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.
Metastatic tumors in the pancreas are uncommon, and most cases are difficult to distinguish from a primary pancreatic cancer. Accurate identification of isolated pancreatic metastases is critical in determining the best surgical and/or medical management [
A 70-year-old man presented with a three-month history of progressive abdominal pain and weight loss. His past medical history was unremarkable including no prior history of malignancy. On examination by his primary physician, he was alert and without jaundice or scleral icterus. He had mild epigastric tenderness on abdominal examination, and there were palpable lymph nodes in the left supraclavicular fossa. The remainder of his examination was unremarkable. Laboratory test results were all within normal limits including common blood cell counts, liver chemistries, and serum lipase. Transabdominal ultrasound showed a large distal pancreatic mass. CT scanning revealed a 3.8 cm hypodense mass in the pancreatic body with lymphadenopathy in the left supraclavicular region. It also showed a 3 cm lung mass posterior to the left main stem bronchus (Figure
Computed tomography. (a) A conglomerate of lymph nodes in the left supraclavicular fossa measuring 3 cm (arrow). (b) A 2 cm left mid lung mass posterior to the left main stem bronchus (arrow). (c and d) A 3.8 cm hypodense mass in the pancreatic body with associated ill-defined soft tissue inseparable from the distal celiac axis and its branches (arrow).
(a) Endoscopic ultrasound (EUS) demonstrating a 3 cm hypoechoic mass in the left lung. (b) EUS-guided fine needle biopsy (FNB) of the left lung nodule with a 25-gauge needle. (c) EUS demonstrating a 3.8 cm hypoechoic mass in the pancreatic body abutting the splenic artery. It shows the same internal echotexture as the lesion in the mediastinum. (d) EUS-FNB of the pancreatic mass with a 25-gauge needle.
(a) Hematoxylin and eosin staining of a specimen obtained from lung mass with EUS-guided fine needle biopsy. (b) Small core biopsy fragments show invasive carcinoma with clusters and cords of cells that show squamous morphology. (c and d) Immunostains showed that the neoplastic cells express p63 (c) and CK 5/6 (d).
(a) Hematoxylin and eosin staining of a specimen obtained from pancreatic mass with EUS-guided fine needle biopsy. (b) Biopsy fragments show invasive carcinoma morphologically similar to the carcinoma identified in the supraclavicular lymph node and the mediastinal mass. (c and d) Immunostains show that the neoplastic cells express p63 (c) and CK 5/6 (d).
Clinically apparent pancreatic metastases, while infrequent, are not rare, accounting for up to 3% of solid pancreatic lesions [
These metastatic lesions are usually asymptomatic or the symptoms are nonspecific. In many cases, the metastatic lesions are discovered incidentally and are mistaken for primary pancreatic tumors. There are no radiological findings that are pathognomonic of pancreatic metastases. On EUS evaluation, it is reported that metastatic lesions are more likely to have well-defined borders compared with primary pancreatic cancer, but, otherwise, EUS features cannot distinguish between the two groups [
The usefulness of EUS-guided tissue sampling in the diagnosis of pancreatic metastases has previously been reported [
In conclusion, although pancreatic metastases from squamous cell carcinoma of the lung are unusual, differentiation from primary pancreatic neoplasms is important. EUS-FNB can allow for a definite histological diagnosis and determination of the most appropriate treatment plan.
The authors declare that there are no conflicts of interest regarding the publication of this article.