Two cases of resectable pancreatic cancer diagnosed by open surgical biopsy after endoscopic ultrasound fine-needle aspiration failed to yield diagnosis: case reports

Abstract

Background: Tumor biopsy for histological diagnosis is required preoperatively and before initiating chemotherapy or radiation therapy for patients with pancreatic cancer (Cancer of the Pancreas: Clinical Practice Guidelines, European Society for Medical Oncology). Endoscopic ultrasound fine-needle aspiration (EUS-FNA) is widely applied to obtain tissue samples for histological examination. However, in some cases, EUS-FNA cannot be performed safely or tissue samples are insufficient to establish a definitive diagnosis. We present two cases of pancreatic cancer diagnosed by open surgical biopsy after EUS-FNA failed to yield a diagnosis.

Case presentation: Case 1 was a 50-year-old man. Computed tomography showed a hypovascular lesion in the uncus of the pancreas. Although EUS-FNA was conducted twice, we could not collect enough quantity of tissue samples to establish a definitive diagnosis. Open surgical biopsy revealed adenocarcinoma, and the patient underwent preoperative chemoradiation therapy followed by curative operation. Case 2 was a 68-year-old man. Computed tomography showed a hypovascular tumor in the uncus of the pancreas. EUS revealed a 14-mm hypoechoic lesion, but we could not perform EUS-FNA because the superior mesenteric vein was located in the puncture line. Open surgical biopsy revealed adenocarcinoma, and the patient underwent preoperative chemoradiation therapy followed by pancreaticoduodenectomy.

Conclusions: EUS-FNA is the first choice in the diagnostic modalities of pancreatic neoplasm, but open surgical biopsy is an effective diagnostic method if EUS-FNA is unsuccessful.

Keywords: Intraoperative pancreas biopsy; Open surgical biopsy; Pancreatic cancer.

Fig. 1

Radiological and endoscopic ultrasonographic findings for case 1. a CECT revealed a hypovascular tumor in the uncus of the pancreas (red circle). b PET-CT revealed that 18 F-FDG accumulation was within normal range. c EUS revealed a 22-mm hypoechoic lesion in the uncus of the pancreas (red arrows)

Fig. 2

Pathological analysis by EUS-FNA compared to open surgical biopsy in case 1. a Macroscopic view of specimen obtained by EUS-FNA. The specimen contained large quantities of blood clots. b Microscopic view of specimen (×100 magnification) revealed enlarged nuclei and disordered ductal structures. c Specimen obtained by open surgical biopsy. Most of the specimen consisted of pancreatic parenchyma. d Microscopic view of specimen obtained by open surgical biopsy (×100 magnification) revealed abundant dyskaryotic cells with enlarged nuclei, disordered ductal structures

Fig. 3

Radiological and endoscopic ultrasonographic findings in case 2. a CECT revealed an 8-mm hypovascular tumor in the uncus of the pancreas. b PET-CT showed FDG accumulation (SUVmax 5.6) corresponding with the pancreas tumor. c EUS detected a 14 × 12-mm hypoechoic lesion in the uncus, but we could not perform EUS-FNA because the superior mesenteric vein was located in the puncture line

Fig. 4

Pathological analysis by open surgical biopsy in case 2. a The biopsy specimen had dyskaryotic cells with enlarged nuclei and atypical irregular ductal structures. b Microscopic view of specimen (×100 magnification)