Endoscopic ultrasound-guided biopsy of pancreatic metastases: a large single-center experience

The Role of Endoscopic Ultrasonography (EUS) in Metastatic Tumors in the Pancreas: 10 Years of Experience from a Single High-Volume Center

BACKGROUND

Metastatic pancreatic lesions (MPLs) are relatively uncommon, constituting 2 to 5% of all pancreatic tumors. They often manifest as solitary lesions without distinct clinical symptoms, usually identified incidentally during radiologic imaging for the surveillance of prior malignancies. Differentiating these lesions from primary pancreatic tumors presents a significant challenge due to their nonspecific presentation.

METHODS

We aimed to prospectively assess the effectiveness of endoscopic ultrasound (EUS) and EUS-guided fine needle aspiration/biopsy (EUS-FNA/B) in diagnosing MPLs in a carefully selected cohort of patients presenting with pancreatic masses. Additionally, we sought to examine the relevance of specific EUS findings in supporting the initial diagnosis of MPLs and their agreement with the definitive cytological diagnosis. This study retrospectively analyzed data from 41 patients diagnosed with MPLs between 2013 and 2023, focusing on their clinical and pathological characteristics, the echogenic features of the pancreatic lesions, and the techniques used for tissue acquisition.

RESULTS

The incidence of MPLs in our cohort was 3.53%, with the most frequent primary tumors originating in the kidney (43.90%), colorectum (9.76%), lung (9.76%), lymphoma (9.76%), and breast (4.88%). MPLs typically presented as hypoechoic, oval-shaped lesions with well-defined borders and were predominantly hypervascular. Interestingly, 68.29% of the cases were discovered incidentally during follow-up of the primary tumors, while the involvement of the common bile duct was uncommon (19.51%).

CONCLUSIONS

EUS and EUS-FNA/B have been validated as valuable diagnostic tools for identifying MPLs. While our findings are promising, further multicenter studies are necessary to corroborate these results and elucidate the predictive value of specific EUS characteristics in determining the metastatic origin of pancreatic lesions.

Metastases to pancreas diagnosed by endoscopic ultrasound-guided fine-needle aspiration: A case series and review of imaging and cytologic features

Fine-needle aspiration (FNA) is ideal for the diagnosis of pancreatic neoplasms with high precision. We described five cases of metastases to the pancreas, highlighting the importance of clinical data, imaging features and the use of immunocytochemistry to lead the diagnosis. We retrospectively searched our archives for metastatic neoplasm to the pancreas diagnosed with FNA performed with endoscopic ultrasound, over a 5-year period. Furthermore, we reviewed the literature for imaging and cytologic features. We described five cases of metastatic neoplasms, a renal cell carcinoma, a breast carcinoma, one leiomyosarcoma, a hepatocellular carcinoma, and ovarian serous carcinoma. All of them has history of primary malignancy and were confirmed with immunostains. All the patients were asymptomatic and identified the metastasis during the follow-up, except for the ovarian serous carcinoma were the patient had acute abdominal pain, and the most common imaging feature were the irregular borders. Although the metastases to pancreas are rare, its important to always have the history of the patient, imaging features, and the suspicion at the moment of the evaluation of the smears and cell-block, because the management and prognostic its different compared to primary malignancies.

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.

Solitary pancreatic metastasis from squamous cell lung carcinoma: A case report and review of literature

BACKGROUND

Pancreatic metastases from squamous cell lung carcinoma (SCLC) are unusual. These lesions are often asymptomatic and detected incidentally or during follow-up investigations, occasionally several years after removal of the primary tumor.

CASE SUMMARY

A 56-year-old male with SCLC developed jaundice 1 mo after the cancer diagnosis. An abdominal computed tomography (CT) scan showed a mass in the pancreatic head with distention of both intra- and extrahepatic biliary ducts. Endoscopic retrograde cholangiopancreatography and sphincterotomy were performed first, culminating with plastic biliary stent placement. Cytological examination of the pancreatic mass sample collected by fine-needle aspiration (FNA) under endoscopic ultrasound (EUS) guidance revealed the presence of malignant cells compatible with well-differentiated squamous cell carcinoma. After liver function normalized, chemotherapy was initiated with carboplatin and paclitaxel; however, 4 d later, the patient presented dysphagia. Cervico-thoraco-abdominal CT showed tracheoesophageal fistula and stent migration. After replacement with a 10 cm/10 mm uncovered metallic biliary stent and treatment of the tracheoesophageal fistula with a fully covered esophageal stent, the patient was able to start oral feeding progressively. He died 9 mo after the initial diagnosis.

CONCLUSION

The diagnosis of pancreatic metastasis from SCLC is challenging for clinicians. EUS-FNA is the primary exam for confirmatory diagnosis.

An exceptionally rare case of metastatic high-grade urothelial carcinoma of the renal pelvis to the pancreas diagnosed on endoscopic ultrasound-guided fine-needle aspiration: A diagnostic challenge

Metastases to the pancreas are rare and can be confused with the primary adenocarcinoma of the pancreas. Metastasis of renal pelvis urothelial carcinomas to the pancreas are extremely rare. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) biopsy is a very safe and effective diagnostic method. In this study, we present a 65-year-old male patient with a solitary mass in the pancreas. A moderate cellular tumoral lesion was observed in the aspiration cytology performed from the 55-millimeter solid mass invading the head of the pancreas via EUS-FNA. Tumor cells consisted of cells with irregular borders, different shapes and sizes, hyperchromatic, narrow cytoplasm with dark nuclei, and cells with anisonucleosis in focal areas. Cellblock obtained from aspirated was found diffusely positive with high molecular weight cytokeratin, Thrombomodulin, p63, GATA-3, and CK7, and negative with CK20, PAX8, and PSA. Having a primary malignancy in the medical history of the patients is very important in the differential diagnosis of primary and secondary pancreatic cancers. The potential for metastasectomy in pancreatic metastases can be applied in cases with isolated metastatic disease. Primary tumor histopathology may have an impact on the long-term survival of the case. This study aimed to describe the cytomorphological features of solid and solitary pancreatic malignancies and to evaluate the role of immunohistochemistry performed from aspirate cell block in detecting the primary tumor origin.

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.

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.

Case report of oxalate nephropathy in a patient with pancreatic metastases from renal carcinoma

BACKGROUND

Patients with metastatic renal carcinoma frequently have pre-existing renal impairment and not infrequently develop worsening renal function as a complication of their treatment. The presence of pancreatic metastases in patients with metastatic renal carcinoma, often confers a more favourable prognosis and as a consequence this patient group may be exposed to such treatments for more prolonged periods of time. However, the development of renal failure may also be a consequence of the cancer itself rather than its treatment.

CASE PRESENTATION

We present an 84-year-old patient receiving the tyrosine kinase inhibitor (TKI) pazopanib for metastatic renal carcinoma who developed oxalate nephropathy as a consequence of pancreatic exocrine insufficiency resulting from pancreatic metastases.

CONCLUSIONS

This case demonstrates the importance of investigating unexpected toxicities and highlights the potential consequences of pancreatic insufficiency and its sequelae in patients with pancreatic metastases.

Endoscopic Ultrasonography-guided Fine-needle Aspiration Revealed Metastasis-induced Acute Pancreatitis in a Patient with Adrenocortical Carcinoma

A 26-year-old woman complained of upper abdominal pain. Computed tomography (CT) showed acute pancreatitis, a left adrenal tumor and solitary right pulmonary metastasis. She underwent left adrenalectomy; the adrenal tumor was diagnosed as adrenocortical carcinoma (ACC). When preparing to resect the pulmonary metastasis, she suffered a second acute pancreatic attack. Magnetic resonance cholangiopancreatography (MRCP) showed that the proximal main pancreatic duct (MPD) was dilated, and the distal MPD was diminished; however, no pancreatic tumor was observed on CT or MRCP. Endoscopic ultrasonography revealed a solitary pancreatic mass, which was diagnosed as pancreatic metastasis from ACC by endoscopic ultrasonography-guided fine-needle aspiration.

Pancreatic Cytology

The diagnostic approach to pancreaticobiliary disease requires a multidisciplinary team in which the cytopathologist plays a crucial role. Fine-needle aspiration, obtained by endoscopic ultrasound, is the diagnostic test of choice for pancreatic lesions. Preoperative clinical management depends on many factors, many of which rely on accurate cytologic assessment. Pancreaticobiliary cytology is wrought with diagnostic pitfalls. Clinical history, imaging studies, cytology samples, and ancillary tests, including immunohistochemistry, biochemical analysis, and genetic sequencing, are integral to forming a complete diagnosis and guiding optimal patient management. This article reviews clinical aspects and the diagnostic work-up of commonly encountered diagnostic entities within the field of pancreatic cytology.

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.

Analysis of Prognostic Factors in Pancreatic Metastases: A Multicenter Retrospective Analysis

OBJECTIVES

Pancreatic metastases (PMs) account for 1% to 2% of pancreatic tumors, and their prognostic significance is poorly defined. We evaluated the incidence and clinical characteristics of primary tumors and defined prognostic factors.

METHODS

This retrospective study of 39 Japanese tertiary referral hospitals (January 2005 to August 2015) analyzed patient and tumor characteristics and survival time. Kaplan-Meier analysis and Cox proportional hazards models were applied to evaluate overall survival and prognostic factors, respectively.

RESULTS

We enrolled 159 patients with a pathologic diagnosis of PM. The most common primary tumor was renal cell carcinoma (38.4%), followed by lung cancer (24.5%), colorectal cancer (11.3%), and sarcoma (6.3%). Eight patients were lost during follow-up, and 151 patients were included for statistical analysis. Median overall survival was 43.0 months, and the 5-year survival rate was 42.6%. Multivariate analysis identified 3 independent prognostic factors: extrapancreatic metastasis (hazard ratio, 2.13; 95% confidence interval, 1.11-4.07; P = 0.02), tumor-related symptoms at diagnosis (hazard ratio, 5.39; 95% confidence interval, 2.92-9.91; P < 0.001), and pathologic diagnosis of primary tumors (P < 0.001).

CONCLUSIONS

Treatment strategies and prognoses for PMs completely differ according to the primary tumor type. A definitive pathologic diagnosis of PMs is essential for selecting the appropriate treatment.

Asymptomatic Pancreatic Metastasis from Renal Cell Carcinoma Diagnosed 21 Years after Nephrectomy

This report presents our experience with a case of pancreatic metastasis of renal cell carcinoma (RCC) at a long-term follow-up after nephrectomy. A 73-year-old man underwent nephrectomy for right RCC 21 years ago; computed tomography (CT) scanning on routine follow-up revealed a solid mass in the tail of the pancreas, and magnetic resonance imaging (MRI) showed some tumors in the head and tail of the pancreas. The patient was asymptomatic and allergic to contrast medium. Therefore we could not perform contrast CT/MRI for further examination to diagnose pancreatic tumors. We undertook endoscopic ultrasonography (EUS) and detected a hypervascular and low echoic mass; tumor tissues were obtained by EUS-guided fine-needle aspiration (EUS-FNA). Pathological diagnosis revealed pancreatic metastasis of clear cell RCC; this was similar to the pathological findings of tumor tissues initially obtained by nephrectomy. EUS-FNA was extremely useful for the definitive diagnosis of a rare type of pancreatic tumor.

Clinical diagnosis and detection of genetic mutations of pancreatic metastases: A report of four cases and review of the literature

The present study aimed to report our clinical experience regarding the diagnosis and detection of genetic mutations of pancreatic metastases, and to review the relevant literature to expand knowledge of this disease. A total of 4 cases involving pancreatic metastases, which were treated at The First Affiliated Hospital of Soochow University between January 2013 and July 2016, were retrospectively analyzed. This retrospective study considered the clinicopathological variables of the 4 patients, and compared this data with those from the literature, which was searched using PubMed, EMBASE and the Cochrane Library. All 4 patients with pancreatic metastases were diagnosed by computed tomography (CT) scan and confirmed by pathological staining and immunohistochemistry. Mutation analysis was performed in 3 patients to obtain precise mutation information for guiding and evaluating the use of molecularly targeted drugs. In summary, pancreatic metastases are rare and the majority of pancreatic metastases develop from renal cell carcinoma. Diagnoses of pancreatic metastases predominantly rely on CT, pathology and immunohistochemistry. Detection of mutations has clinical value in auxiliary diagnosis and therapy of pancreatic metastases. Based on mutation information, molecularly targeted drugs may prolong the survival of patients with unresectable pancreatic metastases.

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.

An Unusual Case of Pancreatic Metastasis from Squamous Cell Carcinoma of the Lung Diagnosed by EUS-Guided Fine Needle Biopsy

We report a case of a 70-year-old man who presented with abdominal pain and weight loss, with initial imaging showing simultaneous mass lesions in the pancreas and lungs along with extensive lymphadenopathy in the thorax up to the left supraclavicular region. Core biopsies of the left supraclavicular lymph node showed squamous cell carcinoma, which required differentiation between secondary and primary pancreatic neoplasms. Endoscopic ultrasound-guided sampling using a novel fine needle biopsy system was key to making a definite histological diagnosis and determining the best treatment plan.

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 Metastasis from Rectal Cancer that was Diagnosed by Endoscopic Ultrasonography-guided Fine Needle Aspiration (EUS-FNA)

Pancreatic metastasis from colorectal cancer is rare, and there have been only a few reports of its preoperative diagnosis by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) with immunohistochemical staining. We herein describe the case of a 77-year-old woman in whom a solitary mass in the pancreatic tail was detected 11 years after rectal cancer resection. The patient also had a history of pulmonary tumor resection. We performed EUS-FNA and a histopathological examination showed adenocarcinoma with CD20+, CD7-, and CDX2+ (similar to her rectal cancer). EUS-FNA enabled a histopathological examination, including immunohistochemical staining, which helped to confirm the diagnosis of pancreatic and pulmonary metastasis from rectal cancer.

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.

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

BACKGROUND

Pancreatic masses may seldom represent a metastasis or secondary involvement by lymphoproliferative disorders. Recognition of this uncommon occurrence may help render an accurate diagnosis and avoid diagnostic pitfalls during endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). In this study, we review our experience in diagnosing secondary tumors involving the pancreas.

MATERIALS AND METHODS

The electronic database of cytopathology archives was searched for cases of secondary tumors involving the pancreas at our institution and a total of 31 cases were identified. The corresponding clinical presentations, imaging study findings, cytological diagnoses, the results of ancillary studies, and surgical follow-up, if available, were reviewed.

RESULTS

Nineteen of the patients were male and 12 female, with a mean age of 66 years. Twenty-three patients (74%) had a prior history of malignancy, with the latency ranging from 6 months to 19 years. The secondary tumors involving the pancreas included metastatic carcinoma (24 cases), metastatic sarcoma (3 cases), diffuse large B-cell lymphoma (2 cases), and plasma cell neoplasm (2 cases). The most common metastatic tumors were renal cell carcinoma (8 cases) and lung carcinoma (7 cases). Correct diagnoses were rendered in 29 cases (94%). The remaining two cases were misclassified as primary pancreatic carcinoma. In both cases, the patients had no known history of malignancy, and no ancillary studies were performed.

CONCLUSIONS

Secondary tumors involving the pancreas can be accurately diagnosed by EUS-FNA. Recognizing uncommon cytomorphologic features, knowing prior history of malignancy, and performing ancillary studies are the keys to improve diagnostic performance and avoid diagnostic pitfalls.

Endoscopic Ultrasonography-Guided Biopsy for Differentiation of Benign and Malignant Pelvic Lesions: A Systematic Review and Meta-Analysis

BACKGROUND

Preoperative diagnosis of pelvic lesions remains challenging despite advances in imaging technologies. Endoscopic ultrasonography (EUS)-guided biopsy is an effective diagnostic modality for sampling the digestive tract and surrounding areas. However, a meta-analysis summarizing the diagnostic efficacy of EUS-guided biopsy for pelvic lesions has not been published.

AIMS

We aimed to evaluate the utility of EUS-guided biopsy in the diagnosis of pelvic lesions.

METHODS

Articles were identified via structured database search; only studies where pelvic lesions were confirmed by surgery or clinical follow-up were included. Data extracted were selected with strict criteria. A fixed-effects model was used to estimate the sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR). A summary receiver operating characteristic curve (SROC) was also constructed.

RESULTS

Ten studies containing a total of 246 patients were included. The pooled sensitivity of EUS-guided biopsy for differential diagnosis of pelvic masses was 0.89 (95% CI 0.83-0.94), and the specificity was 0.93 (95% CI 0.86-0.97). The area under the SROC was 0.9631. The combined PLR, NLR, and DOR were 11.75 (95% CI 5.90-23.43), 0.12 (95% CI 0.07-0.20), and 100.06 (95% CI 37.48-267.10) respectively. There is potential presence of publication bias in this meta-analysis.

CONCLUSIONS

Our meta-analysis shows that EUS-guided biopsy is a powerful tool for differentiating pelvic masses with a high sensitivity and specificity. Furthermore, it is a safe procedure with low rate of complication, although more high-quality prospective studies are required to be done.

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.

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.

Endoscopic Ultrasound in the Diagnosis and Staging of Pancreatic Cancer

Pancreatic cancer is one of the digestive cancers with the poorest prognosis, so an early and correct diagnosis is of utmost importance. With the development of new therapeutic options an accurate staging is essential. Endoscopic ultrasonography (EUS) has a major role in all stages of the management of these patients. EUS has a high accuracy in the diagnosis of pancreatic adenocarcinoma and the possibility to perform fine-needle aspiration/biopsy (FNA/FNB) increases the diagnostic yield of EUS. There is still no consensus on the several technical aspects of FNA, namely on the rapid on-site evaluation (ROSE), the diameter and type of needle, the number of passes and the use of stylet and suction. Contrast-enhanced EUS (CE-EUS) and EUS elastography (EUS-E) have been used in recent years as an adjunct to EUS-FNA. Given the higher sensitivity of these techniques a negative cytology by EUS-FNA should not exclude malignancy when CE-EUS and/or EUS-E are suggestive of pancreatic neoplasia. EUS remains one of the main methods in the staging of pancreatic adenocarcinoma, namely to further evaluate patients with non-metastatic disease that appears resectable on initial imaging. EUS is crucial for an accurate preoperative evaluation of pancreatic cancer which is essential to choose the correct management strategy. The possibility to obtain samples from suspicious lesions or lymph nodes, by means of EUS-guided fine-needle aspiration as well as the use of contrast-enhanced and elastography, makes EUS an ideal modality for the diagnosis and staging of pancreatic cancer.

Diagnostic ability of EUS-FNA for pancreatic solid lesions with conventional 22-gauge needle using the slow pull technique: a prospective study

OBJECTIVE

Endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) using the slow pull technique (SP-FNA) has recently attracted attention as an effective tissue acquisition technique. However, efficacy of SP-FNA with a 22-gauge conventional needle remains unclear. The aim of this study is to evaluate the diagnostic ability of SP-FNA with a 22-gauge needle.

MATERIAL AND METHODS

Patients with a pancreatic solid lesion were prospectively enrolled in this study. SP-FNA was performed at two needle passes with a 22-gauge needle. One dedicated pathologist evaluated the obtained samples in terms of quantity (Grade 0: scant; Grade 1: inadequate; Grade 2: adequate), quality (Grade 0: poor; Grade 1: moderate; Grade 2: good), and blood contamination (Grade 0: significant; Grade 1: moderate; Grade 2: low), and provided a pathological diagnosis. Additional EUS-FNA was performed by applying suction (SA-FNA). The evaluation points were as follows: diagnostic accuracy of SP-FNA compared with that of SA-FNA, and the quantity, quality, and blood contamination level of SP-FNA-obtained samples.

RESULTS

We enrolled 40 cases. The diagnostic accuracy of SP-FNA was 90% (36/40). There was no significant difference in the accuracy between SP-FNA and SA-FNA (90% vs. 90%, p = 1.000). The samples obtained using SP-FNA were assessed as Grade 2 for quantity in 29 cases (73%), quality in 31 (78%), and blood contamination in 25 (63%).

CONCLUSIONS

Adequate, high-quality, and unsubstantially blood-contaminated samples could be obtained using SP-FNA. The diagnostic ability of SP-FNA was 90%, which appeared to be similar to that of SA-FNA.

Metastases to the Pancreas: Computed Tomography Imaging Spectrum and Clinical Features: A Retrospective Study of 18 Patients With 36 Metastases

The aim of this study is to identify the key computed tomography (CT) imaging findings and clinical characteristics of pancreatic metastases for its differential diagnosis. CT images and clinical features of 18 patients with 36 histopathologically proven pancreatic metastases were retrospectively reviewed. The primary malignancy included non-small cell lung cancer (NSCLC) (n = 7), gastrointestinal carcinoma (n = 5), renal cell carcinoma (RCC) (n = 3), osteosarcoma (n = 1), cardiac sarcomas (n = 1), and neuroendocrine ethmoid sinus carcinoma (n = 1). Pancreatic metastases were metachronous in 12 patients (ranging from 4 to 72 months). Tumor markers were elevated for 8 patients, of which 7 patients had NSCLC and gastrointestinal carcinoma, and 1 patient had osteosarcoma. Metastases from NSCLC and gastrointestinal carcinoma frequently presented as small well-circumscribed lesions, with homogeneous or rim enhancement, and or local pancreatic infiltration instead of focal mass, mimicking local pancreatitis. Neuroendocrine ethmoid sinus carcinoma affecting the pancreas also exhibited local pancreatic infiltration. Metastases from RCC and cardiac sarcomas had typical characteristics of hypervascular lesions. Osteosarcoma metastasizing to pancreas had special manifestation, that is, cystic lesion with thick wall and calcification. Although pancreatic metastases have a broad spectrum of CT appearances, lesions from some types of primary tumors exhibited characteristic imaging features, which, in combination with oncological history, will contribute to correct diagnosis.

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.

Diagnosis of Metastatic Renal Cell Carcinoma on Fine-Needle Aspiration Cytology

Fine-needle aspiration has assumed an increasingly important role in the diagnosis and management of patients with advanced stage cancer. Given its predilection for metastases to distant sites and organs at the time of presentation, metastatic renal cell carcinoma (RCC) is not infrequently encountered in the setting of fine-needle aspiration for initial diagnosis. In some instances, fine-needle aspiration may be the only opportunity to obtain diagnostic tissue to diagnose and subclassify RCC. Therefore, cytopathologists and cytotechnologists should be familiar with and recognize the cytomorphology of RCC and the ancillary studies that can be used to confirm and subclassify RCC. Herein, we describe a case of metastatic RCC initially diagnosed on fine-needle aspiration, discuss the cytomorphologic features of RCC subtypes, and review pertinent ancillary immunohistochemical and cytogenetic adjuncts.

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.

How good is fine needle aspiration? What results should you expect?

Tissue acquisition plays a key role before treatment decision in most of oncological pathologies but also in several benign diseases. By offering tissue sampling, endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has become an essential tool in the diagnostic processes. One of the reasons for the success of the technique is related to its excellent diagnostic performance. The diagnostic accuracy of EUS-FNA is above 80% for most of the usual indications. These performances are however dependent on some factors related to both the disease and patient's medical history but also related to medical staff expertise. Endoscopist needs to know how to reach a lesion but also how to efficiently acquire good tissue samples. This review aims to report general recommendations available in the literature for high quality EUS-FNA. Sample processing and sample interpretation also influence diagnostic accuracy of FNA. This paper includes a discussion on sample processing and benefits of the on-site pathology examination. It also provides the results reported in the literature of sample adequacy and diagnostic performance of EUS-FNA for most common indications: Pancreatic diseases, sub-mucosal lesion, mucosal thickenings, lymph nodes, cystic lesion and free fluids.

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.

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.