A case of gastric wall implantation caused by EUS-FNA 22 months after pancreatic cancer resection.

The patient was a 78-year-old woman in whom abdominal ultrasonography in a medical examination revealed dilatation of the main pancreatic duct. She, therefore, attended our hospital. Computed tomography (CT) [Figure 1] and magnetic resonance imaging (MRI) revealed a mass lesion 10 mm in diameter in the pancreatic body. EUS-FNA was performed using a 25-gauge needle [Figure 2], leading to a cytological diagnosis of adenocarcinoma. Distal pancreatectomy with splenectomy was followed by adjuvant systemic chemotherapy with S-1 for 1 year. Histopathological diagnosis of the surgically resected specimen was well-differentiated tubular adenocarcinoma (T3N0M0, Stage IIA), and there was no remnant of cancer in intraoperative or pathological findings. CT and/or MRI were repeated performed every 3–5 months until 18 months after resection showed no evidence of tumor recurrence or metastasis.

Figure 1

Abdominal computed tomography: A mass lesion 10 mm in diameter in the pancreatic body (red arrow)

Figure 2

EUS-FNA was performed using a 25-gauge needle

The patient was subsequently brought to the emergency center of our hospital with hematemesis 22 months later after surgery. Upper gastrointestinal endoscopy was performed, and a Borrmann type 2-like lesion with bleeding was detected in the posterior wall of the gastric body [Figure 3] and confirmed as tubular adenocarcinoma from biopsy. CT revealed a gastric mass lesion located near the previous EUS-FNA puncture site [Figure 4]. No evidence of any other metastatic lesions was apparent, and the patient was scheduled for partial gastrectomy.

Figure 3

Upper gastrointestinal endoscopy image showing a Borrmann type 2-like lesion with bleeding in the posterior wall of the gastric body

Figure 4

Abdominal computed tomography: A gastric mass lesion located near the previous EUS-FNA puncture site (yellow arrows)

Intraoperatively, peritoneal disseminated lesions were confirmed, so the patient only underwent local resection of the stomach. Histological examination of the resected specimen revealed well-to-moderately differentiated tubular adenocarcinoma located from the mucosa to the serosa, with no evidence of cancer cells on the serosal surface [Figure 5]. KRAS mutation testing performed in both the pancreatic and gastric carcinomas demonstrated identical genetic alterations (G12V) in each specimen. The gastric lesion, therefore, indicated gastric wall implantation after the initial EUS-FNA for the pancreatic cancer.

Figure 5

Histological examination of the resected specimen revealed well-to-moderately differentiated tubular adenocarcinoma located from the mucosa to the serosa, with no evidence of cancer cells on the serosal surface

Seeding of pancreatic cancer after EUS-FNA has seldom been reported. Ikezawa et al. reported that EUS-FNA for pancreatic cancer did not significantly increase the risk of peritoneal carcinomatosis.[1] Needle tract seeding after surgery for pancreatic cancer has been reported in four patients since 2012.[2345] In all these cases, the cancer was localized to the pancreatic body, preoperative transgastric EUS-FNA was performed, and 8–28 months after surgery, metastases were identified in the gastric wall. Preoperative transgastric EUS-FNA in patients with resectable pancreatic body and tail cancer thus needs to be reconsidered in collaborative discussion with surgeons.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initial will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

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Conflicts of interest

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