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 […]

Case Report A 39-year-old woman presented with a two months history of epigastric pain partially relieved with proton pump inhibitors (PPI). She had no history of nausea, vomiting, diarrhoea or weight loss. She had no significant medical or family history. Physical examination was unremarkable. The workup revealed haemoglobin of 13.8 g/dL, albumin of 3.6 g/dL and fasting serum gastrin of 37.7 ng/mL. Serologic test for Helicobacter pylori (H. pylori) was positive. An upper gastrointestinal endoscopy revealed giant folds with a polypoid appearance in the greater curvature of the stomach body with sparing of the antrum (Fig. 1). Tissue specimens of altered gastric mucosa were obtained using standard biopsy forceps. Endoscopic ultrasound showed thickening of the mucosal layer of the stomach body with preservation of wall stratification. Antrum wall had normal thickness and structure (Fig. 2 and Video 1). Video 1. EUS showing an echogenic thickening of the mucosal layer wall of stomach body with sparing of the antrum. Quiz Discussion Histology revealed foveolar hyperplasia, glandular tortuosity and dilatation, mucosal oedema and decreased number of parietal cells (Fig. 3). These features are consistent with the diagnosis of Ménétrier’s Disease (MD). The patient was treated with concomitant therapy (PPI, amoxicillin, clarithromycin and metronidazole) for H. pylori eradication. She remains asymptomatic two months after the treatment and H. pylori eradication was verified with urea breath test. Additional invasive procedures were deferred because she became pregnant. MD is a rare, idiopathic hypertrophic gastropathy characterized by giant rugal folds in the gastric body, foveolar hyperplasia and markedly decreased or absent oxyntic glands with antral sparing [1]. The pathogenesis is related to […]

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 […]