|Ahead of print publication
SpyGlass findings of mucinous cystic neoplasm by introducing the fiber-optic into the cyst through a 19-gauge needle during endoscopic ultrasound
Wengang Zhang, Enqiang Linghu
Department of Gastroenterology, Chinese PLA General Hospital, Beijing 100853, China
|Date of Submission||05-Oct-2016|
|Date of Acceptance||27-Feb-2017|
|Date of Web Publication||24-Aug-2017|
Chinese PLA General Hospital and Chinese PLA Medical College, Beijing
Source of Support: None, Conflict of Interest: None
|How to cite this URL:|
Zhang W, Linghu E. SpyGlass findings of mucinous cystic neoplasm by introducing the fiber-optic into the cyst through a 19-gauge needle during endoscopic ultrasound. Endosc Ultrasound [Epub ahead of print] [cited 2018 Dec 17]. Available from: http://www.eusjournal.com/preprintarticle.asp?id=213649
SpyGlass (Boston Scientific, SpyGlass Lightcource 4619, and SpyGlass Camera 4610, USA), a system designed for single-operator cholangioscopy and pancreatoscopy, has been proven to be feasible. It was introduced for direct cholangiopancreatoscopic applications by passing through a duodenoscope in the process of Endoscopic retrograde cholangiopancreatography (ERCP). In this report, we present a case of pathologically proven mucinous cystic neoplasm (MCN), in which SpyGlass findings were obtained by introducing the fiber-optic into the cyst through a 19-gauge needle during endoscopic ultrasound (EUS).
A case of 51-year-old woman was discovered a 3.13 cm × 3.14 cm multilocular cystic lesion with a mural nodule at the pancreatic body on EUS [Figure 1]. Sequentially, we conducted a fine-needle aspiration with a 19-gauge needle and obtained 5 ml transparent gelatinous material which had a positive string sign suggesting a diagnose of MCN [Figure 2] and [Figure 3]. After repeated irrigation with saline solution, a fiber-optic probe (Boston Scientific, SpyGlass 4603, USA) was passed through the needle into the cyst and a intracystic wall with multiple ridge-like partitions and abundant latticed vessels were seen adequately [Figure 4],[Figure 5] and [Video 1]. Then, a surgery was performed for the patient and MCN was diagnosed through surgical pathology, characterized by the presence of epithelial lining of a single layer of columnar cells and ovarian-like subepithelial stroma [Figure 6].
|Figure 1: Endosonographc image. The multilocular cystic lesion with a mural nodule at the pancreatic body on endoscopic ultrasound|
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|Figure 2: Endosonographc image. Fine-needle aspiration with a 19-gauge needle|
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|Figure 5: Spyglass image. A intracystic wall with abundant latticed vessels|
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|Figure 6: Pathological image. Pathological features of the case characterized by the presence of epithelial lining of a single layer of columnar cells and ovarian-like subepithelial stroma|
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| Discussion|| |
Recently, in one publication, Nakai et al. showed a picture of MCN with smooth cyst walls and cloudy fluid via through-the-needle cystoscopy although it was not clear whether the case had a surgical pathology. In the present study, the case had a positive string sign, suggesting a diagnose of mucin-producing cystic neoplasms [Figure 2] and [Figure 3], which were comprised of MCN and intraductal papillary mucinous neoplasms (IPMN). IPMN can be subclassified into main duct IPMN (MD-IPMN) and branch duct IPMN (BD-IPMN). MD-IPMNs are characterized by a diffuse dilatation of the main pancreatic duct in the absence of a prominent cyst, and 93% of BD-IPMNs are found not to be rounded in appearance. However, the case in this study showed neither a diffuse dilatation of the main pancreatic duct nor a nonrounded appearance under EUS [Figure 1] and [Figure 2]; thus, a diagnosis of IPMN could be ruled out preliminarily. Moreover, the surgical pathology showed the presence of epithelial lining of a single layer of columnar cells and ovarian-like subepithelial stroma [Figure 6], which was a pathological diagnosis basis of MCN. Above all, the present case can be diagnosed as MCN.
MCN has the potential to progress to a malignant state and predominantly manifests as unilocular or multilocular cystic lesions. Nakai et al's study showed a unilocular MCN picture with smooth cyst walls and cloudy fluid via through-the-needle cystoscopy, whereas the present study showed a pathologically confirmed multilocular MCN picture with ridge-like partitions and abundant latticed vessel using the same method. It remains unclear that whether it is a gradual process from unilocular to multilocular cystic lesions, and we speculate that the ridge-like partitions might be the former structures of intracystic full partitions and abundant latticed vessels could provide nutritional support. However, it is just a speculation, and more SpyGlass findings of pathologically confirmed MCN may provide new guidelines and evidences.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]