Earlier clinical conundrum resolved: a diagnosis with teeth

We received a number of e-letters (available with the original article1 at www.cmaj.ca) suggesting possible diagnoses in the case of a man who was noted at autopsy to have several unusual structures near his pancreas. Many different pathologies were proposed, including a neuroendocrine neoplasm, cystadenoma, inflammatory pseudotumour, sclerosing mesenteritis (panniculitis), thymus remnant, tuberculoma, hamartoma, and dermoid or hydatid cysts due to foreign body reactions possibly from a remote gun-shot injury or bomb splinter.

Figure.

The most common, and perhaps best argued, diagnosis was a lymphoepithelial cyst of the pancreas. Such a lesion, which is a frequent incidental finding on abdominal CT scans, is benign and occurs more commonly in men than in women. Histologically similar lesions have been found in the parotid and thyroid glands, the neck (brachial cleft cysts), the thymus and the lungs. This clinical entity was described nearly 160 years ago by a dentist who felt that the lesion's characteristic luminal pearls very closely resembled teeth.2

The diagnosis of lymphoepithelial cyst of the pancreas reached us independently on the same day from Dr. Nick G. van der Westhuizen and Dr. Heike Varnholt (who also pointed us to the first case report2). To both we offer a small but nifty prize, a CMAJ combination pedometer and radio.