Dysphagia Secondary to Pancreatic Adenocarcinoma

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Purpose: Gastric submucosal nodules are not uncommonly found during esophagogastrodeodenoscopic (EGD) examination. Cystic lesions remain less common. The utilization of endoscopic ultrasound (EUS) in the evaluation of submucosal lesions allows for a more precise diagnostic and therapeutic assessment. This case displays the advantages of EUS in the investigation with an unexpected diagnosis. A 74-year-old Caucasian man presented to clinic with dysphagia for several months. He reported 40-pound weight loss over same period of time. The dysphagia was described as mainly to solids. Liquids usually induced a cough. The food would stick near the jugular notch and require liquids to dislodge the bolus. He denied transfer dysphagia. An EGD revealed an esophageal impingement from a 3 cm submucosal nodule at the cardia. It was smooth, firm, without ulcerations or color changes. CT scan revealed a septated cystic lesion in the tail of the pancreas measuring 6 cm adjacent to the gastric wall. EUS with fine needle aspiration of the cyst was performed. It showed a 4.3 cm x 3.7 cm cyst invading the wall of the stomach with a 0.9 x 0.4 cm mural nodule. Thirty ml of bloody fluid was aspirated with a 19G needle and sent for CEA and pathology review. After cyst decompression a pancreatic tail mass was visualized. It measured 2.4 x 2.2 cm and fine needle aspiration was performed utilizing 2 passes with a 25G needle. The pancreatic and common bile ducts were normal. The fluid CEA was 4,050 ng/ml and serum CA 19-9 was 2,053 ng/ml. The cyst fluid contained rare malignant cells and the tail mass consisted of malignant epithelial cells in a background of mucin, consistent with pancreatic adenocarcinoma. On follow-up a month later, the dysphagia resolved after cyst decompression. The final impression was a pancreatic tail mass invading the gastric wall causing a hemorrhagic cyst that compressed the esophagus causing dysphagia. EUS is an established diagnostic modality to evaluate gastrointestinal submucosal lesions. This case illustrates that, if possible, when a cyst is found, aspiration should be considered, as a solid component may not be visualized until the fluid is evacuated.