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A rare case of ossification of a celiac cyst
The American Journal of Surgery (2008) 196, e25– e26
Clinical Images
A rare case of ossification of a celiac cyst Yong He, M.D.a,*, Wei Li, M.D.b a
Thoracic Surgery Center, Daping Hospital, Third Military Medical University, Chongqing, China; bGeneral Hospital of Chengdu Military Command, Chengdu, Sichuan, China
KEYWORDS: Ossification; Cyst
Abstract. There has been little report on calcification of cysts inside the abdomen. Here we report a rare case of ossification of celiac cyst. If we understand the images of calcified and ossified cysts, a correct diagnosis can be made. © 2008 Elsevier Inc. All rights reserved.
A female patient, age 35 years, was admitted to Daping hospital after identification of a round cyst in the right inferior abdomen, which was detected by x-ray during physical examination. The patient had undergone appendectomy caused by acute appendicitis in another hospital 6 months earlier. X-ray had not been performed before this appendectomy. No appendicular perforation or abscess was found. On physical examination, the patient was apparently normal; the abdomen was flat and soft; and no symptoms were reported other than slight pain in the right inferior abdomen. A McBurney incision scar 4 cm in length was noted on her right inferior abdomen; no lump was detected. Routine blood examination was normal. Ultrasonic inspection indicated a round structure with a diameter of approximately 4 cm under the incision scar, close to the linea alba abdominis. The structure had no apparent connection with the uterus and uterine appendages. Abdominal computed axial tomography scan indicated a possible tumor with high superficial density and low central density, and the structural details were confirmed using contrast material. After admission, laparotomy was performed along the original incision scar with the patient under epidural anesthesia. There was no apparent accretion in the abdomen. A globular tumor was found just touching the internal side of the incision, which * Corresponding author. Tel.: ⫹011-86-26-68757988; fax: ⫹011-8623-68757987. E-mail address: [email protected] Manuscript received March 17, 2007; revised manuscript August 27, 2007
0002-9610/$ - see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2007.08.075
was located on mesentery, approximately 4 ⫻ 4 ⫻ 4 cm3 in size. The tumor was hard with a smooth surface. One side stuck closely to the mesentery, and the rest of the face covered by lamellar mesenterium. Another irregular induration approximately 1 ⫻ 1 ⫻ 1 cm3 in size was also seen on adjacent mesentery. The globular tumor and the smaller indurations were excised and sent for pathology examination (Figs. 1-3). Pathology results confirmed the presence of one grey, globular tumor mass and an irregular hard induration. Interestingly, the tumor was encased in a hard, ossified envelope. After cutting with a saw, a sclerotic shell with an even thickness of 2 mm could be seen. It was filled with dark yellow necrotic tissue. The hard induration was determined to be a calcified and ossified epidermoid cyst. The patient recovered well after surgery.
Comments Presently there is no clear understanding of the timing and mechanism(s) by which cysts with ossified shells originate. Although the occurrence of calcified splenic cysts has been described previously, there have been no reports on calcified cysts in the abdomen. Here, we describe a rare epidermoid calcified cyst, of ping-pong ball shape and size and located along the mesentery, whose wall had completely ossified. Because the patient had not undergone previous abdominal surgery, and the cyst was very regular
e26
The American Journal of Surgery, Vol 196, No 4, October 2008
Figure 3 Ossification of celiac cyst (hematoxylin and eosin; magnification ⫻ 200).
with high density, one cannot rule out that a leftover surgical instrument may have been responsible.
Acknowledgments
Figure 1 Plain abdominal radiograph displays a ping-pong ball– shaped object at the right inferior of abdomen.
Figure 2 Abdominal X CAT displays the globular tumor at the right inferior abdomen underneath the abdominal wall; the tumor lies outside of the intestine.
We thank Kalkunte Srivenugopal (Texas Tech University Health Sciences Center, USA) for critical reading of the manuscript.
Clinical Images
A rare case of ossification of a celiac cyst Yong He, M.D.a,*, Wei Li, M.D.b a
Thoracic Surgery Center, Daping Hospital, Third Military Medical University, Chongqing, China; bGeneral Hospital of Chengdu Military Command, Chengdu, Sichuan, China
KEYWORDS: Ossification; Cyst
Abstract. There has been little report on calcification of cysts inside the abdomen. Here we report a rare case of ossification of celiac cyst. If we understand the images of calcified and ossified cysts, a correct diagnosis can be made. © 2008 Elsevier Inc. All rights reserved.
A female patient, age 35 years, was admitted to Daping hospital after identification of a round cyst in the right inferior abdomen, which was detected by x-ray during physical examination. The patient had undergone appendectomy caused by acute appendicitis in another hospital 6 months earlier. X-ray had not been performed before this appendectomy. No appendicular perforation or abscess was found. On physical examination, the patient was apparently normal; the abdomen was flat and soft; and no symptoms were reported other than slight pain in the right inferior abdomen. A McBurney incision scar 4 cm in length was noted on her right inferior abdomen; no lump was detected. Routine blood examination was normal. Ultrasonic inspection indicated a round structure with a diameter of approximately 4 cm under the incision scar, close to the linea alba abdominis. The structure had no apparent connection with the uterus and uterine appendages. Abdominal computed axial tomography scan indicated a possible tumor with high superficial density and low central density, and the structural details were confirmed using contrast material. After admission, laparotomy was performed along the original incision scar with the patient under epidural anesthesia. There was no apparent accretion in the abdomen. A globular tumor was found just touching the internal side of the incision, which * Corresponding author. Tel.: ⫹011-86-26-68757988; fax: ⫹011-8623-68757987. E-mail address: [email protected] Manuscript received March 17, 2007; revised manuscript August 27, 2007
0002-9610/$ - see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2007.08.075
was located on mesentery, approximately 4 ⫻ 4 ⫻ 4 cm3 in size. The tumor was hard with a smooth surface. One side stuck closely to the mesentery, and the rest of the face covered by lamellar mesenterium. Another irregular induration approximately 1 ⫻ 1 ⫻ 1 cm3 in size was also seen on adjacent mesentery. The globular tumor and the smaller indurations were excised and sent for pathology examination (Figs. 1-3). Pathology results confirmed the presence of one grey, globular tumor mass and an irregular hard induration. Interestingly, the tumor was encased in a hard, ossified envelope. After cutting with a saw, a sclerotic shell with an even thickness of 2 mm could be seen. It was filled with dark yellow necrotic tissue. The hard induration was determined to be a calcified and ossified epidermoid cyst. The patient recovered well after surgery.
Comments Presently there is no clear understanding of the timing and mechanism(s) by which cysts with ossified shells originate. Although the occurrence of calcified splenic cysts has been described previously, there have been no reports on calcified cysts in the abdomen. Here, we describe a rare epidermoid calcified cyst, of ping-pong ball shape and size and located along the mesentery, whose wall had completely ossified. Because the patient had not undergone previous abdominal surgery, and the cyst was very regular
e26
The American Journal of Surgery, Vol 196, No 4, October 2008
Figure 3 Ossification of celiac cyst (hematoxylin and eosin; magnification ⫻ 200).
with high density, one cannot rule out that a leftover surgical instrument may have been responsible.
Acknowledgments
Figure 1 Plain abdominal radiograph displays a ping-pong ball– shaped object at the right inferior of abdomen.
Figure 2 Abdominal X CAT displays the globular tumor at the right inferior abdomen underneath the abdominal wall; the tumor lies outside of the intestine.
We thank Kalkunte Srivenugopal (Texas Tech University Health Sciences Center, USA) for critical reading of the manuscript.