Case Report A 44-year-old female patient presented in the last 8 months with non-productive cough and occasional right chest pain that worsened with lateral decubitus. Her past medical history was remarkable for uterine leiomyosarcoma that underwent surgery, chemotherapy and radiotherapy 8 years ago. She reported occupational exposure to acrylic compounds for 20 years and active smoking (about 2 pack-year for 4 years). Thoraco-abdomino-pelvic CT revealed a large atypical lesion (82x68x46mm) in the left pulmonary lower lobe, central topography, with invasion of the posterior mediastinal fat and no cleavage plane with the esophagus, and small homolateral pulmonary hilar adenopathies. It was considered more likely to be a primary pulmonary lesion (Fig. 1).  Subsequent bronchoscopy identified a bulging of the posterior segmental bronchus wall of the left lower lobar bronchus with normal-looking mucosa. Transbronchial needle aspiration, distal biopsies and bronchial brushing were performed but histopathological results were not conclusive. The EUS evaluation identified, in topography concordant with station 8 of the mediastinum to the left of the aorta, a hypoechoic and heterogeneous lesion with well-defined limits measuring 40x44mm, without calcifications or vascular invasion, with loss of interface with the esophageal wall. Fine needle biopsy (FNB) using a 22G needle was performed (3 passes; 22G Acquire, Boston Scientific) obtaining material that was sent for histocytologic evaluation, nucleic acid amplification test for M. tuberculosis and microbiological examination (Fig. 2).  Quiz Discussion Histocytological analysis identified a neoplasm composed of spindle cells with moderate to severe pleomorphism and hyperchromatic nuclei arranged in a fascicular pattern. The neoplastic cells were positive […]

Case Report A 65-year old female was referred to our Gastroenterology Department due to  persistent upper abdominal pain and significant weight loss (20Kg) over the previous year. CT revealed a large retroperitoneal hypodense mass, in contiguity with the pancreatic body and tail, with encasement of the celiac trunk and superior mesenteric artery. Endoscopic ultrasonography (EUS) documented an extensive retroperitoneal hypoechoic lesion encasing the aorta, celiac trunk, common hepatic artery (Figure 1) and superior mesenteric artery (Figure 2), without vascular invasion (hyperechoic vascular wall interface was preserved), causing minimal compression of the pancreas. Figure 1. Endoscopic ultrasonography (transduodenal view): retroperitoneal hypoechoic lesion encasing the common hepatic artery, causing minimal compression of the pancreas. Figure 2. Endoscopic ultrasonography (transgastric view): retroperitoneal hypoechoic lesion encasing the superior mesenteric artery (AMS), without vascular invasion (hyperechoic vascular wall interface was preserved). Transgastric EUS-guided FNB (22G, Acquire, Boston Scientific) of the retroperitoneal mass was performed, coursing anterior to the aorta between the celiac trunk and the superior mesenteric artery (Figure 3). Figure 3. Transgastric EUS-guided FNB (22G, Acquire, Boston Scientific) of the retroperitoneal mass.   Quiz   Discussion Biopsy revealed spindle-shaped tumor cells and clusters of ganglion cells, with an eccentric large round vesicular nucleus and prominent macro nucleoli, consistent with ganglioneuroma (Figure 4). Figure 4. Cytology (Magnification: 400x; scale bar corresponds to 50 µm): Spindle-shaped tumor cells and clusters of ganglion cells, with an eccentric large round vesicular nucleus and prominent macro nucleoli (arrows). The retroperitoneum can host a wide spectrum of pathologies, including a […]

Case Report A 31-year-old Indian patient, living in Europe for the last 7 years, was admitted in the emergency department for jaundice, epigastric and right upper quadrant abdominal pain for the last 3 days, loss of 4.5Kg in the previous month, without fever or other remarkable symptoms. Physical examination showed tenderness on the right upper quadrant and icteric sclera. Laboratory studies revealed normal blood cell counts and C-reactive protein levels (3.5 mg/L), elevated total serum bilirubin levels (5.9 mg/dL), mainly due to direct bilirubin (4.4mg/dL), AST of 107U/L, ALT of 132 U/L, ALP of 354 U/L and GGT of 152 U/L.  Computed tomography (CT) showed a hypodense, multiloculated lesion with cystic areas and calcifications, measuring 7×4.5x7cm, in the pancreatic head, isthmus and body, involving the portal vein and extending to the hepatic hilum, including the main bile duct, without significant upstream dilation (Fig. 1 and 2). Endoscopic ultrasound (EUS) revealed a hypoechoic retroperitoneal heterogenous lesion, >58mm, with dispersed calcifications, involving the portal vein and distal portion of the bile duct. The lesion contacted the head, isthmus and corpus of the pancreas; the remaining parenchyma and main pancreatic duct appeared normal (Fig. 3 and 4). Fine needle biopsy (22G Cook® ProCore®) was performed with core tissue acquisition. Quiz Discussion Citologic analysis revealed several epithelioid granulomas with caseous necrosis and the presence of giant Langhans cells. Acid-alcohol-resistant bacilli were detected and nucleic acid amplification test positive for Micobacterium tuberculosis complex. The patient was started on tuberculostatic treatment. Thoracic CT did not show typical signs […]

Assistimos nos últimos 5 anos a importantes progressos na área da endoscopia de intervenção na patologia bilio-pancreática, com a disponibilização de novos acessórios e com a publicação de um número crescente de estudos a avaliar a aplicabilidade clínica de diferentes terapêuticas em ecoendoscopia. O GRUPUGE considerou pertinente sistematizar o estado da arte, privilegiando a publicação de recomendações no formato de “perspectiva do GRUPUGE” sobre 5 temas em patologia bilio-pancreática, em que a ecoendoscopia tem assumido um papel crescente na abordagem terapêutica. 1. Endoscopic Ultrasound-Guided Drainage of Peripancreatic Collections 2. Endoscopic Ultrasound-Guided Biliary Drainage 3. Endoscopic Ultrasound-Guided Celiac Plexus Interventions 4. Endoscopic Ultrasound-Guided Ablation of Focal Pancreatic Lesions 5. Endoscopic Ultrasound-Guided Fine-Needle Tattooing and Fiducial Placement in Pancreatic Cancer

Case Report A 65-year old asymptomatic male was referred to our Gastroenterology Department following incidental detection on abdominal ultrasound of a pancreatic head tumour, strongly hypoechoic, with 35mm in diameter, just above the confluence of the superior mesenteric and splenic veins. Magnetic resonance cholangiography (MRI) suggested a solid lesion measuring 30mm adjacent to the splenic-mesenteric-portal venous confluence and above the pancreatic isthmus; an identic lesion measuring 16mm was detected adjacent to the pancreatic tail (Fig. 1. and 2.). Endoscopic ultrasonography (EUS) documented an anechoic structure with thin well-defined walls adjacent to the portal confluent and continuing with the splenic vein, 30mm in diameter, with positive colour Doppler and monophasic waveform in pulse wave Doppler study; this lesion was adjacent to the pancreas but with a clear interface with it (Fig. 3.). Adjacent to the pancreatic tail another lesion was identified, mildly hypoechoic, homogenous, well defined regular walls, 14mm in diameter, again with a clear interface with the pancreas and the spleen (Fig 4.).  Quiz Discussion A wide range of anatomic variants and pathologic conditions in and around the pancreas may simulate primary pancreatic neoplasia at different imaging modalities. Based on EUS appearance of the lesion and its relation to the splenic vein, the diagnosis of splenic vein aneurysm was easily made. The smaller lesion had very different US characteristics suggesting an accessory spleen, due to its location and US features (namely similar echostructure to the adjacent spleen). Venous system aneurysms are uncommon and splenic vein aneurysms are exceedingly rare. Lowenthal and Jacob described the first case of splenic vein aneurysm in […]

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, […]