and Todd and Alessandro and- Hello, Greg. Anybody else? Hey, Greg. Good to see you. Good morning. We have picked a great time to show up. As you can see, we have a struggle on our hands here, but I'm gonna ask Nick Martinez, who's our advanced ambassadorship fellow, to present this case. I'm just in the room with our nurse, Maura Zimmerman, my always steady tech, Francesco Ortiz, and we have Nancy Manning with CRNA. This is a, you know, cardiology-wise complex case, so we've elected the endotracheal intubation for this patient, and it's a little more, even more complex because he's on one of these new SGL2 inhibitors, which apparently has been associated with prolonged euplycemic ketoacidosis after general anesthesia, so we're gonna make plans to, unfortunately, omit this patient afterwards for observation. But anyway, I'm gonna stop at this point and ask Nick to go ahead and give the case presentation. Good morning, everyone. I'm gonna start with the case presentation. So this is an 81-year-old medical case for a pericardial lymphoma, non-functional, independent diabetes, CAD status for 37 years, coronary at the age of 98, arterial septal MRI in 2004, and heart failure with an EF of 25%, who was admitted in January 14, 2022 for weight loss, dyspolar stool, fever, and liver embolism abnormalities. So as you can see below, he has a polystatic pyelone liver injury with an alpha 663, ALT of 200, AST of 154 with normal bilirubin. So he had CAT scans on his throat, internal exopathic biliary dilation, as well as PD dilation, consistent with double duct signs. There was a fine region of decreased attenuation in the pancreatic alternate, as well as the head, which was unclear if it was related to edema or neoplastic process. So subsequently he had an MRI that showed an ill-defined obstruction matching the pancreatic head, measuring at least 2.3 centimeters concerning the pancreatic adenofasclinoma. This was above the main colon vein, as well as the SMD. There was also moderate intracranial dilation secondary to the pancreatic head mass, as well as dilation of the gallbladder itself. There was no evidence of definite or distinct metastasis or abdominal adenopathy, and there was partial visualization of a soft tissue mass in the left iliac wing. These are the corresponding images of the MRI showing the dilation of the biliary tree as well as dilation of the CPV. Subsequently, underwent an ERCP showing an oddly ulcerated ampulla, as well as, if you look at the cholangiogram, there's a distinct discal CPV picture that the patient underwent brushing with a little placement of a 10 by 5 plastic stent, 10 cents by 5.5. The patient also underwent an EOS showing a massive level of the head of the pancreas, and underwent EOS FNA at that time. So in terms of the cytopathology, the biliary structure brushing came back negative for evidence of malignancy, and the pancreatic head mass FNA came back as a rare atypical cell with a necrotic degree, but the tumor could not be excluded. The patient subsequently underwent a CT PET, which showed increased size of the left iliac soft tissue mass and osteo-convulsion representing the lymphoma, consistent with what was seen in the MRI, in particular, the pancreatic neoplasm and there was no significant uptake of the CT gene. That's the end of the case presentation. I'll turn it back to Dr. Ginsberg. Thanks, Nick. So, you know what, when you may have observed, I don't know if it was on camera or not, but we had a devil of a time getting into his duodenum. First, he has a big J-shaped stomach, but he's developed now, some stenosis at the juncture between the bulb and the second portion. So, you know, it's worth considering what methods you have to use. In this case, we prepped the patient up on his side and that was sufficient, but we were prepared to use a blue dilating catheter from the 12 to 15 and we would use an obturator to get through if we couldn't pass through. All this makes this much more likely, you know, a pancreatic primary. We were concerned that he might've had lymphoma that was causing this. So, but the FDG negative activity, we can open a little bit, makes that not really tenable. So, in this case, we're just gonna go ahead and remove the indwelling stents and start to close. And Fran has gotten that nicely and we will have it just at the end. You can see there's, his papilla is abnormal. You know, it looks like there's tumors there. In a little bit of contrast to what Nick had said in his presentation, there wasn't a real mass in the head region of the pancreas. There was just a little bit of fullness in the anterolary area, but not that really qualified as a tumor. It wasn't much of a target, frankly, for his FNA. So, I'm just gently pulling a stent out now, the strobe, and hopefully you can see that. I'm gonna take my locks off to make that go a little easier. I'm gonna do it slowly enough that we avoid tearing the stent. We're gonna send this guy for cytopathology as well. Although I'm not sure that there's a whole lot of yield. Tom, I'd ask you, because you've published this topic. Yeah, I was gonna say, I don't do it, but one of my colleagues has been doing it for eight years since I've been here. And I don't recall that they've had a positive one. The other concern is when you drag the stent all the way back through the scope, are you potentially losing the cells on your way out? Certainly, it's a low risk, but I don't know what the cost of cytology is. Can you hear me now? Yes. It looks like it has tumors right in it. So, we do this at our hospital, although I think it's just one time that actually got any positive results. So, I don't know. So, I think it's just one time that actually got any positive results from sending out the stent. But because it's easy to do and not much of a risk, we do still tend to do that if we didn't get initial diagnosis. So, yeah. So, the other thing, Greg, since you haven't established that this isn't lymphoma, I guess the main thing is replacing the stent with a removable. If you're going to do metal, you'd want to do a covered stent, even though off-label. I mean, we don't have an indication really for removability in malignant disease, but we all know you can remove it. So, I would caution anybody who might want to put an uncovered metal stent in this situation to be careful. Something you can't remove later. So, the new opportunity from Europe is also using a biodegradable stent. They are not yet approved in the U.S., but we have in Europe. You can put a couple of biodegradable stents. You can take your time. I apologize. I'm having some connectivity issues here at the ITT Center, but hopefully you guys can hear me. One question. I don't know if somebody already mentioned this. Is there any thought that this could be AIP? Well, yes. Yes and no. I mean, as you know, it's rare. It's a very difficult position to hear. But now I have the stent out. It's not a good thing. But to your point just about the... We're really reluctant to replace metal stents in patients who don't have a confirmed malignancy. Now, in this case, who I'm already having trouble getting back and forth to, that makes the idea of maybe putting in a fully covered metal stent a little more attractive. I don't see a... His gallbladder filling. I can't remember whether he's had a colostomy or not, because that matters a little bit. Although we can put a very short stent across. Short stent, of course, is more likely to migrate out. We put a fully covered metal stent in, because then at your point, it's obviously difficult to get there and may become more challenging to get there over time. And at least they have a fully covered stent in now, so you don't have to bring them back, hopefully. Except they'll have a diagnosis. Right. And somebody mentioned IgG4. Well, not likely, but not zero. Right. Has... Was this the first U.S. FNA or was it an FNB? Or is there any thought to trying to do another? We're going to do another one before we finish today, for sure. That's absolutely part of the plan. Can you discuss whether if you put a stent in, does that make your FNA or FNB more difficult to visualize a mass? I actually prefer, when I'm doing cases like this, to go ahead and have the stent in place, because it provides a really good target, frankly, for the FNA. If there's a fully covered stent in there, I've tended to find that sometimes the shadowing from the stent can get in the way at times more so, obviously, than the plastic stent. So, unfortunately, as you saw, I bounced out again. So let me... Fortunately, once you get through, it's usually easy enough to get back in. So to the point of the stent, what I've found personally is that if it's a really subtle mass or stricture, it's hard to see where you need the biopsy because it's a facing. Certainly, like you said, you can see thickening around the stent and target that, whereas if it's an obvious mass, it doesn't, for me personally, interfere. But, you know, whatever works for the individual. I know there are some people that prefer, you know, not to have a stent in for biopsy, but I think it's personal preference. Right. I think there was one study that suggested that if you had a plastic stent in, it didn't interfere, but with a metal stent in, it did tend to interfere a bit. And probably for the location of this specific lesion, a metal stent would be a major problem. Yeah. Because of the uncinate process. Right, right. And it sounded also like Dr. Ginsburg was saying that this mass isn't like a very well-defined mass, but it's a more subtle appearing, so... The fact is that we're really good with EOS diagnosis. I mean, you know, it approaches 95%. Yeah, right. And it really prompted us to almost abandon doing introductive psychology, except in cases that we've, you know, spent the clinic of carcinoma. I agree, yeah. Right. Abandoned my original plan here. You can see, actually, see the ulcer on top? Yes. Okay. So, what I'm going to do is I'm probably shifting gears from what I had planned to stop for a second, is we're going to put a guide wire in, we're going to repeat brush psychology. And our current protocol at Penn is to take two brushes, they go in the same container, one goes for psychology and one goes for a fish. Then I'm going to put a stent back in. I'm going to hold my line on putting in another 10 French stent, and then we'll take a forceps and run a biopsy the heck out of this area, right above the tumor to the edge of the ulcer. Yeah. Yeah, no, that's a good point. Could this be a benign ulcer? You know, is it possible that that's what was responsible for earlier instruction? What about trying to advance the forceps into the bile duct and take some biopsies that way? Take a look. When we repeated the psychology, or the clinicogram, there wasn't much of a structure. Really, there was a real, as you saw in the presentation, a real, very much malignant-appearing structure. Yeah, yeah. I don't think that if there's a yield here, it's going to be- Right around the area where you are, yeah. I think, yeah. This is a very good discussion. Dr. Ginsberg, this is a very good discussion. We will go to Dr. Al-Haddad from Indiana University, and we will come back to you in a few minutes. Very good. All right, thank you all. Dr. Ginsberg, we can see you. Thanks for coming back real quick. We ended up taking our breast cytology as planned and replacing the stent. I did take multiple biopsies. You know, that looks like a benign ulcer right above the papilla. We took biopsies from the margin of it, and now we're repeating the EUS. A couple of things, again, he's got a little bit of a stenosis in the second portion of the duodenum, which is a challenge. As we pull back, we have the stent placed in that house. Right at about 3 o'clock on the screen, you'll see the pancreatic duct inferior, and right above it is the bile duct with the stent in place. That's the ampulla coursing across, which you should be able to discern. And as we come back a little further, you can see the tracts of the stent right underneath the EUS transducer. So the pancreatic duct underneath. Nick, if you want to show with markers on the EUS monitor. Very nice, Dr. Ginsberg. Yeah, so this is nice because I can just follow this back, and it should take me to a tumor. And there you see it. It's a small tumor. Yeah, that hypoechoic region off to the right. And right beyond that, then you see that the PV goes right into it. We've taken three vials, and then beyond that is the dilated pancreatic duct. And I think you saw the stent go right through it. And here's actually a better image of it. And that's what we sampled. It's a difficult tumor to sample because it pops you right out when you put the needle in. But anyway, I just wanted to demonstrate that finding. And I think you can go to one of the other centers now. Thank you. Great view. Thank you so much, Dr. Ginsberg.

pericardial lymphoma

non-functional independent diabetes

ulcerated ampulla

lymphoma

autoimmune pancreatitis