CASES OF THE WEEK – “Pancreatic head cancer missed on CT/MRI but diagnosed by Endoscopic Ultrasound (EUS)” by Dr Piyush Somani, Specialist Gastroenterology, NMC Royal Hospital Sharjah

Pancreatic body adenocarcinoma diagnosed by

Endoscopic Ultrasound (EUS) - FNA with ROSE (Rapid-on-site evaluation)

A 58 years old male, non-alcoholic and chronic-smoker presented with mild abdominal pain with past history of diabetes. His amylase/lipase were mildly elevated. He underwent MRI abdomen with contrast suggestive of 1 cm mass in the body of pancreas. Patient was referred for Endoscopic Ultrasound (EUS) - Fine Needle Aspiration (FNA) to make the final diagnosis.

Patient underwent Endoscopic Ultrasound (EUS) as day case procedure under deep sedation.

The EUS revealed heterogeneous, ill-defined, and irregular predominantly hypoechoic solid mass around 16 mm x 17 mm in size involving predominantly body of pancreas. The blood vessels appears to be not involved by the mass. The main pancreatic duct could not be seen in the mass. The main pancreatic duct distal to the mass was dilated (maximum diameter - 3.4 mm). Using 22 Gauge procore needle, around 6 passes were taken and material was sent for FNA/biopsy.

ROSE (Rapid-on-site evaluation) of the FNA sample was performed inside the endoscopy room by Dr. Ehsan Ahmed (Specialist Anatomical pathologist) which was suggestive of features of pancreatic adenocarcinoma. Patient underwent central pancreatectomy to remove the malignancy.

Routinely, after performing EUS-FNA, the reports of biopsy/FNA are available in 4-6 days. However, with the use of ROSE, the results are available in 10-15 minutes. It’s similar to frozen section during surgery.

Other potential advantages of ROSE includes improvement in the Specimen adequacy, diagnostic yield, less passes and less complications.

In summary, EUS with ROSE helps in making immediate diagnosis in difficult cases of pancreatic masses. This facility is available only in few hospitals in UAE.

Reference:

Yang F, Liu E, Sun S. Rapid on-site evaluation (ROSE) with EUS-FNA: The ROSE looks beautiful. Endosc Ultrasound 2019;
8:283-7.