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A pancreatic metastasis from a colon carcinoma mimicking a primary tumor diagnosed by EUS-guided fine-needle biopsy


1 Gastroenterology and Digestive Endoscopy Unit, Candiolo Cancer Institute, FPO - IRCCS, Candiolo, Torino, Italy
2 Pathology Unit, Candiolo Cancer Institute, FPO - IRCCS, Candiolo, Torino, Italy
3 Surgical Oncology Department, Candiolo Cancer Institute, FPO - IRCCS, Candiolo, Torino, Italy

Date of Submission19-Aug-2021
Date of Acceptance29-Nov-2021
Date of Web Publication21-Mar-2022

Correspondence Address:
Stefano Rizza,
Gastroenterology and Digestive Endoscopy Unit, Candiolo Cancer Institute, FPO - IRCCS, Candiolo, Torino
Italy
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/EUS-D-21-00186

PMID: 35313422



How to cite this URL:
Rizza S, Maldi E, Laudi C, Mellano A, Pisacane A, Staiano T. A pancreatic metastasis from a colon carcinoma mimicking a primary tumor diagnosed by EUS-guided fine-needle biopsy. Endosc Ultrasound [Epub ahead of print] [cited 2022 May 22]. Available from: http://www.eusjournal.com/preprintarticle.asp?id=340253

Pancreatic metastases are rare (2% of pancreatic neoplasms)[1] and only 1.3% originate from colorectal cancer (CRC).[2] As documented, they can appear long after the initial surgery and primary cancer most frequently associated is renal cell carcinoma.[3],[4],[5],[6] A histopathologycal preoperative diagnosis is very challenging.

A 66-year-old male underwent a left hemicolectomy (and then subtotal colectomy for complications) in urgency for an intestinal obstruction of neoplastic origin. Histological examination revealed an ulcerated CRC with a 10% mucinous component (Stage IIIb: pT4aN1M0). Four months later, a computed-tomography (CT) described liver metastases in three liver segments (S) which, after neoadjuvant chemotherapy, were treated with atypical resections.

After 18 months, an 18-fluoro-2-deoxy glucose positron emission tomography/CT (PET/CT) showed uptake in S6 and S8 and in the pancreatic tail. Oncologists decided to perform second-line chemotherapy and a further staging PET-CT revealed a partial response in S8. CT confirmed liver metastasis in S6 and a hypodense lesion of 26 mm of the pancreatic tail, uncertain whether primary or secondary [Figure 1].
Figure 1: Abdominal computed tomography showing a hypodense lesion of the pancreatic tail, in close proximity to posterior gastric wall

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Multidisciplinary team indicated EUS-guided fine-needle biopsy (EUS-FNB). EUS showed a lesion of the pancreatic tail measuring 24 mm × 21 mm, hypoechoic and inhomogeneous, with poorly defined margins, hypovascularized even after administration of contrast medium (Sonovue), of hard consistency on elastosonography, close to the splenic vessels and the posterior gastric wall. The main pancreatic duct was regular [Figure 2]. Based on these findings it was difficult to distinguish whether it was primary or secondary. FNB was performed using a 25-G needle (SharkCore®, Beacon Endoscopic/Medtronic, Newton, MA, USA). Sufficient specimens were obtained after 3 passes. The histopathological and immunohistochemical analysis described the presence of adenocarcinoma and revealed cytokeratin-20 (CK20) and caudal-type homeobox transcription factor-2 (CDX2) positive with CK7 negative, morphologically similar to primary colon cancer cells [Figure 3]. Thus, we reached a final diagnosis of metachronous pancreatic metastasis from CRC and the patient will be discussed for subsequent treatment (chemotherapy or surgery).
Figure 2: EUS showing the lesion of the pancreatic tail appearing hypoechoic and inhomogeneous, with poorly defined margins (a), hypovascularized, hard on elastosonography (b); fine-needle biopsy (NFB) (c)

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Figure 3: Histological section (Hematoxylin and Eosin stain) of the pancreatic metastasis (a) and immunohistochemistry showing cytokeratin-20 and caudal-type homeobox transcription factor-2 (CDX2) positive (b and c) with cytokeratin-7 negative (d)

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EUS-FNB is a fundamental diagnostic tool: it allowed to preoperatively characterize a rare pancreatic lesion, overcoming the limits of imaging alone, so as to discuss the best therapeutic strategy, considering the overall patient's medical history.

Financial support and sponsorship

Nil.

Conflicts of interest

The authors declare no conflict of interest.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.



 
  References Top

1.
Cortez N, Berzosa M, Mahfouz M, et al. Diagnosis and treatment of metastatic disease to the pancreas. J Laparoendosc Adv Surg Tech A 2020;30:1008-12.  Back to cited text no. 1
    
2.
Tani R, Hori T, Yamada M, et al. Metachronous pancreatic metastasis from rectal cancer that masqueraded as a primary pancreatic cancer: A rare and difficult-to-diagnose metastatic tumor in the pancreas. Am J Case Rep 2019;20:1781-7.  Back to cited text no. 2
    
3.
Sano I, Katanuma A, Yane K, et al. Pancreatic metastasis from rectal cancer that was diagnosed by endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA). Intern Med 2017;56:301-5.  Back to cited text no. 3
    
4.
Sekulic M, Amin K, Mettler T, et al. Pancreatic involvement by metastasizing neoplasms as determined by endoscopic ultrasound-guided fine needle aspiration: A clinicopathologic characterization. Diagn Cytopathol 2017;45:418-25.  Back to cited text no. 4
    
5.
Okasha HH, Pawlak KM, Żorniak M, et al. EUS in the evaluation of metastatic lesions to the pancreas. Endosc Ultrasound 2020;9:147-50.  Back to cited text no. 5
    
6.
Carbonari AP, Assef MS, Nakao FS, et al. Pancreatic metastasis from colon carcinoma diagnosed by endoscopic ultrasound fine needle aspiration. Endosc Ultrasound 2013;2:109-11.  Back to cited text no. 6
    


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