Small cell lung cancer (SCLC) is notorious for its aggressive behavior and propensity for metastasis. Although metastasis to the pancreas from SCLC is relatively rare, it warrants attention due to its overlapping symptomatology with primary pancreatic malignancies and other abdominal pathologies (such as those involving the liver or gallbladder). Despite recent advances, the mechanisms driving SCLC metastasis to the pancreas remain elusive, providing challenges in diagnosis and treatment. This case report details the presentation of a 59-year-old woman with SCLC metastasis to the pancreas, initially masquerading as primary pancreatic carcinoma, as highlighted by her presenting symptoms of jaundice, weight loss, and abdominal pain. Diagnostic workup, including imaging studies and tissue sampling, confirmed the unexpected presence of metastatic SCLC in the pancreas. The patient was ultimately transferred to a tertiary care facility for further workup. This case serves as a reminder to maintain a broad differential diagnosis, particularly in the face of such an unusual presentation. It also highlights the need for further research to elucidate the molecular and cellular mechanisms driving SCLC metastasis to the pancreas, with the ultimate goal of improving diagnostic accuracy and therapeutic outcomes for patients with this aggressive disease.

Fibroblast Activation Protein Inhibitor (FAPI) positron emission tomography (PET) imaging has emerged as a useful method for identifying pancreatic disorders, notably pancreatitis. Unlike Fluorine-18 fluorodeoxyglucose (FDG), FAPI uptake is directly proportional to the degree of fibrosis, making it very useful in separating pancreatic tumors from inflammation. Recent investigations have shown that FAPI positron emission tomography/computer tomography (PET/CT) can identify pancreatic inflammation with great sensitivity, providing vital diagnostic information. In this case study, a 52-year-old male with a history of Ewing sarcoma presented with epigastric pain. Pancreatitis was confirmed on a computer tomography (CT) scan showing mild fat stranding in the pancreatic body and tail, in addition to a significant increase in pancreatic head mass, necessitating further evaluation with FDG PET/CT and FAPI PET/CT, as the patient was known to have metastatic sarcoma. While FDG PET/CT revealed an avid infiltrative lesion in the duodenal/pancreatic head area, FAPI PET/CT showed diffuse uptake in the pancreatic body and tail, indicating fibroblast-mediated inflammation consistent with pancreatitis. This case demonstrates the usefulness of FAPI imaging in discriminating between pancreatic metastasis and pancreatitis, with FAPI PET/CT providing crucial diagnostic information when FDG uptake is ambiguous.

A 57-year-old man with a background of chronic pancreatitis presented with acutely worsening abdominal pain and vomiting. He previously had a pancreatic duct stent in situ which had been removed 1 year prior to presentation. Initially suspected to be acute-on-chronic pancreatitis, a computed tomography (CT) scan of the abdomen and pelvis revealed an atrophic pancreas and a new mass in the pancreatic head, raising the suspicion of pancreatic malignancy. An urgent endoscopic ultrasound (EUS)-guided fine needle biopsy of the pancreatic head mass surprisingly revealed the presence of actinomyces colonies on histological evaluation. Prompt initiation of a prolonged antibiotic course led to significant clinical and radiological improvement. This case highlights the rare presentation of pancreatic actinomycosis which can often masquerade as malignancy. Although a gut commensal, actinomyces can elicit pathogenic effects if allowed to enter tissues through a breach in the mucosal lining such as following abdominal surgery or pancreatic duct intervention as observed in this case. Early recognition and appropriate treatment with antibiotics can lead to clinical recovery and complete resolution of the infection.

Pancreatic masses are commonly encountered in clinical practice, with concern for the possibility of cancer. Tissue sampling or outright surgical resection may be offered in this setting. However, surgery has been unnecessarily performed in patients with pancreatic masses that proved to be benign. Less invasive options for pancreatic masses that may be benign like tuberculosis should thus be explored. Three adult Filipino patients less than 60 years old presented with symptomatic pancreatic masses suspected of cancer on abdominal imaging studies. Two were smokers without a history of prior tuberculosis. Without any tissue sampling, anti-tuberculosis treatment was eventually given to all three patients due to concomitant diagnoses of extrapancreatic tuberculosis. Endoscopic ultrasound documentation of post-treatment resolution of pancreatic masses was noted in all cases. In endemic regions, although clinical diagnosis of tuberculosis may be possible for pancreatic masses, empiric treatment should still be a last-line option in cases where tissue sampling cannot be done.

Glucagon-like peptide 1 (GLP-1) agonists are commonly used in the management of type 2 diabetes due to their glucose-lowering effects and potential cardiovascular benefits. While generally well-tolerated, here we report a unique case associated with GLP-1 therapy. A 57-year-old male with a history of type 2 diabetes developed mild abdominal pain with no nausea or vomiting approximately four months after increasing the dose of GLP-1 therapy. Imaging studies revealed mesenteric vein thrombosis and an enlarged pancreatic head. Endoscopic ultrasound with biopsies was completed, which confirmed acute pancreatitis. The patient was promptly treated with a heparin drip and supportive care. The GLP-1 agonist was discontinued. This case highlights a rare but critical adverse event associated with GLP-1 receptor agonists as well as the importance of considering unusual complications in patients initiating such therapy. Further research is warranted to elucidate the underlying mechanisms and risk factors for these adverse events.

BACKGROUND: Endoscopic ultrasound (EUS)-guided tissue acquisition is the preferred modality for diagnosing pancreatic lesions and mediastinal and abdominal lymph nodes. Rapid on-site cytologic evaluation improves the diagnostic outcome of EUS-guided fine-needle aspiration (FNA) but is unavailable at many centers. Alternatively, macroscopic on-site evaluation (MOSE) may improve the diagnostic outcome of EUS-FNA, but data are limited. Hence, the present study was conducted to assess the efficacy of MOSE in improving adequacy and accuracy.
METHODS: We retrospectively analyzed data of consecutive patients with pancreatic or lymph nodal lesions undergoing EUS-guided FNA at a tertiary care center from December 2020 to December 2022. The study\'s primary outcomes were adequacy and diagnostic accuracy of the EUS-guided tissue acquisition, with secondary analysis of predictors of adequacy and accuracy.
RESULTS: Data from 124 patients (44.4% male, median age: 54 years) who underwent EUS-FNA were included in the present analysis. The presence of macroscopic visible core (MVC) on MOSE was reported in 93/124 (75%) cases. An adequate sample for histopathological or cytological examination was obtained in 110/124 (88.7%) cases, while the diagnostic accuracy was 85.5%. On multivariate analysis, the absence of MVC on MOSE was found to be the independent negative predictor of both adequacy (OR 0.092, 95% CI: 0.024-0.349) and accuracy (OR 0.175, 95% CI: 0.057-0.536).
CONCLUSIONS: The presence of MVC on MOSE can be an indicator of specimen adequacy and can improve the diagnostic yield of EUS-FNA.

We describe a case of segmental arterial mediolysis (SAM) in a 2-year-old male who presented with symptoms of acute pancreatitis. SAM is a vascular entity of unknown etiology that involves medium-sized arteries in which the integrity of the vessel wall is compromised, resulting in increased susceptibility to ischemia, hemorrhage, and dissection. The clinical presentation is variable and can range from abdominal pain to more ominous findings of abdominal hemorrhage or organ infarction. This entity should be considered in the correct clinical setting and after other vasculopathies have been excluded. We aim to bring awareness to pediatric providers given this is a rare entity with variable presentation, which could be potentially life threatening.

Malakoplakia is a rare granulomatous tumor-like inflammatory condition, most frequently involving the genitourinary system and occurring in immunosuppressed patients. The gastrointestinal tract is the second most common site, where it is usually seen involving the colon. We report a case of malakoplakia presenting as a pancreatic mass. Imaging showed soft tissue along the pancreatic tail/greater curvature concerning for infiltrating tumor, but endoscopic ultrasound with biopsy showed malakoplakia. Our case discusses malakoplakia at an uncommon site, which was appropriately treated with antibiotics.

Gastrointestinal stromal tumors (GISTs) are one of the most common, potentially malignant, subepithelial lesions identified in the gastrointestinal tract. Hypothesized to derive from the interstitial cells of Cajal (ICC), GISTs commonly demonstrate gain of function mutations in proto-oncogenic receptor tyrosine kinase CD117 (KIT). Depending on mitotic activity and tumor size characteristics, GISTs may transform from benign to malignant neoplasms. Increasing evidence suggests that early identification of a GIST is paramount for optimal prognostic outcomes. We present a rare case of a GIST located in the uncinate pancreas identified via endoscopic ultrasound (EUS) and diagnosed with an EUS-guided fine needle aspiration (EUS-FNA) biopsy.

Primary pancreatic sarcomas are rare malignancies with an incidence of 0.1%. This case report is of a 48-year-old man who presented with this condition. The patient\'s treatment plan consisted of distal pancreatectomy and splenectomy with intraoperative immunohistochemistry and adjuvant chemotherapy. To correctly identify and treat undifferentiated pleomorphic sarcoma, a stepwise strategy involving cross-sectional imaging and extensive histopathology analysis is necessary.