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 Table of Contents  
Year : 2015  |  Volume : 4  |  Issue : 2  |  Page : 158-159

Pancreatic cancer with portal vein invasion diagnosed by endoscopic ultrasound

Department of Endoscopy, Santa Casa de São Paulo Hospital and French-Brazilian Centre of Endoscopic Ultrasound, São Paulo, Brazil

Date of Submission05-Jun-2014
Date of Acceptance26-Jul-2014
Date of Web Publication8-May-2015

Correspondence Address:
Augusto P. C. Carbonari
Department of Endoscopy, Santa Casa de São Paulo Hospital and French-Brazilian Center of ­Endoscopic Ultrasound, São Paulo
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2303-9027.156758

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How to cite this article:
Carbonari AP, Bonfim J, Colaiacovo R, Rossini LG. Pancreatic cancer with portal vein invasion diagnosed by endoscopic ultrasound. Endosc Ultrasound 2015;4:158-9

How to cite this URL:
Carbonari AP, Bonfim J, Colaiacovo R, Rossini LG. Pancreatic cancer with portal vein invasion diagnosed by endoscopic ultrasound. Endosc Ultrasound [serial online] 2015 [cited 2020 Jan 24];4:158-9. Available from: http://www.eusjournal.com/text.asp?2015/4/2/158/156758

An 82-year-old woman with abdominal pain for the preceding 6 months was referred for endoscopic ultrasound (EUS) to evaluate the presence of pancreatic cancer. The patient had a history of diabetes and hypertension. A computed tomography (CT) scan showed a nodular image on the pancreatic body, hypovascularized, measuring 2.5 cm × 2.0 cm, without signs of vascular involvement [Figure 1]. It was also observed, nodular images on the liver, the visceral peritoneum and peri-hepatic lymphonodes.
Figure 1. Computed tomography images of the pancreatic lesion without vascular invasion

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One month later, the patient underwent an EUS that showed a hypoechoic heterogeneous lesion in the body of the pancreas, measuring 4.0 cm × 3.5 cm, with vascular invasion of the portal vein [Figure 2]. Nodular masses in the visceral peritoneum and moderate ascites were also observed [Figure 3]. An EUS fine-needle aspiration of the pancreatic mass was performed with a 22-guage Echo-Tip® needle (Cook Medical Inc., Limerick, Ireland) [Figure 4] and a sufficient cytology material was obtained after three punctures, suggesting malignant cells [Figure 5]. After discussion with the surgery department, it was opted to perform a celiac plexus neurolysis, by injecting absolute alcohol (20 mL) and lidocaine (5 mL) through a fenestrated needle on the celiac plexus.
Figure 2. Endoscopic ultrasound view of a hypoechoic lesion in the body of the pancreas with portal vein invasion

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Figure 3. Endoscopic ultrasound view of nodular images in visceral peritoneum and ascitis

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Figure 4. Endoscopic ultrasound (EUS) view of EUS fi ne-needle aspiration

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Figure 5. Cytology smear suggesting malignant cells

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The optimal approach to preoperative imaging assessment of pancreatic cancer remains unclear in the literature. In a prospective study, Soriano et al., [1] demonstrated that helical CT had the highest accuracy in assessing extent of primary tumor (73%), locoregional extension (74%), vascular invasion (83%), distant metastases (88%), tumor TNM stage (46%), and tumor resectability (83%), whereas EUS had the highest accuracy in assessing tumor size and lymph node involvement (65%). Furthermore, in a retrospective analysis conducted by Zhang et al., [2] CT angiography, can provide reliable information for vascular involvement and general resectability of pancreatic malignant tumors.

On the other hand, in a retrospective study conducted by Buchs et al., [3] EUS was the most valuable imaging modality in assessing vascular invasion (especially for venous invasion) for pancreatic cancer, with an accuracy of more than 80%. In a 2013 meta-analysis, [4] with a total of 1330 patients, CT scan showed lower sensitivity than EUS for vascular invasion (58% vs. 86%); however, the specificities for vascular invasion (95% vs. 93%) were comparable in studies where both imaging techniques were performed. In other systematic review published in 2007, Puli et al., [5] showed that the pooled sensitivity of EUS in diagnosing vascular invasion was 73% and the pooled specificity was 90.2%.

The patient underwent a CT scan as CT angiography was not available, but no signs of vascular involvement were observed. Although the EUS didn't change the treatment on this case, it was possible to demonstrate a portal vein invasion, proceed histological diagnosis and perform celiac plexus neurolysis.

  References Top

Soriano A, Castells A, Ayuso C, et al. Preoperative staging and tumor resectability assessment of pancreatic cancer: Prospective study comparing endoscopic ultrasonography, helical computed tomography, magnetic resonance imaging, and angiography. Am J Gastroenterol 2004;99:492-501.  Back to cited text no. 1
Zhang Y, Jian ZJ, Zhao TT, et al. Preoperative evaluation of vascular involvement and general resectability of pancreatic carcinoma by using 64-slice spiral computed tomographical angiography. Zhonghua Yi Xue Za Zhi 2013;93:1450-3.  Back to cited text no. 2
Buchs NC, Frossard JL, Rosset A, et al. Vascular invasion in pancreatic cancer: Evaluation of endoscopic ultrasonography, computed tomography, ultrasonography, and angiography. Swiss Med Wkly 2007;137:286-91.  Back to cited text no. 3
Nawaz H, Fan CY, Kloke J, et al. Performance characteristics of endoscopic ultrasound in the staging of pancreatic cancer: A meta-analysis. JOP 2013;14:484-97.  Back to cited text no. 4
Puli SR, Singh S, Hagedorn CH, et al. Diagnostic accuracy of EUS for vascular invasion in pancreatic and periampullary cancers: A meta-analysis and systematic review. Gastrointest Endosc 2007;65:788-97.  Back to cited text no. 5


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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