Neil Sharma, MD1, Sharwani Kota, BS2, Jay Krishnakurup, MD1
1Parkview Medical Center, Fort Wayne, IN; 2The College of New Jersey, Ewing, NJ
Introduction: We present a case of pancreatic NET was assessed by EUS guided FNB at our institution during 2018 presenting initially as an incidental cyst on cross sectional imaging. Further evaluation was performed via EUS after patient sought a second opinion. EUS imaging characteristics favored a solid mass rather than a cyst. FNB of a 9.0 mm x 10.5 mm in the head of the pancreas was performed.
Case Description/Methods: A 73 year old female was referred after having an incidental finding on recent CT and MRI indicating abnormal cyst in the head of the pancreas. Her symptoms included dyspepsia, fatigue, and dizziness. She has a past medical history of hypothyroidism, hypertension, hypercholesterolemia, gout, and neuropathy. Initial CT scan done showed an incidental cystic mass in the head of the pancreas which was “benign cyst versus cystic neoplasm,” and an MRI was recommended. Further evaluated through an MRI to be a “cystic neoplasm – possible IMPN. We performed a history and physical exam in the office and then proceeded with an EGD which showed esophageal candida confirmed by cold forceps biopsy that showed PAS and GMS stained positive for invasive fungi Candida esophagitis. We then proceeded with an EUS which revealed a hypoechoic, heterogeneous solid mass in the neck of the pancreas measuring 9.0 mm x 10.5 mm in size and in the head of the pancreas adjacent to the pancreatic duct. The mass was not cystic. The remainder of the pancreatic parenchyma without ductal dilation, normal biliary system, gallbladder, and liver. We performed EUS guided FNB rather than aspiration in order to obtain a large core of histologic tissue. Pathological analysis of the mass reveals a diagnosis of well-differentiated neuroendocrine tumor, grade 1 at a rate of less than 2 mitoses/2mm2. T1N0M0, grade 1 neuroendocrine tumor was confirmed at tumor board review.
Discussion: In conclusion, PNETS are increasing in incidence due to increased use of EUS and cross sectional imaging. Pancreatic cysts have also become a common incidental finding. The complexity arises in determining which cysts seen on cross sectional imaging require further evaluation. Some “cysts” or hypodense pancreatic structures on imaging may not be cystic in nature. EUS provides a greater sensitivity and specificity than high resolution CT scans, and allows for tissue sampling. The shift from EUS-FNA to EUS-FNB has allowed for improved tissue acquisition and true histology via EUS and disgnosis of even subcentimeter lesions.
Citation: Neil Sharma, MD; Sharwani Kota, BS; Jay Krishnakurup, MD. P0977 - BEWARE OF WHEN A PANCREATIC CYST IS NOT A CYST: ENDOSCOPIC ULTRASOUND GUIDED FNB OF NEUROENDOCRINE TUMOR IN THE PANCREAS. Program No. P0977. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.