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In vivo diagnosis of intraductal papillary mucinous neoplasm with per-oral pancreatoscopy–guided confocal laser endomicroscopy

Open AccessPublished:June 12, 2018DOI:https://doi.org/10.1016/j.vgie.2018.03.005
      Intraductal papillary mucinous neoplasm (IPMN) is well known and has a malignant potential. Per-oral pancreatoscopy (POPS) is useful for evaluating the pancreatic duct and diagnosing IPMN. Probe-based confocal laser endomicroscopy (pCLE) is an emerging technique used to obtain real-time in vivo histologic images from various types of mucosa. However, POPS-guided pCLE images of IPMN have not yet been reported in vivo. We present a case of IPMN for which the degree of malignancy was diagnosed by the use of POPS-guided pCLE (Video 1, available online at www.VideoGIE.org).
      A 79-year-old man underwent CT, which indicated expansion of the main pancreatic duct. MRCP also indicated expansion of the entire pancreatic duct (Fig. 1A). EUS showed expansion of the entire pancreatic duct but could not detect the villous protrusions (Fig. 1B). ERCP was performed for a more detailed exploration of the suspected IPMN. Endoscopy revealed dilation of the pancreatic duct orifice and mucus discharge. Pancreatography revealed a defect of the inside of the main pancreatic duct (Figs. 1C and D). POPS (SPYGlass DS; Boston Scientific Corp, Natick, Mass) detected villous protrusions on the inside of the main pancreatic duct (Fig. 1E). POPS-guided fluorescein-dripping pCLE was performed with use of a probe-based device (pCLE; CholangioFlex, Cellvizio; Mauna Kea Technologies, Paris, France). Here, neoplastic tissue was visible as a dark, regularly arranged papillary structure. This finding did not indicate invasive carcinoma (Fig. 1F).
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      Figure 1A, MRCP indicating expansion of the entire pancreatic duct. B, EUS view showing expansion of the entire pancreatic duct but no detection of the villous protrusions. C, Endoscopic view showing dilation of the pancreatic duct orifice and mucus discharge. D, Pancreatographic view showing defect of the inside of the main pancreatic duct. E, Per-oral pancreatoscopic (POPS) view showing villous protrusions on the inside of the main pancreatic duct. F, POPS-guided, fluorescein-dripping, probe-based confocal laser endomicroscopic view depicting neoplastic tissue as a dark, regularly arranged papillary structure. This finding did not indicate invasive carcinoma. G, Histopathologic findings of biopsy tissue specimen, showing atypical tall columnar epithelia composed of pseudostratified oblong-to-fusiform hyperchromatic nuclei and eosinophilic-to-amphophilic cytoplasm, with villous growth, leading to a diagnosis of intraductal papillary mucinous neoplasm with intermediate-grade dysplasia (H&E, orig. mag. ×400).
      Finally, a biopsy of the area imaged by pCLE was performed through a pancreatoscope. Histopathologically, the biopsy tissue specimen contained atypical, tall, columnar epithelia composed of pseudostratified oblong-to-fusiform hyperchromatic nuclei and eosinophilic-to-amphophilic cytoplasm, and it showed villous growth (Fig. 1G). The lesion was diagnosed as IPMN with intermediate-grade dysplasia. Positive immunostaining for both mucin 2 and mucin 5 AC led to a diagnosis of intestinal-type IPMN.
      In this case, the pCLE image and histologic analysis yielded similar sizes of the neoplastic papillae (120-140 μm) and degrees of malignancy. In summary, although additional patient data must be accumulated, we think that the in vivo diagnosis of IPMN with POPS-guided pCLE may be useful for evaluating the degree of malignancy.

      Disclosure

      All authors disclosed no financial relationships relevant to this publication.

      Supplementary data