Fukuda Soma, Hijioka Susumu, Okamoto Kohei, Yagi Shin, Chatto Mark, Saito Yutaka, Okusaka Takuji
Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan.
Department of Medicine, Makati Medical Center, Manila, Philippines.
VideoGIE. 2025 Feb 21;10(6):302-306. doi: 10.1016/j.vgie.2025.02.006. eCollection 2025 Jun.
Diagnosing early-stage pancreatic ductal adenocarcinoma, particularly high-grade pancreatic intraepithelial neoplasia (HG-PanIN), remains challenging. Serial pancreatic juice aspiration cytologic examination (SPACE) using an endoscopic nasopancreatic drainage tube has demonstrated high diagnostic accuracy, but its application in surgically altered anatomy is technically demanding. We present a case in which balloon enteroscopy-assisted SPACE led to the diagnosis of HG-PanIN and successful resection.
A 70-year-old man with a history of distal gastrectomy and Roux-en-Y reconstruction for gastric cancer underwent follow-up imaging, which revealed localized main pancreatic duct (MPD) stricture and parenchymal atrophy in the pancreatic tail. EUS identified a faint hypoechoic area around the stricture, but no distinct mass. EUS-guided tissue acquisition was inconclusive. Double-balloon enteroscopy-assisted endoscopic retrograde pancreatography was performed, revealing MPD stricture and distal dilation. A 5F endoscopic nasopancreatic drainage tube was placed across the stricture, and SPACE was conducted.
Twelve pancreatic juice cytology samples were aspirated every 2 to 3 hours over 3 days, each exceeding 1 mL. One sample (10th) was classified as Class IV, "suspicious for adenocarcinoma," with cytology revealing nuclear enlargement and atypia. The patient was diagnosed preoperatively with pancreatic cancer (TisN0M0 stage 0) and underwent distal pancreatectomy without neoadjuvant chemotherapy. Pathology confirmed HG-PanIN of the MPD. The patient had no postoperative adverse events and remained recurrence-free at the 9-month follow-up.
This case highlights the effectiveness of balloon enteroscopy-assisted SPACE in diagnosing HG-PanIN in surgically altered anatomy. However, given the relatively high risk of pancreatitis, SPACE should be reserved for patients with imaging or clinical findings suggestive of malignancy. By overcoming technical obstacles, this method offers a promising diagnostic strategy for early-stage pancreatic ductal adenocarcinoma in surgically altered anatomy.
诊断早期胰腺导管腺癌，尤其是高级别胰腺上皮内瘤变（HG-PanIN）仍然具有挑战性。使用内镜鼻胰引流管进行连续胰液抽吸细胞学检查（SPACE）已显示出较高的诊断准确性，但其在手术改变解剖结构中的应用技术要求较高。我们报告一例通过球囊小肠镜辅助SPACE诊断HG-PanIN并成功切除的病例。
一名70岁男性，有因胃癌行远端胃切除术及Roux-en-Y重建术的病史，接受了随访影像学检查，发现胰腺尾部主胰管（MPD）局限性狭窄及实质萎缩。超声内镜（EUS）在狭窄周围发现一个模糊的低回声区，但未发现明显肿块。EUS引导下的组织获取结果不明确。进行了双气囊小肠镜辅助的内镜逆行胰胆管造影，显示MPD狭窄及远端扩张。一根5F内镜鼻胰引流管穿过狭窄部位放置，并进行了SPACE检查。
在3天内每2至3小时抽吸12份胰液细胞学样本，每份样本量超过1 mL。其中一份样本（第10份）被分类为IV级，“怀疑为腺癌”，细胞学检查显示细胞核增大及异型性。患者术前被诊断为胰腺癌（TisN0M0 0期），并接受了远端胰腺切除术，未进行新辅助化疗。病理证实为MPD的HG-PanIN。患者术后无不良事件发生，在9个月的随访中无复发。
该病例突出了球囊小肠镜辅助SPACE在手术改变解剖结构中诊断HG-PanIN的有效性。然而，鉴于胰腺炎风险相对较高，SPACE应仅用于有影像学或临床提示恶性肿瘤表现的患者。通过克服技术障碍，该方法为手术改变解剖结构的早期胰腺导管腺癌提供了一种有前景的诊断策略。
