Case Report We present the case of a 56-year-old man with past medical history significant for asymptomatic gallstones. Due to intermediate probability of choledocholithiasis, an MRCP was performed and showed a scleroatrophic gallbladder with stones, no choledocolithiasis and an unspecific 8-mm area with signal changes in the perfusion images located in the pancreatic body. To further characterize the pancreatic incidental finding, the patient was referred to our institution and an EUS was done and found in the distal pancreatic body 4 hypoechoic homogeneous round lesions, between 4 to 7mm in size, with well-defined contour (Video 1). EUS-guided FNB of the 2 largest lesions was performed using an Acquire 22-gauge needle (3 passes in total). Quiz Discussion In patients with multiple pancreatic lesions with the previously mentioned US characteristics (hypoechoic homogeneous round lesions, with well-defined contour) the most commonly found diagnosis is multifocal pNET. However, and interestingly, this was not the case with regard to this patient as pathology revealed lymphoid tissue in both cases, with groups of CD45 positive and CK8/18 negative cells, supporting the diagnosis of intrapancreatic accessory spleens (Figure 1). To our knowledge, this is the first case of multiple intrapancreatic accessory spleens documented by EUS in the literature.  Accessory spleen is a common benign congenital anomaly, with an approximate prevalence of 10–30% [1]. The most frequent location is the splenic hilum (80%), followed by the pancreatic tail (17%) [2]. Intrapancreatic accessory spleen (IPAS) is usually diagnosed incidentally on abdominal US, computed tomography, or magnetic resonance imaging. Usually, it is […]

Case Report A 48-year-old asymptomatic female underwent an abdominal ultrasound due to liver enzymes elevation (AST 45 U/L, ALT 77 U/L) detected on routine evaluation. Abdominal ultrasound revealed an incidental gastric wall lesion that was misinterpreted as A cyst of the pancreatic body measuring 68x45mm. Additional abdominal computed tomography (CT) was performed showing a well-defined, hypodense gastric mass with calcifications, measuring 65mm, on the posterior wall of the distal body, compressing the transverse colon; no lesions were visible on the pancreas or liver. Upper gastrointestinal endoscopy demonstrated a 6cm rounded subepithelial lesion (SEL), with a central depression, on the posterior face of the distal body of the stomach (Fig. 1).  On the endoscopic ultrasound (EUS) examination, the gastric lesion corresponded to a well-defined heterogeneous lesion, with solid iso/hypoechoic areas, necrotic/cystic (anechoic) areas and calcifications, located on the fourth layer (muscularis propria) (Fig. 2). Additionally, rounded and hypoechoic perilesional lymph nodes (maximum diameter 14mm) were identified. EUS-guided fine needle biopsy (FNB) using a 22G needle was performed (two needle passes; AcquireTM Endoscopic Ultrasound FNB Device, Boston Scientific) and the histopathological analyses revealed rare spindle cell tissue fragments, with a fascicular arrangement, without nuclear atypia nor mitosis. Immunohistochemistry staining was positive to S100 and negative to CD117, CD34, DOG 1 and smooth muscle actine (Fig. 3A and 3B).  Quiz Discussion The histopathological features and immunohistochemical staining pattern were consistent with the diagnosis of gastric schwannoma. After multidisciplinary discussion, the patient was submitted to a laparoscopic partial gastrectomy with Roux-en-Y reconstruction, and the histopathological examination of […]

Case Report A 69-year-old woman without relevant past medical history presented with anorexia, jaundice and weight loss for the past 2 months. An abdominopelvic CT scan showed a 4 cm mass of the pancreatic head, along with the double duct sign. This finding was confirmed by endoscopic ultrasound (EUS), revealing an hypoechogenic, heterogeneous, ill-defined solid nodular lesion with 33 x 38 mm, contacting with the splenoportal venous confluence and with the superior mesenteric vein (Fig. 1 and 2). EUS-guided fine-needle biopsy (FNB) using a 22G needle was performed (2 needle passes; AcquireTM Endoscopic Ultrasound FNB Device, Boston Scientific). Quiz Discussion Although pancreatic ductal adenocarcinoma is the most common solid pancreatic lesion, EUS-guided FNB revealed a different diagnosis. Pathology found cell nests consistent with a poorly differentiated carcinoma, ER+ and GATA3+ (Fig. 3), raising the possibility of a breast primary. A thoracic CT, done for staging purposes, surprisingly found a multilobulated irregular mass of the left breast. Biopsy of this lesion showed an invasive lobular carcinoma (Fig. 4), which overlapped morphologically with the pancreatic lesion, thus enabling the diagnosis of pancreatic metastasis secondary to invasive lobular carcinoma (oligometastatic breast cancer).  After multidisciplinary discussion, the patient was started on chemotherapy and hormonal therapy followed by pancreaticoduodenectomy and breast surgery. Up to 10% of solid lesions initially thought to be adenocarcinoma are latter diagnosed as other pancreatic conditions.[1] Therefore, EUS-guided tissue acquisition should be always considered in patients with a pancreatic solid mass in order to establish the pathological diagnosis, thus potentially changing patient management […]

Case Report A 39-year-old woman presented with a two months history of epigastric pain partially relieved with proton pump inhibitors (PPI). She had no history of nausea, vomiting, diarrhoea or weight loss. She had no significant medical or family history. Physical examination was unremarkable. The workup revealed haemoglobin of 13.8 g/dL, albumin of 3.6 g/dL and fasting serum gastrin of 37.7 ng/mL. Serologic test for Helicobacter pylori (H. pylori) was positive. An upper gastrointestinal endoscopy revealed giant folds with a polypoid appearance in the greater curvature of the stomach body with sparing of the antrum (Fig. 1). Tissue specimens of altered gastric mucosa were obtained using standard biopsy forceps. Endoscopic ultrasound showed thickening of the mucosal layer of the stomach body with preservation of wall stratification. Antrum wall had normal thickness and structure (Fig. 2 and Video 1). Video 1. EUS showing an echogenic thickening of the mucosal layer wall of stomach body with sparing of the antrum. Quiz Discussion Histology revealed foveolar hyperplasia, glandular tortuosity and dilatation, mucosal oedema and decreased number of parietal cells (Fig. 3). These features are consistent with the diagnosis of Ménétrier’s Disease (MD). The patient was treated with concomitant therapy (PPI, amoxicillin, clarithromycin and metronidazole) for H. pylori eradication. She remains asymptomatic two months after the treatment and H. pylori eradication was verified with urea breath test. Additional invasive procedures were deferred because she became pregnant. MD is a rare, idiopathic hypertrophic gastropathy characterized by giant rugal folds in the gastric body, foveolar hyperplasia and markedly decreased or absent oxyntic glands with antral sparing [1]. The pathogenesis is related to […]

Case Report A 68-year-old female patient presented with nonspecific abdominal pain and early satiety. Laboratorial tests revealed normal liver function and carbohydrate antigen 19-9 (Ca19.9), as well as an elevated serum amylase (163 U/L). The patient had a prior history of hypertension, type 2 diabetes mellitus and dyslipidemia. An abdominal computed tomography (CT) scan showed a pseudonodular area measuring 12x11mm (axial), with arterial phase hyperenhancement, located in the anterior part of the transition between the body and tail of the pancreas (Fig. 1).  Endoscopic ultrasound (EUS) identified a hypoechoic, homogeneous, round, vascular, well-circumscribed solid nodular lesion, measuring 10×10 mm (Fig. 2 and 3). The lesion did not communicate with the main pancreatic duct. An EUS-guided fine-needle aspiration (FNA) using a 25G needle was performed with three passes (Fig. 4).  Quiz Discussion FNA cytology showed small clusters of cells with salt-and-pepper chromatin nuclei, positive for cytokeratin AE1/AE3 and synaptophysin. The findings were compatible with pancreatic neuroendocrine tumor (pNET). Immunocytochemistry revealed a Ki67 index <1%. The patient also had an elevated serum chromogranin A (108 ng/mL). Positron emission tomography (PET 68Ga-DOTANOC) confirmed a hypermetabolic nodular lesion, without further enhancements. Considering the size and grade of the tumor, the patient was proposed for surveillance. However, considering the patient individual decision, a distal pancreatectomy with complete resection of a non-functional grade 1 pNET was performed.  Increasing numbers of pNET are being diagnosed incidentally during radiologic or endoscopic studies [1]. EUS with FNA is an effective method to provide an accurate identification of pNET, although contrast-enhanced […]

Case Report A 31-year-old asymptomatic female was referred to our department following the incidental detection on abdominal ultrasound of a 54x40mm pancreatic echogenic mass (Fig. 1).  Abdominal magnetic resonance (MRI) revealed a 54-mm lesion in the uncinated process of the pancreas, well-defined, heterogeneous, with internal septa and solid content, presenting with high signal intensity in T2-weighted images, low signal intensity in T1-weighted images and progressive enhancement; no dilation of the main pancreatic duct nor hepatic lesions were visible (Fig. 2).  Endoscopic ultrasonography (EUS) documented an exophytic heterogeneous 48-mm mass, with solid hypoechogenic component and infracentimetric cystic areas, in the uncinated process of the pancreas, adjacent to the mesenteric vessels (Fig. 3). There were no parenchymal calcifications or atrophy, nor dilation of the main pancreatic duct, and no adenopathy was visible. EUS-fine needle biopsy (FNB) was performed with a 22-gauge needle (Fig. 4) and revealed a neoplasia with a microacinar and solid architecture and well-diferentiated epithelial cells arranged around fibrovascular stalks. Quiz Discussion Patient underwent a pancreaticoduodenectomy and histopathological examination revealed a solid pseudopapillary tumor (SPT) of the pancreas (beta-catenin, CD10 and progesterone receptor positivity). SPTs of the pancreas are an uncommon entity representing 2-3% of pancreatic neoplasms, primarily affecting young females (average age 30 years)1,2. It has nonspecific clinical presentations and a considerable percentage of patients are asymptomatic1. SPT can be detected by ultrasonography, computerized tomography or MRI, typically presenting as a well-circumscribed mass consisting of solid and cystic components, mostly located in the pancreatic body and tail1,3. Most SPTs […]

Case Report A 49-year-old, caucasian, healthy man underwent an abdominal ultrasound due to nonspecific abdominal complaints, which revealed an incidental finding in the uncinate process of the pancreas of a nodular area with 26×24 mm. Physical examination was normal. Laboratorial data was unchanged, namely CA 19-9. In addition, he performed other complementary diagnostic tests. Abdominal computed tomography (CT) showed a hypodense, hypovascular focal lesion in the uncinate region of the pancreas, 28 mm in diameter, without Wirsung dilation. Magnetic resonance imaging (MRI) with cholangiography revealed a cystic image with heterogeneous content in the uncinate process, measuring 30 mm, with thickened walls, contacting the terminal portion of the pancreatic duct without dilatation (Fig. 1).  Endoscopic ultrasonography (EUS) identified in the uncinate process, a cystic lesion of 26 mm, with solid content, marked wall thickening and increased peripheral vascularization. No communication with the Wirsung duct, nor vascular invasion was detected. Fine needle aspiration (FNA) of the cyst and biopsy of the wall with micro forceps through the 19G needle were also performed (Fig. 2 and 3) (Video 1). Quiz Discussion The cytohistological description revealed monomorphic cells showing with little cohesion and with scarce, clarified or eosinophilic cytoplasm, sometimes foamy, and round to oval nuclei with indistinct nucleoli. The cells were organized in solid aggregates and in a slightly radial arrangement around fibrovascular axis (Fig. 4). The results of the immunohistochemical study were positive for vimentin (diffuse), beta-catenin (nuclear and cytoplasmic) and negative for chromogranin and estrogen receptors (Fig. 5). The pathology final report made the diagnosis […]

Case Report We present the case of a 71-year-old female patient with past medical history remarkable for a pancreatic head cystic lesion diagnosed in 2009. It was a 24mm multilocular cystic lesion with a central scar, that remained  asymptomatic and stable in size until 2015, when follow-up was lost. In 2019 the patient developed new onset jaundice, choluria and acolia. An abdominal ultrasound was performed and revealed a 47x45mm heterogeneous mass in the pancreatic head, associated with de-novo common bile duct dilatation (CBD, 17mm in the liver hilum) (Fig. 1). Figure 1. Abdominal ultrasound: heterogeneous pancreatic head mass. Magnetic resonance cholangiopancreatography (MRCP) showed a multilocular pancreatic head cystic lesion, measuring 60x70x57mm (Fig. 2) and apparently communicating with the main pancreatic duct (MPD). There was also CBD and intrahepatic bile duct dilation. Figure 2. MRCP: multilocular pancreatic head cystic lesion, apparently communicating with the MPD, and CBD and intrahepatic bile duct dilation. Endoscopic ultrasound (EUS) documented a predominantly microcystic lesion located in the head of the pancreas, measuring 53x46mm, with a few macrocysts and pseudo-solid areas, compressing the CBD and the superior mesenteric vein,  and without vascular invasion or Wirsung dilatation (Fig. 3). Fine needle aspiration (FNA) of the macrocyst and of a pseudo-solid area was performed. Cyst fluid biochemistry analysis revealed a high amilase level (54085 UI/L) and a normal CEA (2 ng/mL).Figure 3. EUS: predominantly microcystic pancreatic lesion located in the head of the pancreas, with a few macrocysts and pseudo solid areas. Quiz Discussion EUS-FNA cytology showed cuboidal cells, negative for CK8/18, […]

Case Report A 51 year-old woman with left iliac fossa discomfort underwent a colonoscopy. Her past medical history only included a breast fibroadenoma diagnosed 4 years earlier. Physical examination and laboratory testing were unremarkable. Colonoscopy revealed a 50 mm polypoid lesion, with normal overlying mucosa, occluding the lumen at 20 cm from the anal verge, compatible with a subepithelial lesion (Fig. 1).   An endoscopic ultrasound (EUS) was performed, showing a 49×32 mm hypoechoic, round, well-demarcated lesion arising from the muscularis mucosa (Fig. 2). EUS-elastography revealed a predominantly hard lesion with dispersed heterogenic soft areas (Fig. 3). A EUS-guided fine-needle aspiration was performed using a 22-gauge needle. Quiz Discussion Hystological examination showed spindle cells arranged in bundles, with dense distribution of nucleus, forming palisades in dense fibrillar stroma. Immunohistochemical stains revealed that the tumor cells were positive for S-100 and negative for CD117, CD34 and a smooth muscle actin. Cytomorphology and the immunostaining pattern were consistent with schwannoma (Fig. 4). The patient was referred to surgical resection. Schwannomas are autonomic nerve tumors arising from Schwann cells of the neural sheath (1). They comprise 2-8% of all gastrointestinal mesenchymal tumors and are typically located at the stomach. Colonic schwannomas are exceedingly rare. They are mostly diagnosed in the sixth decade, have no gender preponderance and are usually asymptomatic. Symptomatic patients usually complain of constipation, hematochezia or abdominal pain (2). Endoscopically, schwannomas appear as wide-based sessile subepithelial lesions with a rubbery or firm consistency (3). Computed tomography and magnetic resonance imaging do not provide additional information for the distinction from other mesenchymal tumors (1, 3). […]

Case Report A 75-year-old male with abdominal pain was admitted to our hospital. Physical examination revealed painful left hypochondrium with a palpable spleen. Blood tests revealed anemia (11 g/dL), normal white cell count (9710 uL) with high lymphocyte ratio (66,5%), thrombocytopenia (101000 uL), elevated  β2-microglobulin (7,82 mg/L), monoclonal hypergammaglobulinemia  (0,52 g/dL) and urinary Bence Jones λ proteinuria. The blood smear showed atypical lymphocytes and imunnophenotyping revealed B lymphocytes with restriction for superficial light  λ chains, CD45+, CD19+, CD20+, CD23-, CD5-, CD10-, CD200-, CD79b+(weak), CD43-. Abdominal ultrasound noted an enlarged spleen and a 5cm solid lesion in the gastric body. Computed tomography (CT) scan was performed and showed abdominal lymphadenopaphies, the largest with 12 mm, and the already known gastric lesion with contrast enhancement (Fig. 1). At this moment, it was important to clarify whether the gastric lesion was related to the known lymphoma or if indeed another diagnosis was present that could change clinical management. Therefore, upper gastrointestinal was performed and revealed a subepitelial lesion (Fig. 2). Further characterization of this lesion by yndoscopic ultrasound (Olympus curvilinear GF-UCT 180 ultrassound gastrovideoscope; Aloka prosound α10) confirmed a 45mm subepithelial lesion in the gastric body, within the third lawyer of the gastric wall (submucosa). The lesion appearance was heterogeneous, being predominantly anechoic, but revealing a solid component that was Doppler positive (Fig. 3).   EUS-FNA using a 22G needle was performed aiming at the solid component. Four cc of dark haematic fluid were collected and small intralesional bleeding was witnessed without clinical impact. Intravenous quinolone was administered. Multiple suspicious celiac lymph nodes were […]