JOP. J (Online) 2020 Nov 30; 21(6): 151-155.

CASE REPORT

Pancreatic from Papillary Carcinoma: A Case Report

Andressa A Machado1, Luciano Lenz1, Regina B Domingues2, Gustavo RA Lima1, Iatagan R Josino1, Martin AC Cordero1, Adriana V Safatle-Ribeiro1, Bruno C Martins1, Caterina MPS Pennacchi1, Carla C Gusmon1, Gustavo A Paulo1, Marcelo S Lima1, Elisa R Baba1, Fábio S Kawaguti1, Ricardo S Uemura1, Fauze Maluf-Filho1

1

2 Departament of Endoscopy, Institute of Sao Paulo (ICESP), University of Sao Paulo, Brazil Departament of Pathology, Cancer Institute of Sao Paulo (ICESP), University of Sao Paulo, Brazil ABSTRACT Introduction differentiated thyroid carcinoma presents with distant metastasis in 4% of cases, usually occurring in the , and thoracic lymph nodes. Pancreatic involvement is extremely rare, with few cases reported in the literature. Case report A 47-years- old female patient presented abdominal pain. She had a history of papillary thyroid carcinoma surgically resected in 2009. After 10 years, computed tomography revealed hepatic lesions suggestive of secondary involvement and a solid mass in the pancreatic head. with immunohistochemistry was positive for , suggesting papillary thyroid carcinoma metastasis. The patient still survives Endoscopic ultrasound fine-needle aspiration was performedConclusion in a heterogeneous hypoechoic mass located at pancreatic head. block at present, treating metastasis with Cabozantinib. endoscopic ultrasound fine-needle aspiration is a minimally invasive and accurate method of sampling lesions of the pancreas. In combination with clinical history and immunohistochemistry, can confirm diagnosis and define management. INTRODUCTION that has 89% accuracy in diagnosing metastasis to pancreas [5]. Differentiated thyroid carcinoma includes the papillary and follicular subtypes. In general, they are indolent, have a good Thus, the present study aims to report a case of papillary prognosis, and the follicular variant is more aggressive [1, 2]. thyroid carcinoma metastatic to pancreas, whose diagnosis was made by EUS-FNA and immunohistochemistry. lymph nodes, and . Pancreatic metastasis is rare, CASE REPORT The preferred localizations of metastases are regional This report is about a 47-year-old female patient with withMetastases few cases correspondreported in the1.8% scientific to 7.6% literature of the pancreatic [3, 4]. masses and the diagnosis is important for clinical staging thyroidectomyan initial diagnosis was performed.of papillary thyroid carcinoma (PTC) in January 2009 (BETHESDA IV). On that occasion, total theseand appropriate masses [5]. management. However, the location of the pancreas makes it challenging to obtain biopsies from thyroid tissue and , and adjuvant A cervical ultrasound performed in June 2009 identified was indicated. After that dose, whole-body Endoscopic ultrasound (EUS) guided fine needle treatment with radioiodine therapy (RAI) with 100mCi aspirationReceived June (FNA) 20th, 2020 is - aAccepted non-invasive August 24 th and, 2020 effective method Keywords (WBS)In Marchshowed 2010,only uptake she presented in the thyroid elevated topography. levels of Ultrasound; Immunohistochemistry AbbreviationsPancreatic cancer; Papillary ; Endoscopic

WBS Whole-body scintigraphy; CT computed tomography; thyroglobulin, and a new dose of RAI with 200mCi was PET-CT positron emission tomography - computed tomography; EUS indicated. WBS detected uptake in the left hemithorax, endoscopic ultrasound; EUS-FNA endoscopic ultrasound fine-needle confirmed by imaging (presence of bilateral pulmonary aspiration; TTF-1 thyroid transcription factor 1; CH-EUS contrast- nodules).In September 2012, positron emission tomography - tumors.enhanced harmonics EUS; RAI radioiodine therapy; SC Smear cytology; CorrespondenceLBC liquid-based cytology; Andressa CB Machado and cell block; NETs Neuroendocrine the number of pulmonary nodules. A new dose of RAI with computed tomography (PET-CT) showed an increase in TelInstituto +5511944464474 do Câncer do Estado de São Paulo (ICESP), FaxServiço +551138932000 de Endoscopia, São Paulo-SP, Brazil 300mCiFrom was July performed. 2015 to June 2017, there was progression of E-mail [email protected] the disease, with development of neoplastic pleural effusion

JOP. Journal of the Pancreas - http://pancreas.imedpub.com/ - Vol. 21 No. 6 – November 2020. [ISSN 1590-8577] 151 JOP. J Pancreas (Online) 2020 Nov 30; 21(6): 151-155. and . The patient started treatment with (Figure 1).

ductEUS-FNA (8.8 mm) was performed with a 22G needle through tyrosineIn June kinase 2019, inhibitor a metastatic ( brain lesion and ).was discovered the duodenal wall. A part of material aspirated was used to prepare slides with panoptic and papanicolau . and treated with radiosurgery. Computed tomography involvement(CT) was performed and a solid tomass investigate in the pancreatic abdominal head. pain. EUS The other part was centrifuged and paraffin embedded. showedCT revealed a heterogeneous hepatic lesions hypoechoic suggestive nodule of with secondary well- Cytology identified epithelioid cell neoplasia, and cell AE1/AE3block material (Figure was 2) . positiveThe patient for started thyroglobulin, treatment thyroid with pancreatic head, promoting dilation of the main pancreatic transcription factor 1 (TTF-1), Ki-67 and cytokeratin defined borders, measuring 19 mm x 17 mm, located at the Cabozantinib and still survives at present moment.

Figure 1. Pancreatic Duct; PN Pancreatic Nodule. CT and EUS images of the pancreatic lesion. Arrow - hepatic metastases, arrowhead - Wirsung duct dilatation, circle-pancreatic nodule, PD

Figure 2.

(2a) Hematoxylin-eosin–stained section, (2b) immunohistochemistry positive for TTF-1, (2c) immunohistochemistry positive for thyroglobulin, (2d) immunohistochemistry positive for AE1/AE3. JOP. Journal of the Pancreas - http://pancreas.imedpub.com/ - Vol. 21 No. 6 – November 2020. [ISSN 1590-8577] 152 JOP. J Pancreas (Online) 2020 Nov 30; 21(6): 151-155.

Table 1.

Cases Demographicof pancreatic metastases from PTC.Primary lesion Metastatic lesion Time after Age at PTC TNM diagnosis Location in Other distant Author Gender Size Location Histology Stain Treatment diagnosis classification of primary pancreas metastasis lesion Sugimura 32 F N/A N/A N/A 7 years None Tg Surgery et al Jobran 5.5 PTC Head 53 M Left T4N1M0 1 month Lung, bone Tg et al cm Adriamycin PTC Surgery+Carboplatin/ Head Adrenal, lung, Meyer et al 62 M N/A N/A (TCV) T4N0M0 4 years Tg Surgery

Siddiqui PTC Head Tg, TTF-1, 62 M 4 cm Right T4N1bM0 7years liver,Lung kidney Surgery et al PTC (TCV) Head Tg, TTF-1, CD15 Angeles 72 M N/A Intrathoracic TxNxM1 N/A Body and tail Brain Surgery at al cytokeratin 7, PTC (classic) cytokeratin 19, Borschitz 34 F 6 cm Right T3N1aM0 9 years None HMBE-1Tg Surgery et al Borschitz Right, PTC (FV) Head 46 M N/A T3N1cM0 13 years Body Lung, bone Tg Surgery et al multifocal Chen et al 82 M N/A N/A PTC TxN1M0 5 years None Tg Lung, Alzahrani PTC (classic) UncinateNeck Unknown 55 M 2 cm Right T4aN1bM0 7 years liver, bone, Tg, TTF-1 et al process omentum PTC (classic) Tunio et al 56 F 4 cm Right T2N1cM0 7 years Lung N/A Surgery+Sorafenib Tg, TTF-1, PTC (FV) Li et al 55 M N/A N/A N/A 11 years Body and tail None Surgery Ki67, CK19, PTC CgA, Syn, CEA, Davidson 3.3 Left and Tg,TTF-1, 82 F T3N1bM0 2 years Body None CD56 Monitoring et al cm isthmus PTC (TCV) Tg, TTF-1, CD57, CEA Diagnosis of 10 Left and primary and Liver, Ren et al 47 M N/A Body and tail PAX-8,Galectin-3, CK19, Surgery cm isthmus metastasis at diaphragm P53,HBME-1, WT, PTC the same time

DPC4, CA19-9, Cho et al 71 Male N/A N/A N/A 10 years Lung TTF-1,MUC1 PAX-8 body Head and PTC (classic) Tg, TTF-1, Unknown

AE1/AE3, Present 2.5 Lung, liver, 38 Female Right T1NxMx 10 years PAX-8,Beta-catenin, Ki-67, case cm bone, brain PTC (classic Head Cabozantinib and FV) alpha 1-anti- chymotrypsinVimentin,

PTC papillary thyroid carcinoma; TCV tall cell variant; FV follicular variant; N/A not available; Tg thyroglobulin; TTF-1 thyroid transcription factor 1; CEA ; CgA ; HMBE-1 Hector Battifora mesothelial-1; F Female; M Male. DISCUSSION investigations, even several years after the removal of the primary tumor [7]. Differentiated thyroid carcinoma presents with distant metastasis in 4% of cases, usually occurring in the lungs, bone and thoracic lymph nodes. 6 Pancreatic involvements the differentiation of primary from are extremely rare [3]. pancreaticDespite advancesmetastases in diagnosticremains challenging imaging techniques, because In a literature review published by Davidson et al cases inthere a patient is no with pathognomonic a previous history feature of [8]. malignancy The finding should of a 1991 to 2017 [6]. The mean age at diagnosis was 55.3 years, beheterogeneous suspected for pancreatic metastasis, mass a clear with indication well-defined for EUS-FNA borders withof pancreatic predominance metastasis in males. from PTCMetastasis have been was founddetected since 1 [9]. month to 13 years after diagnosis of the primary tumor and 7 patients had other sites of metastases beyond the It is also not possible to identify a typical image of literature by 2020 (Table 1). include multiple lesions, dilatation of the main pancreatic pancreas [6]. We identified 3 more cases in the scientific metastatic tumor in EUS; however, suggestive findings Pancreatic metastasis may remain asymptomatic for duct, atrophy, and well-defined margins [5]. usually occurring in the context of an extensive disease diagnosis of solid pancreatic masses, with a sensitivity of 75% [5,a long 7]. It period can be or detected manifest incidentally with non-specific or during symptoms, follow-up EUS-FNA is a noninvasive and effective method for definite

to 93.8% and specificity of 60% to 100% [5]. JOP. Journal of the Pancreas - http://pancreas.imedpub.com/ - Vol. 21 No. 6 – November 2020. [ISSN 1590-8577] 153 JOP. J Pancreas (Online) 2020 Nov 30; 21(6): 151-155.

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