EUS-guided fine-needle tattooing for preoperative localization of early pancreatic adenocarcinoma

A 67-year-old woman was evaluated for recurrent pancreatitis. She had no other significant medical history, and her carbohydrate antigen 19-9, amylase, and lipase levels were normal. An initial pancreatic protocol CT showed normal results. A linear EUS examination revealed a poorly defined 5-mm hypoechoic solid area in the pancreatic body close to the portal confluence (Fig. 1). EUS-guided FNA (EUS-FNA) of this area revealed cells suspicious for adenocarcinoma. The patient decided to undergo a laparoscopic resection of the pancreatic lesion. A repeated pancreatic protocol CT failed to localize the lesion. On the day before her planned laparoscopic pancreatic resection, a repeated EUS again revealed the subtle 5-mm hypoechoic area in the pancreatic body. EUS-FNT was performed by slowly injecting, with a 22-gauge needle (Echo-Tip; Cook Endoscopy, Winston–Salem, NC), 2 mL of a sterile carbon-based ink (SPOT; GI Supply, Camp Hill, Pa) into an area of normal pancreatic parenchyma 2 cm toward the head of the pancreas relative to this mass (Fig. 2). There were no acute complications, such as bleeding, abdominal pain, fever, or pancreatitis at the time of the injection. The patient received preprocedural and postprocedural oral ciprofloxacin. At a laparoscopy, there was no evidence of inflammation or bleeding around the easily recognized tattooed area. Intraoperative evaluation failed to identify the pancreatic body tumor. By using the tattooed area as the most medial aspect, the patient underwent, uneventfully, a laparoscopic distal pancreatic resection. A pathologic evaluation of the resected pancreas revealed a 5-mm intraductal papillary mucinous neoplasm (IPMN) with carcinoma in situ, 2 cm from the surgical resection plane (Fig. 3). The patient was continuing to do well 12 months after surgery. She had no evidence of recurrent pancreatitis, IPMN, or pancreatic cancer.