Endoscopic ultrasound-guided fine-needle aspiration of periarterial tumor extension from mucinous cystic carcinoma

A 57-year-old woman with abdominal pain was admitted to our hospital for close examination. The imaging studies revealed a cystic tumor in the pancreatic tail. The cystic mass, 6 cm in size, was accompanied by internal mural nodules ([Fig. 1 a]), and periarterial tumor extension from the splenic artery to the celiac and common hepatic arteries with encasement ([Fig. 1 b, c]). Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of cystic tumors is a safe technique [1]. However, there are still some concerns about peritoneal dissemination after EUS-FNA of cystic masses [2]. In this context, we decided to perform EUS-FNA of the periarterial tumor extension around the splenic artery ([Fig. 2 a], [Video 1]) instead of puncturing the cystic mass.

Fig. 1 Computed tomography images of the patient with mucinous cystic carcinoma. A cystic mass sized 6 cm with a clear border was seen in the pancreatic tail. a Mural nodules inside the cystic mass (arrows) without dilation of the main pancreatic duct (arrowhead). b, c Axial (b) and coronal (c) images showing continuous tumor extension from the mural nodules within the cyst to the periarterial area (arrows).

Fig. 2 Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of the periarterial tumor extension around the splenic artery. a Hypoechoic lesions of the periarterial tumor extension around the splenic artery with a Doppler image. b A pathological image of the periarterial tumor extension around the splenic artery acquired by EUS-FNA puncture.

Video 1 Endoscopic ultrasound-guided fine-needle aspiration of the periarterial tumor extension around the splenic artery from a mucinous cystic carcinoma (MCC). Mural nodules in the MCC were enhanced by an ultrasound contrast agent (Sonazoid; GE Healthcare, Waukesha, Wisconsin, USA).

EUS showed that the cyst wall was covered with an irregular 5-mm-thick capsule with internal mural nodules as high as 30 mm. The mural nodules in the mucinous cystic carcinoma were enhanced by an ultrasound contrast agent (Sonazoid; GE Healthcare, Waukesha, Wisconsin, USA). We performed EUS-FNA of the 2.5-mm-thick hypoechoic periarterial tumor extension around the splenic artery by puncturing twice with 20 strokes under negative pressure of 20 mL using a 25-gauge nitinol needle (EZ Shot 3 Plus; Olympus, Tokyo, Japan). The cytology and histology showed Class V and adenocarcinoma ([Fig. 2 b]), respectively, which, together with imaging, led us to comprehensively diagnose the cyst as mucinous cystic adenocarcinoma.

Although puncturing a periarterial tumor extension carries the risk of vascular mispuncture, the procedure has been reported to be safe and useful [3] [4], and should be considered an option in order to avoid procedure-related dissemination.

Endoscopy_UCTN_Code_TTT_1AS_2AF

Competing interests

The authors declare that they have no conflict of interest.

Acknowledgments

We thank all our colleagues, Hiroko Shindo, Ei Takahashi, Hiroshi Hayakawa, Natsuhiko Kuratomi, Makoto Kadokura, Dai Yoshimura, Naoto Imagawa, and Tetsuya Okuwaki, for their contribution in providing clinical and secretarial assistance. The authors would like to thank Enago (www.enago.jp) for the English language review.

• References

• 1 Yoon WJ, Daglilar ES, Fernández-del Castillo C. et al. Peritoneal seeding in intraductal papillary mucinous neoplasm of the pancreas patients who underwent endoscopic ultrasound-guided fine-needle aspiration: the PIPE Study. Endoscopy 2014; 46: 382-387
• 2 Hirooka Y, Goto H, Itoh A. et al. Case of intraductal papillary mucinous tumor in which endosonography-guided fine-needle aspiration biopsy caused dissemination. J Gastroenterol Hepatol 2003; 18: 1323-1324
• 3 Levy MJ, Gleeson FC, Zhang L. Endoscopic ultrasound fine-needle aspiration detection of extravascular migratory metastasis from a remotely located pancreatic cancer. Clin Gastroenterol Hepatol 2009; 7: 246-248
• 4 Rustagi T, Gleeson FC, Chari ST. et al. Safety, diagnostic accuracy, and effects of endoscopic ultrasound fine-needle aspiration on detection of extravascular migratory metastases. Clin Gastroenterol Hepatol 2019; 17: 2533-2540

Publikationsverlauf

Artikel online veröffentlicht:
26. April 2023