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Journal of Cancer Research and Practice 3 (2016) 136e139
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Journal of Cancer Research and Practicejournal homepage: http: / /www.journals .e lsevier .com/journal-of-cancer-
Endoscopic ultrasound for detecting small pancreatic tumor missed bycomputed tomography
Hao-Wen Dai a, b, Tsang-En Wang a, b, Cheng-Hsin Chu a, b, Tsang-Pai Liu c,Shou-Chuan Shih a, b, Wei-Chen Lin a, b, *
a Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwanb Mackay Junior College of Medicine, Nursing, and Management, New Taipei City, Taiwanc Division of General Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan
a r t i c l e i n f o
Article history:Received 5 February 2016Received in revised form7 April 2016Accepted 8 April 2016Available online 10 May 2016
Keywords:DiagnosisEndoscopic ultrasoundPancreatic tumor
* Corresponding author. Division of GastroenterolMedicine, Mackay Memorial Hospital, No. 92, Sec. 2, C104, Taiwan.
E-mail address: email@example.com (W.-C. Lin).Peer review under responsibility of The Chinese O
http://dx.doi.org/10.1016/j.jcrpr.2016.04.0012311-3006/Copyright 2016, The Chinese Oncologycreativecommons.org/licenses/by-nc-nd/4.0/).
a b s t r a c t
Pancreatic cancer is the eighth leading cause of cancer-related deaths in Taiwan. Pancreatic cancer has apoor prognosis. Diagnosis of early-stage pancreatic cancer, which can be defined based on resectability,size, or curability, will improve survival. Diagnostic tools for pancreatic cancer include transabdominalultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), endoscopic retrogradecholangiopancreatography (ERCP), and endoscopic ultrasound (EUS). We report the case of a 48-year-oldman who presented with progressively yellowing skin. An CT imaging study did not reveal the pancreaticlesion. Further imaging with EUS was performed to search for the organic lesion causing an abrupt distalcommon bile duct stricture, and a heterogeneous hypoechoic tumor located at the uncinate process wasidentified. The patient underwent a Whipple operation because malignancy could not be ruled out. Thefinal pathological result was moderate to poorly differentiated adenocarcinoma.Copyright 2016, The Chinese Oncology Society. Production and hosting by Elsevier B.V. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Pancreatic cancer has been the eighth leading cause of cancer-related deaths in Taiwan in recent years. In most cases, theoutcome of pancreatic cancer is poor.1 The clinical manifestations ofpancreatic tumors are epigastralgia, jaundice, steatorrhea, bodyweight loss, vomiting, anorexia, and asthenia. Initial clinical pre-sentations, such as painless jaundice and new onset diabetes, maybe early signs of a pancreatic head tumor.2e4
Diagnostic tools for pancreatic cancer include transabdominalultrasonography, computed tomography (CT), magnetic resonanceimaging (MRI), endoscopic retrograde cholangiopancreatography(ERCP), and endoscopic ultrasound (EUS).5e7 In recent years, im-provements in the imaging technologies mentioned above havehelped in the early detection of pancreatic cancer. The high sensi-tivity and specificity of EUS plays an important role when trying to
ogy, Department of Internalhung-Shan North Road, Taipei
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identify a small pancreatic tumor. It also helps in obtaining tissuesamples via fine needle aspiration.5,6
In this case, the initial CT image did not reveal the pancre-atic head tumor. We share our experience of using EUS fordetection of a small pancreatic head tumor. We confirmed thediagnosis of pancreatic head adenocarcinoma after surgicalintervention.
2. Case report
A 48-year-old man had a medical history of hypertension anddiabetes mellitus controlled with an oral hypoglycemic agentcombined with insulin for 2 years. He developed progressivelyyellowing skin over the course of 1 week. He complained of post-prandial abdominal fullness with dull pain, tea colored urine, anddiarrhea with light bright oil muddy stool in the last week. Hedenied the presence of fever, clay-colored stool, and recent bodyweight loss.
Biochemistry data revealed hyperbilirubinemia (total bilirubinlevel: 13 mg/dL, direct bilirubin level: 8.0 mg/dL), elevated alkalinephosphate (ALK-P: 688 IU/L) level, elevated r-glutamyl trans-peptidase (r-GT: 1842 IU/L) level, and an abnormal liver functiontest (aspartate transaminase [AST] level: 230 IU/L, alanine
Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://http://creativecommons.org/licenses/by-nc-nd/4.0/mailto:firstname.lastname@example.org://crossmark.crossref.org/dialog/?doi=10.1016/j.jcrpr.2016.04.001&domain=pdfwww.sciencedirect.com/science/journal/23113006http://www.journals.elsevier.com/journal-of-cancer-research-and-practicehttp://www.journals.elsevier.com/journal-of-cancer-research-and-practicehttp://dx.doi.org/10.1016/j.jcrpr.2016.04.001http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://dx.doi.org/10.1016/j.jcrpr.2016.04.001http://dx.doi.org/10.1016/j.jcrpr.2016.04.001
H.-W. Dai et al. / Journal of Cancer Research and Practice 3 (2016) 136e139 137
transaminase [ALT] level: 395 IU/L). The patient's serum sampletested negative for hepatitis B and hepatitis C. Echography showeda gallbladder (GB) stone and common bile duct (CBD) dilatation.Conventional abdominal CT with and without contrast alsoconfirmed the presence of GB stones and CBD dilatation. It did notreveal any abnormal pancreatic head lesion (Fig. 1).
Endoscopic retrograde cholangiopancreatography (ERCP) wasperformed under the indication of obstructive jaundice. The fluo-roscopy showed proximal CBD dilatation with an abrupt distal CBDstricture. One plastic stent (8.5 Fr, 9 cm) was placed in the distalCBD (Fig. 2A). A biopsy was obtained from the edematous change ofthe papilla with villous appearance (Fig. 2B). The final pathologicalresult was chronic inflammation.
The patient's serum tumor marker levels were as follows: car-cinoembryonic antigen (CEA) 1.71 ng/mL (normal range < 5.00 ng/mL) and CA 19-9 283.90 U/mL (normal range < 37.00 U/mL). Theimmunoglobulin subclass 4 level was within the normal range.
Because of high suspicion of malignancy, we chose endoscopicultrasound (EUS) instead of MRI of the pancreas to detect theorganic lesion that caused the distal CBD stricture because initialabdominal CT did not show any suspicious lesion in the pancreas. Inaddition, tissue sample could be obtained using EUS fine needleaspiration if any suspicious lesions are found. EUS revealedpancreatic duct dilatation in the head portion and one heteroge-neous hypoechoic tumor of about 2.68 2.34 cm located at theuncinate process (Fig. 3). Fine needle aspiration from the uncinateprocess tumor was performed. The final cytology report showednegative results for malignancy.
MRI was performed to view the irregular enhanced lesion at theuncinate process of the pancreas on the arterial phase. Diffusionweighted images also showed relatively high signal intensity in theuncinate process (Fig. 4). A high malignancy potential of thepancreatic uncinate process was suspected from the imagingresults.
We performed a Whipple operation with findings of a hardpancreatic tumor, which compressed to the distal CBD with dila-tation. On gross appearance, it was a circumferential sclerotic tu-mor, measuring 2.5 2.5 1.5 cm in size, involving the pancreatichead. The margins of the peripancreatic tissue were free of tumor.Microscopically, vascular invasionwas absent. Two out of 21 lymphnodes showed metastatic adenocarcinoma. It was proven to be amoderately to poorly differentiated pancreatic head adenocarci-noma (Fig. 5). According to the American Joint Committee onCancer 7th Edition Staging, the pathologic TNM stage was T2N1M0,Stage IIB. After surgical intervention, the patient received systemicchemotherapy with gemcitabine.
Fig. 1. (A) Pre-contrast phase of abdominal CT showed one GB stone (Arrow). (B) Post-contr(Arrow).
Pancreatic cancer is the eighth leading cause of cancer-relateddeaths in Taiwan.1 The most common initial clinical presentationof pancreatic exocrine tumors is pain, jaundice, and weight loss.2
The initial clinical presentation depends on the location of thepancreatic tumor. Jaundice, steatorrhea, and weight loss are morecommon symptoms in patients with pancreatic head tumorscompared with in those with tumors in the body or tail.2e4 Around60 to 70 percent of exocrine pancreatic cancers are located in thehead portion of the pancreas, while only 20 to 25 percent are foundin the body or tail.8 Pancreatic head tumors with an initial pre-sentation of painless jaundice tend to have a more favorableprognosis, making surgical intervention desirable.3,9 The presentpatient had a medical history of diabetes mellitus diagnosed lessthan 2 years ago. New onset diabetes mellitus can be an early signof pancreatic head adenocarcinoma.10
Transabdominal ultrasonography is the first-line imaging studyused in patients with suspected biliary obstruction of unknownetiology.11 Transabdominal ultrasonography is readily available,inexpensive, and does not use ionizing radiation. However, it is nota suitable screening tool for detection of pancreatic masses due toits relatively low sensitivity. A pancreatic carcinoma typically ap-pears as a focal hypoechoic hypovascular solid mass with irregularmargins.12 In one study, the sensitivity for detection of pancreaticmasses has been