EUS better than CT, MRI for detection of sub lesions of the pancreas, cases to be well considered. Radiologic imaging is the gold standard for the diagnosis of lesions of the pancreas. However, not all lesions can be diagnosed via computer tomography or magnetic resonance imaging. In such cases, endoscopic ultrasound can provide helpful assistance that might be crucial for an immediate and accurate diagnosis and treatment. Case 1. A 38-year-old female presented with a history of recurring pancreatitis. Repeated scans showed a bilobular cyst in the tail of the pancreas of around 2 cm. A recent CT scan verified these findings and posed the question of compression of the splenic vein. We performed an endoscopic ultrasound for further characterization of the lesion. In the tail of the pancreas, we could notice a normal pancreatic duct but also an inhomogeneous area of around 2 cm which was not previously described in the radiologic imaging. In elastography, this area appeared to have a somehow hard echo texture. Right next to this area, the bilobular cyst was located. The cyst appeared to have a nodular area within. We decided to proceed to a contrast-enhanced ultrasound. Here you can see that the area of the tail of the pancreas had a contrast uptake in the arterial phase, whereas there was no contrast uptake within the nodular area of the cyst. However, we decided to puncture both of the lobes of the cyst. Here you can see the first lobe. The puncture of the second lobe was somehow difficult because of the risk vascularity of the region. And at last, we could puncture the inhomogeneous area of the tail of the pancreas. The examination of the fluid showed mass in a cystic fluid with high amylase and CEA of around 317 ng per ml. The cytology revealed findings consistent with low-grade mucin-producing cystic neoplasm, more specifically, low-grade side-branch intraductal papillary mucinous neoplasm of the cyst. The cytomorphological and immunohistochemical findings of the lesion in the tail of the pancreas were compatible with the neoplastic origin. The patient was presented to our interdisciplinary board and she underwent a peripheral hemipancreatectomy. The final histology confirmed the presence of a low-grade mucinous neoplastic lesion as well as a neuroendocrine tumor, grade 2, with 1 to 58 positive lymph nodes, PT2N1R0, stage 3, according to the 2017 classification. The second case involves a 63-year-old female patient who presented to our clinic with postprandial abdominal pain. A recent MRI and CT revealed no abdominal abnormality apart from a marginal, mild dilatation of the pancreatic duct of around 3 mm. Her symptoms were initially attributed to functional dyspepsia. We reluctantly performed an endoscopic ultrasound where we located a pancreatic duct of around 4 mm. There were no abnormalities in the pancreatic parenchyma except for a 1 cm inhomogeneous area at the neck of the pancreas, which was in contact with the superior mesenteric vein. The lesion had hard texture in the elastography. We attributed the dilatation of the PT as a compression of the lesion. Therefore, we decided to perform a cautious fine-needle biopsy with a 22-gauze needle. There was no malignancy found in rapid on-site examination. However, in the final cytology, high-grade dysplasia was detected. Considering this lesion as a beginning malignancy, the patient underwent an operation with the plan of a pancreatodudectomy. The intraoperative inspection revealed, unfortunately, foci of peritoneal carcinomatosis and the beginning infiltration of the duodenum from a pancreatic tumor of the neck head of the pancreas. The patient started the palliative chemotherapy thereafter. Conclusions? Endoscopic ultrasound might be a helpful and critical instrument for revealing the underlying pathology in patients with obscure symptoms and or negative radiologic imaging. The consecutive use of endoscopic ultrasound in the hands of the experienced endoscopist, in combination with the right evaluation of patient symptoms, can be decisive of patient's treatment.

endoscopic ultrasound

pancreatic sub lesions

case studies

diagnosis

obscure symptoms