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DOI: 10.1055/s-0043-100217
Endoscopic ultrasound-guided, through-the-needle forceps biopsy in the assessment of an incidental large pancreatic cystic lesion with prior inconclusive fine-needle aspiration
A 68-year-old man underwent endoscopic ultrasound (EUS) and fine-needle aspiration of a large cystic lesion of the pancreatic neck seen incidentally on computed tomography (CT). CT demonstrated a nonenhancing, exophytic, multilocular cystic mass, measuring 82 × 72 mm ([Fig. 1], [Video 1]). A mural calcific focus was noted posteroinferiorly and a more solid component posteriorly. The CT density averaged 19 HU for the cystic component and 40 HU for the solid component.
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Quality:
EUS showed a mixed solid/cystic-appearing lesion without mural nodules. The cystic component contained multiple mobile ball-like structures ([Fig. 2]) and the solid component appeared to be hypoechoic and heterogeneous. No infiltration into the surrounding tissue or pancreatic duct communication was identified and the pancreas was otherwise unremarkable. In addition, no lymphadenopathy was present.
![](https://www.thieme-connect.de/media/endoscopy/2017S01/thumbnails/10-1055-s-0043-100217-i14985cl2.jpg)
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EUS-guided transgastric cyst aspiration was performed using a 19-gauge needle, and 8 ml of an opaque, turbid fluid was sent for cytological examination. Amylase and carcinoembryonic antigen (CEA) levels did not contribute to the diagnosis and the results of cytology investigation were inconclusive, revealing only cholesterol crystals, lipoid droplets, and scant leukocytes.
A repeat EUS was undertaken to biopsy the cyst wall with dedicated through-the-needle Moray micro forceps (US Endoscopy, Mentor, Ohio, USA) ([Fig. 3]). The forceps were passed through a 19-gauge needle and allowed precise and targeted sampling of the cyst wall ([Fig. 2]). In a second pass, the solid-appearing component was targeted and 5 ml of a thick, brown fluid were aspirated.
![](https://www.thieme-connect.de/media/endoscopy/2017S01/thumbnails/10-1055-s-0043-100217-i14985cl3.jpg)
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Histological assessment revealed fragments of keratinizing squamous epithelium with a subepithelial lymphoid infiltrate ([Fig. 4]). Dense keratin was present on the surface. No goblet cells were seen. The findings were diagnostic for a benign lymphoepithelial cyst [1] [2] [3]. Surveillance is not required for this, and surgery is only considered in symptomatic individuals [4] [5]. The patient could therefore be discharged.
![](https://www.thieme-connect.de/media/endoscopy/2017S01/thumbnails/10-1055-s-0043-100217-i14985cl4.jpg)
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The novel through-the-needle micro forceps were easy to use and allowed precise EUS-guided sampling of the cyst wall.
Endoscopy_UCTN_Code_TTT_1AS_2AF
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Competing interests
The Moray micro forceps used in this specific case was a free sample supplied by US Endoscopy, Mentor, Ohio, USA and Device Technologies, Belrose, New South Wales, Australia.
Acknowledgment
We would like to acknowledge US Endoscopy and Device Technologies Australia for the free supply of the Moray micro forceps used in this specific case.
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References
- 1 Mege D, Gregoire E, Barbier L. et al. Lymphoepithelial cyst of the pancreas: an analysis of 117 patients. Pancreas 2014; 43: 987-995
- 2 Adsay NV, Hasteh F, Cheng JD. et al. Lymphoepithelial cysts of the pancreas: a report of 12 cases and a review of the literature. Mod Pathol 2002; 15: 492-501
- 3 Matsubayashi H, Aikawa Y, Sugiura T. et al. Pancreatic lymphoepithelial cyst showing multiple floating ball-like appearances. J Gastrointestin Liver Dis 2016; 25: 239-242
- 4 Yanagimoto H, Satoi S, Toyokawa H. et al. Laparoscopic distal pancreatectomy for a pancreatic lymphoepithelial cyst: case report and review of literature. JOP 2013; 14: 664-668
- 5 Dalal KS, DeWitt JM, Sherman S. et al. Endoscopic ultrasound characteristics of pancreatic lymphoepithelial cysts: A case series from a large referral center. Endosc Ultrasound 2016; 5: 248-253
Corresponding author
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References
- 1 Mege D, Gregoire E, Barbier L. et al. Lymphoepithelial cyst of the pancreas: an analysis of 117 patients. Pancreas 2014; 43: 987-995
- 2 Adsay NV, Hasteh F, Cheng JD. et al. Lymphoepithelial cysts of the pancreas: a report of 12 cases and a review of the literature. Mod Pathol 2002; 15: 492-501
- 3 Matsubayashi H, Aikawa Y, Sugiura T. et al. Pancreatic lymphoepithelial cyst showing multiple floating ball-like appearances. J Gastrointestin Liver Dis 2016; 25: 239-242
- 4 Yanagimoto H, Satoi S, Toyokawa H. et al. Laparoscopic distal pancreatectomy for a pancreatic lymphoepithelial cyst: case report and review of literature. JOP 2013; 14: 664-668
- 5 Dalal KS, DeWitt JM, Sherman S. et al. Endoscopic ultrasound characteristics of pancreatic lymphoepithelial cysts: A case series from a large referral center. Endosc Ultrasound 2016; 5: 248-253
![](https://www.thieme-connect.de/media/endoscopy/2017S01/thumbnails/10-1055-s-0043-100217-i14985cl1.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/endoscopy/2017S01/thumbnails/10-1055-s-0043-100217-i14985cl2.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/endoscopy/2017S01/thumbnails/10-1055-s-0043-100217-i14985cl3.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/endoscopy/2017S01/thumbnails/10-1055-s-0043-100217-i14985cl4.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)