Endoscopic ultrasound and fine needle aspiration for the diagnosis of extragonadal seminoma metastatic to the pancreas

A 35-year man presented with back pain and paraparesis. Computed tomography of the abdomen and chest showed a pancreatic mass and a spinal canal lesion from L5 to S3. Of note, a year earlier, he had been in a motor vehicle accident, at which time emergency computed tomography of the chest showed a mediastinal tumor. Tissue obtained during thoracoscopy demonstrated a granulomatous tissue reaction.

During the present admission, the patient underwent an endoscopic ultrasound (EUS) examination because pancreatic cancer metastatic to the spine was suspected. EUS showed a hypoechoic, infiltrative 2.5-cm lesion in the body of the pancreas. The lesion infiltrated the surrounding tissue and was close to the splenic vein and celiac artery, but without signs of invasion. EUS-guided fine needle aspiration with a 22-gauge needle (Boston Scientific, MA, USA) was used to obtain a specimen. Cytology showed granulomas and a few isolated, large malignant cells, each with a round nucleus, visible nucleoli, and a moderate amount of finely vacuolated cytoplasm ([Fig. 1], [Fig. 2]). The cytologic differential diagnosis included seminoma and large cell lymphoma. Immunocytochemistry was not done. We also obtained a biopsy specimen of the vertebral lesion, which confirmed the diagnosis of seminoma. Both testes were negative for tumor mass, so we suspected that seminoma had already been present in the mediastinum a year earlier. The patient was referred for oncologic therapy.

Fig. 1 Extragonadal seminoma metastatic to the pancreas. An isolated malignant cell has a round nucleus, visible nucleoli, and a moderate amount of finely vacuolated cytoplasm. A few histiocytes are seen in the background (May–Grünwald–Giemsa stain, original magnification × 1000).

Fig. 2 One malignant cell is attached to a cluster of epithelioid histiocytes (May–Grünwald–Giemsa stain, original magnification × 400).

This case is interesting because it shows an unusual metastasis of a nongonadal seminoma to the pancreas. Whereas tumors such as those of the breast, kidney, and lung often metastasize to the pancreas, it is extremely uncommon for a seminoma to present as a pancreatic lesion [1] [2]. This case is of additional interest because it demonstrates the utility of cytology to establish a diagnosis. Our case and the case reported by Wehrschütz et al. underscore the importance of cytohistopathologic examination [3]. Lastly, these unique cytologic images may be useful to illustrate the characteristics of metastatic seminoma.

Endoscopy_UCTN_Code_CCL_1AF_2AZ_3AB

Publication History

Publication Date:
19 November 2014 (online)

• References

• 1 Gnemmi V, Leroy X, Triboulet JP. et al. Pancreatic metastases of renal clear cell carcinoma: a clinicopathological study of 11 cases with special emphasis on the usefulness of PAX2 and mesothelin for the distinction from primary ductal adenocarcinoma of the pancreas. Anal Quant Cytol Histol 2013; 35: 157-162
• 2 Olson MT, Wakely Jr PE, Ali SZ. Metastases to the pancreas diagnosed by fine-needle aspiration. Acta Cytol 2013; 57: 473-480
• 3 Wehrschütz M, Stöger H, Ploner F. et al. Seminoma metastases mimicking primary pancreatic cancer. Onkologie 2002; 25: 371-373