Pancreatic juice cytology (PJC) performed via endoscopic retrograde cholangiopancreatography
(ERCP) has been adapted as an alternative to endoscopic ultrasonography-guided tissue
acquisition for identifying pancreatic ductal adenocarcinoma (PDAC) in cases in which
mass lesions cannot be visualized; however, its diagnostic accuracy is limited [1]
[2]. Recently, PJC using a cell-block (CB) technique (in which tissue fragments obtained
from pancreatic juice are processed into paraffin blocks) has been reported [3]
[4]
[5]. Herein, we report a case of early-stage PDAC diagnosed using the CB technique in
a patient with altered anatomy. An asymptomatic 63-year-old man with a history of
Billroth-II gastroenterostomy presented with main pancreatic duct (MPD) dilatation.
Magnetic resonance cholangiopancreatography revealed MPD dilatation in the body and
tail of the organ ([Fig. 1]). Contrast-enhanced computed tomography revealed focal MPD stenosis in the body
of the pancreas with no obvious mass lesions ([Fig. 2]). On endoscopic ultrasonography, although localized MPD stenosis in the body was
detected, mass lesions were not visualized even with contrast-enhanced imaging ([Fig. 3]). Then, single-balloon enteroscopy-assisted ERCP was performed. On pancreatography,
the MPD was narrowed in the body, and the dilated caudal MPD could be imaged only
after guidewire passage ([Fig. 4]). A 5-mL aliquot of pancreatic juice was aspirated using an ERCP catheter with negative
pressure via a 10-mL syringe. Half of the collected pancreatic juice was used for
PJC and the rest for CB. Although PJC was indeterminate, histopathological evaluation
of the CB specimen revealed atypical cell clusters with irregular-size nuclei that
tested positive for Ber-EP4 and Claudin-4 on immunostaining ([Fig. 5], [Video 1]). Following distal pancreatectomy, a final diagnosis of stage IA PDAC with a tumor
diameter of 6 mm was made. This case highlights the usefulness of the CB technique
with ancillary immunostaining as a diagnostic tool for PDAC, even in patients with
altered anatomy.
Early diagnosis of pancreatic cancer via pancreatic juice cytology with a cell-block
technique in a patient with altered anatomy.Video 1
Fig. 1 Magnetic resonance cholangiopancreatography showing main pancreatic duct dilatation
in the pancreatic body and tail (arrowheads).
Fig. 2 Contrast-enhanced computed tomography showing focal main pancreatic duct stenosis
in the pancreatic body with no obvious mass lesions (arrowheads). a Early phase. b Delayed phase.
Fig. 3 Endoscopic ultrasonography showing no visible mass lesions in the pancreas around
the focal main pancreatic duct stenosis. a Fundamental B-mode image. b Contrast-enhanced harmonic image.
Fig. 4 Pancreatography using single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography
showing main pancreatic duct stricture in the body of the organ (arrows). The caudal
pancreatic duct could be imaged only after the guidewire advanced beyond the stricture
(arrowheads).
Fig. 5 Histopathological evaluation of the specimen via the cell-block technique demonstrating
a atypical cell clusters with irregularly sized nuclei b that tested positive for Ber-EP4 and c Claudin-4 by immunostaining.
