Endoscopic ultrasound-guided fine-needle marking of a small pancreatic tumor

We report a case of endoscopic-ultrasound-guided fine-needle marking (EUS-FNM) of a 6-mm pancreatic tumor. The patient was suspected of having pancreatitis, but instead an isolated and hypoechoic lesion was detected in the tail of the pancreas ([Fig. 1]).

Fig. 1 Endoscopic ultrasound (EUS) shows a 6-mm hypoechoic tumor in the tail of the pancreas.

EUS-guided fine-needle aspiration (FNA) biopsy was suggestive of malignant cells, and surgery was planned. In order to facilitate the intraoperative detection of the lesion, EUS-FNM of the tumor was performed 18 days preoperatively with a specially manufactured silver pin. The pin (5 × 0.8 mm) was made to fit into a 19-gauge needle. Following manual loading of the pin into the tip of the needle under sterile conditions ([Fig. 2]), the lumen was sealed with sterile lidocaine gel to prevent dislocation of the pin.

Fig. 2 a Stylet, silver pin, and 19-gauge needle. b Pin fitting inside the hollow needle.

The needle was inserted into the tumor under EUS guidance, and the stylet was reintroduced to push the pin into the tumor. The position of the pin was easily verified as a hyperechoic linear structure with a shadow ([Fig. 3]).

Fig. 3 The silver pin within the tumor is seen on EUS as a linear, hyperechoic structure with an acoustic shadow.

Two pins were placed in the tumor, and no antibiotics were given. There were no signs of complications in the period before surgery.

The pins were easily located using laparoscopic and intraoperative ultrasound. The exact position within the tumor was confirmed by splitting of the specimen ([Fig. 4]).

Fig. 4 Both pins identified inside the tumor.

The postoperative course was uneventful. Histological examination revealed a nonfunctional glucagonoma without any histological reaction to the pin.

EUS is particularly useful in the assessment of small pancreatic tumors missed by other imaging techniques [1] [2]. EUS-guided tumor injection with dyes has been described, but dyes dilute over time and distance, making it necessary to perform the procedure as near in time to surgery as possible [3] [4].

EUS-guided injection and antitumor therapy are evolving rapidly, and EUS-FNM follows the same principle [5]. EUS-FNM may be performed during the primary EUS and independently of surgical planning. The pin is a radiopaque and ultrasonically visible marker, and may thus facilitate intraoperative location of the tumor and reduce surgical time. However, more data are needed to establish the safety and clinical utility of this new marking technique.

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References

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• 2 Anderson M A, Carpenter S, Thompson N W. et al . Endoscopic ultrasound is highly accurate and directs management in patients with neuroendocrine tumors of the pancreas.  Am J Gastroenterol. 2000;  95 2271-2277
• 3 Ashida R, Yamao K, Okubo K. et al . Indocyanine green is an ideal dye for endoscopic ultrasound-guided fine-needle tattooing of pancreatic tumors.  Endoscopy. 2006;  38 190-192
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