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|Ahead of print publication
A rare case of multifocal intraductal nodules and a solid mass of the pancreas
Jun Li, Yilong Wang, Feng Liu
Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
|Date of Submission||01-Apr-2021|
|Date of Acceptance||07-Jul-2021|
|Date of Web Publication||08-Nov-2021|
Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Mid. Yanchang Road, Shanghai, 200072
Source of Support: None, Conflict of Interest: None
A 69-year-old woman presented with epigastric pain for 1 month. She gave a past history of cholecystectomy for gallstones before 20 years and two occurrences of pancreatitis within 10 years. Her physical examination was unremarkable. Laboratory tests revealed elevated levels of ALT (204 U/L), AST (205 U/L), ALP (1502 U/L) and γ-GT (1127 U/L). The levels of total bilirubin (22 μmol/L) and CA19-9 (49 U/mL) were slightly elevated. Contrast-enhanced computed tomography revealed dilated intra- and extrahepatic bile duct and cystic dilatation of the main pancreatic duct. There were multifocal nodules within the dilated pancreatic duct in the head, neck and body of the pancreas, and a non-enhanced solid mass in the tail of the pancreas [Figure 1]a and [Figure 1]b. EUS demonstrated multiple slightly hyperechoic intraductal nodules measuring up to 19 mm × 16 mm in the main pancreatic duct and a 35 mm × 25 mm hypoechoic mass in the tail of the pancreas [Figure 1]c and [Figure 1]d. EUS and endoscopic retrograde cholangiopancreatography with intraductal ultrasound revealed dilated common bile duct but no significant signs of intraductal lesions. The papilla showed no obvious fish mouth appearance [Figure 2].
|Figure 1: Contrast-enhanced computed tomography displaying multifocal nodules (a, red arrow) within the dilated pancreatic duct and a solid mass in pancreatic tail (b, green arrow). EUS showing slightly hyperechoic intraductal nodules (c, yellow arrow) in pancreatic body and a hypoechoic mass (d, white arrow) in the tail|
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|Figure 2: Endoscopic view of the papilla showed no obvious fish mouth appearance|
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We performed EUS-guided fine-needle biopsy (EUS-FNB) using a 22-gauge needle for both the intraductal nodules and the solid mass. Tissue pathologies showed complex, arborizing papillae lined by multiple layers of cuboidal and columnar epithelial cells with abundant oncocytic cytoplasm [Figure 3]a, foci of cells with enlarged nuclei, prominent nucleoli and scattered mitotic figures [Figure 3]b. These characteristics are consistent with the general features of intraductal oncocytic papillary neoplasm (IOPN) with high grade dysplasia.
|Figure 3: Histopathology revealing complex, arborizing papillaes lined by multiple layers of cuboidal and columnar epithelial cells with abundant oncocytic cytoplasm (a, ×200) and foci of cells with enlarged nuclei, prominent nucleoli and scattered mitotic figures (b, ×400)|
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IOPN is a rare type of cystic pancreatic tumors, which is historically considered a subtype of IPMN but now a distinct entity according to 2019 WHO classification. IOPN differs biologically, prognostically, and molecularly from IPMN as well as other pancreatic tumors. The prognosis of IOPN is favored after resection even when metastasis occurred. Accurate diagnosis of IOPN before treatment is important to ensure proper management, but usually difficult by radiological imaging. Cystic fluid analyses also provide limited information with low cytological yield. Reported IOPNs were mainly diagnosed by surgical specimens. To the best of our knowledge, this is the first report of IOPN histologically diagnosed by EUS-FNB.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Wang T, Askan G, Adsay V, et al.
Intraductal oncocytic papillary neoplasms: Clinical-pathologic characterization of 24 cases, with an emphasis on associated invasive carcinomas. Am J Surg Pathol
Basturk O, Esposito I, Fukushima N, et al
. Pancreatic intraductal oncocytic papillary neoplasm. In: WHO Classification of Tumors: Digestive System Tumours. 5th
ed. Lyon, France: IARC; 2019.
Reid MD, Stallworth CR, Lewis MM, et al.
Cytopathologic diagnosis of oncocytic type intraductal papillary mucinous neoplasm: Criteria and clinical implications of accurate diagnosis. Cancer Cytopathol
[Figure 1], [Figure 2], [Figure 3]