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Total necrosis of rapid growing hilar cholangiocarcinoma
At the Focal Point
tion of contrast medium. Upper endoscopy demonstrated an elevated area with a small fistulous orifice (A, arrow). Once the patient was asymptomatic, conservative treatment was adopted. After nasoenteral feeding for 5 days, an oral diet was introduced with good acceptance. Weekly serial endoscopies demonstrated progressive migration of the bullet to the esophageal lumen (B). Twenty-seven days after the trauma, the bullet was removed with alligator forceps. An orifice with adjacent edema was noted at the impact site of the bullet. (C). One week later, the endoscopic study revealed healing of the bullet track and regenerating mucosa adjacent to the site of the previous fistula (D). The patient remained asymptomatic during a 6-month follow-up period.
DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Cristiane Kibune Nagasako, MD, MSc, Ciro Garcia Montes, MD, PhD, Endoscopy Unit of Gastrocentro, Luiz Roberto Lopes, MD, PhD, Department of Surgery, Marina da Silveira Bossi, MD, Endoscopy Unit of Gastrocentro, Maria Aparecida Mesquita, MD, PhD, Gastroenterology Division, Faculty of Medical Sciences, State University of Campinas, Campinas, Brazil http://dx.doi.org/10.1016/j.gie.2013.01.038
Commentary I gotta say this is one of my favorite Focal Points of all time. But without high-tech imagery, obscure once-in-a-lifetime diagnoses, and cutting-edge, high-risk endoscopic solutions—what makes it so cool? Because it beautifully demonstrates both the principles of primum non nocere and cura te ipsum (cure yourself). What drives the microcurrents that wend wayward foreign bodies to the nearest exit (in the case of a splinter, to the outside world; in this case, to the esophageal lumen), and how do they know in what direction to flow? This migratory phenomenon is just one of the wonderments the body does really well; add it to the list that includes hepatic lobar regeneration and about a million others. The authors were prudent to let nature take her course; the close endoscopic surveillance and well-timed armament recovery mission prevented yet more trouble for this remarkably lucky cop. David Robbins, MD, MSc Assistant Editor for Focal Points
Total necrosis of rapid growing hilar cholangiocarcinoma An 81-year-old woman with cryptogenic liver cirrhosis presented with right upper quadrant pain and pruritus. A complete blood cell count showed a hemoglobin of 11.8 g/dL (normal range, 12.0-16.0 g/dL), white blood cell count of 3340 cells/L (normal range, 4000-10,000 cells/ L), and a platelet count of 83,000/L (normal range, 150,000-400,000/L). Liver biochemical tests revealed aspartate aminotransferase of 51 IU/L (normal range, 0-31 IU/L), alanine aminotransferase of 55 IU/L (normal range, 0-31 IU/L), alkaline phosphatase of 179 IU/L (normal range, 39-117 IU/L), and a total bilirubin of 7.3 mg/dL (normal range, 0.2-1.3 mg/dL). A 2-cm moderately attenuated nodular mass at the hilum, not seen on a CT 3 months previously, was noted on abdominal CT (A, arrow). A nasobiliary catheter was inserted for decompression of the bile duct. Fluid cytology showed a few syncytial clusters of malignant columnar cells with prominent nucleoli and intracytoplasmic mucin vacuoles (B, ThinPrep, Papanicolaou ⫻400). Considering her advanced age and liver cirrhosis, we opted for endoscopic management instead of an open operation. A cholangiogram revealed a Bismuth type II⫺like, mobile, amorphous filling defect
956 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 6 : 2013
(C). We grasped and completely resected the mass in a piecemeal fashion with a retrieval balloon and Dormia basket under ERCP. The mass was grossly hemorrhagic and necrotic (D). Fragments of the mass showed nearly totally infarcted clusters of atypical cells (B, rectangle, H&E ⫻100) with hyperchromatic, pyknotic nuclei and prominent nucleoli (inset, *, H&E ⫻400). We made a diagnosis of a necrotic, rapidly growing hilar cholangiocarcinoma. Four months later, follow-up CT and ERCP showed no intraluminal mass at the hilum. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. In Hye Cha, MD, Jin Nam Kim, MD, Myoung Ki Oh, MD, Soo Hyung Ryu, MD, You Sun Kim, MD, Jeong Seop Moon, MD, Division of Gastroenterology, Department of Internal Medicine, Hye Kyung Lee, MD, Department of Pathology, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea http://dx.doi.org/10.1016/j.gie.2013.01.036
www.giejournal.org
At the Focal Point
Commentary Cholangiocarcinoma (CCA) is often a rapidly fatal malignancy with a surgical cure rate of approximately 10%. “Go for broke” surgical principles demand extensive hepatic resection for tumors involving the biliary confluence. Adjuvant chemoradiotherapy is of dubious value at best, and palliative therapy is all about biliary decompression—it does not prolong life. Part of the grave prognosis relates to the underlying debilitated state of its victims; the patient described here was entrapped by both cirrhosis (which may be a risk factor for CCA) and advanced age. If I had to nominate a GI cancer deserving of even a modest breakthrough, CCA would have my vote. The therapeutic landscape, as seen through an endoscope, has, however, recently shown some perceptible signs of change. Endoscopic techniques such as photodynamic therapy, reincarnated from its initial www.giejournal.org
Volume 77, No. 6 : 2013 GASTROINTESTINAL ENDOSCOPY 957
At the Focal Point
debut in fighting esophageal cancer, have shown some preliminary efficacy in the metastatic arena. But the authors of this strikingly slick Focal Point elected not to wait for the next randomized, controlled trial and simply used what was already in their accessory closet. Like a snare to a defiant colon adenoma, the polypoid (ie, resectable!) obstructing mass was dealt a swift blow with old-school panache. Congratulations to the authors for a really tough job done really well. David Robbins, MD, MSc Assistant Editor for Focal Points
A case of primary pancreatic Burkitt’s lymphoma diagnosed by EUS-guided FNA
An 86-year-old man was seen with jaundice and abdominal pain. Magnetic resonance imaging revealed a mass in the head of the pancreas, with a homogeneous low signal on T1- and T2-weighted images; the main 958 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 6 : 2013
pancreatic duct was observed clearly within the mass and was without caliber variation (A, B). Positive emission tomography/CT showed uptake in the pancreas and peripancreatic lymph nodes. EUS-FNA was performed with a www.giejournal.org
tion of contrast medium. Upper endoscopy demonstrated an elevated area with a small fistulous orifice (A, arrow). Once the patient was asymptomatic, conservative treatment was adopted. After nasoenteral feeding for 5 days, an oral diet was introduced with good acceptance. Weekly serial endoscopies demonstrated progressive migration of the bullet to the esophageal lumen (B). Twenty-seven days after the trauma, the bullet was removed with alligator forceps. An orifice with adjacent edema was noted at the impact site of the bullet. (C). One week later, the endoscopic study revealed healing of the bullet track and regenerating mucosa adjacent to the site of the previous fistula (D). The patient remained asymptomatic during a 6-month follow-up period.
DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Cristiane Kibune Nagasako, MD, MSc, Ciro Garcia Montes, MD, PhD, Endoscopy Unit of Gastrocentro, Luiz Roberto Lopes, MD, PhD, Department of Surgery, Marina da Silveira Bossi, MD, Endoscopy Unit of Gastrocentro, Maria Aparecida Mesquita, MD, PhD, Gastroenterology Division, Faculty of Medical Sciences, State University of Campinas, Campinas, Brazil http://dx.doi.org/10.1016/j.gie.2013.01.038
Commentary I gotta say this is one of my favorite Focal Points of all time. But without high-tech imagery, obscure once-in-a-lifetime diagnoses, and cutting-edge, high-risk endoscopic solutions—what makes it so cool? Because it beautifully demonstrates both the principles of primum non nocere and cura te ipsum (cure yourself). What drives the microcurrents that wend wayward foreign bodies to the nearest exit (in the case of a splinter, to the outside world; in this case, to the esophageal lumen), and how do they know in what direction to flow? This migratory phenomenon is just one of the wonderments the body does really well; add it to the list that includes hepatic lobar regeneration and about a million others. The authors were prudent to let nature take her course; the close endoscopic surveillance and well-timed armament recovery mission prevented yet more trouble for this remarkably lucky cop. David Robbins, MD, MSc Assistant Editor for Focal Points
Total necrosis of rapid growing hilar cholangiocarcinoma An 81-year-old woman with cryptogenic liver cirrhosis presented with right upper quadrant pain and pruritus. A complete blood cell count showed a hemoglobin of 11.8 g/dL (normal range, 12.0-16.0 g/dL), white blood cell count of 3340 cells/L (normal range, 4000-10,000 cells/ L), and a platelet count of 83,000/L (normal range, 150,000-400,000/L). Liver biochemical tests revealed aspartate aminotransferase of 51 IU/L (normal range, 0-31 IU/L), alanine aminotransferase of 55 IU/L (normal range, 0-31 IU/L), alkaline phosphatase of 179 IU/L (normal range, 39-117 IU/L), and a total bilirubin of 7.3 mg/dL (normal range, 0.2-1.3 mg/dL). A 2-cm moderately attenuated nodular mass at the hilum, not seen on a CT 3 months previously, was noted on abdominal CT (A, arrow). A nasobiliary catheter was inserted for decompression of the bile duct. Fluid cytology showed a few syncytial clusters of malignant columnar cells with prominent nucleoli and intracytoplasmic mucin vacuoles (B, ThinPrep, Papanicolaou ⫻400). Considering her advanced age and liver cirrhosis, we opted for endoscopic management instead of an open operation. A cholangiogram revealed a Bismuth type II⫺like, mobile, amorphous filling defect
956 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 6 : 2013
(C). We grasped and completely resected the mass in a piecemeal fashion with a retrieval balloon and Dormia basket under ERCP. The mass was grossly hemorrhagic and necrotic (D). Fragments of the mass showed nearly totally infarcted clusters of atypical cells (B, rectangle, H&E ⫻100) with hyperchromatic, pyknotic nuclei and prominent nucleoli (inset, *, H&E ⫻400). We made a diagnosis of a necrotic, rapidly growing hilar cholangiocarcinoma. Four months later, follow-up CT and ERCP showed no intraluminal mass at the hilum. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. In Hye Cha, MD, Jin Nam Kim, MD, Myoung Ki Oh, MD, Soo Hyung Ryu, MD, You Sun Kim, MD, Jeong Seop Moon, MD, Division of Gastroenterology, Department of Internal Medicine, Hye Kyung Lee, MD, Department of Pathology, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea http://dx.doi.org/10.1016/j.gie.2013.01.036
www.giejournal.org
At the Focal Point
Commentary Cholangiocarcinoma (CCA) is often a rapidly fatal malignancy with a surgical cure rate of approximately 10%. “Go for broke” surgical principles demand extensive hepatic resection for tumors involving the biliary confluence. Adjuvant chemoradiotherapy is of dubious value at best, and palliative therapy is all about biliary decompression—it does not prolong life. Part of the grave prognosis relates to the underlying debilitated state of its victims; the patient described here was entrapped by both cirrhosis (which may be a risk factor for CCA) and advanced age. If I had to nominate a GI cancer deserving of even a modest breakthrough, CCA would have my vote. The therapeutic landscape, as seen through an endoscope, has, however, recently shown some perceptible signs of change. Endoscopic techniques such as photodynamic therapy, reincarnated from its initial www.giejournal.org
Volume 77, No. 6 : 2013 GASTROINTESTINAL ENDOSCOPY 957
At the Focal Point
debut in fighting esophageal cancer, have shown some preliminary efficacy in the metastatic arena. But the authors of this strikingly slick Focal Point elected not to wait for the next randomized, controlled trial and simply used what was already in their accessory closet. Like a snare to a defiant colon adenoma, the polypoid (ie, resectable!) obstructing mass was dealt a swift blow with old-school panache. Congratulations to the authors for a really tough job done really well. David Robbins, MD, MSc Assistant Editor for Focal Points
A case of primary pancreatic Burkitt’s lymphoma diagnosed by EUS-guided FNA
An 86-year-old man was seen with jaundice and abdominal pain. Magnetic resonance imaging revealed a mass in the head of the pancreas, with a homogeneous low signal on T1- and T2-weighted images; the main 958 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 6 : 2013
pancreatic duct was observed clearly within the mass and was without caliber variation (A, B). Positive emission tomography/CT showed uptake in the pancreas and peripancreatic lymph nodes. EUS-FNA was performed with a www.giejournal.org