EUS-guided through-the-needle microforceps biopsy for diagnosis of tubercular lymphadenitis mimicking pancreatic cystic lesion (with video).

A 40-year-old male presented with upper abdominal discomfort and ultrasound abdomen revealed a cystic lesion in the uncinate process. Contrast-enhanced computed tomography revealed a thick-walled cystic lesion measuring 4.2 cm in the uncinate process [Figure 1]. Positron emission computed tomography revealed flouro-deoxyglucose avidity in the wall of this cystic lesion [Figure 2]. EUS-guided fine-needle biopsy from the cystic lesion done elsewhere was inconclusive on two separate occasions. EUS done at our center revealed a complex cystic lesion posterior to the head of the pancreas and closely abutting the inferior vena cava with normal uncinate process [Figure 3; arrows]. Contrast-enhanced harmonic EUS using Sonovue (Bracco, Milan, Italy) at low mechanical index of 0.12 revealed nonhomogenous enhancement of the cystic lesion with solid areas showing enhancement [arrows; Figure 4] and anechoic areas not enhancing. EUS-guided fine-needle biopsy form the solid as well as liquid areas was inconclusive and revealed necrosis only. Thereafter, tissue sampling was done from the solid area of the lesion under EUS guidance using through the needle forceps device (Moray Micro Forceps, US Endoscopy, United States) [Figure 5 and Video 1]. To improve the visualization of opening of forceps in the lesion, biopsy was performed using both B mode and harmonic EUS [Video 1]. The use of harmonic EUS led on to better visualization of the tip of Microforceps. Two passes were taken and crush smear was prepared with one specimen and the other specimen was sent in formalin vial. The cytopathological examination revealed lymphoid tissue with the presence of loose collection of epitheloid cells and necrosis [Figure 6]. No acid fast bacilli could be detected. The rapid nucleic acid amplification test (Xpert MTB/RIF; Cepheid, Sunnyvale, CA, USA) performed on the aspirated specimen was negative. The Mantoux test was positive (induration of 16 mm), C-reactive protein was elevated (16 mg/L), and the patient was started on anti-tubercular therapy (ATT). The patient responded to ATT and the abdominal discomfort subsided after 1 month of initiating ATT. Serum CRP normalized at 2 months and ultrasound of the abdomen done three months after initiation of ATT revealed reduction in size of the lesion (2.3 cm).Figure 1: Contrast enhanced computed tomography: thick walled cystic lesion in the uncinate process of pancreasFigure 2: Positron emission computed tomography: flouro-deoxyglucose avidity in the wall of cystic lesionFigure 3: EUS: Complex cystic lesion (arrows) posterior to the head of pancreas and closely abutting the inferior vena cava with normal uncinate processFigure 4: Contrast-enhanced harmonic EUS: Nonhomogenous enhancement of the cystic lesion with solid areas showing enhancement (arrows) and anechoic areas not enhancingFigure 5: EUS-guided biopsy using through the needle forceps deviceFigure 6: Microphotograph of microbiopsy specimen: a loose collection of epithelioid cells (arrows) with necrosis in the background (H and E, ×40)To improve the diagnostic yield of EUS-guided tissue sampling, through-the-needle micro-forceps device has been introduced and studies have reported high diagnostic yield in pancreatic cystic lesions.[1,2] It can also be used for tissue diagnosis in difficult to diagnose lesions as in the index case. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest Surinder Singh Rana is an Editorial Board Member of the journal. This article was subject to the journal’s standard procedures, with peer review handled independently of this editor and his research group.