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ORIGINAL ARTICLE
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


 Department of Gastroenterology, Chinese PLA General Hospital, Beijing 100853, China

Date of Submission05-Oct-2016
Date of Acceptance27-Feb-2017
Date of Web Publication24-Aug-2017

Correspondence Address:
Enqiang Linghu,
Chinese PLA General Hospital and Chinese PLA Medical College, Beijing
China
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/eus.eus_24_17

PMID: 28836517



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.[1] 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].[2] 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].[3]
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 3: String sign. Appearing a positive string sign

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Figure 4: Spyglass image. A intracystic wall with ridge-like septums

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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 Top


Recently, in one publication, Nakai et al.[4] 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],[2] 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.[3] Above all, the present case can be diagnosed as MCN.

MCN has the potential to progress to a malignant state[3] and predominantly manifests as unilocular or multilocular cystic lesions.[5] 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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Chen YK, Pleskow DK. SpyGlass single-operator peroral cholangiopancreatoscopy system for the diagnosis and therapy of bile-duct disorders: A clinical feasibility study (with video). Gastrointest Endosc 2007;65:832-41.  Back to cited text no. 1
    
2.
Bick BL, Enders FT, Levy MJ, et al. The string sign for diagnosis of mucinous pancreatic cysts. Endoscopy 2015;47:626-31.  Back to cited text no. 2
    
3.
Tanaka M, Fernández-del Castillo C, Adsay V, et al. International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology 2012;12:183-97.  Back to cited text no. 3
    
4.
Nakai Y, Iwashita T, Park DH, et al. Diagnosis of pancreatic cysts: EUS-guided, through-the-needle confocal laser-induced endomicroscopy and cystoscopy trial: DETECT study. Gastrointest Endosc 2015;81:1204-14.  Back to cited text no. 4
    
5.
Hijioka S, Hara K, Mizuno N, et al. Morphological differentiation and follow-up of pancreatic cystic neoplasms using endoscopic ultrasound. Endosc Ultrasound 2015;4:312-8.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

 
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