Description:

A 67 yrs male diabetic patient was referred to us for the favor of EUS evaluation for a suspected pancreatic tumor on CT Scan, which showed a 4 cms lesion in the genu and body of pancreas. Patient did not have any jaundice and has undergone PET CT Scan which showed the mass in the pancreas without any obvious distant metastasis and therefore was scheduled for surgery by a leading oncosurgeon. 

However, patient was reluctant getting surgery done without tissue diagnosis and therefore the family physician referred this patient for an EUS sos guided FNA. EUS revealed an irregular hypoechoic mass in the genu of pancreas extending into the body of pancreas measuring 4.5 cms x 3.5 cms. The mass appeared to adherent to Splenic vein / Portal  vein confluence with few hypoechoic peritumorous nodes. There was minimal free fluid was seen in the perihepatic space ( 1-2 ml) and while examining the left lobe of liver on EUS we saw three subcentimeter hypoechoic lesions in the left lobe of liver which were completely missed on CT Scan as well as on PET CT Scan. 

In view of these findings, EUS guided FNA was then performed from the left lobe liver lesion and also from the primary tumor in the pancreas. The cytology report showed liver FNA to be metastatic adenocarcinoma and the pancreatic lesion also showed poorly differentiated adenocarcinoma. Thus, after these results the surgery was cancelled and patient was given an option of neoadjuvant therapy and symptomatic treatment.

Expert Comments

As we have seen in this case that on the basis of CT Scan and PET CT Scan the patient was considered resectable and was scheduled for surgery. However, due to EUS we were able to get tissue diagnosis not only from the primary mass but also from detected subcentimeter liver metastasis that were completely missed on CT Scan as well as PET CT Scan. This protocol allowed us to change the management strategy in this patient.

Take Home Message

Our experience of over 20,000 EUS procedures have taught us one lesson and that is whenever a tumor in pancreas seen resectable or unresectable on CT Scan and PET CT Scan it is worth

getting an EUS guided tissue diagnosis and accurate staging before a definitive surgery or neoadjuvant therapy. As we know that subcentimeter small liver metastasis and minimal ascites are usually difficult to detect on all conventional CT scans and PET CT scans at present. I am sure these are evolving protocols and in coming years when more efficient EUS centres will start in India, we will see this staging protocol implemented in routine practice.

Image:

1. EUS showed an irregular hypoechoic mass in the pancreatic body 

2. EUS Guided FNA of the pancreatic mass performed

3. A small 6 mm hypoechoic lesion seen in the left lobe of liver

4. EUS guided FNA of the left lobe liver 6 mm lesion performed, tip of the needle seen transgastric into the lesion on EUS