In vivo and ex vivo needle-based confocal endomicroscopy of intraductal papillary mucinous neoplasm of the pancreas

Abstract

A 68-year-old man presented with recurrent episodes of pancreatitis and a 40-pound weight loss. The CA 19-9 was 31 IU/mL. EUS demonstrated a mixed-type intraductal papillary mucinous neoplasm (IPMN) revealing a dilated (9 mm) segment of the pancreatic duct (PD) extending from the genu to the proximal body (3.6-cm segment) communicating with a 3.5-cm branch-duct (BD) cyst. The major duodenal papilla appeared unremarkable. An intracystic mural nodule (20 mm) was observed. Needle-based confocal endomicroscopy (nCLE) with an AQ-Flex-19 miniprobe (Cellvizio; Mauna Kea Technologies Inc, Suwanee, Ga) was performed (Video 1, available online at www.giejournal.org). Multiple finger-like papillae (epithelial thickness: 50-60 μm) were observed in the dilated PD and BD cyst (Fig. 1A). Some views (Fig. 1B) showed nuclei extending from the basement membrane to the surface, suggestive of higher grades of dysplasia. Viscosity of the fluid aspirated was unacceptable for estimation of carcinoembryonic antigen. The patient underwent a subtotal distal pancreatectomy. Ex vivo confocal laser endomicroscopy was performed with a Gastroflex probe (Cellvizio) (Video 1). This offers a higher resolution and an opportunity to examine all of the involved areas. Ex vivo findings validated the in vivo nCLE observations. Histopathology demonstrated predominantly intestinal-type IPMN in the main PD and gastric-type IPMN in the BD cyst with foci of high-grade dysplasia. There was no evidence of invasion, and resection margins were not involved.