Allegheny Health Network Pittsburgh, PA, United States
Sripriya Gonakoti, MD1, Kossivi Dantey, MD1, Gursimran Singh Kochhar, MD, CNSC2 1Allegheny Health Network, Pittsburgh, PA; 2Drexel University School of Medicine, Allegheny Health Network, Pittsburgh, PA
Introduction: Osteosarcoma is most commonly associated with metastases to the lungs, brain, other bones, and lymph nodes. Pancreatic and duodenal metastases from osteosarcoma are rare.
Case Description/Methods: A 63-year-old female patient was diagnosed with primary osteosarcoma of her left distal femur. She also had brain and lung metastases and was treated with chemotherapy and resections. She was found to have a pancreatic head mass that measured 1.9 x 1.2 cm on a CT scan. Endoscopic Ultrasound (EUS) revealed an oval, hypoechoic cystic mass with smooth outer margins that measured 36 mm x 26 mm in the uncinate process. Fine needle aspiration cytology (FNAC) of the cystic mass revealed a metastatic malignant tumor with highly pleomorphic atypical tumor cells similar (Fig a, b, c, and d) to cells seen in her lung biopsy specimens and was consistent with primary osteosarcoma.
A second EUS performed due to anemia, revealed an increase in size of the pancreatic mass to 4.3 cm and an ulcerated, oozing mass in the 3rd portion of the duodenum concerning for an invasive tumor. Biopsy of this duodenal mass revealed highly pleomorphic atypical cells with an osteoid matrix consistent with metastasis from the primary osteosarcoma (Fig e and f). Over time, she developed obstruction of the duodenum and eventually succumbed to complications from her disease.
Discussion: Osteosarcoma is a malignant osteogenic tumor that usually has a first peak in adolescence and a second peak in adults, 65 or older, with metastasis most commonly to the lungs, brain, other bones and lymph nodes. Metastasis to the pancreas is rare. Even fewer reports mention both pancreatic and duodenal metastases from primary osteosarcoma. They mostly occurred in patients who were 13 to 53 years of age and were not gender specific. The primary osteosarcoma was usually a long bone tumor, although there were reports of pancreatic metastases from osteosarcoma of the maxillary sinus and vertebral osteosarcoma. Patients were usually asymptomatic; however, reports mention melena, acute blood loss anemia & pyloric stenosis as presenting symptoms. Others mention a telangiectatic type of pancreatic metastasis with acute bleeding and metastasis induced acute pancreatitis (MIAP). Given the non-specific presentation, clinicians should be aware that in patients with osteosarcoma, pancreatic and duodenal masses may be secondary tumors.
Figure: Figure a - Microscopic findings of lung metastatic high-grade osteosarcoma (x400) (hematoxylin-eosin). Higher magnification of above picture. Note presence of highly pleomorphic atypical cells producing osteoid.
Figure b - Touch imprint cytology of pancreatic lesion core needle biopsy. (x400) (DQ). Highly pleomorphic atypical tumor cells morphologically similar to cells consistent with high-grade metastatic osteosarcoma seen in the lung metastasis specimen (Higher magnification).
Figure c- Needle core biopsy material from pancreatic lesion. (x200) (hematoxylin-eosin). Highly pleomorphic atypical tumor cells morphologically similar to cells seen in the lung metastatic high grade osteosarcoma specimen.
Figure d - Needle core biopsy material from pancreatic lesion. (x400) (hematoxylin-eosin). Highly pleomorphic atypical tumor cells with mitosis, morphologically similar to cells seen in the lung metastatic high grade osteosarcoma specimen (higher magnification).
Figure e - 20X: Microscopic findings of duodenum metastatic high-grade osteosarcoma (x200) (hematoxylin-eosin). Note presence of highly pleomorphic atypical cells with associated malignant osteoid matrix.
Figure f - 40X: Microscopic findings of duodenum metastatic high-grade osteosarcoma (x400) (hematoxylin-eosin). Higher magnification of the first picture.
Sripriya Gonakoti indicated no relevant financial relationships.
Kossivi Dantey indicated no relevant financial relationships.
Gursimran Singh Kochhar indicated no relevant financial relationships.
Sripriya Gonakoti, MD1, Kossivi Dantey, MD1, Gursimran Singh Kochhar, MD, CNSC2. P1148 - Not All Pancreatic Masses Are Pancreatic Adenocarcinoma - A Rare Presentation of Pancreatic and Duodenal Metastases From Primary Osteosarcoma, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.