Primary pancreatic leiomyosarcoma: a rare diagnosis obtained by EUS-FNA cytology
Descrição do Produto
Letters to the Editor
appears to be more effective than pneumatic dilation, with a lower rate of adverse events. It would have been preferable to include these data in the guideline. However, the meta-analysis was published after the guideline had been finalized and submitted for publication. This highlights the inherent difficulty of including contemporaneous data in guidelines. The ASGE Standards of Practice Guidelines are prepared as an educational tool to provide information that may assist in the endoscopic management of patients with GI disorders. They do not lend themselves to an in-depth comparison of endoscopic to non-endoscopic management options. Clinical decisions in any particular case involve a complex analysis and discussion of the patient’s clinical condition and available options of management. After review of the contemporary data, our recommendation on the endoscopic management of achalasia remains unchanged. We recommend that both endoscopic and surgical treatment options for achalasia be discussed with the patient. In patients who opt for endoscopic management and are good surgical candidates, we recommend pneumatic dilation with large-caliber balloon dilators for the endoscopic treatment of achalasia. This should not be interpreted as a recommendation of endoscopy pneumatic dilatation preferentially to laparoscopic Heller myotomy, but rather a recommendation that pertains to the current level of evidence regarding the various available endoscopic management options for achalasia. Shabana F. Pasha, MD Division of Gastroenterology Mayo Clinic Arizona Scottsdale, Arizona, USA Brooks D. Cash, MD, FASGE University of South Alabama Mobile, Alabama, USA
Figure 1. EUS-guided FNA performed with a curvilinear echoendoscope, demonstrating a large hypoechoic mass in the pancreatic head region.
Figure 2. Cytologic features consisting of cohesive spindle-shaped cells in parallel arrangement, with large blunt-ended “cigar” nuclei, with pleomorphism, high nuclear-cytoplasmic (N/C) ratios, and mitotic figures embedded in thick metachromatic fibrotic stroma (Diff-Quik, 200).
REFERENCES
Leiomyosarcoma of the pancreas is an extremely rare malignancy. A pathologic tissue diagnosis to guide appropriate clinical management can be established with
EUS-FNA cytology. We believe this to be the first report of a primary leiomyosarcoma of the pancreas diagnosed by EUS-FNA cytology. A 68-year-old man presented with persistent vague abdominal pain. Abdominal CT showed an 8-cm mass arising from the pancreas. EUS revealed a 9 7.5 cm heterogeneous mass replacing the pancreatic uncinate process, head, and neck (Fig. 1). Transduodenal FNA of the pancreatic head with a 22-gauge needle yielded blood. Because of stromal fibrosis, a flexible 19-gauge needle was used for subsequent passes. A malignant spindle cell lesion was confirmed on the second pass at on-site evaluation (Fig. 2). Needle rinses were made into the cell block, which contained multiple fragmented cores whose architecture was consistent with leiomyosarcoma. The diagnosis was supported by immunohistochemistry results that were positive for smooth muscle actin
www.giejournal.org
Volume 80, No. 2 : 2014 GASTROINTESTINAL ENDOSCOPY 361
1. ASGE Standards of Practice Committee, Pasha SF, Acosta RD, Chandrasekhara V, et al. The role of endoscopy in the evaluation and management of dysphagia. Gastrointest Endosc 2014;79:191-201. 2. Yaghoobi M, Mayrand S, Martel M, et al. Laparoscopic Heller’s myotomy versus pneumatic dilation in the treatment of idiopathic achalasia: a meta-analysis of randomized, controlled trials. Gastrointest Endosc 2013;78:468-75. http://dx.doi.org/10.1016/j.gie.2014.02.1024
Primary pancreatic leiomyosarcoma: a rare diagnosis obtained by EUS-FNA cytology To the Editor:
Letters to the Editor
(SMA) and desmin, and negative for CD34, c-kit, and discovered on GIST-1 (DOG-1). The result of platelet derived growth factor-a (PDGFR-a) mutational analysis was negative. The patient died 8 weeks later, and autopsy revealed extensive disease throughout the abdomen and complete obliteration of the pancreas. Sarcomas of the pancreas are exceedingly rare, representing less than 1% of all pancreatic malignancies.1 Many cases initially thought to be primary leiomyosarcoma of the pancreas are later shown to originate in adjacent organs. We were able to confirm our diagnosis because the imaging showed no evidence of contiguous spread or metastatic disease. Leiomyosarcomas are cystic and fibrous in nature,2 and a diagnostic EUS-FNA aspirate can be difficult to obtain. The initial 22-gauge needle yielded hemorrhagic cyst fluid, and by changing to a flexible 19-gauge needle we were able to obtain several diagnostic solid tissue fragments. The exact nature of the stromal malignancy was confirmed by EUS-FNA cytology, avoiding the need for increasingly morbid, invasive tissue acquisition procedures in a patient with advanced disease.
DISCLOSURE The following authors disclosed financial relationships relevant to this publication: S. Varadarajulu: consultant for Olympus and Boston Scientific. S. Hébert-Magee: consultant for Boston Scientific. All other authors disclosed no financial relationships relevant to this publication. Shantel Hébert-Magee, MD Shyam Varadarajulu, MD Center for Interventional Endoscopy Florida Hospital, Orlando, Florida, USA Andra R. Frost, MD Division of Anatomic Pathology Department of Pathology Jayapal Ramesh, MD, FRCP (UK) Division of Gastroenterology and Hepatology Department of Medicine The University of Alabama at Birmingham Birmingham, Alabama, USA
REFERENCES 1. Baylor SM, Berg JW. Cross-classification and survival characteristics of 5,000 cases of cancer of the pancreas. J Surg Oncol 1973;5: 335-58. 2. Lane RH, Stephens DH, Reiman HM. Primary retroperitoneal neoplasms: CT findings in 90 cases with clinical and pathologic correlation. AJR Am J Roentgenol 1989;152:83-9. http://dx.doi.org/10.1016/j.gie.2014.02.030
362 GASTROINTESTINAL ENDOSCOPY Volume 80, No. 2 : 2014
Endoscopic suturing closure of large mucosal defects after endoscopic submucosal dissection: Is the technique, at all times, feasible and effective? To the Editor: We read the article by Kantsevoy et al1 regarding endoscopic suturing closure of large mucosal defects after endoscopic submucosal dissection (ESD) by using an endoscopic suturing device. Twelve mucosal defects of the colon and stomach were closed by using the Overstitch device, with excellent results in terms of cost and adverse events. Defect closure after ESD via endoscopic suturing is an innovative procedure. We have found that defect closure via suturing after ESD, by using our suturing device, is effective.2 We agree that this technique can eliminate the need for hospitalization and reduce the number and severity of adverse events. However, in our experience, closure of mucosal defects by using endoscopic suturing has some limitations. Additional ESD or ablation is difficult to perform in cases of residual cancer after ESD; therefore, additional resection or ablative treatments might be required after ESD, before defect closure.3,4 Additionally, closure of the mucosal defect around the cardia or pylorus could induce stenosis because of stomach deformity. The risk of stenosis after lesion resection must be considered in cases of lesion location near the anal canal or ileocecal valve in the colon, for example. In the study by Kantsevoy et al,1 the Overstitch device (Apollo Endosurgery Inc, Austin, Tex) was used to suture mucosal defects on the antrum and body of the stomach, but whether its use near the cardia and lesser curvature of the upper stomach required turning of the endoscopy tip was not reported. We wonder whether the tumor location may present a challenge during suturing when using the Overstitch device. This article highlights the cost benefit of suturing by using Overstitch compared with the endoclip technique. However, ESD is a globally used procedure, so the cost of ESD devices may vary in different medical centers and regions, and hospitalization depends on the physician’s treatment plan. Large, prospective, multicenter studies are required to confirm these results, as the authors suggested. Hyuk Soon Choi, MD, PhD Hoon Jai Chun, MD, PhD Eun Sun Kim, MD, PhD Bora Keum, MD, PhD Yoon Tae Jeen, MD, PhD Division of Gastroenterology and Hepatology Department of Internal Medicine Institute of Digestive Disease and Nutrition Korea University College of Medicine, Seoul, Korea
www.giejournal.org
Lihat lebih banyak...
Comentários