Novel techniques for diagnosis of serous cystadenoma: fern pattern of vascularity confirmed by in vivo and ex vivo confocal laser endomicroscopy

      An asymptomatic 59-year-old woman presented with an incidental pancreatic lesion on CT scan. EUS demonstrated a multiseptated cyst in the pancreatic tail that measured 6 cm × 3.5 cm. There was no associated mass or communication with the pancreatic duct. Needle-based confocal endomicroscopy (nCLE) with an AQ-Flex-19 miniprobe (Cellvizio; Mauna Kea Technologies Inc, Suwanee, Ga) was performed (Video 1, available online at A large superficial vascular network in a fern-leaf pattern was observed and supported the diagnosis of serous cystadenoma (SCA) (Fig. 1). Cytologic examination did not show malignant cells or mucin. The fluid amylase determination was 13 U/L, and the carcinogenic embryonic antigen level was 0.5 ng/mL. Despite these findings, owing to a cumulative increase in the size of the cyst by 1.5 cm over 1 year and the patient’s preference to avoid continued imaging, the decision was taken for surgical resection. The patient underwent a laparoscopic distal pancreatectomy and splenectomy. According to protocol, postsurgical ex vivo confocal laser endomicroscopy was performed with a Gastroflex probe (Cellvizio) (Video 1) that validated the in vivo findings. The pathologic findings confirmed the diagnosis of SCA. This report establishes reference patterns for EUS-nCLE–guided diagnosis of SCA and demonstrates the potential use of nCLE in the management of pancreatic cystic lesions.
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      Figure 1EUS-guided in vivo confocal laser endomicroscopic view demonstrating a fern pattern of vascularity with tortuous blood vessels emanating from a larger blood vessel.
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