A 64-year-old woman with newly diagnosed type 2 diabetes mellitus was admitted with
intermittent abdominal pain of 3 years’ duration. Computed tomography (CT) showed
multifocal pancreatic cystic lesions with a dilated main pancreatic duct and calcification
of a cyst wall ([Fig. 1]), raising suspicion of a mucinous neoplasm of the pancreas.
Fig. 1 Computed tomography (CT) image showing multifocal pancreatic cystic lesions with
dilated main pancreatic duct (black arrow) and calcification of cyst wall (white arrow).
The patient was a 64-year-old woman with newly diagnosed type 2 diabetes mellitus
and with intermittent abdominal pain of 3 years’ duration.
Needle-based confocal laser endomicroscopy (nCLE) (AQ-Flex 19; Mauna Kea Technologies,
France) is a novel imaging technique that enables real time in vivo microscopic imaging
of a cyst wall during endoscopy, with a promising diagnostic yield [1]
[2]
[3]. The diagnosis of intraductal papillary mucinous neoplasm (IPMN) is indicated by
the presence of finger-like papillae, while mucinous cystic neoplasms (MCNs) have
a characteristic single band-like epithelium on nCLE [1]
[2]
[3].
We performed endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in our
patient, with EUS confirming multifocal anechoic cystic lesions extending from the
head of the pancreas to the tail, with hyperechoic margins. nCLE showed dark aggregates
of cells with surrounding small vessels ([Video 1]), which had indicated features concerning for neoplasia in an earlier study [4]. The cyst fluid had a mucinous appearance and viscosity, and FNA cytology confirmed
neoplastic mucinous cells ([Fig. 2 a, b]). The patient consequently underwent a total pancreatectomy ([Fig. 3]). Histopathological examination revealed an IPMN with high grade dysplasia ([Fig. 4]). Lymph node sampling was negative for metastasis.
Video 1 Needle-based confocal laser endomicroscopy (nCLE) in the diagnosis of multifocal
intraductal papillary mucinous neoplasm with high grade dysplasia: endoscopic ultrasound
shows multifocal cystic lesions with hyperechoeic margins, and nCLE shows dark aggregates
of cells with surrounding small vessels.
Fig. 2 a Fine needle aspiration (FNA) specimen showing mucinous appearance. b FNA cytology shows neoplastic mucinous cells (hematoxylin and eosin [H&E], × 200).
Fig. 3 The surgically resected specimen. Throughout the pancreas there were multifocal cystic
lesions filled with mucus.
Fig. 4 Histopathological appearance shows papillae protruding into the cyst lumen and neoplastic
mucinous cells arranged in an irregular multilamellar pattern without infiltration
(hematoxylin and eosin [H&E], × 40).
Wider use of nCLE has resulted in consensus on some of the characteristic features
of common pancreatic cystic lesions, but this is an evolving area with scope for further
definition of diagnostic features. In this case, nCLE images showed features concerning
for neoplasia prior to surgery. The pattern of dark aggregates of cells surrounded
by small vessels may be a promising characteristic in identification of malignant
pancreatic cystic lesions (MPCLs). Further studies are required to confirm these findings
and to establish nCLE criteria in the diagnosis of MPCLs.
Endoscopy_UCTN_Code_CCL_1AF_2AF_3AC
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