CASE REPORT

As radiologic examinations evolve, the detection of asymptomatic pancreatic cystic lesions is rising and, consequently, there is a growing challenge to decide the best approach to this type of lesions. We report the case of a 48-years-old female patient with a prior history of HIV and HCV co-infections, asymptomatic gallstones, active smoking and social alcohol intake, with no prior history of acute pancreatitis. In a routine ultrasound, an incidental pancreatic cystic lesion in the body/tail transition was found. This lesion was further characterized by magnetic resonance imaging and endoscopic ultrasound (EUS). It was a cystic lesion with a long axis of 17 mm, a regular but thick wall and thin internal septations, apparently communicating with the main pancreatic duct (Figure 1).

Figure 1 – Ultrasonographic aspects of the pancreatic lesion.

Due to the characteristics of the lesion, with the presence of one worrisome feature, we decided to perform EUS-guided fine needle aspiration (EUS-FNA) (Figure 2).

Figure 2 – EUS-FNA of the lesion.

The cytologic examination with immunochemistry demonstrated small cells with scarce eosinophilic cytoplasm, eccentric round nucleus, with immunoreactivity to synaptophysin and chromogranin. These finding were suggesive of the diagnosis of a pancreatic neuroendocrine tumour (NET).

Commentary

Pancreatic NETS represent 1-2% of pancreatic neoplasms and are typically solid lesions. Their presentation as cystic lesions is rare, and it’s assumed that it is the consequence of tumour necrosis. The decision to proceed to EUS-FNA of a pancreatic cystic lesion is still a question of debate, and the existent recommendations are based in low-quality evidence. In this case, the existence of a worrisome feature was the main reason for this decision. Therefore, even though in the most recent recommendations of the American Gastroenterological Association the authors only suggest EUS-FNA in the presence of 2 or more risk features, we emphasize the importance of a case-by-case decision. We outline the importance of this case due to the atypical presentation of an uncommon pancreatic neoplasm and due to the major role of EUS-FNA to the final diagnosis.

References:

1. Vege, Santhi SwaroopAdams, Megan A. et al (2015), American Gastroenterological Association Institute Guideline on the Diagnosis and Management of Asymptomatic Neoplastic Pancreatic Cysts. Gastroenterology , Volume 148 , Issue 4 , 819 – 822.

2. Morales-Oyarvide, V., Yoon, W. J., Ingkakul, T., Forcione, D. G., Casey, B. W., Brugge, W. R., Fernández-del Castillo, C. and Pitman, M. B. (2014), Cystic pancreatic neuroendocrine tumors: The value of cytology in preoperative diagnosis. Cancer Cytopathology, 122: 435–444.

Authors:

Sousa P^1,2, Lago P^1b, Martins C^1,3, Costa F⁴, Coelho A⁴, Castro- Poças F^1b, Pedroto I¹

1. Serviço de Gastrenterologia, Centro Hospitalar do Porto

1b) Setor de Ultrassons e Serviço de Gastrenterologia, Centro Hospitalar do Porto

2. Serviço de Gastrenterologia, Centro Hospitalar Tondela-Viseu

3. Serviço de Gastrenterologia, Centro Hospitalar de Setúbal

4. Serviço de Anatomia Patológica, Centro Hospitalar do Porto