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. 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 […]
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