Solid Pancreatic Masses Research Articles

Endoscopic ultrasound-guided sampling of solid pancreatic masses: the fine needle aspiration or fine needle biopsy dilemma. Is the best needle yet to come?

Fine needle aspiration (FNA) is currently the standard of care for sampling pancreatic solid masses by using endoscopic ultrasound (EUS). The accuracy of the technique is reported to be high, especially if coupled with the rapid on site evaluation (ROSE), and it has a high safety profile. However, FNA presents some limitations, such as the small amount of tissue that can be collected and the inability of obtaining a core tissue with intact histological architecture, which is relevant to perform immunohistochemical analysis, molecular profiling and, therefore, targeted therapies. Moreover, the presence of the ROSE by an expert cytopathologist is very important to maximize the diagnostic yield of FNA technique; however, it is not widely available, especially in small centers. Hence, the introduction of EUS fine needle biopsy (FNB) with a new generation of needles, which show a high safety profile too and a satisfying diagnostic accuracy even in the absence of ROSE, could be the key to overcome the limitations of FNA. However, FNB has not yet shown diagnostic superiority over FNA. Considering all the technical aspects of FNA and FNB, the different types of needle currently available, comparisons in term of diagnostic yield, and the different techniques of sampling, a tailored approach should be used in order to determine the needle that is most appropriate for the different specific scenarios.

Endoscopic ultrasound-guided sampling of solid pancreatic masses: the fine needle aspiration or fine needle biopsy dilemma. Is the best needle yet to come?

Endoscopic ultrasound-guided sampling of solid pancreatic masses: the fine needle aspiration or fine needle biopsy dilemma. Is the best needle yet to come?

Endoscopic Ultrasound Findings in Patients Diagnosed with Exocrine Pancreatic Insufficiency by Low Fecal Elastase-1.

Background and Aims Fecal elastase-1 (FE-1) as a screening test for exocrine pancreatic insufficiency (EPI) is gaining popularity in clinical practice. The role of imaging in patients with FE-1-related suspicion of EPI remains unclear. The aim of this study was to characterize endoscopic ultrasound (EUS) findings for patients with low FE-1. Methods A retrospective cross-sectional study was performed in 40 patients who had low FE-1 and underwent EUS to evaluate the pancreas. We obtained data on demographic and lifestyle factors, EUS findings, and histopathology results. We compared these variables between patients with FE‐1 < 100 mcg/g vs. 100-200 mcg/g. Results Most patients (82.5%) established one or more new diagnoses from EUS. Diagnoses included: definitive chronic pancreatitis (n = 29, 72.5%), fatty pancreas (n = 9, 22.5%), and pancreatic solid mass or cyst (n = 9, 22.5%). Half (n = 4) of the solid or cystic lesions were neoplastic. All patients with a solid pancreatic mass also had concurrent chronic pancreatitis. There were no significant differences in EUS findings or demographic or lifestyle factors between groups with FE‐1 < 100 mcg/g vs. 100-200 mcg/g. Conclusion Chronic pancreatitis is the most common EUS finding in patients with low FE-1 levels. EUS appears helpful in determining the cause of EPI in most patients with low FE-1 and may detect unsuspected pancreatic neoplasia.

Coexisting pancreatic serous cystadenoma and pancreatic ductal adenocarcinoma: A cytological-pathologic correlation with literature review

Pancreatic serous cystadenoma (SCA) is a benign neoplastic lesion with a distinctive gross and microscopic appearance consisting of numerous thin-walled cysts lined by uniform epithelial cells with clear cytoplasm and small nuclei. The vast majority of serous cystadenomas are benign. Pancreatic SCA has rarely been reported in association with other pancreatic lesions. We present a challenging case in which a cystic and solid pancreatic mass was identified on imaging studies. FNA was performed and showed clusters of atypical cells with significant nuclear pleomorphism (>4:1), disorganized, overlapping nuclei, and prominent nucleoli. The FNA diagnosis was positive for malignancy, consistent with adenocarcinoma. The patient underwent neoadjuvant therapy and pancreaticoduodenectomy. Final pathology showed a serous cystadenoma associated with small foci of high-grade PanIN. The lack of invasive adenocarcinoma in the resection specimen was most likely due to complete response of the tumor to neoadjuvant chemoradiation therapy, but it is also possible that only high-grade PanIN was present initially. To our knowledge, this is the first reported case of SCA and high grade PanIN/PDAC that was assessed by FNA. We discuss the cytologic differential diagnosis and how to avoid potential pitfalls highlighted by this case.

Comparison of 19-gauge versus 20-gauge fine needle biopsy needles for endoscopic ultrasound-guided sampling of solid pancreatic or peripancreatic masses

Comparison of 19-gauge versus 20-gauge fine needle biopsy needles for endoscopic ultrasound-guided sampling of solid pancreatic or peripancreatic masses

Tu1394 SLOW-PULL VERSUS SUCTION EUS-GUIDED FINE-NEEDLE ASPIRATION TECHNIQUES FOR SOLID PANCREATIC MASS LESIONS – A SYSTEMATIC REVIEW AND META-ANALYSIS

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is an invaluable diagnostic tool in the management of solid pancreatic mass lesions. EUS-FNA is presently performed by a standard suction technique, however, emerging data on a new technique called the slow pull EUS-FNA has shown to have better diagnostic yield by limiting blood contamination in obtained specimens. The aim of this systematic review and meta-analysis is to compare the two EUS-FNA techniques in the diagnosis of solid pancreatic masses.

A "Back Light System" for Identification of Sites for Endoscopic Ultrasound-Guided Fine-Needle Aspiration in Solid Pancreatic Masses: A Prospective, Randomized Study with a Crossover Design.

Background/AimsWe applied a back light system (BLS) with a magnifying glass to improve the ability to assess the adequacy of specimen sampling using endosonography. We conducted this study to evaluate the efficacy of the BLS in sampling of specimens by endoscopic ultrasound-guided fine needle aspiration of solid pancreatic masses. MethodsThis was a prospective, randomized, crossover, single-center clinical trial. An endosonographer evaluated adequacy on gross visual inspection and identified whitish specimen sampling sites with and without the BLS according to a randomization sequence in the first and second passes with a 25-G needle. On cytological evaluation, the presence of well-defined pancreatic ductal epithelium was evaluated by a cytopathologist who was blinded to any clinical information. ResultsA total of 80 consecutive patients were eligible during the study period. Adequacy was observed for 52 specimens (65%) with the BLS and 54 (68%) without the BLS (p=0.88). In assessment of specimen adequacy on gross examination, only fair agreement was observed both with and without BLS (kappa score 0.40 and 0.29, respectively). ConclusionsThe BLS did not influence the ability to identify specimen sampling sites or reliable assessment of specimen site adequacy using gross visual inspection.

Establishment of pancreatic cancer cell lines with endoscopic ultrasound-guided biopsy via conditionally reprogrammed cell culture.

Recent studies have identified the mutational landscape of pancreatic cancer and suggested tumor‐specific subtypes. However, the major hurdle against personalized treatment is the difficulty to obtain sufficient cancer tissues from most inoperable cases. We investigated whether patient‐derived conditionally reprogrammed cells (CRCs) can be constructed using a small piece of tumor tissue using endoscopic ultrasound (EUS)‐guided fine needle biopsy (FNB). Thirty patients with pancreatic solid mass (mean size, 34.6 mm) were enrolled prospectively. Among 22 patients who were diagnosed with pancreatic ductal adenocarcinoma, we established patient‐derived pancreatic cancer cell lines from eight patients (36.4%). Immunofluorescence colony staining for CRCs showed that the cytoplasm of cancer cells was clearly stained with anti‐cytokeratin 19 monoclonal antibody. In the soft agar colony formation assay, CRCs formed colonies compared with the negative control by day 15. In vivo, implanted CRCs showed tumor engraftment and hematoxylin and eosin staining showed pancreatic cancer ductal structure. All established CRCs showed a KRAS mutation. In conclusion, we established patient‐derived pancreatic cancer cell lines with a small tumor tissue obtained by EUS‐FNB. With in vitro drug sensitivity and genomic studies, established patient‐derived cell lines can be used in identification of new targets for diagnosis and treatment of pancreatic cancer.

Study of Yield of Endoscopic Ultrasound: Fine Needle Aspiration Cytology in Patients with Solid Pancreatic Masses at S.M.S. Medical College, Jaipur

Study of Yield of Endoscopic Ultrasound: Fine Needle Aspiration Cytology in Patients with Solid Pancreatic Masses at S.M.S. Medical College, Jaipur

EUS-guided core biopsies of pancreatic solid masses using a new fork-tip needle: A multicenter prospective study

Background and aimEndoscopic ultrasound-guided sampling (EUS sampling) is a safe and effective technique. The study aim was to evaluate the presence of a histological core from pancreatic lesions using a new 25G fork-tip needle. MethodsObservational multicenter prospective and analytical study, including consecutive patients with solid pancreatic masses referred for EUS-guided sampling. At each needle pass, the endoscopist performed macroscopic on-site evaluation (MOSE). The primary outcome was the histological core procurement rates. Secondary outcomes were the evaluation of interobserver agreement between endoscopists and pathologists, adequacy of EUS samples for the diagnosis and post-procedure adverse events. Results100 patients were enrolled in 3 centers. The mean size of the lesions was 28.5 mm (SD 11.7). Final diagnoses were adenocarcinoma (68%), neuroendocrine tumor (21%), inflammatory mass/benign lesions (8.0%), and pancreatic metastasis (3.0%). The pathologists described the presence of a core in 67 samples (67.0% of patients), with poor agreement with MOSE (kappa, 0. 12; 95% CI: 0.03–0.28). The diagnostic accuracy was 93%. We observed 6% of mild adverse events. ConclusionThe new 25-gauge core needle showed good overall adequacy and a good rate of histological specimens during EUS sampling of solid pancreatic masses, with a minimum number of passes and no major complications. Clinicaltrial.gov number, NCT02946840.

EUS-FNB with or without on-site evaluation for the diagnosis of solid pancreatic lesions (FROSENOR): Protocol for a multicenter randomized non-inferiority trial

BackgroundRapid on-site evaluation (ROSE) of cytological specimensacquired with EUS-guided fine needle aspiration (EUS-FNA) represents the most accurate available technique to reach a definitive diagnosis in patients with pancreatic solid masses. Recently, needles with high histological yield have been developed for EUS-guided fine needle biopsy (EUS-FNB), with which the need for ROSE can be potentially overcome. AimsThe primary aim is to compare the diagnostic accuracy of EUS-FNB with or without ROSE. The main endpoint will be measured against the gold standard diagnosis (surgical pathology whenever available or diagnostic work-up in agreement with a clinical course of at least six months). Secondary endpoints include: (a) safety; (b) presence of tissue core; (c) quality of specimens; (d) time of the sampling procedure. Reliability of macroscopic on-site evaluation (MOSE) by endosonographers will be also assessed. MethodsFROSENOR is an international randomized non-inferiority ongoing study at sixteen centers in four continents. Eight hundred patients will be randomized in two arms (EUS-FNB + ROSE vs. EUS-FNB alone) and outcomes compared. Sample size has been calculated in order to demonstrate the non-inferiority of FNB alone. Randomization and data collection will be performed online. DiscussionThis study will ascertain if ROSE is still needed when performing EUS-FNB of solid pancreatic lesions.

Comparison of 20-gauge Procore® and 22-gauge Acquire® needles for EUS-FNB of solid pancreatic masses: an observational study

Background and Aims: Endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) has been proposed to obtain high-quality tissue samples for pancreatic tumors. We performed an observational study to compare EUS-FNB with a 20-gauge Procore® needle versus a 22-gauge Acquire® needle. Our primary endpoint was the quantity of the obtained tissue, as defined by the mean cumulative length of tissue core biopsies per needle pass.Methods: Sixty-eight EUS-FNB were consecutively performed on patients with a pancreatic mass. The choice of needle depended on availability at the time of admission: 34 punctures were performed with each needle. Histological material was studied in a blinded manner with respect to the needle, and the cumulative length of tissue core biopsies per needle pass was determined. Intraobserver and interobserver variability of this criterion was then evaluated.Results: There were no between-group differences. Histological diagnosis was achieved and core biopsy specimens were obtained in 28 out of 34 patients (82%) in the 20-gauge Procore® group and in 33 out of 34 patients (97%) in the 22-gauge Acquire® group (p = .1). The mean cumulative length of tissue core biopsies per needle pass was significantly higher with the 22-gauge Acquire® needle with 8.2 ± 4.2 mm versus 4.2 ± 3.8 mm for the 20-gauge Procore® needle (p < .01). No intra and inter-observer variability of this criterion was observed.Conclusions: Our results suggest significant differences, with a mean cumulative length of tissue core biopsies per needle pass significantly higher with the 22-gauge Acquire® needle. This simple criterion seems reliable and reproducible.

Image-Guided Percutaneous Biopsy for Pancreatic Lesions: 10-Year Experience in a Tertiary Cancer Center

IntroductionImage-guided biopsy is an important tool in the diagnosis of solid pancreatic masses. This study aims to evaluate the accuracy and complications associated with this procedure. MethodsWe conducted a retrospective cohort study of all patients referred to interventional radiology for pancreatic biopsy at our institution from July 2004-July 2015. Two radiologists independently reviewed the images, technical aspects, and clinical characteristics. ResultsA total of 82 patients underwent pancreatic biopsy using a combination of computed tomography (CT) and/or ultrasound guidance. Mean age was 67.8 years with 56% males. Most lesions were located in the head (63.4%), followed by the tail (19.5%), and the body (17.1%). The procedures were performed using the anterior (79.3%), lateral (7.3%), or posterior (13.4%) approach, with direct access in 85.4% of the patients and indirect access (transgastric or transhepatic) in 14.6% of cases. Core biopsies were obtained in 81.7% of cases, and fine needle aspiration was performed in 18.3% of cases. Needle size varied from 18–22 gauge (median 20 gauge). The median number of samples collected was 3 (range 1–8). A conclusive result was obtained in 82.9% of cases. There were 9 (11%) patients with minor complications: minor bleeding, pain, and inadvertent bowel puncture with no clinical repercussion. There were no deaths or major complications. ConclusionPercutaneous image-guided pancreatic mass biopsy can be performed safely with excellent accuracy. Our results are comparable with endoscopic biopsy/aspiration, and percutaneous biopsy may be used as an alternative, particularly at institutions where endoscopy facilities are limited.

Diagnostic strategy with a solid pancreatic mass

The correct diagnosis of a patient presenting with a solid pancreatic mass requires a careful diagnostic work-up, since many differential diagnoses are possible that completely alter the following treatments. In our chapter, we have discussed the clinical approach to the problem in a sort of diagnostic flow-chart. Firstly, we analysed the different potential presentations of a solid pancreatic mass, which can be both asymptomatic or symptomatic, and the differential diagnosis based on the symptoms of presentation. Then we focused on the various imaging techniques commonly used in the diagnostic work-up, stressing on the different presentations according to the type of disease, and the operative procedures that can supplement this part. Lastly, we discussed the best diagnostic work up that should be followed to fully understand the characteristics of each disease, which is of paramount importance to choose the adequate treatment plan, with special attention to pancreatic adenocarcinoma and its many treatment strategies such as chemotherapy, surgery, or medical therapy. In patients presenting with a solid pancreatic mass it is crucial to reach a definitive diagnosis using a well determined diagnostic work-up to better characterize the lesion, since the best treatment varies widely according not only to the type of disease but also to its features.

The importance of pancreatic inflammation in endosonographic diagnostics of solid pancreatic masses

Endosonography (EUS) is one of the main diagnostic tools for the differential diagnosis of pancreatic masses. Theaim of our study was to describe the value of this technique in the work-up of solid pancreatic lesions, considering the influenceof the morphological evidence of pancreatic inflammation in the diagnostic process. Retrospectiveanalysis of prospectively collected data in our tertiary University center. From March 2007 to October 2015, 218 patientsunderwent EUS for a suspected solid pancreatic neoplasm (based on previous cross-sectional imaging results, idiopatic acutepancreatitis, weight loss, pancreatic hyperenzymemia, painless jaundice or elevated Ca 19-9 values). Malignantlesions were diagnosed in 98 (45%) patients. Sensitivity of EUS for malignancy was 91% and specificity 89.2%. Signs ofpancreatic inflammation in the surrounding pancreatic parenchyma around the focal lesion were present in 97 patients (44.4%)(more often in men, smokers and drinkers, and the most common etiology was focal chronic pancreatitis) and in these patientsthe sensitivity and sensibility dropped to 44% and 87.1%, respectively. In patients without signs of pancreatic inflammation,the pancreatic focal lesions were adenocarcinoma, neuroendocrine tumor, ventral/dorsal split, non-pancreatic pathology, pancreaticlipomatosis and autoimmune pancreatitis. Pancreatic inflammation (either focal or involving the wholegland) lowers the diagnostic sensibility of EUS in the work- up of pancreatic masses suspected for cancer, requiring furtherinvasive diagnostic methods. Focal autoimmune pancreatitis and paraduodenal pancreatitis are still confused with pancreaticcancer, even in the absence of pancreatic inflammation.

19 G nitinol needle versus 22 G needle for transduodenal endoscopic ultrasound-guided sampling of pancreatic solid masses: a randomized study.

The aim of this prospective multicenter study was to compare a flexible 19 G needle with nitinol shaft (19 G Flex) with a standard 22 G needle for transduodenal endoscopic ultrasound (EUS)-guided sampling of pancreatic head tumors. Patients with pancreatic head tumors requiring tissue diagnosis were randomized into two arms: puncture with either a 19 G Flex needle or a 22 G needle. The primary end point was diagnostic accuracy for malignancy. The secondary end points were ergonomic scores, sample cytohistological quality, and complications. A 6-month follow-up was performed. 125 patients were randomized and 122 were analyzed: 59 patients in the 19 G Flex arm and 63 patients in the 22 G arm. The final diagnosis was malignancy in 111 patients and benign condition in 11. In intention-to-treat analysis, the diagnostic accuracy for malignancy of the 19 G Flex and 22 G needles was 69.5 % (95 % confidence interval [CI] 56.1 % - 80.8 %) vs. 87.3 % (95 %CI 76.5 % - 94.4 %), respectively (P = 0.02). In per-protocol analysis excluding eight technical failures in the 19 G Flex group, the diagnostic accuracy of the 19 G Flex and 22 G needles was not statistically different: 80.4 % (95 %CI 66.9 % - 90.2 %) vs. 87.3 % (95 %CI 76.5 % - 94.4 %; P = 0.12). Technical success was higher in the 22 G arm than in the 19 G Flex arm: 100 % (95 %CI 94.3 % - 100 %) vs. 86.4 % (95 %CI 75.0 % - 94.0 %), respectively (P = 0.003). Transduodenal EUS-guided sampling was more difficult with the 19 G Flex (odds ratio 0.68, 95 %CI 0.47 - 0.97). CONCLUSION : The 19 G Flex needle was inferior to a standard 22 G needle in diagnosing pancreatic head cancer and more difficult to use in the transduodenal approach.

Can diffusion-weighted MRI replace conventional contrast enhanced MRI in the differentiation between benign and malignant pancreatic masses?

PurposeTo evaluate the role of diffusion weighted MRI (DW MRI) in the differentiating between benign and malignant pancreatic masses. Patients and MethodsSixty patients (36 men, mean age, 62 years; range, 48–72 years], 24 women (mean age, 64 years; range, 54–69 years] suspected to have solid pancreatic masses were examined by conventional and DWI. None of our patients had a history of pancreatic disease. DWI of the pancreas was performed in addition to the routine liver MR. Final diagnosis was obtained by diagnostic biopsy, lab. data and follow up. Results38 patients had a benign lesion and 22 patients had a malignant lesion. Using DWI, 36 cases were diagnosed to have benign lesions and 24 cases were diagnosed to have malignant lesions. There were two false positive cases due to low ADC value. The mean ADC values of malignant lesions were lower compared with benign lesion. The mean ADC value for malignant lesions was 1.1 +/− 0.201 × 10−3 mm2/sec, and for benign lesions it was 1.6 + l − 0.121 × 10−3 mm2/sec. ConclusionDWI and ADC values can help differentiate between benign and malignant pancreatic masses. Also DWI can be used for investigating patients for whom contrast-enhanced CT or MRI studies are contraindicated.

A Rare Case of B-Cell Lymphoma Presenting as a Large Solid Pancreatic Mass: A Case Report

The differential diagnosis of a pancreatic mass is categorized into cystic and solid lesions. Cystic pancreatic lesions include non-neoplastic cysts and pancreatic cystic neoplasms. Possible differential diagnoses for a solid pancreatic mass include primary exocrine pancreatic cancer, pancreatic neuroendocrine tumors, metastatic cancer, focal chronic pancreatitis, and autoimmune pancreatitis. We are presenting a rare case of B cell lymphoma presenting as a large solid pancreatic mass. A 62-year-old female with past medical history of type II diabetes and hypertension presented to University Medical Center (UMC) hospital in Las Vegas emergency room with four days of epigastric abdominal pain associated with jaundice. She reported unintentional weight loss, but no fever or night sweats. She had no history of pancreatic disease or malignancies. She denied smoking or alcohol use. Physical exam was significant for scleral icterus and a palpable epigastric mass. Initial liver function panel showed AST 189, ALT 213, ALP 140, total bilirubin 7.4 with direct bilirubin 6.2, Albumin 2.9 g/dl, Lipase 63, Lactate dehydrogenase 1,008 and CEA 12.6. Autoimmune panel was sent including antinuclear antibodies, antimitochondrial antibodies, anti-LKM antibodies, IgA, IgG and IgM levels. All were found to be unremarkable. CT of the abdomen and pelvis with IV contrast showed a 5.5 x 3.7 x 3.0 cm mass in the pancreatic tail encasing the splenic vein with splenic vein thrombosis in addition to enlarged retroperitoneal lymph nodes (figure 1). Gastroenterology was consulted and an endoscopic ultrasound with fine needle aspiration was subsequently performed. Tissue pathology revealed aggressive B cell lymphoma. A consult was made with oncology for further management. Hematologic malignancies can often manifest in extranodal locations. We present a rare case of aggressive B cell lymphoma presenting as a large pancreatic mass. Rare cases of hematologic malignancies presenting as pancreatic masses have been reported in the past. Early diagnosis is of primary importance so as to avoid unnecessary surgical resection. Clues suggesting the possibility of a primary hematologic malignancy include constitutional symptoms (weight loss, fever, and night sweats), an elevated serum lactate dehydrogenase (LDH) or beta-2 microglobulin level and a normal serum carbohydrate antigen 19-9 (CA 19-9).1429.tif Figure 1: 5.5 x 3.7 x 3.0 cm mass in the pancreatic tail encasing the splenic vein with splenic vein thrombosis in addition to enlarged retroperitoneal lymph nodes

Pancreatic Head Mass: A Rare Manifestation of Granulomatosis With Polyangiitis

A solid pancreatic mass is found to be malignant 95% of the time, while inflammation accounts for the remaining cases. We report a case of granulomatosis with polyangiitis (GPA) presenting as an inflammatory mass initially suspected to be metastatic pancreatic cancer. This is a 73-year-old male who presented to the ED with weakness, fevers, night sweats, and weight loss. His medical history was significant for severe chronic sinusitis and nasal polyps. On physical examination, he was noted to have bilateral lower extremity nodular purple plaques with necrotic centers. Laboratory studies were significant for leukocytosis, mildly elevated alkaline phosphatase, normal kidney function, transaminases and bilirubin. CT imaging demonstrated a low-attenuation mass in the pancreatic head along with multiple cavitary pulmonary nodules without hepatic lesions. Our differential diagnoses included metastatic pancreatic cancer versus an autoimmune process. CA 19-9 and CEA were within normal limits. An autoimmune work-up showed negative ANA, positive RF, elevated WSR, elevated IgE, and an elevated C-ANCA. Skin biopsy yielded leukocytoclastic vasculitis with granular fluorescence of C3 and IgG. Biopsy of lung nodules revealed extensive necrosis with acute neutrophilic infiltrates, fibrin thrombi, multinucleated giant cells, consistent with GPA. He was started on high dose steroids. He was discharged with plans for repeat imaging and biopsy of the pancreatic mass. A pancreatic mass in an elderly patient is highly concerning for cancer, which was our primary differential diagnosis. The absence of hepatic involvement and normal tumor markers decreased the likelihood of a primary pancreatic cancer with lung metastases. Due to his history of recurrent sinusitis, nasal polyps, and skin lesions, an autoimmune etiology was explored. A positive C-ANCA coupled with the lung biopsy findings established the diagnosis of GPA, a very rare cause of pancreatic masses. Most cases detailing GI manifestations of GPA present with pancreatitis or painless jaundice, but few have reported pancreatic masses. Necrotizing vasculidities can mimic pancreatic carcinoma and should be considered in the differential diagnosis of atypical cases. It is important to distinguish a pancreatic mass caused by GPA from pancreatic cancer due to the significant differences in treatment and prognosis. More studies are needed to determine whether these pancreatic masses should be biopsied or followed with imaging.1406_A.tif Figure 1: ßLungßonstrating extensive necrosis with acute neutrophilic infiltrates, fibrin thrombi, and multinucleated giant cells.1406_B.tif Figure 2: Low attenuation mass anteriorly in the pancreatic head measuring approximately 2.0 cm. The margins of the mass are inseparable from posterior wall of the duodenal bulb.1406_C.tif Figure 3: Bilateral lower extremity lesions described as nodular purple plaques with necrotic centers.

Rising Incidence of Solid Organ Tumors Metastasizing to the Pancreas

Introduction: Unlike primary pancreatic carcinoma, metastatic lesions of the pancreas are uncommon and account for approximately 2% of pancreatic malignancies. Identification of the etiology of a pancreatic mass is important, particularly if malignancy is suspected. Metastatic disease to the pancreas should be considered within the differential of a pancreatic mass. Methods: Aim: To determine the incidence of metastatic cancer presenting as a solitary pancreatic mass. Methods: Retrospective chart review of patients referred for Endoscopic ultrasound (EUS) evaluation of a solid pancreatic mass from January 2015 to June 2018. All patients with a final diagnosis of malignancy after EUS-FNA of a pancreatic mass were included. Results: Out of 640 charts reviewed, 116 patients were diagnosed with cancer by EUS-FNA. 92 out of 115 (80%) patients were identified to have primary adenocarcinoma of the pancreas, 12 out of 115 (10.5%) with primary neuroendocrine tumors of the pancreas, and 11 out of 115 (9.5%) with metastasis to the pancreas from another primary cancer. Of the metastatic cases, the distant primary tumor was from renal cell carcinoma in 4/11, colon carcinoma 3/11, squamous cell carcinoma of the lung 3/11, and urothelial carcinoma 1/11. 10 out of 11 patients had a prior history of cancer ranging from 1 to 12 years (Mean 6 years) from the time of diagnosis of the primary tumor to the time of metastatic disease to the pancreas. 10/11 presented as a solitary mass in the pancreas without any evidence of metastatic disease elsewhere. Of these solitary masses, 5/11 appeared to be resectable pancreatic tumors on initial imaging before EUSFNA. Limitation: Unable to correct the referral bias to a tertiary center. Conclusion: There appears to be a higher incidence (9.5% in our series) of metastatic cancer to the pancreas as compared to prior reports (up to 2%). In our experience, EUS-FNA allowed to diagnose (5/11) cases with metastatic cancer when initial imaging suggested a resectable primary pancreatic tumor. Metastatic cancer to the pancreas should be considered in patients with prior history of cancer presenting with solitary pancreatic mass (90 % of our cases had a cancer history). In these patients, tissue diagnosis by EUS-FNA becomes particularly important, especially if surgical resection is being considered (45% of the cases in our series).