Role of endoscopic ultrasonography in evaluation of metastatic lesions to the pancreas: a tertiary cancer center experience

Comments on and Illustrations of the EFSUMB CEUS Guidelines: Transabdominal and Endoscopic Ultrasound Features of Intrapancreatic Metastases and the Role of Multiparametric Imaging and EUS-Guided Sampling in Rare Pancreatic Tumors

A definite pathologic diagnosis of intrapancreatic metastasis is crucial for the management decision, i.e., curative or palliative surgery versus chemotherapy or conservative/palliative therapy. This review focuses on the appearance of intrapancreatic metastases on native and contrast-enhanced transabdominal ultrasound and endoscopic ultrasound. Differences and similarities in relation to the primary tumor, and the differential diagnosis from pancreatic carcinoma and neuroendocrine neoplasms are described. The frequency of intrapancreatic metastases in autopsy studies and surgical resection studies will be discussed. Further emphasis is placed on endoscopic ultrasound-guided sampling to confirm the diagnosis.

Secondary Tumors of the Pancreas: A Multicenter Analysis of Clinicopathological and Endosonographic Features

Many tumors may secondarily involve the pancreas; however, only retrospective autopic and surgical series are available. We retrospectively collected data from all consecutive patients with histologically confirmed secondary tumors of the pancreas referred to five Italian centers between 2010 and 2021. We described clinical and pathological features, therapeutic approach and treatment outcomes. EUS characteristics of the lesions and the tissue acquisition procedures (needle, passages, histology) were recorded. A total of 116 patients (males/females 69/47; mean age 66.7) with 236 histologically confirmed pancreatic metastases were included; kidney was the most common primary site. EUS was performed to confirm the diagnosis in 205 lesions which presented as predominantly solitary (59), hypoechoic (95) and hypervascular (60), with a heterogeneous (n = 54) pattern and well-defined borders (n = 52). EUS-guided tissue acquisition was performed in 94 patients with an overall accuracy of 97.9%. Histological evaluation was possible in 88.3% of patients, obtaining final diagnosis in all cases. When cytology alone was performed, the final diagnosis was obtained in 83.3% of cases. A total of 67 patients underwent chemo/radiation therapy, and surgery was attempted in 45 (38.8%) patients. Pancreatic metastases are a possible event in the natural history of solid tumors, even long after the diagnosis of the primary site. EUS-guided fine needle biopsy may be suggested to implement the differential diagnosis.

The Utility of Endoscopic-Ultrasonography-Guided Tissue Acquisition for Solid Pancreatic Lesions

Endoscopic-ultrasonography-guided tissue acquisition (EUS-TA) has been widely performed for the definitive diagnosis of solid pancreatic lesions (SPLs). As the puncture needles, puncture techniques, and sample processing methods have improved, EUS-TA has shown higher diagnostic yields and safety. Recently, several therapeutic target genomic biomarkers have been clarified in pancreatic ductal carcinoma (PDAC). Although only a small proportion of patients with PDAC can benefit from precision medicine based on gene mutations at present, precision medicine will also be further developed for SPLs as more therapeutic target genomic biomarkers are identified. Advances in next-generation sequencing (NGS) techniques enable the examination of multiple genetic mutations in limited tissue samples. EUS-TA is also useful for NGS and will play a more important role in determining treatment strategies. In this review, we describe the utility of EUS-TA for SPLs.

Metastatic tumors to the pancreas: Balancing clinical impression with cytology findings

Backgrounds/Aims

Metastatic lesions of the pancreas (PMET) account for 1%–5% of all malignant solid pancreatic lesions (SPL). In this study we evaluated the utility of endoscopic ultrasonography with fine needle aspiration (EUS-FNA) in diagnosing PMET.

Methods

Patients who underwent EUS-FNA at a community referral center between 2011–2017 for SPL were identified. Clinical, radiologic, and EUS-FNA features of those with PMET were compared to those with primary solid tumors of the pancreas: pancreatic adenocarcinoma (PDAC) and neuroendocrine tumors (PNET).

Results

A total of 191 patients were diagnosed with solid pancreatic malignancy using EUS-FNA: 156 PDAC, 27 PNET, and eight (4.2%) had PMET. Patients with PMET were less likely to have abdominal pain (25.0% vs. 76.3% vs. 48.2%; p < 0.01) or obstructive jaundice (37.5% vs. 58.3% vs. 0%; p < 0.01) compared to PDAC and PNET. Those with PMET were more likely to have mass lesions with/without biliary or pancreatic ductal dilatations (100% vs. 86.5% vs. 85.2%; p < 0.01) and lower CA19-9 (82.5 ± 43.21 U/mL vs. 4,639.30 ± 11,489.68 U/mL vs. 10.50 ± 10.89 U/mL; p < 0.01) compared to PDAC and PNET. Endosonographic features were similar among all groups. Seven (87.5%) patients with PMET had a personal history of malignancy prior to PMET diagnosis. The primary malignancy was renal cell carcinoma in five PMET.

Conclusions

PMET are exceedingly rare, comprising less than 5% of SLP. Patients with PMET are less likely to present with symptoms and mostly identified by surveillance imaging for the primary malignancy.

A case of hypervascular tumors in the liver and pancreas: synchronous hepatocellular carcinoma and pancreatic metastasis from renal cell carcinoma 36 years after nephrectomy

It is sometimes difficult to distinguish between multiple cancers and metastases using only diagnostic imaging, particularly when multiple hypervascular tumors are found in multiple organs. We present a case in which the preoperative histological evaluation was essential to determine the management of a hypervascular pancreatic tumor and liver tumor.

Solid Tumor Metastases to the Pancreas Diagnosed Using Fine-Needle Aspiration

OBJECTIVES

Solid tumor metastases to the pancreas are rare, and only limited literature on the topic is available. In this retrospective study, we reviewed 107 cases of solid tumor metastases to the pancreas diagnosed by fine-needle aspiration (FNA) from 2005 to 2019.

METHODS

Information including the patients' clinical histories, radiologic and pathologic findings, treatments, and follow-up were collected.

RESULTS

The mean age of the patients was 62.4 years. The mean tumor size was 2.64 cm with even distribution throughout the pancreas (head, neck and body, and tail). The most common primary site was the kidney, followed by the lung, skin, and breast and the gynecologic, gastrointestinal, and genitourinary tracts. The most common tumor type was carcinoma, followed by melanoma and sarcoma. In comparison to patients with nonkidney primary cancers, those with primary renal cell carcinoma had a longer median interval between primary diagnosis and metastasis (8.5 vs 4.0 years; P < .01), less often had metastasis outside the pancreas (38% vs 74%; P < .01), and had a significantly longer 5-year survival rate (65.7% vs 24.8%; P < .01).

CONCLUSIONS

FNA plays a crucial role in diagnosing metastases to the pancreas. Metastases originating from kidney and nonkidney primary tumors have distinct clinicopathologic features and prognoses.

EUS-FNA Diagnosis with Core Biopsy of Pancreatic Metastases from Primary Breast Cancer

BACKGROUND

The pancreas as a site of metastasis of other primary tumors is a rare event. Pancreatic metastases may occur years after the start of treatment of a neoplasm of another organ or may be the initial manifestation of an unidentified primary tumor. The most commonly reported primary sites for pancreatic metastases are the kidneys, lungs, breast, bowel, and skin (melanoma). Case Summary. The authors report a case of pancreatic metastasis derived from a primary breast cancer that underwent endoscopic ultrasound fine-needle aspiration (EUS-FNA) core biopsy to obtain tissue, which made it possible to perform an immunohistochemical study.

CONCLUSION

We emphasize the importance of outpatient follow-up after the treatment of a neoplasia and the completion of control exams. In addition, we should always be aware of the finding of a secondary lesion in patients who have already been diagnosed with cancer, even if it is located in unusual organs, as in this case, where two metastases of a breast carcinoma to the pancreas were detected.

Diagnosis and Treatment of Metastatic Disease to the Pancreas

Introduction: Metastatic disease to the pancreas is a rare entity from all malignant pancreatic masses. Its diagnosis is very challenging, but with the introduction of endoscopic ultrasound (EUS)-fine needle aspiration (FNA), now there is a feasible way to make an accurate histopathological and definitive diagnosis. Materials and Methods: This is a retrospective review of 11 patients with metastasis to the pancreas diagnosed with EUS-FNA in a tertiary referral center over a period of 3 years. We describe our institutional experience in diagnosing metastatic disease to the pancreas through EUS-FNA. Results: Between January 2015 and June 2018, 115 patients were diagnosed with pancreatic malignancy by EUS-FNA and only 11 (10%) with metastatic disease to the pancreas. Most common primary malignancy was renal cell carcinoma, followed by colon carcinoma, squamous/small cell carcinoma of the lung, and urothelial carcinoma. Five of 11 patients presented as a solitary pancreatic mass on initial imaging without any evidence of primary or metastatic disease elsewhere. Conclusions: In our experience, metastatic disease to the pancreas can represent up to 10% of solid pancreatic masses, which is lower compared to the reported incidence in previous literature. Our findings reveal that early identification and diagnosis help patient management and limit surgical morbidity and mortality.

Solitary Colorectal Cancer Metastasis to the Pancreas

Introduction

Secondary pancreatic metastasis from other solid organ malignancy is rare and accounts for less than 2% of all pancreatic tumors. The aim of this study is to highlight that colorectal metastatic disease in the pancreas could be in selected cases an indication for surgery rather than for palliative chemotherapy.

Case Presentation

We present a case of a 62-year-old Caucasian female with a history of rectal adenocarcinoma. Four years ago, the patient underwent low anterior resection of the rectosigmoid, post neoadjuvant chemoradiotherapy, with adjuvant chemotherapy. During her follow-up, imaging examinations revealed a lesion in the pancreatic neck with features indicating primary pancreatic cancer. Near-total distal pancreatectomy with en bloc splenectomy was performed. Histopathology revealed metastatic disease compatible with colorectal adenocarcinoma as the primary cancer. Second-line chemotherapy was decided from the institutional tumor board. The patient remains disease free one year later.

Conclusion

Pancreatic lesions in patients with a history of extrapancreatic malignancy should raise suspicions of metastatic disease. Surgical intervention is a legitimate treatment option for these pancreatic lesions, since they represent solitary disease deposits and of course in the context of multidisciplinary meeting decisions, and after proper and extensive staging investigations.

Evaluation of metastases to the pancreas with fine needle aspiration: A case series from a single centre with review of the literature

OBJECTIVE

Fine needle aspiration (FNA) is a minimally invasive albeit highly effective modality used to detect solid and cystic pancreatic lesions. This manuscript aims to present our experience in diagnosing metastases to the pancreas and highlight the importance of immunocytochemistry in the diagnostic process. It also aims to provide a brief review of the literature on this topic.

METHODS

We retrospectively searched our archives for cases of metastatic deposits to the pancreas diagnosed with FNA over a 5-year period. We also reviewed the literature for such cases.

RESULTS

We describe seven cases from our archives that metastasised to the pancreas. Three of them (43%) represented metastatic renal cell carcinoma while the rest four comprised deposits from a lung adenocarcinoma, a colon adenocarcinoma, an adrenal leiomyosarcoma, and a small cell carcinoma of the urinary bladder, respectively. History of primary malignancy was available for all seven patients. All diagnoses were confirmed with the use of immunostains. In our literature review, similar to our case series, renal cell carcinoma was the most common metastasis to the pancreas managed with FNA (around one out of three patients; 35%). Of interest, our endoscopic ultrasound-FNA case of pancreatic metastasis from urinary bladder small cell carcinoma is the first reported.

CONCLUSIONS

As metastases to the pancreas are commonly accompanied by diverse prognostic signatures and management strategies compared to primary pancreatic malignancies, their accurate identification is imperative. Pancreatic FNA is a diagnostic modality that can confirm or exclude metastasis to the organ, especially when immunocytochemistry is applied.

Papillary thyroid carcinoma metastatic to the pancreas: Case report

Papillary thyroid carcinoma (PTC) is generally associated with an excellent long-term outcome. Distant metastasis is rare with only 5-7% of patients developing distant disease. Metastasis of PTC to the pancreas is an exceedingly rare occurrence. To date, few cases have been reported. We present the case of an 81-year-old man with past medical history of PTC status post total thyroidectomy with local recurrence treated with radioactive iodine and selective neck dissection. Ten years after his initial diagnosis, PET-CT scan revealed a new hypermetabolic 1.1 cm × 0.9 cm left lower lobe lung nodule and hypermetabolism in the proximal body of the pancreas. Follow-up MRI cholangiogram showed a 1.0 × 0.8 cm T1 hypointense lesion in the proximal body of the pancreas. Endoscopic ultrasound-guided fine-needle aspiration biopsy of the pancreatic mass showed neoplastic epithelial cells arranged in papillary clusters with fibrovascular cores and syncytial sheets with high nuclear to cytoplasmic ratio, visible nucleoli, nuclear pallor, focal nuclear grooves, and rare intranuclear pseudoinclusions. Immunohistochemical stains performed on the smears showed positive nuclear expression of TTF-1 and PAX-8. The findings were consistent with metastatic PTC. Surgical resection of the lung nodule confirmed metastatic PTC. Pancreatic metastases usually occur after long time intervals with reports of up to 8 years in PTC. This makes the diagnosis more challenging, and metastatic disease should always be in the differential diagnosis in cases presenting with a pancreatic mass, especially in patients with a prior malignancy.

Endoscopic ultrasound-guided fine-needle aspiration diagnosis of secondary tumors involving pancreas: an institution's experience

INTRODUCTION

Metastases that present as pancreatic masses are rare. Understanding and recognizing this uncommon occurrence during endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) will help in making an accurate diagnosis and planning for clinical management. In this study, we reviewed our experience in diagnosing pancreatic secondary tumors.

MATERIALS AND METHODS

A pathology archive database search was performed for EUS-FNAs of the pancreas with a diagnosis of metastatic tumor at our institution. The corresponding clinical presentations, imaging studies, cytological diagnoses, ancillary studies, and surgical follow-up were collected.

RESULTS

A total of 30 cases were identified with 18 male and 12 female patients. Twenty-eight patients (93.3%) had a prior history of malignancy, with a latency ranging from 0 to 36 years. The secondary tumors included carcinoma (18 of 30), neuroendocrine tumor (5 of 30), melanoma (4 of 30), and sarcoma (3 of 30). The most common metastatic tumor was clear cell renal cell carcinoma (37%, 11 of 30). Correct diagnoses were rendered in 28 cases (93.3%). The remaining 2 cases failed to be accurately diagnosed: one pleomorphic carcinoma (reported as pleomorphic sarcoma) and one liposarcoma (reported as poorly differentiated malignant neoplasm). Both cases did not have immunohistochemistry performed because of a lack of diagnostic materials in cell blocks.

CONCLUSIONS

Our data demonstrated that metastatic clear cell renal cell carcinoma was the most common secondary tumor involving the pancreas. Secondary tumors involving the pancreas can be accurately diagnosed by EUS-FNA. Knowing the prior history of malignancy, recognizing uncommon cytomorphologic features, and performing ancillary studies are keys to improve diagnostic accuracy.

Metastatic neoplasms to the pancreas diagnosed by fine-needle aspiration/biopsy cytology: A 15-year retrospective analysis

BACKGROUND

Metastatic tumors to the pancreas are rarely encountered and diagnostically challenging. We aspired to determine the incidence and origin of all metastases to the pancreas at our institution, and to examine their clinicopathologic and cytomorphologic features. We also sought to ascertain the effect of endoscopic ultrasound (EUS) guidance implementation.

METHODS

A search of our database was undertaken to review all pancreatic FNA and/or CNB examined from January 2000 through December 2014.

RESULTS

During our 15-year study, 636 patients underwent pancreatic FNA/CNB, including 252 (40%) computerized tomography (CT) and 384 (60%) EUS-guided biopsies. Malignancy was diagnosed in 221 (35%). Only 16 had metastases to the pancreas, comprising 2.5% of pancreatic biopsies and 7.2% of malignancies. Three (18.8%) presented with their first manifestation of cancer. EUS guidance was utilized in 50%, with rapid on-site evaluation (ROSE) employed in 14 (88%). The most common primary site was lung (6,38%), followed by 3 (19%) each of renal and gastrointestinal malignancies. The remaining included malignant melanoma, Merkel and gallbladder small cell carcinomas, and olfactory neuroblastoma.

CONCLUSION

Cytologic diagnosis of metastasis to the pancreas is rare in our institution, comprising only 2.5% and 7.2% of total and malignant pancreatic FNA/CNB, respectively. FNA/CNB with ROSE proved to be an effective diagnostic modality, thereby obviating the need for more invasive procedures in the setting of pancreatic metastases. EUS-FNA was equally effective as CT-guided biopsies in achieving specimen adequacy and definitive diagnoses. We also present the first known case of a metastatic olfactory neuroblastoma to the pancreas diagnosed by imprint cytology.

Utilization of preoperative endoscopic ultrasound for pancreatic adenocarcinoma

BACKGROUND

Endoscopic ultrasound (EUS) is used for pancreatic adenocarcinoma staging and obtaining a tissue diagnosis. The objective was to determine patterns of preoperative EUS and the impact on downstream treatment.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) Medicare-linked database was used to identify patients with pancreatic adenocarcinoma. The staging period was the first staging procedure within 6 months of surgery until surgery. Logistic regression was used to determine factors associated with preoperative EUS. The main outcome was EUS in the staging period, with secondary outcomes including number of staging tests and time to surgery.

RESULTS

2782 patients were included, 56% were treated at an academic hospital (n = 1563). 1204 patients underwent EUS (43.3%). The factors most associated with receipt of EUS were: earlier year of diagnosis, SEER area, and a NCI or academic hospital (all p < 0.0001). EUS was associated with a longer time to surgery (17.8 days; p < 0.0001), and a higher number of staging tests (40 tests/100 patients; p < 0.0001).

CONCLUSIONS

Factors most associated with receipt of EUS are geographic, temporal, and institutional, rather than clinical/disease factors. EUS is associated with a longer time to surgery and more preoperative testing, and additional study is needed to determine if EUS is overused.

Pancreatic involvement by metastasizing neoplasms as determined by endoscopic ultrasound-guided fine needle aspiration: A clinicopathologic characterization

BACKGROUND

Pancreatic tumors often represent primary neoplasms, however organ involvement with metastatic disease can occur. The use of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) to determine the underlying pathology provides guidance of clinical management.

METHODS

25 cases were identified in a retrospective review of our institution's records from 2006 to 2016. Clinical parameters and prognosis are described.

RESULTS

Metastatic lesions to the pancreas diagnosed by EUS-FNA accounted for 4.2% of all pancreatic neoplastic diagnoses, each lesion had a median greatest dimension of 1.5 cm, were most often located in the head of the pancreas, and by EUS were typically hypoechoic masses with variably defined borders. Patients were of a median age of 64 years old at diagnosis of the metastatic lesion(s) and the mean interval from primary diagnosis to the diagnosis of metastasis to the pancreas was 58.7 months (95% confidence interval, CI, 35.4 to 82.0 months). The rates of 24-month overall survival after diagnoses of metastatic renal cell carcinoma or all other neoplasms to the pancreas were 90% and 7% respectively. The origin of the neoplasms included the kidney (n = 10), colon (n = 4), ovary (n = 3), lung (n = 2), et al. Smear-based cytomorphology, and a combination of histomorphology and immunohistochemical studies from cell block preparations showed features consistent with the neoplasm of derivation.

CONCLUSION

Metastases to the pancreas can be diagnosed via EUS-FNA, with enough specimen to conduct immunohistochemical studies if necessary to delineate origin. The determination of metastatic disease to the pancreas alters management and prognosis of the patient. Diagn. Cytopathol. 2017;45:418-425. © 2017 Wiley Periodicals, Inc.

Pancreatic Cytopathology

Pancreatic cytopathology, particularly through the use of endoscopic ultrasound-guided fine-needle aspiration (FNA), has excellent specificity and sensitivity for the diagnosis of pancreatic lesions. Such diagnoses can help guide preoperative management of patients, provide prognostic information, and confirm diagnoses in patients who are not surgical candidates. Furthermore, FNA can be used to obtain cyst fluid for ancillary tests that can improve the diagnosis of cystic lesions. In this article, we describe the cytomorphological features and differential diagnoses of the most commonly encountered pancreatic lesions on FNA.

Endoscopic ultrasound-guided fine needle aspiration cytology of metastatic renal cell carcinoma to the pancreas: A multi-center experience

Introduction:

The increasing use of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) cytology to examine pancreatic neoplasms has led to an increase in the diagnosis of metastases to the pancreas. Renal cell carcinoma (RCC) is the most common metastasis to the pancreas. Our study examines 33 cases of metastatic RCC to the pancreas sampled by EUS-FNA from four large tertiary care hospitals.

Materials and Methods:

We searched the cytopathology database for RCC metastatic to the pancreas diagnosed by EUS-FNA from January 2005 to January 2015. Patient age, history of RCC, nephrectomy history, follow-up postnephrectomy, radiological impression, and EUS-FNA cytologic diagnosis were reviewed.

Results:

Thirty-three patients were identified. The average age was 67.5 years (range, 49–84 years). Thirty-two patients had a previous documented history of RCC. One patient had the diagnosis of pancreatic metastasis at the same time of the kidney biopsy. Thirty-one patients had been treated with nephrectomy. Twenty-seven patients were being monitored annually by computed tomography or magnetic resonance imaging. Twenty-five patients had multiple masses by imaging, but 8 patients had a single mass in the pancreas at the time of EUS-FNA. EUS-FNA of 20 cases showed classic morphology of RCC. Thirteen cases had either “atypical” clinical-radiologic features or morphologic overlaps with primary pancreatic neoplasms or other neoplasms. Cell blocks were made on all 13 cases and immunochemical stains confirmed the diagnosis.

Conclusions:

EUS-FNA cytology is useful for the diagnosis of metastatic RCC to the pancreas. Cytomorphology can be aided with patient history, imaging analyses, cell blocks, and immunochemical stains.

The role of endoscopic ultrasound in pancreatic cancer screening

Pancreatic cancer (PC) is a highly lethal cancer. Despite a significant advancement in cancer treatment, the mortality rate of PC is nearly identical to the incidence rates. Early detection of tumor or its precursor lesions with dysplasia may be the most effective approach to improve survival. Screening strategies should include identification of the population at high risk of developing PC, and an intense application of screening tools with adequate sensitivity to detect PC at an early curable stage. Endoscopic ultrasound (EUS) and magnetic resonance imaging (MRI) seem to be the most promising modalities for PC screening based on the data so far. EUS had an additional advantage over MRI by being able to obtain tissue sample during the same examination. Several questions remain unanswered at this time regarding the age to begin screening, frequency of screening, management of asymptomatic pancreatic lesions detected on screening, timing of resection, and extent of surgery and impact of screening on survival. Novel techniques such as needle-based confocal laser endomicroscopy (nCLE), along with biomarkers, may be helpful to identify pancreatic lesions with more aggressive malignant potential. Further studies will hopefully lead to the development of strategies combining EUS with other technological/biological advancements that will be cost-effective and have an impact on survival.

Pretest prediction and diagnosis of metastatic lesions to the pancreas by endoscopic ultrasound-guided fine needle aspiration

BACKGROUND AND AIM

Early diagnosis of solid pancreatic lesions (SPLs) enables prompt treatment. The study aims to identify factors differentiating metastatic lesion to the pancreas (PMET) from pancreatic ductal adenocarcinoma (PDAC) and pancreatic neuroendocrine tumors (PNETs).

METHODS

This is a retrospective study at a tertiary cancer center. Consecutive patients referred for endoscopic ultrasound (EUS) of SPLs from 2004 to 2011 were reviewed. The main outcomes were pre-EUS-FNA (endoscopic ultrasound-guided fine needle aspiration) predictors and diagnostic accuracy of EUS-FNA for PMETs.

RESULTS

Among a total of 1108 EUS-FNAs for pancreatic lesions, 672 patients had neoplastic SPLs (PMETs = 53; PDACs = 528, PNETs = 91). The sensitivity, specificity, positive predictive value, and accuracy of EUS-FNA for diagnosis of PMETs were 84.9%, 100%, 100%, and 98.8%, respectively. The mean number of EUS-FNA passes for diagnosis of PMET was 3.1 per patient. For each endosonographer, preceding 3-year EUS volume (mean/year) significantly correlated with fewer needle passes (rs [-0.30], P = 0.03). The most common PMET was renal cell carcinoma. Stratified multivariate analyses were performed. Compared with patients with PDACs, PMETs were more common in men (odds ratio [OR] = 2.0; 95% confidence interval [CI] = 1.0-4.0); located in the pancreatic tail (OR = 2.4; 95%CI = 1.1-5.2); and were less likely with increasing age (OR = 0.95; 95%CI = 0.92-0.99), presence of major symptoms (abdomen pain/diarrhea/weight loss; OR = 0.2; 95%CI = 0.1-0.4), elevated bilirubin (OR = 0.3; 95%CI = 0.13-0.69), and imaging evidence of arterial invasion (OR = 0.15; 95%CI = 0.03-0.67). Compared with PNETs, PMETs were more common with increase age (OR = 1.05; 95%CI = 1.02-1.08) and increasing lesion size (OR = 1.03; 95%CI = 1.0-1.1), and were less likely in patients with diabetes (OR = 0.34; 95%CI = 0.11-0.99).

CONCLUSION

Among the largest numbers of neoplastic SPLs evaluated at a single center, pre-test features reliably characterize, and EUS-FNA provides a highly specific diagnosis of PMETs.

Ultrasound techniques in the evaluation of the mediastinum, part 2: mediastinal lymph node anatomy and diagnostic reach of ultrasound techniques, clinical work up of neoplastic and inflammatory mediastinal lymphadenopathy using ultrasound techniques and how to learn mediastinal endosonography

Ultrasound imaging has gained importance in pulmonary medicine over the last decades including conventional transcutaneous ultrasound (TUS), endoscopic ultrasound (EUS), and endobronchial ultrasound (EBUS). Mediastinal lymph node (MLN) staging affects the management of patients with both operable and inoperable lung cancer (e.g., surgery vs. combined chemoradiation therapy). Tissue sampling is often indicated for accurate nodal staging. Recent international lung cancer staging guidelines clearly state that endosonography should be the initial tissue sampling test over surgical staging. Mediastinal nodes can be sampled from the airways [endobronchial ultrasound combined with transbronchial needle aspiration (EBUS-TBNA)] or the esophagus [endoscopic ultrasound fine needle aspiration (EUS-FNA)]. EBUS and EUS have a complementary diagnostic yield and in combination virtually all MLNs can be biopsied. Additionally endosonography has an excellent yield in assessing granulomas in patients suspected of sarcoidosis. The aim of this review in two integrative parts is to discuss the current role and future perspectives of all ultrasound techniques available for the evaluation of mediastinal lymphadenopathy and mediastinal staging of lung cancer. A specific emphasis will be on learning mediastinal endosonography. Part 1 deals with an introduction into ultrasound techniques, MLN anatomy and diagnostic reach of ultrasound techniques and part 2 with the clinical work up of neoplastic and inflammatory mediastinal lymphadenopathy using ultrasound techniques and how to learn mediastinal endosonography.

Multiple pancreatic metastases from malignant melanoma: Conclusive diagnosis with endoscopic ultrasound-guided fine needle aspiration

Pancreatic metastases are rare, ranging from 2% to 5% of pancreatic malignancies. Differentiating a primary pancreatic malignancy from a metastasis can be difficult due to similarities on imaging findings, but is crucial to ensure proper treatment. Although transabdominal ultrasound, computed tomography, and magnetic resonance imaging provide useful images, endoscopic ultrasound (EUS) with fine needle aspiration (FNA) is often needed to provide a cytologic diagnosis. Here, we present a unique case of malignant melanoma with pancreatic metastases. It is important for clinicians to recognize the possibility of melanoma metastasizing to the pancreas and the role of EUS with FNA in providing cytological confirmation.

Metastasis-Induced Acute Pancreatitis Successfully Treated with Chemotherapy and Radiotherapy in a Patient with Small Cell Lung Cancer

Although involvement of pancreas is a common finding in small cell lung cancer (SCLC), metastasis-induced acute pancreatitis (MIAP) is very rare. A 50-year-old female with SCLC who had limited disease and achieved full response after treatment presented with acute pancreatitis during her follow-up. The radiologic studies revealed a small area causing obliteration of the pancreatic duct without mass in the pancreatic neck, and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) confirmed the metastasis of SCLC. The patient was treated successfully with systemic chemotherapy and radiotherapy delivered to pancreatic field. In SCLC, cases of MIAP can be encountered with conventional computed tomography with no mass image, and positron emission tomography and EUS-FNA can be useful for diagnosis of such cases. Aggressive systemic and local treatment can prolong survival, especially in patients with good performance status.

Solid tumor metastases to the pancreas diagnosed by FNA: A single-institution experience and review of the literature

BACKGROUND

Pancreatic fine-needle aspiration (FNA) is useful for diagnosing pancreatic masses. This article describes the experience of a single institution with metastases to the pancreas sampled by FNA and provides a review of the literature.

METHODS

Medical records were retrospectively searched for pancreatic FNA that showed metastatic disease. Data were gathered for the tumor size, focality, and time period between the primary tumor and the metastasis. A literature search using PubMed was performed.

RESULTS

Pancreatic FNA was performed 2327 times in 14 years at the authors' institution. Twenty-two cases showed metastatic disease. The average size of the metastatic lesions in their greatest dimension was 3.7 cm (range, 1.5-6.5 cm). The majority of the tumors were unifocal (16 of 22 or 73%). A rapid onsite adequacy evaluation was performed for 13 patients (4 were diagnostic of metastasis, 3 were positive for malignant cells, 6 were atypical, and none were negative). There were 14 renal cell carcinomas, 2 colonic adenocarcinomas, 1 urothelial carcinoma, 1 non-small cell lung carcinoma, 1 ovarian serous carcinoma, 1 prostatic adenocarcinoma, 1 papillary thyroid carcinoma, and 1 mesenchymal chondrosarcoma. The median time between the diagnosis of the primary tumor and the initial pancreatic metastasis was 9 years (range, concurrent diagnosis to 21 years). A literature review yielded 12 case series with a variety of metastases to the pancreas diagnosed by FNA and surgical pathology specimens.

CONCLUSIONS

In agreement with prior series, the most common metastasis to the pancreas was renal cell carcinoma. A variety of other primary malignancies were also documented in this study and in the literature. Also, this article reports the first case of metastatic mesenchymal chondrosarcoma to the pancreas diagnosed by FNA.

Pancreatic metastasectomy: experience of the Irish National Surgical Centre for Pancreatic Cancer

BACKGROUND

Metastatic tumours of the pancreas are rare and the optimal management of these tumours remains unclear, given the paucity of data existing in the literature. We report our experience of pancreatic metastasectomy.

METHODS

Data were reviewed on all patients who underwent pancreatic resection for pathologically confirmed metastatic lesions over a consecutive 7-year period.

RESULTS

Seven patients (two men and five women) underwent a pancreatectomy for a metastatic pancreatic tumour. The primary tumours were renal cell carcinoma (n = 3), colorectal carcinoma (n = 2) and leiomyosarcoma (n = 2). There was no operative mortality. Postoperative morbidities occurred in two patients. The median follow-up was 49 months (range 17-76). Overall 1- and 2-year survivals were 100 and 86 %, respectively, with a 2-year disease-free survival of 72 %.

CONCLUSIONS

Our series further supports that pancreatic metastasectomy can be performed safely and achieves acceptable survival outcomes.

Contrast harmonic endoscopic ultrasonography in the characterization of pancreatic metastases (with video)

OBJECTIVE

The differential diagnosis between primary pancreatic neoplasms versus pancreatic metastases (PM) is challenging. Endoscopic ultrasonography with fine-needle aspiration can be used to differentiate primary versus metastatic tumors although with a suboptimal accuracy. Recently, contrast harmonic EUS (CH-EUS) has been reported as an adjunct in the diagnosis of pancreatic neoplasms. We evaluated the potential role of CH-EUS in the differential diagnosis of PM.

METHODS

This study is a retrospective analysis of a prospectively maintained database. Of the 266 patients, 4.1% were diagnosed with PM. Endoscopic ultrasonography with fine-needle aspiration and/or surgical pathology represented our criterion standard.

RESULTS

The origins of PM were renal cancer (3 patients), colon cancer(2 patients), breast cancer (2 patients), ovarian cancer (1 patient), melanoma(1 patient), lymphoma (1 patient), and sarcoma (1 patient). All lesions appeared hypoechoic at standard EUS. At CH-EUS, of the 11 lesions, 6 appeared hypoenhancing (colon cancer, sarcoma, and breast and ovarian cancer), 4 were hyperenhancing (renal cancer and lymphoma),and 1 was isoenhancing (melanoma).

CONCLUSIONS

In our population, standard EUS features of PM were unremarkable. At CH-EUS, most of the PM appeared hypoenhancing suggesting a possible malignant origin. However, a subset of PM showed hyperenhancing pattern. In the appropriate context, particularly when cancer history is present, CH-EUS may add to the differential diagnosis and potentially spare endoscopic ultrasonography with fine-needle aspiration.

Diagnostic evaluation of solid pancreatic masses

Determining the etiology of a solid pancreatic lesion is a critical first step toward developing an appropriate treatment plan for patients with a benign or malignant pancreatic mass. Technological advances in cross-sectional and endoscopic imaging modalities offer pancreatic imaging options with degrees of resolution that were not available even 15-20 years ago. In most cases, the nature of a solid pancreatic mass can be determined using computerized tomography, magnetic resonance imaging, and endoscopic ultrasound with fine-needle aspiration. Knowledge about the basics of these modalities, as well as their strengths and limitations, plays an important role in understanding how patients with solid pancreatic masses should be evaluated.

Pancreatectomy for metastatic disease: a systematic review

AIM

Tumours rarely metastasise to the pancreas. While surgical resection of such metastases is believed to confer a survival benefit, there is limited data to support such management. We present a systematic review of case series of pancreatic metastasectomy and analysis of survival outcomes.

METHODS

A literature search was performed using the PubMed and Cochrane databases and the reference lists of relevant articles, searching for sizeable case series of pancreatic metastasectomy with curative intent. Data extracted included basic demographics, histological primary tumour, presentation, operative management, complications and survival, while the MINORS index was used to assess study quality.

RESULTS

18 studies were found which met our inclusion criteria, involving 399 patients. Renal cell carcinoma (RCC) was the commonest malignancy metastasising to the pancreas, responsible for 62.6% of cases, followed by sarcoma (7.2%) and colorectal carcinoma (6.2%). While survival data was not uniformly reported, the median survival post-metastasectomy was 50.2 months, with a one-year survival of 86.81% and five-year survival of 50.02%. Median survival for RCC was 71.7 months with 70.4% five-year survival. Median survival was similar in patients with synchronous and metachronous pancreatic metastases, but patients with additional extrapancreatic metastases had a significantly shorter survival than patients with isolated pancreatic metastases (26 versus 45 months). Study quality was poor, with a median MINORS score of 10/16.

CONCLUSIONS

Within the limitations of a review of non-randomised case series, it would appear that pancreatic metastasectomy confers a survival benefit in selected patients. Better evidence is required, but may prove difficult to acquire.

Pancreatic metastases from renal cell carcinoma: a case report and literature review of the clinical and radiological characteristics

Metastatic pancreatic cancer is rare, accounting for approximately 2% of all pancreatic malignancies, and most cases arise from renal cell carcinoma. We report the case of a 63-year-old woman, who presented with a pancreatic tumor detected during her annual health examination. She had undergone left nephrectomy 13 years previously for renal cell carcinoma. Computed tomography (CT) revealed two tumors in the head and body of the pancreas, a hypervascular tumor and a hypovascular tumor with an enhanced rim, respectively. She underwent pylorus-preserving pancreaticoduodenectomy, and metastatic pancreatic tumors arising from the kidney with clustered clear cell carcinoma immunohistochemically positive for CD10 were diagnosed. This report presents the different enhancement features of different lesions on CT scans. Because the enhancement features of lesions have been reported to vary according to the size of the metastatic tumor, a knowledge of the history of renal cell carcinoma is crucial for diagnosis.