Differential diagnosis of pancreatic lesions is really challenging, especially when the patient is diagnosed with primary cancer at another site. In this case report, we managed to histologically confirm pancreatic metastasis from squamous cell lung carcinoma, which is a very rare entity, using endoscopic ultrasound fine needle biopsy

Charalampos Pappas

Emmanouil Mastorakis

Evangelos Voudoukis

Georgios Kazamias

Ioannis Stoupis

Panagiotis Ieromonachou

GE Portuguese Journal of Gastroenterology

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Clinical Case StudyGE Port J Gastroenterol 2020;27:29–32A Rare Pancreatic Tail Metastasis from Squamous Cell Lung Carcinoma Diagnosed by EUS-FNB and a Small Review of the LiteratureIoannis Stoupis a    Evangelos Voudoukis b    Emmanouil Mastorakis c    Georgios Kazamias c    Panagiotis Ieromonachou d    Charalampos Pappas e    a Department of Internal Medicine, Division of Internal Oncology, Rethymnon General Hospital, Rethymnon, Greece; b Department of Gastroenterology, Venizeleion General Hospital of Heraklion, Rethymnon, Greece; c Department of Cytopathology, Venizeleion General Hospital of Heraklion, Rethymnon, Greece; d Department of Histopathology, Venizeleion General Hospital of Heraklion, Rethymnon, Greece; e Pneumonology Department, Rethymnon General Hospital, Rethymnon, GreeceReceived: December 9, 2018Accepted after revision: January 29, 2019Published online: April 1, 2019Ioannis StoupisDepartment of Internal Medicine, Division of Internal OncologyGeneral Hospital of Rethymnon, Trandalidou Street 17GR–74100 Rethymnon, Crete (Greece)E-Mail stigiannis @ gmail.com© 2019 Sociedade Portuguesa de GastrenterologiaPublished by S. Karger AG, BaselE-Mail karger@karger.comwww.karger.com/pjgDOI: 10.1159/000497387KeywordsLung cancer · Squamous cell · Pancreatic metastasis ·  EUS-FNBAbstractDifferential diagnosis of pancreatic lesions is really challeng-ing, especially when the patient is diagnosed with primary cancer at another site. In this case report, we managed to histologically confirm pancreatic metastasis from squamous cell lung carcinoma, which is a very rare entity, using endo-scopic ultrasound fine needle biopsy.© 2019 Sociedade Portuguesa de Gastrenterologia Published by S. Karger AG, BaselUm caso raro de metástase na cauda do pâncreas de carcinoma de células escamosas do pulmão por EUS-FNB e uma pequena revisão da literaturaPalavras ChaveCancro pulmão de células escamosas · Metástase pancreática · EUS-FNBResumoO diagnóstico diferencial de lesões pancreáticas é desafi-ante, especialmente quando o doente é diagnosticado com cancro primário noutro local. Neste caso clínico foi possível confirmar histologicamente o diagnóstico de metástase pancreática de carcinoma de células escamo-sas do pulmão, que se trata de uma entidade muito rara, através de punção com agulha fina ecoguiada por ecoen-doscopia. © 2019 Sociedade Portuguesa de Gastrenterologia Publicado por S. Karger AG, BaselIntroductionSecondary lesions in the pancreas are uncommon and difficult to discriminate from a primary pancreatic can-cer. An accurate diagnosis can provide the appropriate treatment to the patient. In this case, the patient had syn-chronous pancreatic metastasis originating from a pri-mary non-small cell lung cancer, and the pancreatic tu-mor was diagnosed using endoscopic ultrasound-guided fine needle biopsy (EUS-FNB). EUS has proven to be a safe and optimal diagnosing tool for evaluating pancre-atic tumors [1].This article is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND) (http://www.karger.com/Services/OpenAccessLicense). Usage and distribution for commercial purposes as well as any dis-tribution of modified material requires written permission.Stoupis/Voudoukis/Mastorakis/Kazamias/Ieromonachou/PappasGE Port J Gastroenterol 2020;27:29–3230DOI: 10.1159/000497387Case ReportA 60-year-old woman, a current smoker with > 50 pack/years, was admitted to the General Hospital of Rethymnon on February 2018 due to fatigue, cough, and hemoptysis. She reported loss of appetite and a 10-kg weight loss during the past 6 months. Her blood count was low with iron deficiency anemia (Hgb 9.2 g/dL), but the rest of the blood tests were within normal limits. The tumor marker results were as follows (CEA 1.5 μg/L, Ca19-9 22.4 U/mL, and Ca15-3 30.6 U/mL).During the medical workup, a chest X-ray depicted a large mass on the right upper lung lobe, which was confirmed on contrast-enhanced chest computed tomography (CT) scan (Fig. 1). CT scan also revealed 2 pathologically enlarged right hilar lymph nodes. Subsequent bronchoscopy revealed obstruction of the right supe-rior lobar bronchus from a mass, and histopathology reported squamous cell carcinoma (SCC) of the lung. The physician ordered a positron emission tomography/CT, which showed increased 2-deoxy-2-[F-18]fluoro-D-glucose uptake in the right lung and pancreatic tail (Fig. 2).Subsequently, the patient was referred for EUS, and a hy-poechoic 4.5-cm pancreatic-tail round mass with slightly irregular borders was identified. The lesion was clearly separated from the left adrenal gland and the kidney, and EUS-FNB was performed using a 22-gauge needle (Acquire, Boston Scientific, Natick, MA, USA) (Fig.  3). Cytology stain slides revealed atypical squamous cells suggestive of the diagnosis of SCC (Fig. 4). Needle core frag-ments were collected separately and sent for histopathological evaluation, which revealed keratin debris, apoptotic keratinocytes, and few solid aggregates of atypical cells featuring focally intercel-lular bridges and intracellular keratinization (Fig. 5). Positive im-munostaining with p40 supports the squamous phenotype (Fig. 6). Thus, this was diagnosed as a metastatic pancreatic tumor from lung cancer.A programmed cell death-1 (PD-L1) biomarker test (22C3 PharmDx DAKOTM kit) was done using paraffin-embedded slides of the primary tumor which showed a Tumor Proportion Score of 5.801/6.408 (90.5%). After that, the patient was treated with the anti-PD-L1 antibody pembrolizumab, and she is still alive after 7 cycles of therapy without having any adverse events and with stable tumor burden after her last CT scans.DiscussionThe prevalence of pancreatic metastases, in large au-topsy series of metastatic disease, has been described to range from 1.6 to 11% [2]. Metastatic tumors in the pan-creas are uncommon neoplasms accounting for less than 3% of solid pancreatic lesions and are mainly re-lated to advanced disease [3, 4]. Most common meta-static malignancies in the pancreas are those of the kid-ney, lung, melanoma, and breast. Lung cancers have the tendency to metastasize to adrenal glands, liver, brain, Fig. 1. A large tumor on the right upper lung lobe on computed tomography.Fig. 2. Increased 18-FDG uptake in the pancreatic tail.Pancreatic Metastasis from SCC of  the Lung Diagnosed by EUS-FNB31GE Port J Gastroenterol 2020;27:29–32DOI: 10.1159/000497387and bones and less frequently to other sites [5]. Regard-ing lung-related pancreatic metastases, the frequency is mostly related to the histological type, with small cell carcinoma being the most common, followed by adeno-carcinoma, large cell carcinoma, and lastly SCC, being the least frequent, occurring only in 1.1% of these tu-mors [4]. To our knowledge, only 4 cases of metastatic lung SCC in the pancreas have been reported world-wide, but 3 of them were lesions identified several months after the diagnosis and treatment of lung cancer and were not a concomitant diagnosis of primary and metastatic site as in our case [3, 4, 6, 7]. Pancreatic SCC could be of primary origin, but this constitutes a rather questionable entity, as the pancreas is devoid of squa-mous cells, and, thus, in such cases, an extensive workup should be performed to rule out possible metastasis from the lungs, esophagus, and cervix [8].EUS is now considered the gold standard examination for diagnosing and differentiating pancreatic tumors [1]. Over the last few years, a new trend has been developed for solid abdominal and especially pancreatic lesions regard-ing the type of tissue acquisition needle used. FNB needles have gained ground as they are now considered delivering a more accurate diagnostic sample and with fewer passes needed compared to fine aspiration needles in EUS [9–11].Fig. 3. Endoscopic ultrasound-guided fine needle biopsy of the pancreatic tail tumor.Fig. 4. Cytological examination of the endoscopic ultrasound sam-ple: aggregate of malignant squamous cells focally (arrows) kera-tinized. Smear, Pap stain, ×40.Fig. 5. Histopathological examination of the endoscopic ultra-sound sample. Hematoxylin and eosin stain, ×40.Stoupis/Voudoukis/Mastorakis/Kazamias/Ieromonachou/PappasGE Port J Gastroenterol 2020;27:29–3232DOI: 10.1159/000497387There are no defined criteria for the management of metastases in the pancreas, but the prognosis is poor and, often, a more conservative approach is preferred. In con-clusion, when faced with pancreatic solid lesions, physi-cians should always keep in mind the likelihood of metas-tasis from tumors with unusual site and histology. EUS with FNB remains the optimal diagnostic tool for these kinds of lesions.Statement of EthicsWe state that the subject of this case has given her written in-formed consent to publish her case (including publication of im-ages).Disclosure StatementThere are no conflicts of interest.Funding SourcesThere is no financial support and sponsorship for this article.Author ContributionsIoannis Stoupis: manuscript writer, medical oncologist in charge of making the treatment plan for the patient. Evangelos Voudoukis: manuscript writer, has done the EUS-FNB to the pa-tient. Emmanouil Mastorakis: manuscript writer, contributed to immunohistochemistry and histological diagnoses of the EUS-FNB specimen. Georgios Kazamias: manuscript writer, contrib-uted to cytological diagnoses of the EUS-FNB specimen. Pana-giotis Ieromonachou: manuscript writer, contributed to immuno-histochemistry and histological diagnoses of the EUS-FNB specimen. Charalampos Pappas: manuscript writer, contributed to bronchoscopy, staging procedures, and diagnoses of the primary tumor.Fig. 6. Histopathological examination of the endoscopic ultra-sound sample. Immunostaining with p40.References 1 Hasan MK, Hawes RH. EUS-guided FNA of solid pancreas tumors. Gastrointest Endosc Clin N Am. 2012 Apr; 22(2): 155–67. 2 Adsay NV, Andea A, Basturk O, Kilinc N, Nassar H, Cheng JD. Secondary tumors of the pancreas: an analysis of a surgical and autopsy database and review of the literature. Vir-chows Arch. 2004 Jun; 444(6): 527–35. 3 Ishikawa T, Hirooka Y, Teman CJ, Goto H, Belletrutti PJ. An Unusual Case of Pancreatic Metastasis from Squamous Cell Carcinoma of the Lung Diagnosed by EUS-Guided Fine Needle Biopsy. Case Rep Gastrointest Med. 2017; 2017: 3212056. 4 Liratzopoulos N, Efremidou EI, Papageor-giou MS, Romanidis K, Minopoulos GJ, Ma-nolas KJ. Extrahepatic biliary obstruction due to a solitary pancreatic metastasis of squa-mous cell lung carcinoma. Case report. J Gas-trointestin Liver Dis. 2006 Mar; 15(1): 73–5. 5 Kurihara N, Saito H, Nanjo H, Konno H, Minamiya Y. Pancreatic metastasis from non-small-cell lung cancer diagnosed using endo-scopic ultrasound-guided fine needle aspira-tion biopsy: A case report. Turk J Gastroen-terol. 2017 Nov; 28(6): 502–4. 6 Sharma A, Alfa-Wali M, Rodriguez-Justo M, Polychronis A. Squamous cell carcinoma of pancreas: an unusual site of relapse from ear-ly-stage lung cancer: 12-month postsurgery. BMJ Case Rep. 2013 Apr;(apr22 1): 2013. 7 Mockli GC, Silversmith M. Squamous cell carcinoma of the lung metastatic to the pan-creas: diagnosis by fine-needle aspiration bi-opsy. Diagn Cytopathol. 1997 Mar; 16(3): 287–8. 8 Brijbassie A, Stelow E, Shami VM. Squamous Cell Carcinoma of the Pancreas: A Case Re-port and Review of Literature. Gastroenterol Res. 2014 Aug; 7(3-4): 102–4. 9 Tian L, Tang AL, Zhang L, Liu XW, Li JB, Wang F, et al. Evaluation of 22G fine-needle aspiration (FNA) versus fine-needle biopsy (FNB) for endoscopic ultrasound-guided sampling of pancreatic lesions: a prospective comparison study. Surg Endosc. 2018 Aug; 32(8): 3533–9.10 Cheng B, Zhang Y, Chen Q, Sun B, Deng Z, Shan H, et al. Analysis of Fine-Needle Biopsy vs Fine-Needle Aspiration in Diagnosis of Pancreatic and Abdominal Masses: A Pro-spective, Multicenter, Randomized Con-trolled Trial. Clin Gastroenterol Hepatol. 2018 Aug; 16(8): 1314–21.11 Lee YN, Moon JH, Kim HK, Choi HJ, Choi MH, Kim DC, et al. Core biopsy needle versus standard aspiration needle for endoscopic ul-trasound-guided sampling of solid pancreatic masses: a randomized parallel-group study. Endoscopy. 2014 Dec; 46(12): 1056–62.

A Rare Pancreatic Tail Metastasis from Squamous Cell Lung Carcinoma Diagnosed by EUS-FNB and a Small Review of the Literature

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A Rare Pancreatic Tail Metastasis from Squamous Cell Lung Carcinoma Diagnosed by EUS-FNB and a Small Review of the Literature

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