- Email: [email protected]
A case of cystic type intraductal papillary neoplasm of the bile duct diagnosed by SpyGlass DS, a novel peroral cholangioscopy
Arab Journal of Gastroenterology xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Arab Journal of Gastroenterology journal homepage: www.elsevier.com/locate/ajg
Images in gastroenterology
A case of cystic type intraductal papillary neoplasm of the bile duct diagnosed by SpyGlass DS, a novel peroral cholangioscopy Takeshi Kuwada ⇑, Masahiro Shiokawa, Norimitsu Uza, Yuzo Kodama Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
a r t i c l e
i n f o
Article history: Received 27 May 2017 Accepted 28 May 2017 Available online xxxx
a b s t r a c t . Ó 2017 Pan-Arab Association of Gastroenterology. Published by Elsevier B.V. All rights reserved.
A 60-year-old woman was referred for further evaluation of a hepatic mass. Contrast-enhanced computed tomography showed a multilocular cystic lesion in the right paramedian section of the liver, measuring 10 9 cm, with thick, irregular walls with enhancement during the arterial phase (Fig. 1). T2-weighted magnetic resonance imaging showed nodules in the cystic lesion (Fig. 2). As a differential diagnosis of the cystic tumour, cystic type intraductal papillary neoplasm of bile duct (IPNB) and mucinous cystic neoplasm (MCN) of the liver were considered. Endoscopic retrograde cholangiopancreatography showed compression of intrahepatic bile ducts and inflow of the contrast agent into the cystic tumour (Fig. 3). Peroral cholangioscopy (POCS), using SpyGlass DS Direct Visualization System (SPY DS, Boston Scientific, Natick, Massachusetts, USA), successfully identified the communication between the tumour and the origin of right hepatic duct, and confirmed huge amounts of thickened mucous visualized within the tumour. With SPY DS efficient aspiration of the mucous, demonstration of multiple papillary nodules (Fig. 4) and biopsy taking under direct vision could be achieved. Histopathology revealed papillary growth with nuclear atypia. Based on these findings, the patient was diagnosed with IPNB, and underwent right hepatic trisegmentectomy. The surgically resected specimen revealed an IPNB with carcinoma in situ lesion. IPNB is a relatively rare variant of bile duct tumours, which is characterized by papillary or villous growth within the bile duct lumen and produce mucin in variable quantities. IPNB is classified into some types such as a polypoid type, a cast-like growth type, a superficial-spreading type, and a cystic type [1,2]. POCS has been reported to be useful for the diagnosis of IPNB. However, in cases ⇑ Corresponding author at: Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, 54 Shogoin-kawahara-cho, Sakyoku, Kyoto 606-8507, Japan. E-mail address: [email protected] (T. Kuwada).
Fig. 1. Axial arterial phase computed tomography scan showing a low-density lesion in the right paramedian section of the liver, with thick, irregular, enhanced walls.
with cystic type IPNB, it is difficult to confirm the communication between the tumour and the bile duct and to obtain tumour tissues, making difficult to distinguish from MCN [3,4]. Recently, the SPY DS has been available, and it shows a dramatic improvement in favourable visualization and newly added injection and suction functions [5]. In the current case, POCS with SPY DS provided good direct visualization and preoperative histological diagnosis of IPNB. SPY DS may help the management of cystic type IPNB.
http://dx.doi.org/10.1016/j.ajg.2017.05.014 1687-1979/Ó 2017 Pan-Arab Association of Gastroenterology. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Kuwada T et al. A case of cystic type intraductal papillary neoplasm of the bile duct diagnosed by SpyGlass DS, a novel peroral cholangioscopy. Arab J Gastroenterol (2017), http://dx.doi.org/10.1016/j.ajg.2017.05.014
2
T. Kuwada et al. / Arab Journal of Gastroenterology xxx (2017) xxx–xxx
Fig. 2. T2-weighted magnetic resonance imaging showing papillary nodules in the cystic lesion, and dilated right posterior segmental duct.
Fig. 4. Peroral cholangioscopy (POCS) showing the tumour wall lined with multiple papillary nodules.
Conflict of interest statement The authors have declared that no conflict of interest exists. References
Fig. 3. Endoscopic retrograde cholangiopancreatography showing compression of right and left hepatic duct (RHD and LHD, respectively), and inflow of the contrast agent into the cystic tumour (arrow).
[1] Kim H, Lim JH, Jang KT, Kim MJ, Lee J, Lee JY, et al. Morphology of intraductal papillary neoplasm of the bile ducts: radiologic-pathologic correlation. Abdom Imaging 2011;36:438–46. [2] Yoon HJ, Kim YK, Jang KT, Lee KT, Lee JK, Choi DW, et al. Intraductal papillary neoplasm of the bile ducts: description of MRI and added value of diffusionweighted MRI. Abdom Imaging 2013;38:1082–90. [3] Tsuyuguchi T, Sakai Y, Sugiyama H, Miyakawa K, Ishihara T, Ohtsuka M, et al. Endoscopic diagnosis of intraductal papillary mucinous neoplasm of the bile duct. J Hepatobiliary Pancreat Sci 2010;17:230–5. [4] Kubota K, Nakanuma Y, Kondo F, Hachiya H, Miyazaki M, Nagino M, et al. Clinicopathological features and prognosis of mucin-producing bile duct tumor and mucinous cystic tumor of the liver: a multi-institutional study by the Japan Biliary Association. J Hepatobiliary Pancreat Sci 2014;21:176–85. [5] Imanishi M, Ogura T, Kurisu Y, Onda S, Takagi W, Okuda A, et al. A feasibility study of digital single-operator cholangioscopy for diagnostic and therapeutic procedure (with videos). Medicine (Baltimore) 2017;96:e6619.
Please cite this article in press as: Kuwada T et al. A case of cystic type intraductal papillary neoplasm of the bile duct diagnosed by SpyGlass DS, a novel peroral cholangioscopy. Arab J Gastroenterol (2017), http://dx.doi.org/10.1016/j.ajg.2017.05.014
Contents lists available at ScienceDirect
Arab Journal of Gastroenterology journal homepage: www.elsevier.com/locate/ajg
Images in gastroenterology
A case of cystic type intraductal papillary neoplasm of the bile duct diagnosed by SpyGlass DS, a novel peroral cholangioscopy Takeshi Kuwada ⇑, Masahiro Shiokawa, Norimitsu Uza, Yuzo Kodama Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
a r t i c l e
i n f o
Article history: Received 27 May 2017 Accepted 28 May 2017 Available online xxxx
a b s t r a c t . Ó 2017 Pan-Arab Association of Gastroenterology. Published by Elsevier B.V. All rights reserved.
A 60-year-old woman was referred for further evaluation of a hepatic mass. Contrast-enhanced computed tomography showed a multilocular cystic lesion in the right paramedian section of the liver, measuring 10 9 cm, with thick, irregular walls with enhancement during the arterial phase (Fig. 1). T2-weighted magnetic resonance imaging showed nodules in the cystic lesion (Fig. 2). As a differential diagnosis of the cystic tumour, cystic type intraductal papillary neoplasm of bile duct (IPNB) and mucinous cystic neoplasm (MCN) of the liver were considered. Endoscopic retrograde cholangiopancreatography showed compression of intrahepatic bile ducts and inflow of the contrast agent into the cystic tumour (Fig. 3). Peroral cholangioscopy (POCS), using SpyGlass DS Direct Visualization System (SPY DS, Boston Scientific, Natick, Massachusetts, USA), successfully identified the communication between the tumour and the origin of right hepatic duct, and confirmed huge amounts of thickened mucous visualized within the tumour. With SPY DS efficient aspiration of the mucous, demonstration of multiple papillary nodules (Fig. 4) and biopsy taking under direct vision could be achieved. Histopathology revealed papillary growth with nuclear atypia. Based on these findings, the patient was diagnosed with IPNB, and underwent right hepatic trisegmentectomy. The surgically resected specimen revealed an IPNB with carcinoma in situ lesion. IPNB is a relatively rare variant of bile duct tumours, which is characterized by papillary or villous growth within the bile duct lumen and produce mucin in variable quantities. IPNB is classified into some types such as a polypoid type, a cast-like growth type, a superficial-spreading type, and a cystic type [1,2]. POCS has been reported to be useful for the diagnosis of IPNB. However, in cases ⇑ Corresponding author at: Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, 54 Shogoin-kawahara-cho, Sakyoku, Kyoto 606-8507, Japan. E-mail address: [email protected] (T. Kuwada).
Fig. 1. Axial arterial phase computed tomography scan showing a low-density lesion in the right paramedian section of the liver, with thick, irregular, enhanced walls.
with cystic type IPNB, it is difficult to confirm the communication between the tumour and the bile duct and to obtain tumour tissues, making difficult to distinguish from MCN [3,4]. Recently, the SPY DS has been available, and it shows a dramatic improvement in favourable visualization and newly added injection and suction functions [5]. In the current case, POCS with SPY DS provided good direct visualization and preoperative histological diagnosis of IPNB. SPY DS may help the management of cystic type IPNB.
http://dx.doi.org/10.1016/j.ajg.2017.05.014 1687-1979/Ó 2017 Pan-Arab Association of Gastroenterology. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Kuwada T et al. A case of cystic type intraductal papillary neoplasm of the bile duct diagnosed by SpyGlass DS, a novel peroral cholangioscopy. Arab J Gastroenterol (2017), http://dx.doi.org/10.1016/j.ajg.2017.05.014
2
T. Kuwada et al. / Arab Journal of Gastroenterology xxx (2017) xxx–xxx
Fig. 2. T2-weighted magnetic resonance imaging showing papillary nodules in the cystic lesion, and dilated right posterior segmental duct.
Fig. 4. Peroral cholangioscopy (POCS) showing the tumour wall lined with multiple papillary nodules.
Conflict of interest statement The authors have declared that no conflict of interest exists. References
Fig. 3. Endoscopic retrograde cholangiopancreatography showing compression of right and left hepatic duct (RHD and LHD, respectively), and inflow of the contrast agent into the cystic tumour (arrow).
[1] Kim H, Lim JH, Jang KT, Kim MJ, Lee J, Lee JY, et al. Morphology of intraductal papillary neoplasm of the bile ducts: radiologic-pathologic correlation. Abdom Imaging 2011;36:438–46. [2] Yoon HJ, Kim YK, Jang KT, Lee KT, Lee JK, Choi DW, et al. Intraductal papillary neoplasm of the bile ducts: description of MRI and added value of diffusionweighted MRI. Abdom Imaging 2013;38:1082–90. [3] Tsuyuguchi T, Sakai Y, Sugiyama H, Miyakawa K, Ishihara T, Ohtsuka M, et al. Endoscopic diagnosis of intraductal papillary mucinous neoplasm of the bile duct. J Hepatobiliary Pancreat Sci 2010;17:230–5. [4] Kubota K, Nakanuma Y, Kondo F, Hachiya H, Miyazaki M, Nagino M, et al. Clinicopathological features and prognosis of mucin-producing bile duct tumor and mucinous cystic tumor of the liver: a multi-institutional study by the Japan Biliary Association. J Hepatobiliary Pancreat Sci 2014;21:176–85. [5] Imanishi M, Ogura T, Kurisu Y, Onda S, Takagi W, Okuda A, et al. A feasibility study of digital single-operator cholangioscopy for diagnostic and therapeutic procedure (with videos). Medicine (Baltimore) 2017;96:e6619.
Please cite this article in press as: Kuwada T et al. A case of cystic type intraductal papillary neoplasm of the bile duct diagnosed by SpyGlass DS, a novel peroral cholangioscopy. Arab J Gastroenterol (2017), http://dx.doi.org/10.1016/j.ajg.2017.05.014