patient who
presented to the emergency room with left
upper quadrant pain. The workup showed a
pancreatic tail mass which was suspicious for
cancer.
CASE REPORT
A 56-year-old man presented with recurrent
abdominal pain, mostly in the left upper
quadrant and epigastrium. Past medical
history was positive for a bout of pancreatitis
two years earlier. A complete blood count,
electrolytes, and liver function tests were all
normal. A CT scan showed a 2.5x3.6x4cm
cystic lesion between the spleen and the
pancreas (Figure 1). A MRI further localized
Figure 1. CT view of the lymphoepithelial cyst tumor
at the level of the pancreatic tail.

Page 2
JOP. J Pancreas (Online) 2008; 9(1):46-49.
JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 9, No. 1 - January 2008. [ISSN 1590-8577]
47
the cyst to the distal pancreas adjacent to the
hilum of the spleen (Figure 2).
The patient was taken to the operating room
electively. After anesthesia was induced, a
left subcostal incision was performed. The
stomach was reflected to expose the pancreas
and spleen. Upon further dissection, no
definite mass was identified. The
intraoperative ultrasound could not identify
the cyst. During the procedure, the cyst
became unapparent and could not be
identified by simple palpation. Because
careful cooperation between the surgeon and
the pathologist occurred, the cyst was
identified histologically and cancer was
excluded. Because radiological examination
showed the mass to have been apposed to
both pancreas and spleen in close proximity to
the splenic artery and vein, distal
pancreatectomy and splenectomy was
performed. A Jackson-Pratt drainage was left
in place in the left upper quadrant. The patient
recovered on the ward and the drainage was
taken out postoperative day two after the
patient started eating an advanced diet and
discharged on postoperative day 4. The
patient returned to his normal activities.
At pathologic examination, no gross lesion
was appreciated; the entire pancreas segment
was evaluated histologically. In three distal
sections, adjacent to pancreas parenchyma,
lay a cyst lining comprised of benign
stratified squamous epithelium atop a
lymphoid tissue layer (Figures 3 and 4). The
pancreas also showed focal fibrosis and
inflammation. The spleen showed congestive
splenomegaly. No cancer was seen, as
expected in this type of cyst.
DISCUSSION
Lymphoepithelial cysts of the pancreas are
rare lesions [2, 3, 4, 5, 6, 7]. About 88 cases
have been reported. Most often, the lesions
appear in middle aged men, as is true in this
case. The most common symptoms are
abdominal pain, nausea and vomiting,
anorexia and weight-loss, general malaise and
altered bowel habits, but many patients are
asymptomatic, coming to the surgeons
attention as incidental radiological findings.
The cysts can occur at any location in the
Figure 2. MRI view of the lymphoepithelial cyst
tumor.
Figure 3. Low power view of lymphoepithelial cyst
showing cyst lining on left and pancreatic parenchyma
on right. (Hematoxylin and eosin. Original
magnification 40x).
Figure 4. High power view of lymphoepithelial cyst
lining showing benign stratified squamous epithelium
overlaying a layer of lymphoid tissue. (Hematoxylin
and eosin. Original magnification 200x).

Page 3
JOP. J Pancreas (Online) 2008; 9(1):46-49.
JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 9, No. 1 - January 2008. [ISSN 1590-8577]
48
pancreas, have been as large as 13 cm. Most
such cysts are multilocular. The differential
diagnosis is cancer and the final diagnosis can
only be done after resection.
The etiology is unclear, but the cysts have
arisen in association with Sjogren’s disease
and AIDS; this patient had neither of these
conditions. It has been posited that the lesion
is an enlarged epithelial inclusion in a
peripancreatic lymph node that has undergone
squamous metaplasia; [8] the location of our
patient’s lesion, immediately apposed to the
pancreatic parenchyma, further supports this
hypothesis. Others have identified these cysts
in ectopic pancreatic tissue in peripancreatic
lymph nodes [9, 10]. Although one might
suggest the lesion arises from an obstructed
pancreatic duct [7], the presence of a zone of
lymphoid tissue cannot be explained on this
basis. Others have posited these as being
benign epithelial inclusions embedded in the
pancreas or brachial cleft cysts fused with the
pancreatic anlage during embryogenesis [1,
6].
The differential diagnosis, includes primary
splenic cysts, pseudocysts, cystadenocarcinomas,
left adrenal cysts, cystic aneurysms,
retroperitoneal cysts, duplication cysts, and
mesenteric cysts; most of these diagnoses can
be excluded by MRI, as was done in this case.
CT scans usually show a low-attenuation
mass with a thin enhancing rim and focal wall
calcification, as in our case [11]. Ultra-
sonography can be used to further support the
cystic nature of these lesions [12]. Most cysts
are radiologically consistent with a pancreatic
pseudocyst; fine needle aspiration may be of
utility to exclude malignant cells [7, 13, 14].
With all of the risks related in our case, given
the vicinity of the splenic hilum that was
never taken into consideration. From our case,
we learned that the cyst is not easily defined
by gross palpation during the surgical
exploration. Therefore, it is of utmost
importance to have an anatomical map with
CT and MRI. A good and quick pathological
evaluation on the resected specimen is
important to document that the cyst was
resected. A good margin taken during the
resection of the pancreatic segment is a key to
find potential malignant lesion. The two most
important lessons learned from this case are:
1) preoperative anatomical mapping is
extremely important in the surgical strategy;
2) good communication and cooperation with
the pathologist plays a key role in the
optimization of the surgical resection,
particularly if the cyst is not palpable in the
operating room.
CONCLUSION
Lymphoepithelial cyst of the pancreas is a
rare disease that often presents as an
incidental radiological finding, but may, as in
this case, cause symptoms that require an
emergency room visit. Radiological
procedures are of great utility in ruling out
other diagnoses. Percutaneous aspiration may
be of use, but for most patients surgical
exploration will be required to exclude
cancer. For the cysts that are close to the
splenic hilum, distal pancreatectomy and
splenectomy are indicated to avoid potential
lesions to the spleen and complete specimen
resection to exclude cancer.
Received September 26
th
, 2007 - Accepted
November 7
th
, 2007
Keywords Lymphatic Vessel Tumors;
Neoplasms, Glandular and Epithelial;
Pancreatic Neoplasms; Pathology
Acknowledgements Poster presented at the
Southeastern Surgical Congress Meeting;
Savannah, GA, USA; February 10-13, 2007
Correspondence
Eldo Ermenegildo Frezza
Department of Surgery
Division of General Surgery
Texas Tech University Health Sciences Center
3601 4
th
Street, MS 8312
Lubbock, TX 79430
USA
 

Page 4
JOP. J Pancreas (Online) 2008; 9(1):46-49.
JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 9, No. 1 - January 2008. [ISSN 1590-8577]
49
References
1. Truong LD, Rangdaeng S, Jordan PH Jr.
Lymphoepithelial cyst of the pancreas. Am J Surg
Pathol 1987; 11:899-903. [PMID 3674287]
2. Liu J, Shin HJ, Rubenchik I, Lang E, Lahoti S,
Staerkel GA. Cytologic features of lymphoepithelial
cyst of the pancreas: two preoperatively diagnosed
cases based on fine-needle aspiration. Diagn
Cytopathol 1999; 21:346-50. [PMID 10527483]
3. Adsay NV, Hasteh F, Cheng JD, Bejarano PA,
Lauwers GY, Batts KP, et al. Lymphoepithelial cysts
of the pancreas: a report of 12 cases and a review of the
literature. Mod Pathol 2002; 15:492-501. [PMID
12011254]
4. Adsay NV, Hasteh F, Cheng JD, Klimstra DS.
Squamous-lined
cysts
of
the
pancreas:
lymphoepithelial cysts, dermoid cysts (teratomas), and
accessory-splenic epidermoid cysts. Sem Diagn Pathol
2000; 17:56-65. [PMID 10721807]
5. Kim YH, Auh YH, Kim KW, Lee MG, Kim KS,
Park SY. Lymphoepithelial cysts of the pancreas: CT
and sonographic findings. Abdom Imaging 1998;
23:185-7. [PMID 9516512]
6. Tateyama H, Tada T, Murase T, Fujitake S,
Eimoto T. Lymphoepithelial cyst and epidermoid cyst
of the accessory spleen in the pancreas. Mod Pathol
1998; 11:1171-7. [PMID 9872647]
7. Neyman EG, Georgiades CS, Horton KH,
Lillemoe KD, Fishman EK. Lymphoepithelial cyst of
the pancreas--evaluation with multidetector CT. Clin
Imaging 2005; 29:345-7. [PMID 16153542]
8. Sako S, Isozaki H, Hara H, Tsutsumi A, Tanigawa
N. Cystic lymphoepithelial lesions of the pancreas and
peripancreatic region: report of two cases. Surg Today
1999; 29:467-71. [PMID 10333422]
9. Strapko A, Botash RJ, Murthy UK, Landas SK.
Lymphoepithelial cyst of the pancreas: a case report
and review of the literature. Dig Dis Sci 1998; 43:870-
4. [PMID 9558046]
10. Tsuchiya Y, Suzuki S, Sakaguchi T, Kojima Y,
Okamoto K, Kurachi K, et al. Lymphoepithelial cyst of
the pancreas report of a case. Surg Today 2000;
30:856-60. [PMID 11039720]
11. Koga H, Takayasu K, Mukai K, Muramatsu Y,
Mizuguchi Y, Furukawa H, et al. CT of
lymphoepithelial cysts of the pancreas. J Comput
Assist Tomogr 1995; 19:221-4. [PMID 7890845]
12. Yamamoto K, Fujimoto K, Matsushiro T, Ota K.
Lymphoepithelial cyst in pancreas: a case report.
Gastroenterol Jpn 1990; 25:758-61. [PMID 2279638]
13. Mandavilli SR, Port J, Ali SZ. Lymphoepithelial
cyst (LEC) of the pancreas: cytomorphology and
differential diagnosis on fine-needle aspiration (FNA).
Diagn Cytopathol 1999; 20:371-4. [PMID 10352910]
14. Bolis GB, Farabi R, Liberati F, Macciò T.
Lymphoepithelial cyst of the pancreas. Report of a case
diagnosed by fine needle aspirat

There are no products listed under this category.