Stacy Prall, D.O.Gastroenterology Fellow

Resident Research DayResident Research Day

Geisinger Medical CenterGeisinger Medical Center

May 18, 2007May 18, 2007

Endoscopic Ultrasound: A Useful Tool to Diagnose Masqueraders of Pancreatic Cancer

The role of endoscopic ultrasound (EUS) The role of endoscopic ultrasound (EUS) continues to expand. EUS combined with continues to expand. EUS combined with fine needle aspiration biopsy (EUS-FNAB) fine needle aspiration biopsy (EUS-FNAB) is becoming the preferred mode of staging is becoming the preferred mode of staging pancreatic, esophageal, and mediastinal pancreatic, esophageal, and mediastinal malignancies. EUS continues to gain favor malignancies. EUS continues to gain favor in distinguishing between pancreatic lesions in distinguishing between pancreatic lesions and extra-intestinal lymphomas specifically and extra-intestinal lymphomas specifically peripancreatic, ampullary, and periduodenal peripancreatic, ampullary, and periduodenal masses. The aforementioned lesions often masses. The aforementioned lesions often mimic pancreatic tumors on alternative mimic pancreatic tumors on alternative imaging modalities like CT scans. imaging modalities like CT scans.

According to the National Cancer Institute According to the National Cancer Institute (NCI) pancreatic cancer now represents the (NCI) pancreatic cancer now represents the fourth leading cause of cancer related death fourth leading cause of cancer related death in males and the fifth in females (in males and the fifth in females (http://seer.cancer.govhttp://seer.cancer.gov). Distinguishing ). Distinguishing between pancreatic malignancies and peri-between pancreatic malignancies and peri-intestinal malignancies is crucial for intestinal malignancies is crucial for treatment options and prognosis. treatment options and prognosis.

We report three cases of presumed We report three cases of presumed pancreatic masses referred to Geisinger pancreatic masses referred to Geisinger Medical Center for EUS diagnosis and Medical Center for EUS diagnosis and staging. EUS revealed extra-intestinal staging. EUS revealed extra-intestinal lymphoma in all 3 cases. lymphoma in all 3 cases.

Case 1

66 year old female presented with weight 66 year old female presented with weight loss and abdominal pain. CT done at loss and abdominal pain. CT done at outside hospital revealed 5.4 cm pancreatic outside hospital revealed 5.4 cm pancreatic head mass. EUS-FNAB demonstrated a head mass. EUS-FNAB demonstrated a paraduodenal mass in the region of the paraduodenal mass in the region of the pancreatic head consistent with follicular pancreatic head consistent with follicular lymphoma, grade 2. lymphoma, grade 2.

Case 2

47 year old male presented with abdominal 47 year old male presented with abdominal pain and weight loss. CT revealed pain and weight loss. CT revealed abnormally enlarged body and tail, fullness abnormally enlarged body and tail, fullness at the pancreatic head with encasement of at the pancreatic head with encasement of the splenic artery concerning for the splenic artery concerning for malignancy. malignancy.

Pancreatic body and tail abnormal enlargement, head prominent. Concerning for pancreatic malignancy

EUS FNA demonstrated peri-pancreatic lymphoma

Case 3

74 year old male presented with weight loss 74 year old male presented with weight loss and fevers. CT performed at outside and fevers. CT performed at outside hospital revealed a 4 cm lateral pancreatic hospital revealed a 4 cm lateral pancreatic head mass on CT. EUS with FNAB head mass on CT. EUS with FNAB revealed peripancreatic Non-Hodgkin’s B revealed peripancreatic Non-Hodgkin’s B cell lymphoma. cell lymphoma.

Data on EUS-FNA sensitivity, specificity, Data on EUS-FNA sensitivity, specificity, and accuracy in diagnosing lymphoma is and accuracy in diagnosing lymphoma is limited. Recent studies report EUS-FNA limited. Recent studies report EUS-FNA sensitivity and specificity to be 96-100%, sensitivity and specificity to be 96-100%, 77-95% in lymphomas.77-95% in lymphomas.11 The importance of The importance of cellular adequacy in diagnosing lymphoma cellular adequacy in diagnosing lymphoma is critical. is critical.

EUS coupled with FNAB affords the EUS coupled with FNAB affords the clinician an accurate minimally invasive clinician an accurate minimally invasive diagnostic technique. EUS-FNA sampling diagnostic technique. EUS-FNA sampling typically requires several needle passes to typically requires several needle passes to provide adequate sample size. In our cases provide adequate sample size. In our cases series all specimens were adequate for series all specimens were adequate for diagnosis. diagnosis.

Extra-intestinal lymphomas traditionally Extra-intestinal lymphomas traditionally required surgery or CT-FNAB for diagnosis required surgery or CT-FNAB for diagnosis and staging. EUS-FNAB appears poised to and staging. EUS-FNAB appears poised to replace this practice allowing for rapid replace this practice allowing for rapid accurate diagnosis upon which treatment accurate diagnosis upon which treatment can be based. The 3 patients in our case can be based. The 3 patients in our case series all received chemotherapy with good series all received chemotherapy with good clinical response 1 to 2 years from the time clinical response 1 to 2 years from the time of initial diagnosisof initial diagnosis

References

Pugh JL. Jhala NC. Eloubeidi MA. Chhieng DC. Pugh JL. Jhala NC. Eloubeidi MA. Chhieng DC. Eltoum IA. Crowe DR. Varadarajulu S. Jhala DN. Eltoum IA. Crowe DR. Varadarajulu S. Jhala DN. Diagnosis of deep-seated lymphoma and Diagnosis of deep-seated lymphoma and leukemia by endoscopic ultrasound-leukemia by endoscopic ultrasound-guided fine-needle aspiration biopsy.guided fine-needle aspiration biopsy. [Journal Article] [Journal Article] American Journal of Clinical American Journal of Clinical Pathology. 125(5):703-9, 2006 MayPathology. 125(5):703-9, 2006 May