The Ohio State University Wexner Medical Center Columbus, OH
Nolan P. Ladd, MD1, Gavisha Waidyaratne, MD1, Olivia Battistoni, MPH2, Fred Karaisz, MD1, Lokman Cevik, MD3, Jordan Burlen, MD1 1The Ohio State University Wexner Medical Center, Columbus, OH; 2The Ohio State University College of Medicine, Columbus, OH; 3The Ohio State University, Columbus, OH
Introduction: Tumor seeding by endoscopic ultrasound (EUS)-guided procedures is a rare phenomenon and there is little data to guide proper detection and management. Here, we describe a unique case of pancreatic ductal adenocarcinoma (PDAC) seeding to stomach wall by EUS-guided cystogastrostomy with lumen-apposing metal stent (LAMS).
Case Description/Methods: A 51-year-old woman presented to the hospital with an enhancing pancreatic tail mass on CT. She underwent EUS-guided biopsy via two passes with a 22-G biopsy needle using a transgastric approach diagnostic of PDAC. Labs were significant for elevated CA 19-9 and staging CT showed localized disease (Fig. 1). She subsequently underwent neoadjuvant chemotherapy and robotic-assisted distal pancreatectomy and splenectomy. The tumor was staged as ypT1cN2 moderately-differentiated adenocarcinoma arising in a background of high-grade pancreatic intraepithelial neoplasm (PanIN) with negative margins and 7 of 21 positive lymph nodes. Her post-operative course was complicated by intra-abdominal fluid collection at the surgical bed. Due to persistence of this collection despite antibiotics and percutaneous drain placement, she underwent EUS-guided fluid collection drainage (Fig.2) with LAMS, seven months after her surgery.
On 2-year follow-up after surgery, she was found to have progressive CA 19-9 elevation. Repeat CT and EUS were unrevealing, and she underwent short-interval imaging with close monitoring of CA 19-9. A follow-up PET scan demonstrated a hypermetabolic focus involving the gastric fundus anterior to a surgical clip (Fig. 3). EGD and EUS showed wall thickening in the fundus and body of the stomach; cold snare biopsies of stomach wall nodularity in the site of prior LAMS stent was concerning for adenocarcinoma morphologically similar to prior PDAC. She was initiated on chemotherapy.
Discussion: Tumor seeding by EUS-guided procedures represents a rare, but potentially morbid, complication. To our knowledge, this is the first instance of EUS-guided cystogastrostomy leading to tumor seeding of PDAC. Similar to data reported on needle-track seeding from EUS-guided biopsies, our case shows that presentation can occur over 12 months after seeding. Due to the low incidence of tumor seeding, data guiding proper clinical detection and optimal management is lacking. In this instance, CA 19-9 monitoring was crucial for early detection.
Figure: Figure 1. Fluid collection associated with distal pancreatectomy resolving with cystogastrostomy with LAMS. Figure 2. Nuclear PET showing hypermetabolic focus involving/overlapping the gastric fundus anterior to a surgical clip (arrow), suspicious for malignant spread. Figure 3. Histopathological characteristics of neoplasms in gastric mucosal biopsy and previous pancreatectomy specimen. Rare malignant glands found in the deep gastric mucosa (A, Hematoxylin & Eosin stain), which are also highlighted by cytokeratin AE1/AE3 immunohistochemical stain (B). Higher power demonstrates morphologic similarity between the malignant glands in the gastric mucosa (C) and those in the patient’s prior pancreatectomy specimen (D), supporting the diagnosis of metastatic pancreatic adenocarcinoma involving the stomach. Original magnification, A and B, 20x; C and D 400x.
Disclosures:
Nolan Ladd indicated no relevant financial relationships.
Gavisha Waidyaratne indicated no relevant financial relationships.
Olivia Battistoni indicated no relevant financial relationships.
Fred Karaisz indicated no relevant financial relationships.
Lokman Cevik indicated no relevant financial relationships.
Jordan Burlen indicated no relevant financial relationships.
Nolan P. Ladd, MD1, Gavisha Waidyaratne, MD1, Olivia Battistoni, MPH2, Fred Karaisz, MD1, Lokman Cevik, MD3, Jordan Burlen, MD1. P1091 - Rare Case of Tumor Seeding by Endoscopic Ultrasound-Guided Cystogastrostomy with Lumen-Apposing Metal Stent, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.
