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Annals of Clinical and Medical
Case Reports
Case Report Volume 5
ISSN 2639-8109
Pancreatic Metastasis from Unresectable Lung Adenocarcinoma: A Case Report
Wang R, Zhan H, Yu L, Li D and Wang W*
Department of Gastroenterology, 900 Hospital of the Joint Logistics Team, Fuzong Clinical Medical College of Fujian Medical
University; Eastern Hospital Affiliated to Xiamen University, China
*Corresponding author:
Wen Wang,
Department of Gastroenterology, 900 Hospital of
the Joint Logistics Team, Fuzong Clinical Medical
College of Fujian Medical University; Eastern Hospital
Affiliated to Xiamen University, China,
E-mail: wangwenfj@163.com
Received: 17 Dec 2020
Accepted: 11 Jan 2021
Published: 14 Jan 2021
Copyright:
©2021 Wang W et al., This is an open access article dis-
tributed under the terms of the Creative Commons Attri-
bution License, which permits unrestricted use, distribu-
tion, and build upon your work non-commercially.
Citation:
Wang W. Pancreatic Metastasis from Unresectable Lung
Adenocarcinoma: A Case Report. Ann Clin Med Case
Rep. 2021; V5(8): 1-4.
Keywords:
Lung Adenocarcinoma; Pancreatic Metastasis;
EUS-FNA
Authors' contributions:
Wang R, Zhan H, Yu L, Li D and Wang W. These authors
have contributed equally to this article
Abbreviations:
CA199: CarbohydrateAntigen 199; CEA: Carcinoembry-
onic Antigen; EUS-FNA: Endoscopic Ultrasound-Guided
Fine Needle Aspiration; TTF-1: Thyroid Transcription
Factor-1; ERCP: Endoscopic Retrograde Cholangiopan-
creatography
1. Abstract
1.1. Background: Metastatic lesions of the pancreas are uncom-
mon, accounting for approximately 2% of pancreatic malignan-
cies. The most common primary tumors to give rise to pancreatic
metastases are lung cancer, renal cell carcinoma and carcinoma
of gastrointestinal origin. Less commonly metastases from lung
adenocarcinoma have been reported.
1.2. Case presentation: Here we reported a case with pancre-
atic and Left adrenal metastasis 6 months after chemoradiother-
apy for lung adenocarcinoma who was diagnosed in July 2017,
and the pancreatic tumor was diagnosed using endoscopic ultra-
sound-guided fine needle aspiration (EUS-FNA).
1.3. Conclusions: The blood CA19-9 level may be slightly elevat-
ed when pancreatic metastasis was found,we think that the detec-
tion of blood CA19-9 combined with EUS-FNA is of great signif-
icance in differentiating pancreatic primary tumors and metastatic
tumors.
2. Background
Lung adenocarcinoma is derived from bronchial epithelium and
glands. Most of them are peripheral. They often metastasized in
blood, involving brain, bone, adrenal, liver, contralateral lung and
pleura, etc, and usually metastasized to hilar lymph node. Howev-
er, metastatic cancer infrequently involves the pancreas. Less than
5% of reported pancreas FNA contain metastatic disease [1, 2].
Yoon et al [3] reported 53 pathologicaly proven metastatic tumors
of the pancreas and 14 cases were originate from non-small cell
lung cancer. Metastatic tumors of the pancreas are rarely found
clinically, although their incidence has been reported to be approx-
imately 12% among malignant disease autopsies [4]. The case we
report here was diagnosed using endoscopic ultrasound-guided
fine needle aspiration (EUS-FNA) and EUSFNA appears to be
useful for the diagnosis of metastatic pancreatic tumors, particu-
larly in patients with multiple cancers.
3. Case Presentation
A 49-year-old male with no relevant past medical history was
referred to our department for complaining of irritate cough 2
months. He Smoked for 30 years and 20 cigarettes per day. Dou-
ble J tube was implanted 20 years ago due to left ureteral stenosis
and left kidney hydronephrosis. The Chest CT scan showed: 1.
http://www.acmcasereport.org/ 1
DOI: http://dx.doi.org/10.47829/ACMCR.2021.5801
The right upper lung hilar tumor was considered as lung cancer
with hilar lymph node metastasis; 2. Destruction of the Side of
the 10th rib bone suspicious for bone metastasis. Non-small cell
cancer cells were prompted of bronchoscopy biopsy pathology,
tend to adenocarcinoma (Figure 1). The diagnosis was right up-
per lung adenocarcinoma (stage cT3N0M1 IV). Consider of the
occurrence of distant metastasis then the patient underwent four
cycles of chemotherapy (pemetrexed 800mg Intravenous infusion
in day1 and carboplatin 500mg intravenous infusion of the first
two days, every 21 days repeated). Plus a course of the local right
hilar lesions palliative radiotherapy (dose 60Gy / 30f / 6w). The
blood CEA maintained at 220ng/ml, CA19-9 was normal monthly
during chemoradiotherapy.
Figure 1: Microscopic findings of the lung tumor showing non-small cell
cancer cells, tend to adenocarcinoma (Hematoxylin and Eosin staining,
original magnification, ×200.
Six months after treatment, MRI of the upper abdomen
showed: Nodular abnormal signal shadow showed in pancreatic
body(1.6x1.6cm), metastatic tumor was possible (Figure 2). The
blood CEA showed 700 ng/ml and CA19-9 showed 61.4U/ml
(Figure 3). We performed EUS-FNA to diagnose the pancreatic
tumor because the chemotherapy protocol would be different de-
pending on whether the pancreatic tumor was primary pancreat-
ic cancer or metastasis from lung cancer (Figure 4). No signs or
symptoms were noted of the patient during or after the procedure.
The pathologic diagnosis of the biopsy specimen of the pancre-
as strongly suggested metastatic poorly differentiated adenocar-
cinomaa (Figure 5). γ-knife was performed to liver and stomach
space + pancreatic body + retroperitoneal + left adrenal metastasis
and the patient received four cycles of chemotherapy (docetaxel,
120mg, iv, D1+bevacizumab, 400mg, iv, D1*q21 days). In sum-
mary,combined with the patient's history and pathological re-
sults, he was Confirmed as lung adenocarcinoma with pancreatic
metastasis.
Figure 2: MRI shows nodular abnormal signal shadow in the pancreatic
body(1.6x1.6cm)
Figure 3: Changes of CA19-9 in the course of disease
Figure 4: Endoscopic ultrasound showed a mass in the pancreas body
with a diameter of 18 mm. The border of the mass was relatively clear, and
the internal echo was low and approximately heterogeneous
http://www.acmcasereport.org/ 2
Volume 5 Issue 8-2021 Case Report
Figure 5: Microscopic findings of the pancreatic tumor, showing metastatic poorly differentiated adenocarcinoma(Hematoxylin and Eosin staining,
original magnification, ×100(left) ×400(right)).
4. Discussion and Conclusions
The clinical and imaging features of most metastatic pancreatic
malignancies are similar to those of primary pancreatic tumors
which may easily lead to misdiagnosis. So clear history of malig-
nant tumor is important for diagnosis. Pancreatic head metastasis
with less expansion of the bile duct and pancreatic duct, which
may be related to the primary tumor cells metastasized to the pan-
creas by blood or lymph node and do not infiltrates the wall of pan-
creatic duct, it would cause the dilatation of the obstructive biliary
and pancreatic duct only when the tumor occurs oppression. In
our case, there was no dilation of the bile and pancreatic duct. It is
believed that acute pancreatitis and obstructive jaundice in biliary
malignancies results from infiltration of the metastatic tumor into
the pancreatic ducts. In such instances, ERCP with stent insertion
can be a plausible palliative therapy for biliary drainage [5].
PET-CT helps to understand the systemic metastasis and recur-
rence of primary lesions which has a certain significance in re-
ducing unnecessary surgical exploration, but its clinical value is
mainly reflected in the level of tumor glucose metabolism, and
cannot be clear about the histological and biological types of tu-
mors. EUS-FNA plays a extremely important role in the diagnosis
of pancreatic metastatic malignant tumors. On US and EUS, a met-
astatic pancreas tumor often shows an internally heterogeneous
low echo mass image, as conventional pancreatic cancer does. The
border of a metastatic pancreatic tumor is often clear, and this is
useful for differentiation [6]. The EUS results of this case are the
same as above. So EUS-FNA with high sensitivity and specificity
in differentiating pancreatic cancer. Moreover, it is also a safe di-
agnostic modality with little complications [7].
It is necessary to consider pancreatic neoplasm in the differential
diagnosis of pancreatic tumors if the patient has a past history of
malignancy. The blood CA19-9 with high value in the diagnosis
of primary pancreatic cancer, but it may be expressed as normal
and elevated only in a few cases in patients with pancreatic me-
tastases. The blood CA19-9 level in this patient has been elevated
when pancreatic metastasis was found. Therefore, the detection of
blood CA19-9 combined with EUS-FNA is of great significance in
differentiating pancreatic primary tumors and metastatic tumors.
Thyroid transcription factor 1 (TTF-1) is one of the most com-
monly utilized immunohistochemical markers in the diagnosis of
lung cancers. It is expressed in 60-90% of lung adenocarcinomas,
90% of small cell lung cancers and the majority of thyroid carci-
nomas, but is rarely expressed in adenocarcinomas of other sites
or in squamous cell lung carcinomas [8, 9]. In general, TTF-1
is negative and CA199 is positive in pancreatic cancer, whereas
TTF-1 is positive in lung adenocarcinoma.TTF-1 is primarily used
to distinguish adenocarcinomas of lung (and thyroid) origin from
carcinomas of other sites and to distinguish lung adenocarcinomas
and small cell lung cancers from squamous cell carcinomas [10].
In this case, TTF-1 is positive and which is more likely to indicate
that pancreatic tumor is metastasis of lung cancer in combination
with CA 19-9.
Secondary pancreatic tumors are advanced tumors and how to
choose different modes of comprehensive treatment should be
based on the biological characteristics of their primary tumors.
The response of pancreatic metastases to radiotherapy and che-
motherapy is consistent with its primary tumor. In our case,the
relationship between adrenal metastasis and pancreatic metastasis
is still unknown. It was found that the median survival time of
pancreatic metastases was 57.6 months after operation which was
much higher than that of primary pancreatic cancer. The prognosis
of patients is not only related to the completeness of surgical resec-
tion, but also the biological characteristics of primary tumors and
the effect of comprehensive treatment.
5. Declarations
Ethics approval and consent to participate: The study was ap-
proved by the relevant ethics committee (the name of the ethics
committee and the reference number:Fuzhou General Hospital
ethics committee of Nanjing Military Area Command, 2017-019),
and the participant has gave informed consent.
Funding: Guiding (Key) Project of Social Development in Fujian
Province (2018Y0066).
http://www.acmcasereport.org/ 3
Volume 5 Issue 8-2021 Case Report
References
1. Layfield LJ, Hirschowitz SL, Adler DG. Metastatic disease to the
pancreas documented by endoscopic ultrasound guided fine-needle
aspiration:a seven-year experience. Diagn Cytopathol. 2012; 40:
228-233.
2. Adsay NV, Andea A, Basturk O, Kilinc N, Nassar H, Cheng JD.
Secondary tumors of the pancreas: an analysis of a surgical and au-
topsy database and review of the literature. Virchows Archiv. 2004;
444: 527-535.
3. Yoon WJ, Ryu JK, Kim YT, Yoon YB, Kim SW, Kim WH. Clinical
features of metastatic tumors of the pancreas in Korea: a single-cen-
ter study. Gut Liver. 2011; 5: 61-4.
4. Abrams HL, Spiro R, Goldstein N. Metastases in carcinoma: analy-
sis of 1000 autopsied cases. Cancer. 1950; 3: 74-85.
5. Chu D, Adler DG. Malignant biliary tract obstruction: evaluation
and therapy. J Natl Compr Canc Netw 2010; 8: 1033-1044.
6. DeWitt J, Jowell P, Leblanc J, et al. EUS-guided FNA of pancreat-
ic metastases: a multicenter experience. Gastrointest Endosc. 2005;
61: 689-96.
7. Chen G, Liu S, Zhao Y, Dai M, Zhang T. Diagnostic accuracy of
endoscopic ultrasound-guided fine-needle aspiration for pancreatic
cancer:A meta-analysis. Pancreatology. 2013; 13(3): 298-304.
8. Brunnstrom H, Johansson L, Jirström K, Jönsson M, Jönsson P,
Planck M. Immunohistochemistry in the differential diagnostics of
primary lung cancer: an investigation within the Southern Swedish
Lung Cancer Study. Am J Clin Pathol. 2013. 140(1): 37-46.
9. Mukhopadhyay S and Katzenstein AL, Comparison of monoclonal
napsin A, polyclonal napsin A, and TTF-1 for determining lung ori-
gin in metastatic adenocarcinomas. Am J Clin Pathol. 2012; 138(5):
703-11.
10. Rekhtman N, Ang DC, Sima CS, Travis WD, Moreira AL. Immuno-
histochemical algorithm for differentiation of lung adenocarcinoma
and squamous cell carcinoma based on large series of whole-tis-
sue sections with validation in small specimens. Mod Pathol. 2011;
24(10): 1348-59.
http://www.acmcasereport.org/ 4
Volume 5 Issue 8-2021 Case Report

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Pancreatic Metastasis from Unresectable Lung Adenocarcinoma: A Case Report

  • 1. Annals of Clinical and Medical Case Reports Case Report Volume 5 ISSN 2639-8109 Pancreatic Metastasis from Unresectable Lung Adenocarcinoma: A Case Report Wang R, Zhan H, Yu L, Li D and Wang W* Department of Gastroenterology, 900 Hospital of the Joint Logistics Team, Fuzong Clinical Medical College of Fujian Medical University; Eastern Hospital Affiliated to Xiamen University, China *Corresponding author: Wen Wang, Department of Gastroenterology, 900 Hospital of the Joint Logistics Team, Fuzong Clinical Medical College of Fujian Medical University; Eastern Hospital Affiliated to Xiamen University, China, E-mail: wangwenfj@163.com Received: 17 Dec 2020 Accepted: 11 Jan 2021 Published: 14 Jan 2021 Copyright: ©2021 Wang W et al., This is an open access article dis- tributed under the terms of the Creative Commons Attri- bution License, which permits unrestricted use, distribu- tion, and build upon your work non-commercially. Citation: Wang W. Pancreatic Metastasis from Unresectable Lung Adenocarcinoma: A Case Report. Ann Clin Med Case Rep. 2021; V5(8): 1-4. Keywords: Lung Adenocarcinoma; Pancreatic Metastasis; EUS-FNA Authors' contributions: Wang R, Zhan H, Yu L, Li D and Wang W. These authors have contributed equally to this article Abbreviations: CA199: CarbohydrateAntigen 199; CEA: Carcinoembry- onic Antigen; EUS-FNA: Endoscopic Ultrasound-Guided Fine Needle Aspiration; TTF-1: Thyroid Transcription Factor-1; ERCP: Endoscopic Retrograde Cholangiopan- creatography 1. Abstract 1.1. Background: Metastatic lesions of the pancreas are uncom- mon, accounting for approximately 2% of pancreatic malignan- cies. The most common primary tumors to give rise to pancreatic metastases are lung cancer, renal cell carcinoma and carcinoma of gastrointestinal origin. Less commonly metastases from lung adenocarcinoma have been reported. 1.2. Case presentation: Here we reported a case with pancre- atic and Left adrenal metastasis 6 months after chemoradiother- apy for lung adenocarcinoma who was diagnosed in July 2017, and the pancreatic tumor was diagnosed using endoscopic ultra- sound-guided fine needle aspiration (EUS-FNA). 1.3. Conclusions: The blood CA19-9 level may be slightly elevat- ed when pancreatic metastasis was found,we think that the detec- tion of blood CA19-9 combined with EUS-FNA is of great signif- icance in differentiating pancreatic primary tumors and metastatic tumors. 2. Background Lung adenocarcinoma is derived from bronchial epithelium and glands. Most of them are peripheral. They often metastasized in blood, involving brain, bone, adrenal, liver, contralateral lung and pleura, etc, and usually metastasized to hilar lymph node. Howev- er, metastatic cancer infrequently involves the pancreas. Less than 5% of reported pancreas FNA contain metastatic disease [1, 2]. Yoon et al [3] reported 53 pathologicaly proven metastatic tumors of the pancreas and 14 cases were originate from non-small cell lung cancer. Metastatic tumors of the pancreas are rarely found clinically, although their incidence has been reported to be approx- imately 12% among malignant disease autopsies [4]. The case we report here was diagnosed using endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and EUSFNA appears to be useful for the diagnosis of metastatic pancreatic tumors, particu- larly in patients with multiple cancers. 3. Case Presentation A 49-year-old male with no relevant past medical history was referred to our department for complaining of irritate cough 2 months. He Smoked for 30 years and 20 cigarettes per day. Dou- ble J tube was implanted 20 years ago due to left ureteral stenosis and left kidney hydronephrosis. The Chest CT scan showed: 1. http://www.acmcasereport.org/ 1 DOI: http://dx.doi.org/10.47829/ACMCR.2021.5801
  • 2. The right upper lung hilar tumor was considered as lung cancer with hilar lymph node metastasis; 2. Destruction of the Side of the 10th rib bone suspicious for bone metastasis. Non-small cell cancer cells were prompted of bronchoscopy biopsy pathology, tend to adenocarcinoma (Figure 1). The diagnosis was right up- per lung adenocarcinoma (stage cT3N0M1 IV). Consider of the occurrence of distant metastasis then the patient underwent four cycles of chemotherapy (pemetrexed 800mg Intravenous infusion in day1 and carboplatin 500mg intravenous infusion of the first two days, every 21 days repeated). Plus a course of the local right hilar lesions palliative radiotherapy (dose 60Gy / 30f / 6w). The blood CEA maintained at 220ng/ml, CA19-9 was normal monthly during chemoradiotherapy. Figure 1: Microscopic findings of the lung tumor showing non-small cell cancer cells, tend to adenocarcinoma (Hematoxylin and Eosin staining, original magnification, ×200. Six months after treatment, MRI of the upper abdomen showed: Nodular abnormal signal shadow showed in pancreatic body(1.6x1.6cm), metastatic tumor was possible (Figure 2). The blood CEA showed 700 ng/ml and CA19-9 showed 61.4U/ml (Figure 3). We performed EUS-FNA to diagnose the pancreatic tumor because the chemotherapy protocol would be different de- pending on whether the pancreatic tumor was primary pancreat- ic cancer or metastasis from lung cancer (Figure 4). No signs or symptoms were noted of the patient during or after the procedure. The pathologic diagnosis of the biopsy specimen of the pancre- as strongly suggested metastatic poorly differentiated adenocar- cinomaa (Figure 5). γ-knife was performed to liver and stomach space + pancreatic body + retroperitoneal + left adrenal metastasis and the patient received four cycles of chemotherapy (docetaxel, 120mg, iv, D1+bevacizumab, 400mg, iv, D1*q21 days). In sum- mary,combined with the patient's history and pathological re- sults, he was Confirmed as lung adenocarcinoma with pancreatic metastasis. Figure 2: MRI shows nodular abnormal signal shadow in the pancreatic body(1.6x1.6cm) Figure 3: Changes of CA19-9 in the course of disease Figure 4: Endoscopic ultrasound showed a mass in the pancreas body with a diameter of 18 mm. The border of the mass was relatively clear, and the internal echo was low and approximately heterogeneous http://www.acmcasereport.org/ 2 Volume 5 Issue 8-2021 Case Report
  • 3. Figure 5: Microscopic findings of the pancreatic tumor, showing metastatic poorly differentiated adenocarcinoma(Hematoxylin and Eosin staining, original magnification, ×100(left) ×400(right)). 4. Discussion and Conclusions The clinical and imaging features of most metastatic pancreatic malignancies are similar to those of primary pancreatic tumors which may easily lead to misdiagnosis. So clear history of malig- nant tumor is important for diagnosis. Pancreatic head metastasis with less expansion of the bile duct and pancreatic duct, which may be related to the primary tumor cells metastasized to the pan- creas by blood or lymph node and do not infiltrates the wall of pan- creatic duct, it would cause the dilatation of the obstructive biliary and pancreatic duct only when the tumor occurs oppression. In our case, there was no dilation of the bile and pancreatic duct. It is believed that acute pancreatitis and obstructive jaundice in biliary malignancies results from infiltration of the metastatic tumor into the pancreatic ducts. In such instances, ERCP with stent insertion can be a plausible palliative therapy for biliary drainage [5]. PET-CT helps to understand the systemic metastasis and recur- rence of primary lesions which has a certain significance in re- ducing unnecessary surgical exploration, but its clinical value is mainly reflected in the level of tumor glucose metabolism, and cannot be clear about the histological and biological types of tu- mors. EUS-FNA plays a extremely important role in the diagnosis of pancreatic metastatic malignant tumors. On US and EUS, a met- astatic pancreas tumor often shows an internally heterogeneous low echo mass image, as conventional pancreatic cancer does. The border of a metastatic pancreatic tumor is often clear, and this is useful for differentiation [6]. The EUS results of this case are the same as above. So EUS-FNA with high sensitivity and specificity in differentiating pancreatic cancer. Moreover, it is also a safe di- agnostic modality with little complications [7]. It is necessary to consider pancreatic neoplasm in the differential diagnosis of pancreatic tumors if the patient has a past history of malignancy. The blood CA19-9 with high value in the diagnosis of primary pancreatic cancer, but it may be expressed as normal and elevated only in a few cases in patients with pancreatic me- tastases. The blood CA19-9 level in this patient has been elevated when pancreatic metastasis was found. Therefore, the detection of blood CA19-9 combined with EUS-FNA is of great significance in differentiating pancreatic primary tumors and metastatic tumors. Thyroid transcription factor 1 (TTF-1) is one of the most com- monly utilized immunohistochemical markers in the diagnosis of lung cancers. It is expressed in 60-90% of lung adenocarcinomas, 90% of small cell lung cancers and the majority of thyroid carci- nomas, but is rarely expressed in adenocarcinomas of other sites or in squamous cell lung carcinomas [8, 9]. In general, TTF-1 is negative and CA199 is positive in pancreatic cancer, whereas TTF-1 is positive in lung adenocarcinoma.TTF-1 is primarily used to distinguish adenocarcinomas of lung (and thyroid) origin from carcinomas of other sites and to distinguish lung adenocarcinomas and small cell lung cancers from squamous cell carcinomas [10]. In this case, TTF-1 is positive and which is more likely to indicate that pancreatic tumor is metastasis of lung cancer in combination with CA 19-9. Secondary pancreatic tumors are advanced tumors and how to choose different modes of comprehensive treatment should be based on the biological characteristics of their primary tumors. The response of pancreatic metastases to radiotherapy and che- motherapy is consistent with its primary tumor. In our case,the relationship between adrenal metastasis and pancreatic metastasis is still unknown. It was found that the median survival time of pancreatic metastases was 57.6 months after operation which was much higher than that of primary pancreatic cancer. The prognosis of patients is not only related to the completeness of surgical resec- tion, but also the biological characteristics of primary tumors and the effect of comprehensive treatment. 5. Declarations Ethics approval and consent to participate: The study was ap- proved by the relevant ethics committee (the name of the ethics committee and the reference number:Fuzhou General Hospital ethics committee of Nanjing Military Area Command, 2017-019), and the participant has gave informed consent. Funding: Guiding (Key) Project of Social Development in Fujian Province (2018Y0066). http://www.acmcasereport.org/ 3 Volume 5 Issue 8-2021 Case Report
  • 4. References 1. Layfield LJ, Hirschowitz SL, Adler DG. Metastatic disease to the pancreas documented by endoscopic ultrasound guided fine-needle aspiration:a seven-year experience. Diagn Cytopathol. 2012; 40: 228-233. 2. Adsay NV, Andea A, Basturk O, Kilinc N, Nassar H, Cheng JD. Secondary tumors of the pancreas: an analysis of a surgical and au- topsy database and review of the literature. Virchows Archiv. 2004; 444: 527-535. 3. Yoon WJ, Ryu JK, Kim YT, Yoon YB, Kim SW, Kim WH. Clinical features of metastatic tumors of the pancreas in Korea: a single-cen- ter study. Gut Liver. 2011; 5: 61-4. 4. Abrams HL, Spiro R, Goldstein N. Metastases in carcinoma: analy- sis of 1000 autopsied cases. Cancer. 1950; 3: 74-85. 5. Chu D, Adler DG. Malignant biliary tract obstruction: evaluation and therapy. J Natl Compr Canc Netw 2010; 8: 1033-1044. 6. DeWitt J, Jowell P, Leblanc J, et al. EUS-guided FNA of pancreat- ic metastases: a multicenter experience. Gastrointest Endosc. 2005; 61: 689-96. 7. Chen G, Liu S, Zhao Y, Dai M, Zhang T. Diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration for pancreatic cancer:A meta-analysis. Pancreatology. 2013; 13(3): 298-304. 8. Brunnstrom H, Johansson L, Jirström K, Jönsson M, Jönsson P, Planck M. Immunohistochemistry in the differential diagnostics of primary lung cancer: an investigation within the Southern Swedish Lung Cancer Study. Am J Clin Pathol. 2013. 140(1): 37-46. 9. Mukhopadhyay S and Katzenstein AL, Comparison of monoclonal napsin A, polyclonal napsin A, and TTF-1 for determining lung ori- gin in metastatic adenocarcinomas. Am J Clin Pathol. 2012; 138(5): 703-11. 10. Rekhtman N, Ang DC, Sima CS, Travis WD, Moreira AL. Immuno- histochemical algorithm for differentiation of lung adenocarcinoma and squamous cell carcinoma based on large series of whole-tis- sue sections with validation in small specimens. Mod Pathol. 2011; 24(10): 1348-59. http://www.acmcasereport.org/ 4 Volume 5 Issue 8-2021 Case Report