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 […]

Case Report A 57-year-old asymptomatic male, with a medical history of nephrectomy due to renal cell carcinoma, was referred to our Gastroenterology Department following incidental detection on annual follow-up computed tomography (CT) of a gastric mass measuring 35mm x 28mm, located on the posterior wall of the transition body-antrum. The lesion was well demarcated and round shaped, with central calcification, dense enhancement and a small area of central necrosis (Fig. 1). There was no evidence of local recurrence of the renal cell carcinoma, metastatic disease, adenopathy, ascites or peritoneal implants. Endoscopic ultrasonography (EUS) documented a subepithelial lesion on the posterior wall of the stomach, body-antrum transition, measuring 36mm x 29m, heterogeneously hypoechoic, hypervascular, with irregular but well-defined limits and central calcification, arising from the 4th layer, without invasion of adjacent layers (Fig. 2 and 3). EUS-FNA using a 22-gauge needle was performed. Quiz Discussion The EUS-FNA specimen revealed some smooth muscular cells and a proliferation of uniform cells with a rounded and regular shape, round nucleus, clear cytoplasm and a high nucleus-cytoplasm ratio and perivascular distribution. The cells did not have nuclear atypia or mitotic activity. Immunohistochemical staining was positive for smooth muscle actin, type IV collagen and cytokeratin AE1/AE3. The pathologic diagnosis of gastric glomus tumour was made. After multidisciplinary decision, the tumour was completely removed through a submucosal wedge gastric resection. The patient did not receive any adjuvant therapy because the tumour did not show signs of malignancy. Two years after surgery, the patient remains asymptomatic and disease free. Glomus tumour is a rare mesenchymal neoplasm originating […]

Case Report A 47-year old female patient with previous history of psoriatic arthritis, medicated with etanercept, was referred to our Gastroenterology Department due to episodic dysphagia to solids. The patient had already performed a computed tomography (CT) scan, which revealed a 3.5cm subcarinal nodular lesion, well circumscribed, hypodense with cystic areas, and without contrast enhancement.  For better characterization, a magnetic resonance imaging (MRI) was done and confirmed the subcarinal nodular lesion, with the same dimensions, well delimited, T1 isointense and T2 heterogeneous hyperintense, and with heterogeneous contrast enhancement (Fig. 1). Therefore, an endoscopic ultrasonography (EUS) was performed and documented, between 24 and 28 cm from the incisors, a hypoechoic and heterogeneous well delimited lesion in the esophageal wall, arising from the fourth layer (muscular propria), without invasion of the adjacent structures (Fig 2). A fine needle aspiration was made (3 passes with a 19G needle). Quiz Discussion Cytological examination revealed aspects compatible with a benign nerve sheath tumor/schwannoma. Immunohistochemical staining was positive for S-100 and negative for desmin and α-smooth muscle actin. Benign primary tumors of the esophagus are uncommon (2% of all esophageal tumors) [1]. The most common is leiomyoma [2]. Scwannoma of the esophagus is extremely rare with few cases reported in the literature [3]. The most common symptom of this condition is mild to moderate dysphagia, but dyspnea and chest pain can also occur depending on the tumor size. Actually many patients are asymptomatic and are incidentally found to have a benign esophageal tumor [2]. The diagnosis […]

Case Report We present a case of a 52-year-old patient with acromegaly and pituitary macroadenoma, previously resected and treated with adjuvant radiotherapy due to remnant adenoma, referred to our unit due to a large multiloculated cystic lesion of the pancreatic tail diagnosed during follow-up imaging. The patient was asymptomatic and had no previous medical history of abdominal complaints. Abdominal MRI reported several giant hepatic hemangiomas and a pancreatic tail multiloculated cyst, with 80 x 58 mm, with thick septa but no mural nodules (Fig. 1). Tumor markers were within normal range. EUS was performed and a large macrocystic lesion was identified in the pancreatic tail, mostly with anechoic content, with 64 x 50mm and without wall thickness or mural nodules. Pancreatic duct was within the expected diameter and apparently showed no communication with the lesion (Fig. 2). An EUS-FNA with a 19-gauge needle was performed and a chylous-like cystic fluid was obtained (negative string sign) (Fig. 3).   Quiz Discussion Biochemical evaluation of the cyst liquid revealed amylase and CEA within the normal range and a high triglycerides count – 1028 mg/dl. Cytology was suggestive of non-mucinous pancreatic cyst. The diagnosis of pancreatic lymphangioma was then made. This case was presented at the tumor board with no indication for surgery.  Lymphangiomas are rare benign, slow-growing cystic lesions, with a female predominance. Less than 1% of lymphangiomas are found as pancreatic lesions and less than 100 cases are reported to date. Most lesions are asymptomatic, with no clear predominance in their location, […]

Case Report A 50-year-old female patient without relevant past medical history was admitted in the emergency department for persisting vomiting and epigastric pain. Laboratory examinations revealed mild leukocytosis (white blood cells 13330 u/L) and hypokalemia (3.21mmol/L). An abdominal computed tomography was performed showing marked dilation of the stomach (Figure 1) related to a ill-defined hypoechogenic mass with 44mm in the transition between the second and third portion of the duodenum (Figure 2).  Upper endoscopy was performed showing a stenosis in the transition between D2 and D3, not transposable with the endoscope with edema of the mucosa, consistent with extrinsic compression (Figure 3).  She was admitted with nasogastric tube placement and parenteral nutrition. Endoscopic ultrasound (EUS) was performed using a linear endoscope showing a hypoechogenic heterogeneous lesion with 37x30mm in relation to the fourth layer of the duodenal wall (Figure 4). The lesion was only observed by EUS in the bulb since it was not possible to transpose the stenosis.  An EUS-guided fine needle aspiration (FNA) was performed with a 22 Gauge needle in 3 passages (Figure 5).  Quiz Discussion Cytological exam was compatible with adenocarcinoma and the patient was submitted to a gastroduodenopancreatectomy. Pathologic examination showed an adenosquamous carcinoma of the ampulla of Vater with invasion of the pancreatic parenchyma, the duodenal wall, from the mucosa to the subserosa and lymphovascular and perineural invasion.  The margins were free of lesion. The final diagnosis was adenosquamous carcinoma of the ampulla de Vater pT3b N1 LV1 Pn1 R0 and the patient was proposed […]

Case Report A 55-year-old female, smoker, with a history of hypertension was admitted to the emergency department with an oedematous acute pancreatitis. She improved after conservative treatment but maintained symptoms of epigastric pain aggravated by food ingestion and vomiting. An upper endoscopy revealed gastric erythema and biopsies were compatible with a chronic gastritis. On abdominal ultrasound no hepato-biliary-pancreatic lesions were found. Despite medication with proton pump inhibitor, pancreatine and alcohol/tobacco abstinence, she kept complaints of epigastalgia, nausea and a loss of 5 Kg.  Additional workup with magnetic resonance imaging (MRI) showed a nodular wall thickening of the second portion of the duodenum, having contrast enhancement, with 15x17x14mm (LxTxPA) – Fig 1. CEA and Ca 19.9 were normal. Figure 1. MRI showing nodular wall thickening of D2 An endoscopic ultrasound (EUS) was performed and showed areas of duodenal wall thickening in D2 and D3, with infracentimetric hypoechoic foci. The pancreatic parenchyma was heterogenous in the pancreatic head and uncinate process, with hyperechoic striae (honeycomb pattern) and hypoechoic lobulations; pancreatic duct was normal. Figures 2 and 3. EUS showing hypoechoic thickening of the D2 and D3 wall and a hypoechoic foci Quiz Discussion A diagnosis of paraduodenal pancreatitis (PP) was assumed and the patient was started on octreotide.  Paraduodenal pancreatitis has been defined as a distinct subset of chronic pancreatitis involving the duodenal wall in the region of the minor papilla. (1,2) Patients are predominantly males, with 40-50 years old and a history of alcohol abuse and heavy smoking. (1,2,3) The pathogenesis of […]

Case Report A 19-year-old female patient, with no past medical or surgical history, and no family background of cancer, was referred to our hospital due to an asymptomatic lesion in the pancreatic tail, which was identified by abdominal ultrasonography performed to investigate a mild elevation of alanine transaminase in routine lab tests. The subsequent computed tomography (CT) scan showed a mixed solid and cystic heterogeneous round lesion of 36×31 mm in the posterior region of the tail of the pancreas, touching the left adrenal gland. There was no pancreatic parenchymal atrophy or dilatation of the main pancreatic duct. No ascites or metastases were observed. These findings were confirmed by magnetic resonance imaging (MRI) (Fig. 1). Figure 1. Magnetic resonance imaging (MRI) characteristics of the lesion: The lesion was heterogeneous and had higher signal intensity on T2-weighted images, low signal intensity on T1-weighted images, restrictive diffusion and mild rim enhancement. Blood tests, including CA 19-9 and CEA, were normal. The comprehensive endoscopic ultrasonography (EUS) displayed a well-demarcated heterogeneous mass with several small cystic areas, hypovascular, located in the pancreatic tail and with preserved cleavage plane with the left adrenal gland (Fig. 2). The remaining pancreas was normal. Besides a gallstone, the EUS did not reveal additional changes. EUS-guided sampling was not performed. Figure 2. Endoscopic ultrasonography (EUS) appearance of the lesion: The sonographic images demonstrate a well-demarcated isoechoic/hypoechoic, solid-appearing, heterogenous mass with small anechoic, irregularly shaped lakes of fluid, located in the pancreatic tail. The lesion was hypovascular and maintained cleavage plan […]

Case Report A 70-year old female without significant past medical history was referred to our Gastroenterology Department due to abdominal pain and a big heterogeneous mass of the pancreatic body and tail found on an abdominal ultrasound (Fig. 1). Figure 1. Abdominal ultrasound: heterogeneous pancreatic mass. An abdominal computed tomography (CT) (Fig. 2) was performed and revealed, in the pancreatic body, a vascularized andheterogeneous mass with 66mm. Vascular locoregional structures and posterior gastric wall were slightly deformed bymass effect, however no signs of organ/vessels invasion were detected. Splenomegaly and loco-regional, retro-peritoneal and retro-crural ganglionic clusters were also described. Figure 2. Abdominal CT: vascularized andheterogeneous pancreatic mass. Therefore, an endoscopic ultrasonography (EUS) was performed and documented, in the pancreatic body, a roundand well delimited large mass (> 6 cm), with markedly microcystic and hypervascularized echotexture (Fig .3A). Multiple large adenopathies with heterogeneous echotexture and marked adjacent vascularization, located in various ganglion chains (including the hepatic pedicle) were identified (Fig. 3B). Cervical adenopathies and large retro-cardiac and sub-carinal adenopathic conglomerates were also visualized. A diffusely enlarged spleen was also described. Figure 3A. EUS: large pancreatic mass (> 6 cm), with markedly microcystic echotexture. Figure 3B. EUS: Multiple large adenopathies.   Quiz Discussion The pancreatic mass in EUS had the usual aspect of serous cystadenoma (SCA). Besides that, for better characterization of the pancreatic lesion, an abdominal magnetic resonance (MR) was performed and also found documented a multiloculated cystic mass, showing no areas of diffusion restriction, suggestive of serous pancreatic cystadenoma (Fig. 4). Figure 4. Abdominal MR: serous […]

Case Report A 50-year-old female patient without significant past medical history, presented with isolated GGT elevation (135U/L) and weigh loss (3Kg) in the past 6 months. Abdominal and pelvic MRI revealed a well-defined, round, hypervascular solid lesion, with 10mm, located in the pancreatic tail (Fig. 1). She was then referred to our clinical center. Figure 1. Abdominal and pelvic MRI – T2 (axial view):  10mm, well-defined, round, hypervascular solid lesion, located in the pancreatic tail. A 99mTc-sulfur colloid scintigraphy was done and did not show any uptake in the location of the lesion previously described (Fig. 2). Figure 2. 99mTc-sulfur colloid scintigraphy: no uptake in the location of the pancreatic lesion previously described. An EUS was therefore performed and a 12x7mm hypoechoic lesion was identified in the pancreatic tail. It was a round-shaped, well-defined, homogeneous intrapancreatic mass (Fig. 3). The lesion characterization was complemented by EUS-elastography, which displayed a homogeneous green elastographic pattern (Fig. 4). The remaining pancreas was unremarkable. EUS-FNB (Acquire – Boston Scientific; 25G, 1 pass) was performed. Figure 3. EUS (transgastric view): 12x7mm round-shaped, well-defined, hypoechoic, homogeneous lesion in the pancreatic tail. Figure 4. EUS – elastography (transgastric view): pancreatic solid lesion, with homogeneous green elastographic pattern.   Quiz   Discussion Cytoblock showed groups of CKAE1-AE3 negative and CD45 positive cells, supporting the diagnosis of an intrapancreatic accessory spleen (Fig. 5). Figure 5. Pathology – cytoblock (H&E; CKAE1-AE3; CD45): groups of CKAE1-AE3 negative and CD45 positive cells.   Accessory spleen is a common benign congenital anomaly, with an […]