|LETTER TO EDITOR
|Ahead of print publication
Malignant gastric duplication cyst diagnosed by EUS-FNA
Thomas Togliani1, Rosa Rinaldi2, Stefano Pilati1
1 Gastroenterology and Endoscopy Unit, ASST Poma, Mantova, Italy
2 Pathology Unit, ASST Poma, Mantova, Italy
|Date of Submission||14-May-2020|
|Date of Acceptance||12-Jul-2020|
|Date of Web Publication||09-Sep-2020|
Gastroenterology and Endoscopy Unit, ASST Poma, Strada Lago Paiolo, 10 - Mantova
Source of Support: None, Conflict of Interest: None
The primitive respiratory and digestive tracts develop in the 4th–5th week of the embryogenic formation; at this time, an accessory bud from the primitive foregut can migrate downward till to the abdomen before the diaphragm closes in the 7th week. Among digestive duplications, gastric ones are very uncommon, most of them are benign, and a neoplastic progression has been described in only 15 cases.,
A 67-year-old male presenting with anorexia, epigastric pain, and severe weight loss was admitted in our Hospital. Abdominal computed tomography scan showed the presence of a 4-cm cystic lesion between the gastric fundus and the body of the pancreas [Figure 1]a. EUS demonstrated that the cyst originated from the stomach [Figure 1]b and its 1-cm thick wall showed an early diffused enhancement after injection of SonoVue; there was no infiltration of the surrounding structures. An EUS-FNA was performed through the wall and in the lumen of the cyst with a 19G nitinol needle. Cytology with hematoxylin and eosin staining revealed the presence of markedly atypical epithelial cells with squamous differentiation; immunohistochemistry was positive for CK5, CK7, and p63 [Figure 1]c. A total body18 F-fludeoxyglucose positron emission tomography scan revealed a high peripheral uptake (standardized uptake value = 7) at the level of the lesion [Figure 1]d. The patient underwent total gastrectomy; histology confirmed the presence of a gastric duplication cyst with malignant squamous degeneration; and immunohistochemistry was positive for p63 and p40.
|Figure 1: (a) Computed tomography scan shows a 4-cm cyst among the stomach, the liver, and the pancreas (yellow arrows), encasing the left gastric artery. (b) At EUS, the thick cyst originates from the gastric wall. (c) FNA cytology (H and E, ×40) displays atypical epithelial cells with squamous differentiation (in the box: immunohistochemical positivity for p63). (d)18F-fludeoxyglucose positron emission tomography scan reveals a high uptake in the periphery of the lesion|
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This is the 16th case of malignant gastric duplication cyst described in English-language literature and the 2nd diagnosed by EUS-FNA ever reported. Compared with the previously published case, our patient underwent also a contrast-enhanced EUS evaluation of the cyst; this added additional information about the proliferative behavior of the thickened cystic wall, thus guiding the FNA needle into the most likely vital parts of the lesion while avoiding the left gastric artery encased in the cystic wall. Radiology often misdiagnoses these extremely rare tumors as gastric GISTs, pancreatic cystic neoplasms, or teratomas, and a correct diagnosis is generally obtained only after surgery., EUS, instead, can achieve an accurate differential diagnosis and a precise local staging of many gastric and perigastric diseases. Thus, before planning any surgical or oncological therapy, the most up-to-date EUS-guided technologies should be used when any imaging technique finds an upper abdominal cystic lesion of indeterminate origin.
Declaration of patient consent
The authors certify that he has obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his names and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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