Written Transcript of Video Audio

Written Transcript of Video Audio:

Title Page: Novel Technique for Diagnosis of Mucinous Cystic Neoplasms: In-Vivo and Ex-Vivo Confocal Laser Endomicroscopy

Disclosures: None of the authors have any disclosures to report

Acknowledgement: Subject was prospectively enrolled in the INDEX study that was funded by the American College of Gastroenterology pilot research grant

Keywords: Keywords include EUS, mucinous cystic neoplasm, confocal laser Endomicroscopy, AQ-Flex-19 miniprobe and gastroflex probe

Background: Mucinous cystic neoplasms (MCNs) are typically seen in middle-aged women. The majority of lesions are located in the pancreatic body or tail and have no association with the main pancreatic duct. Hallmark to MCN is ovarian stroma seen on histopathology. Although MCNs can progress to cancer, the decision regarding surgical resection is often institution dependent

Case: A 51-year-old woman presented with a 6-month history of intermittent abdominal pain without dysphagia, weight loss, or fevers. The patient was a current smoker with a 25-year pack history. She denied any previous episodes of pancreatitis and family history showed a paternal uncle with unknown type of pancreatic cancer. CA 19-9 was mildly elevated to 40.66 IU/mL.

CT imaging: CT imaging revealed a well-circumscribed 4.4 x 3.8 cm hypodense lesion within the tail of the pancreas. There were no nodular enhancing components and minimal prominence of the downstream pancreatic duct. The remaining pancreas demonstrates relatively homogeneous enhancement throughout. There was minimal adjacent stranding in the distal body and tail without inflammatory changes or focal fluid collections.

EUS: During endoscopic ultrasound, an anechoic lesion suggestive of a cyst was identified in the pancreatic body without communication with the pancreatic duct. The lesion measured 4.1 by 4.0 centimeters and the outer wall of the lesion was thin with no associated mass. There was internal debris within the fluid-filled cavity and the main pancreatic duct in the tail of the pancreas was dilated in appearance to 3.2 millimeters.

EUS nCLE: Needle-based confocal endomicroscopy was performed during EUS as part of a study protocol comparing in-vivo and ex-vivo imaging against surgical histopathology of pancreatic cystic lesions. The 19-gauge flex needle was used to puncture the cyst in the pancreatic tail. The AQ flex needle confocal endomicroscopy probe was introduced through the working channel of the 19-gauge needle. Image acquisition was then performed. In Vivo: During in-vivo needle-based confocal endomicroscopy, solitary epithelial bands without any type of papillary confirmation were seen. In MCNs, these bands are best described as having a horizon type configuration with variable thickness. There were no confocal endomicroscopy findings of other pancreatic cystic lesions including intraductal papillary mucinous neoplasms.

Management: Fine needle aspiration was also performed with cytology demonstrating mucin and CEA elevated to 75.5. Given the fact that the patient was symptomatic, location and size of the lesion, and the presence of mucin on cytology, it was ultimately decided the patient undergo a laparoscopic distal pancreatectomy and splenectomy.

Ex Vivo: Immediately after surgical resection of the pancreatic lesion, ex-vivo confocal endomicroscopy was performed using the gastroflex ultrahigh definition probe. This provided correlation of EUS guided needle based confocal laser endomicroscopy imaging by AQ-flex 19 probe. The higher resolution of gastroflex probe resulted in better image quality and allowed us to examine all areas of the cyst unlike in-vivo imaging. Similar to in-vivo findings, ex-vivo confocal laser endomicroscopy showed solitary epithelial bands without any type of papillary conformation. Because of improved image acquisition, these horizon type epithelial bands can be examined more closely.

Pathology: Pathological biopsies from the distal pancreas confirmed our suspicion for a mucinous cystic neoplasm. Here you can appreciate the mucinous epithelial with low-grade dysplasia. Focal atypical glands are identified in the wall of the pancreas that are favored to be reactive. The adjacent pancreas demonstrates fibrosis.

Ex Vivo and Pathological Correlation: This is a point-to-point comparison of the ex-vivo and pathologic findings for the mucinous cystic neoplasm.

Conclusion: The patient is doing well postoperatively. Here we present in-vivo needle-based confocal laser endomicroscopy findings suggestive of MCN that was correlated with ex-vivo and pathologic findings. Confocal laser endomicroscopy can supplement EUS and cytology in the workup of MCNs and ultimately aid in management decisions of pancreatic cystic lesions.