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 […]

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, […]