An unusual case of a hypervascular solid pancreatic lesion: all that glitters is not gold

A 72-year-old woman was referred to our outpatient clinic for endoscopic ultrasound (EUS) evaluation of a small lesion in the pancreatic tail ([ Video 1 ]). Video 1 The diagnostic work-up of a hypervascular solid pancreatic lesion finally diagnosed as a metastasis of follicular thyroid carcinoma. Download Video Previously, during cardiac surgery preoperative workup for severe mitral regurgitation requiring valve replacement, contrast-enhanced computed tomography incidentally revealed an 8 mm hypervascular round lesion ([ Fig. 1 ]), suspicious for a neuroendocrine tumor, in an otherwise asymptomatic patient. Fig. 1 The CT scan appearance of the solid pancreatic lesion. Contrast-enhanced magnetic resonance cholangiopancreatography confirmed a 9-mm nodular lesion ([ Fig. 2 ]), mildly hyperintense on T2-weighted images, with diffusion restriction and marked postcontrast enhancement, again suggestive of a neuroendocrine tumor. Fig. 2 The T2-weighted MRI appearance of the solid pancreatic lesion. Conversely, a 68-gallium positron emission tomographic scan demonstrated only mild tracer uptake in the pancreatic tail, without significant somatostatin receptor overexpression. Therefore, to better clarify the nature of the lesion, we performed an EUS with needle sampling, which showed a 12×9 mm solid, hypoechoic focal lesion with mixed stiffness on elastography, hypervascularity on detective flow imaging, and avid contrast uptake after contrast administration ([ Fig. 3 ]). Fig 3 EUS hyperenhancement of the pancreatic lesion after contrast administration. Cytology revealed a prominent microfollicular architecture with a colloid-like material and no overt cytonuclear atypia, with strong, diffuse immunoreactivity for thyroid transcription factor-1 and paired-box gene 8 (PAX8) and negative staining for calcitonin, chromogranin A, carboxypeptidase A1, glycoprotein 2, and synaptophysin ([ Fig. 4 ]). Fig 4 Cell block showing the presence of a well cellularized fragment, consisting of elements arranged in a follicular architecture with dense eosinophilic luminal secretion (colloid) ( a and b ). These elements resulted negative to immunohistochemical staining for chromogranin A ( c ), while they were positive for thyroglobulin ( d ), TTF-1 ( e ) and PAX8 monoclonal antibody ( f ), confirming the thyroid origin of the neoplasm. Review of the medical history disclosed thyroidectomy 15 years earlier for a solitary nodule reported as follicular adenoma in nodular hyperplasia. These findings, together with clinical and anamnestic data, are consistent with a diagnosis of pancreatic metastasis from follicular thyroid carcinoma. Metastases to the pancreas from follicular thyroid carcinoma are extremely rare, with only a few cases reported, and their correct characterization, as for most pancreatic lesions, requires the careful review of the patient’s clinical history, comprehensive multimodality imaging assessment, and EUS-guided cytohistological sampling for definitive histopathological diagnosis. Endoscopy_UCTN_Code_CCL_1AF_2AZ Publication History Received: 12 April 2026 Accepted after revision: 28 May 2026 Article published online: 07 July 2026 © 2026. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany