At the Focal Point
Commentary History has a funny way of repeating itself. That’s why we can often learn from studying it. (I was a history major in college but found I learned more from making bad decisions, which was not an available major.) And that’s the main reason we ask patients for their histories. Epithelial ovarian carcinoma, of the sort presented here, is the leading cause of death from gynecologic cancer in the United States. Unlike colonoscopy for colorectal cancer, randomized data do not support routine screening for ovarian cancer. Delayed diagnosis is not uncommon; its symptoms have significant overlap with those that a gastroenterologist is likely to hear all day long: meteorism, early satiety, and abdominal pain. Endovaginal US is reasonable in patients at high risk (BRCA mutations, family history) or in those whose symptoms appear in the middle decades. In the vast majority of patients, ovarian cancer will recur, and even long-term survivors should be seen annually. The stomach is not a popular destination for metastatic cells looking for a place to settle down; the reported incidence of metastatic lesions involving the stomach is well under 2%; common offenders include melanoma and lung, breast, and esophageal carcinoma. The endoscopic appearance of metastatic ovarian cancer is varied but often takes the form of nodule(s) with or without surface ulceration or exudate and necrotic ulcers with raised margins. How wayward cancer cells travel is fascinating and ovarian cancer keeps its options open: whether by intraperitoneal, hematogenous, or lymphatic means, transmural gastric invasion is rare but clearly possible. Select cells undergo an epithelial-to-mesenchymal transition, which loosens the attachment of epithelial cells to the basement membrane and the intercellular adhesions between adjacent cancer cells. It may surprise the reader that this patient ended up in the operating room because resection of most metastatic tumors has not been found to improve survival. The benefit of cytoreduction suggests a dramatic difference in the biological behavior of ovarian cancer (and neuroendocrine tumors) compared with other malignancies. So take a comprehensive history, use it in your differential, and think inside (and outside) the peritoneal box. David Robbins, MD, MSc Assistant Editor for Focal Points
Liver cancer presenting as a pancreatic mass A 52-year-old man with a history of hepatitis C and compensated cirrhosis was seen with jaundice. A CT scan of the abdomen (A) showed a large pancreatic head and uncinate process mass, along with occlusion of the portal vein and superior aspect of the superior mesenteric vein. Patchy low attenuation foci were seen within the liver that measured up to 2.5 cm in diameter. EUS examination (B) revealed a 5 7-cm highly vascular and fairly well circumscribed mass in the head of the pancreas with peripheral bile duct dilation. FNA of the pancreatic mass revealed thickened trabeculae of hepatocytes surrounded by endothelial cells (C), rendering a diagnosis of metastatic hepatocellular carcinoma. Biliary drainage was established after sphincterotomy and stent placement, but the patient progressively deteriorated. He was not deemed a candidate
for sorafenib. He was placed under hospice care and discharged. DISCLOSURE The authors disclosed no financial relationships relevant to this publication. Rony Ghaoui, MD, Division of Gastroenterology, Department of Medicine, Maria Gonzalez, MD, Department of Pathology, David J. Desilets, MD, PhD, Division of Gastroenterology, Department of Medicine, Baystate Medical Center, Tufts University School of Medicine, Springfield, Massachusetts, USA http://dx.doi.org/10.1016/j.gie.2013.10.016
Commentary Oh, the treachery of images! If Magritte (who’s being exhibited now at the MOMA in Manhattan) were here to opine, he might agree with the authors that “ceci n’est pas le cancer du pancréas.” This is one of a just a few cases in which metastatic hepatocellular carcinoma (HCC) presented as a pancreatic mass with painless obstructive jaundice. Although extrahepatic metastases are not rare at the diagnosis of HCC, the most frequent sites of extrahepatic metastases are the lung, abdominal lymph nodes, and bone, certainly not the pancreas.
www.giejournal.org
Volume 79, No. 2 : 2014 GASTROINTESTINAL ENDOSCOPY 333
At the Focal Point
I am often asked by surgeons at our multidisciplinary tumor board to defend my practice of pursuing a tissue diagnosis in most cases of an isolated pancreatic mass (usually with EUS-FNA and immunohistochemical tumor typing). If this should happen to you, this case is a great one to keep in your back pocket. A variety of malignant tumors has been shown to metastasize in multiples to the pancreas (the primary tumor is usually lung), but solitary pancreatic metastasis at the time of diagnosis is rare and only accounts for about 2% of solid pancreatic tumors (and it is usually hypernephroma). Interestingly, most pancreatic metastases are diagnosed during surveillance after treatment for the initial primary, suggesting a different and perhaps less virulent cancer biology. Results of surgical resection of isolated metastases to the pancreas, from various primary tumors, suggest an improvement in long-term survival. When tissue is the issue, get that EUS-FNA. Returning to our case, most extrahepatic HCC occurs in patients with advanced disease (stage IVA), and this patient was not a surgical candidate. For patients who present with more advanced HCC, sorafenib (a multikinase inhibitor) can prolong life by about 6 months. Although we do not know whether he was part of a screening program, routine US examination every 6 months (in lieu of serum a-fetoprotein measurement) is the best defense against this dreaded disease in patients with established cirrhosis. David Robbins, MD, MSc Assistant Editor for Focal Points 334 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 2 : 2014
www.giejournal.org
Commentary History has a funny way of repeating itself. That’s why we can often learn from studying it. (I was a history major in college but found I learned more from making bad decisions, which was not an available major.) And that’s the main reason we ask patients for their histories. Epithelial ovarian carcinoma, of the sort presented here, is the leading cause of death from gynecologic cancer in the United States. Unlike colonoscopy for colorectal cancer, randomized data do not support routine screening for ovarian cancer. Delayed diagnosis is not uncommon; its symptoms have significant overlap with those that a gastroenterologist is likely to hear all day long: meteorism, early satiety, and abdominal pain. Endovaginal US is reasonable in patients at high risk (BRCA mutations, family history) or in those whose symptoms appear in the middle decades. In the vast majority of patients, ovarian cancer will recur, and even long-term survivors should be seen annually. The stomach is not a popular destination for metastatic cells looking for a place to settle down; the reported incidence of metastatic lesions involving the stomach is well under 2%; common offenders include melanoma and lung, breast, and esophageal carcinoma. The endoscopic appearance of metastatic ovarian cancer is varied but often takes the form of nodule(s) with or without surface ulceration or exudate and necrotic ulcers with raised margins. How wayward cancer cells travel is fascinating and ovarian cancer keeps its options open: whether by intraperitoneal, hematogenous, or lymphatic means, transmural gastric invasion is rare but clearly possible. Select cells undergo an epithelial-to-mesenchymal transition, which loosens the attachment of epithelial cells to the basement membrane and the intercellular adhesions between adjacent cancer cells. It may surprise the reader that this patient ended up in the operating room because resection of most metastatic tumors has not been found to improve survival. The benefit of cytoreduction suggests a dramatic difference in the biological behavior of ovarian cancer (and neuroendocrine tumors) compared with other malignancies. So take a comprehensive history, use it in your differential, and think inside (and outside) the peritoneal box. David Robbins, MD, MSc Assistant Editor for Focal Points
Liver cancer presenting as a pancreatic mass A 52-year-old man with a history of hepatitis C and compensated cirrhosis was seen with jaundice. A CT scan of the abdomen (A) showed a large pancreatic head and uncinate process mass, along with occlusion of the portal vein and superior aspect of the superior mesenteric vein. Patchy low attenuation foci were seen within the liver that measured up to 2.5 cm in diameter. EUS examination (B) revealed a 5 7-cm highly vascular and fairly well circumscribed mass in the head of the pancreas with peripheral bile duct dilation. FNA of the pancreatic mass revealed thickened trabeculae of hepatocytes surrounded by endothelial cells (C), rendering a diagnosis of metastatic hepatocellular carcinoma. Biliary drainage was established after sphincterotomy and stent placement, but the patient progressively deteriorated. He was not deemed a candidate
for sorafenib. He was placed under hospice care and discharged. DISCLOSURE The authors disclosed no financial relationships relevant to this publication. Rony Ghaoui, MD, Division of Gastroenterology, Department of Medicine, Maria Gonzalez, MD, Department of Pathology, David J. Desilets, MD, PhD, Division of Gastroenterology, Department of Medicine, Baystate Medical Center, Tufts University School of Medicine, Springfield, Massachusetts, USA http://dx.doi.org/10.1016/j.gie.2013.10.016
Commentary Oh, the treachery of images! If Magritte (who’s being exhibited now at the MOMA in Manhattan) were here to opine, he might agree with the authors that “ceci n’est pas le cancer du pancréas.” This is one of a just a few cases in which metastatic hepatocellular carcinoma (HCC) presented as a pancreatic mass with painless obstructive jaundice. Although extrahepatic metastases are not rare at the diagnosis of HCC, the most frequent sites of extrahepatic metastases are the lung, abdominal lymph nodes, and bone, certainly not the pancreas.
www.giejournal.org
Volume 79, No. 2 : 2014 GASTROINTESTINAL ENDOSCOPY 333
At the Focal Point
I am often asked by surgeons at our multidisciplinary tumor board to defend my practice of pursuing a tissue diagnosis in most cases of an isolated pancreatic mass (usually with EUS-FNA and immunohistochemical tumor typing). If this should happen to you, this case is a great one to keep in your back pocket. A variety of malignant tumors has been shown to metastasize in multiples to the pancreas (the primary tumor is usually lung), but solitary pancreatic metastasis at the time of diagnosis is rare and only accounts for about 2% of solid pancreatic tumors (and it is usually hypernephroma). Interestingly, most pancreatic metastases are diagnosed during surveillance after treatment for the initial primary, suggesting a different and perhaps less virulent cancer biology. Results of surgical resection of isolated metastases to the pancreas, from various primary tumors, suggest an improvement in long-term survival. When tissue is the issue, get that EUS-FNA. Returning to our case, most extrahepatic HCC occurs in patients with advanced disease (stage IVA), and this patient was not a surgical candidate. For patients who present with more advanced HCC, sorafenib (a multikinase inhibitor) can prolong life by about 6 months. Although we do not know whether he was part of a screening program, routine US examination every 6 months (in lieu of serum a-fetoprotein measurement) is the best defense against this dreaded disease in patients with established cirrhosis. David Robbins, MD, MSc Assistant Editor for Focal Points 334 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 2 : 2014
www.giejournal.org
