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IMAGE IN EUS
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
Brazil
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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 2019 Oct 22];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

1.
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
    
2.
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
    
3.
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
    
4.
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
    
5.
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
    


    Figures

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



 

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