Re-recurrence after distal gastrectomy for recurrence caused by needle tract seeding during endoscopic ultrasound-guided fine-needle aspiration of a pancreatic adenocarcinoma

A 78-year-old woman, who was suspected of having pancreatic cancer, underwent endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). Three punctures were applied using a 22-gauge needle (Boston Scientific, Tokyo, Japan) ([Fig. 1]). The procedure was completed without complication, and adenocarcinoma was diagnosed. Distal pancreatectomy was performed and the lesion was confirmed as an infiltrating pancreatic duct cancer pT3N0M0, pStage IIA.

Fig. 1 Endoscopic ultrasound-guided fine-needle aspiration was performed and involved three punctures using a 22-gauge needle (Boston Scientific, Tokyo, Japan). The procedure was completed without complication, and adenocarcinoma was diagnosed.

On upper gastrointestinal endoscopy 6 months later, a lesion, which was thought to be recurrence caused by needle tract seeding during EUS-FNA, could be seen in the lower posterior wall of the stomach body ([Fig. 2]). Positron emission tomography (PET) showed abnormal accumulation of fluorine-18-deoxyglucose (FDG) locally ([Fig. 3]). Distal gastrectomy was subsequently performed ([Fig. 4]), and the lesion was confirmed to be histopathologically similar to the tissue of the previous pancreatic cancer.

Fig. 2 On upper gastrointestinal endoscopy 6 months later, a lesion was observed in the lower posterior wall of the stomach body. The lesion was thought to be recurrence of the tumor caused by needle tract seeding during endoscopic ultrasound-guided fine-needle aspiration.

Fig. 3 Positron emission tomography/computed tomography indicated abnormal fluorine-18-deoxyglucose accumulation locally in the posterior wall of the body of the stomach (arrow).

Fig. 4 Distal gastrectomy was performed and the 18 × 14 mm lesion was found to be histopathologically similar to the tissue of the previous pancreatic cancer. The recurrence was thought to be caused by needle tract seeding during endoscopic ultrasound-guided fine-needle aspiration and implantation in the stomach.

Adjuvant chemotherapy using S-1 (tegafur/gimeracil/oteracil) was administered, and no recurrence was observed during the subsequent course. At 21 months after distal gastrectomy the patient complained of general malaise. PET showed abnormal FDG accumulation locally in the gastric wall ([Fig. 5]). On upper gastrointestinal endoscopy, a lesion, which was thought to be re-recurrence, could be seen in the upper posterior wall of the operated stomach body ([Fig. 6]). Biopsies showed adenocarcinoma, which was thought to be metastasis in the gastric wall.

Fig. 5 Positron emission tomography scan 21 months after distal gastrectomy showed abnormal fluorine-18-deoxyglucose accumulation in the gastric wall (arrow).

Fig. 6 On upper gastrointestinal endoscopy, a lesion, which was thought to be re-recurrence, was observed in the upper posterior wall of the operated stomach body. Biopsies showed adenocarcinoma, which was thought to be metastasis in the gastric wall.

Total gastrectomy was planned, but the patient refused this treatment and continued with chemotherapy.

Eight cases of seeding during EUS-FNA for pancreatic cancer have been reported [1] [2] [3] [4] [5] [6] [7] [8]. In three cases, curative surgical resection of the recurrent seeded lesion was performed [5] [6] [7]. Since the long-term prognosis of radical surgical resection of recurrent lesions seeded into the stomach by EUS-FNA is unknown, this issue has not been fully discussed. To our knowledge, the present case is the first report of repeated recurrence of these types of lesions in the stomach after radical surgical resection. The very existence of such cases suggests that the option of performing total gastrectomy first must be considered rather than simple surgical resection of the seeded lesions.

Endoscopy_UCTN_Code_CPL_1AL_2AB

Competing interests: None

• References

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