Case Report The authors present the case of an 81-year-old male patient with a history of smoking and hypertension, referred for an endoscopic ultrasound (EUS) due to the appearance of obstructive jaundice. The patient previously performed abdominal CT scan that revealed a pancreatic head mass, measuring 40x40mm and multiple bone lesions in the sternum and ribs. Laboratory study revealed hyperbilirubinemia (total bilirubin 4.3 mg/dL, direct bilirubin 3.2 mg/dL) and cholestasis (alkaline phosphatase 341U/I, gamma-glutamyl transferase 641 U/I). CA 19.9 and carcinoembryonic antigen were normal. EUS revealed in the cephalopancreatic region a vaguely nodular area, heterogeneous, hypoechogenic, and with ill-defined limits and contours, with approximately 36x37mm (Figure 1). The elastography study of the lesion revealed a heterogeneous green pattern with a strain-ratio of 6.8 (Figure 2). The main pancreatic duct had a normal caliber in the body and tail, with mild ectasia in the cephalic/periampullary region. Tissue sampling was obtained through fine needle biopsy (FNB), 2 passages, using an AcquireTM 22G needle (Boston Scientific). Histopathological analysis identified an infiltration of the pancreatic parenchyma with intermediate size anaplastic cells, some of which with plasmacytoid phenotype. Immunohistologically there was positivity of CD138; proliferative activity assessed by Ki67 was 80%, and CD20 and cytokeratins were negative. Quiz Discussion The histopathological analysis was compatible with a pancreatic plasmacytoma. About 5% of plasma cell tumors form an isolated solitary lesion, called plasmacytoma.1 Extramedullary plasmacytoma is a very rare tumor derived from plasma cells and found outside the bone marrow. Only 10% of extramedullary plasmacytomas occur in the gastrointestinal tract, where […]

Case Report The authors present the case of a 73-year-old male patient with a history of smoking and chronic obstructive pulmonary disease. A thoracic CT scan was performed and revealed multiple esophageal nodules in all segments (Fig. 1). The patient was asymptomatic, with no dysphagia, thoracic or epigastric pain or weight loss. An esophagogastroscopy was performed and documented multiple bulges covered by normal mucosa, non-pulsatile, of hard consistency without pillow sign (Fig. 2). Endoscopic ultrasonography (EUS) revealed hypoechoic nodules arising from the fourth layer of the esophageal wall, the largest with 25×18 mm (Fig. 3). Fine needle biopsies (FNB) were performed (Acquire 22 G, Boston Scientific). Quiz Discussion These findings were compatible with multiple leiomyomas. Histopathological analysis revealed benign leiomyomatous cellular proliferation, positive for muscle specific actin and negative for CD117 and S100. A final diagnosis of multiple leiomyomas was made. Primary intramural benign tumors of the esophagus are responsible for 2% of all esophageal tumors [1]. Leiomyoma is the most common solid benign tumor of the esophagus, and comprises of around 70% of esophageal subepithelial lesions [2,3]. It occurs more often in male patients (2:1) at a median age of 30-35 years and rarely presents as multiple lesions, with few cases reported [1]. By EUS, leiomyomas present as well-defined hypoechoic nodules in the muscularis propria or the muscularis mucosae (fourth and second EUS layers, respectively) [4]. Histology demonstrates well-differentiated smooth muscle cells with immunohistochemical findings positive for muscle actin and negative for CD117 and S100. CD117 corresponds to c-Kit […]

Case Report A 62 years-old female patient with a personal medical history of a JAK2 mutation-negative essential thrombocythemia under hydroxyurea was referred for an endoscopic ultrasound (EUS) due to a perihepatic hypodense ovoid lesion on abdominal computed tomography. The lesion measured 20×16 mm, and was mildly enhanced in arterial phase and moderately enhanced in portal phase. Apart from a mild abdominal pain in the previous months, the patient did not report any other symptoms. She denied past abdominal trauma or surgeries. Laboratory studies were unremarkable. The EUS revealed in the periportal region, a nodular lesion with 18x14mm, isoechogenic in relation to the liver parenchyma, with distinct margins and well-demarcated from the surrounding organs (Fig. 1). No enlarged hilar lymph nodes or left liver masses were recognized. Tissue sampling was obtained through fine needle biopsy (FNB), 3 passages, using an AcquireTM 22G needle (Boston Scientific) (Fig. 2). Histopathological analysis (Fig. 3A) identified a mesenchymal tumor with spindle cells arranged in bundles and palisades with no nuclear atypia. Immunohistochemical staining (Fig. 3B) was diffusely positive for S-100 protein, and with no expression for DOG1, CD117, alpha-actin, smooth muscle actin, desmin and CD34.  Quiz Discussion The histopathological analysis was compatible with a schwannoma. A schwannoma is a tumor that arises from Schwann cells, which form the inner portion of the peripheral nerve sheath(1). Intraperitoneal schwannomas are relatively uncommon, and porta hepatic schwannomas are even rarer, with very few (<20) cases described in the literature(1). Tumors in this region can be associated to symptoms by compressing […]

Case Report We present the case of a 65-year-old male patient with past medical history significant for mixed acinar-neuroendocrine carcinoma of the pancreas diagnosed in 2010, submitted to distal pancreatectomy and adjuvant chemotherapy, and multiple myeloma since 2020 (IgG kappa, ISS stage 1), under 2nd line chemotherapy, awaiting bone marrow transplantation. Due to an abnormal pancreatic head fluorodeoxyglucose (FDG) uptake (SUVmax 8.5) documented in PET-CT (Fig. 1), MRI was performed, which showed a 27x20mm hypovascular well delimited lesion in the pancreatic head (Fig. 2).  Endoscopic ultrasound (EUS) confirmed a 27x25mm round homogeneous hypoechoic lesion, with well-defined contour, located in the pancreatic head, without upstream biliary or pancreatic duct dilation. An EUS-guided fine needle biopsy (EUS-FNB) of the lesion was performed using an Acquire 22G needle (2 passes) (Fig. 3). Quiz Discussion Pathology showed sheets of plasma cells (CK8/18-, Synaptophysin-, CD138+ and CD56+) with moderate cytologic atypia (Fig. 4), consistent with the diagnosis of extramedullary plasmocytoma involving the pancreas. The patient is now proposed for local radiotherapy of the pancreatic lesion and for 3rd line chemotherapy. Multiple myeloma (MM) is a plasma cell neoplasia and comprises 10-15% of all hematopoietic malignancies. MM may present as diffuse myelomatosis, as solitary myeloma of the bone or as an extramedullary plasmocytoma. Extramedullary plasmocytomas are uncommon, occurring in less than 5% of plasma cells neoplasms, and are usually associated with a more aggressive form of the disease. Though upper respiratory tract is the most common site for extramedullary involvement (80–90%), any tissue or organ, including the gastrointestinal tract (10%, mainly the liver), can be involved. Pancreatic involve­­­ment is extremely rare, with […]

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 71-year-old man with a 3-year history of calculous cholecystitis was referred for upper gastrointestinal endoscopy due to increasing upper abdominal pain, nausea and intermittent vomiting for the past few weeks. He had no fever and liver function tests were normal. Gastroscopy showed a large circumscribed abutment of the gastric antrum suggesting a subepithelial lesion (Fig. 1).  Endoscopic ultrasound was performed for additional characterization and documented a scleroatrophic gallbladder with stones and a large collection, extrinsic to the gastric wall – abutting the anterior wall of the gastric antrum, with anechoic content and several calcifications (with shadowing) suggestive of stones (Fig. 2). Quiz Discussion Endoscopic ultrasound favored an organized collection of bile (biloma) and MR/MRCP confirmed a perigastric 65x40x45mm collection, filled with fluid and several gallstones, contiguous to a scleroatrophic gallbladder (Fig. 3).  The patient underwent an open cholecystectomy, with marsupialization and drainage of the perigastric biloma. No intraoperative evidence of gallbladder perforation was noted and the patient had a favorable outcome.  Biloma is defined as an encapsulated collection of bile (which may also contain sludge and gallstones) outside the biliary tree. Most cases are either iatrogenic (following cholecystectomy) or traumatic. Rare cases of spontaneous biloma as a complication of acute cholecystitis, choledocholithiasis and cholangiocarcinoma have also been reported [1,2]. The proposed mechanism is raised intravesicular or intraductal pressure, caused by obstruction (from a gallstone or a tumor), leading to bile leakage [3]. We report a case of a spontaneous biloma as a complication of cholecystitis, with an insidious presentation, mimicking a subepithelial gastric […]

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 […]