The finding of gastric metachronous metastasis, several years after the diagnosis of primary lung large cell carcinoma is rare and incidental. Even more extremely rare is the finding of a synchronous primary pancreas cancer. EUS-FNA with immunohistochemistry is useful for diagnosing metastatic lesions and differentiating those from synchronous primary lesions

El Hajj, Ihab I.

Lawrence, Karen A.

Shahda, Safi

Sherman, Stuart

Tirkes, Temel

English

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1368  |    Clin Case Rep. 2018;6:1368–1370.wileyonlinelibrary.com/journal/ccr31 |  CASE DESCRIPTIONA 59- year- old man presented with eight- week history of nausea, abdominal pain, and 20- lbs weight loss. Two years prior to the current presentation, the patient was  diagnosed with a stage T1A nonsmall cell lung cancer of the right upper lobe (large cell carcinoma) and his initial staging Positron Emission Tomography and Computed Tomography (PET- CT) was negative except for the above- mentioned lesion. The patient refused surgery at the time and completed Stereotactic Body Radiation Therapy (SBRT). His serial six- month interval surveillance imag-ing has been negative.With his prior history of cancer and the current presenta-tion, a total body PET- CT was ordered. This showed thick-ening of the wall of the gastric fundus, a mass in the tail of the pancreas (both with increased radiotracer uptake), and a Received: 16 December 2017 | Revised: 15 April 2018 | Accepted: 16 April 2018DOI: 10.1002/ccr3.1571C L I N I C A L  I M A G EMetachronous gastric metastasis from lung primary, with synchronous pancreatic neuroendocrine carcinomaIhab I. El Hajj1,2  | Karen A. Lawrence3 | Temel Tirkes4 | Safi Shahda5 |  Stuart Sherman1This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the  original work is properly cited.© 2018 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.1Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA2Division of Gastroenterology, Saint George Hospital University Medical Center, University of Balamand, Beirut, Lebanon3Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA4Department of Radiology, Indiana University School of Medicine, Indianapolis, IN, USA5Division of Hematology/Oncology, Indiana University School of Medicine, Indianapolis, IN, USACorrespondenceIhab I. El Hajj, Indiana University School of Medicine, Indianapolis, IN, USA.Email: ihabelhajj@hotmail.comKey Clinical MessageThe finding of gastric metachronous metastasis, several years after the diagnosis of primary lung large cell carcinoma is rare and incidental. Even more extremely rare is the finding of a synchronous primary pancreas cancer. EUS- FNA with immunohis-tochemistry is useful for diagnosing metastatic lesions and differentiating those from synchronous primary lesions.K E Y W O R D Sendoscopic ultrasound, gastric metastasis, lung cancer, neuroendocrine carcinoma, pancreatic cancerF I G U R E  1  PET- CT image showing thickening of the wall of the gastric fundus, a mass in the tail of the pancreas (both with increased radiotracer uptake), and a 1.1- cm filling defect within the splenic vein   | 1369EL HAJJ Et AL.1.1- cm filling defect within the splenic vein consistent with thrombus (Figure 1). Upper endoscopy showed a 5- cm infil-trative and ulcerated mass with heaped- up margins and ne-crotic center located in the gastric fundus (Figure 2). Gastric biopsies showed poorly differentiated carcinoma (positive TTF1 and cytokeratin AE1- 3, negative CDX- 2) (Figure 3), suggestive of metachronous metastasis from a lung primary. Endoscopic ultrasound (EUS) was performed and showed a 26 mm × 23 mm hypoechoic round mass in the tail of the pancreas with local vascular involvement and splenic vein thrombus (Figure 4). EUS- guided fine needle aspiration (FNA) and fine needle biopsy (FNB) of the mass was per-formed through the gastric lumen (away from the gastric tumor to avoid tumor contamination or seeding by the needle tract). This confirmed neuroendocrine carcinoma (positive synaptophysin and chromogranin, positive Ki- 67 and CDX- 2, negative TTF1) (Figure 3). Findings were suggestive of synchronous primary pancreatic neuroendocrine carcinoma. Treatment options were discussed with the patient and his family. Patient opted for palliative care and received symp-tomatic treatment.Metastasis of primary lung tumor to the stomach is infrequent and sporadic.1 The pathogenesis is thought to be related to the tumor cell spread via the hematoge-nous and lymphatic routes, but there is no specific data demonstrating a particular tropism for a segment of the gastrointestinal (GI) tract.1 Only 21 sporadic cases have been reported in the English literature and involved dif-ferent malignant cell types: squamous cell carcinoma (10 cases), adenocarcinoma (6 cases), small cell carcinoma (2 cases), pleomorphic (2 cases), and large cell carcinoma (1 case).2 Symptomatic cases presented with epigastric pain, chronic anemia, signs of GI bleed (hematemesis, melena), and gastric perforations (in two cases). The definite role of F I G U R E  2  Endoscopy image showing a 5- cm infiltrative and ulcerated mass with heaped- up margins and necrotic center in the gastric fundusF I G U R E  3  Fine needle aspirate (FNA) of the tail of pancreas mass exhibits loosely cohesive groups of cells with high nuclear/cytoplasmic ratios and nuclear molding (Diff Quik, x40). Gastric biopsy exhibits sheets of closely packed cells with vesicular nuclei and scant to absent cytoplasm (H&E, x20)F I G U R E  4  EUS image showing a 26 mm × 23 mm hypoechoic round mass in the tail of the pancreas with local vascular involvement and splenic vein thrombus1370 |   EL HAJJ Et AL.PET- CT in the diagnosis of GI metastasis from lung can-cer is still controversial because of the few cases and lack of enough clinical data.1 EUS- FNA in combination with immunohistochemistry is useful for diagnosing metastatic lesions and differentiating those from synchronous primary lesions.3,4CONFLICT OF INTERESTNone declared.CONSENTInformed consent was obtained for this case report.AUTHORSHIPIE and SS: involved in management of the patient. TT: re-viewed the radiology images. KL: reviewed the cyotology and pathology slides. All authors were involved in revision of the manuscript and approval of the final draft.ORCIDIhab I. El Hajj  http://orcid.org/0000-0001-5835-7940 REFERENCES1. Yang CJ, Hwang JJ, Kang WY, et al. Gastro- intestinal metastasis of primary lung carcinoma: clinical presentations and outcome. Lung Cancer. 2006;54:319‐323.2. Azar I, Koutroumpakis E, Patel R, Mehdi S. Squamous cell lung carcinoma presenting as melena: a case report and review of the literature. Rare Tumors. 2017;9:7164.3. Yamao K, Kitano M, Kudo M, Maenishi O. Synchronous pancreatic and gastric metastasis from an ovarian adenocarcinoma diagnosed by endoscopic ultrasound- guided fine- needle aspiration. Endoscopy. 2015;47(Suppl 1):UCTN:E596-7.4. Sileri P, D’Ugo S, Del Vecchio Blanco G, et al. Solitary metachro-nous gastric metastasis from pulmonary adenocarcinoma: report of a case. Int J Surg Case Rep. 2012;3:385‐388.How to cite this article: El Hajj II, Lawrence KA, Tirkes T, Shahda S, Sherman S. Metachronous gastric metastasis from lung primary, with synchronous pancreatic neuroendocrine carcinoma. Clin Case Rep. 2018;6:1368–1370. https://doi.org/10.1002/ccr3.1571

Metachronous gastric metastasis from lung primary, with synchronous pancreatic neuroendocrine carcinoma

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Metachronous gastric metastasis from lung primary, with synchronous pancreatic neuroendocrine carcinoma

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