• 14 yr old FS DSH with history of chronic vomiting and weight loss as well as stage 2 crf;  
• Abdominal ultrasound showed tissue just caudal to the caudal spleen with a hypoechoic nodule in it.  Not sure at the time if this was an extension of the spleen or really long left limb of the pancreas.  The kidneys were at the small end in size with thickened, echogenic cortices and poor corticomedullary definition.
• I performed FNA’s on the splenic-left pancreatic lesion as well as the right renal cortex (to rule out LSA or look for amyloid).
• FNA cytology of the lesions came back as:  

  1. Spleen (2 slides): Smears are comprised of fresh blood lacking distinctive spleenic elements (such as lymphoid tissue, stromal cells, erythroid precursors), and is comprised of several small to large aggregates of epithelial cells occasionally forming acinar-like structures. Cells contain a single, uniform, round nucleus, inconspicuous nucleoli, and moderate granular basophilic cytoplasm resembling pancreatic type. Mitoses are absent; inflammation is absent. Lymphoid tissue is absent.

  2. Kidney (4 slides): Smears are comprised of fresh blood and scattered intact and disrupted well-differentiated renal epithelial cells, frequently exhibiting one or more cytoplasmic vacuoles. Inflammation is absent. Lymphoid tissue is not observed.

  Diagnosis
  1. Spleen: Splenic elements are not appreciated on the specimen submitted. Findings favor sampling of epithelial tissue with pancreatic features. Considerations include pancreatic epithelial hyperplasia, a well-differentiated pancreatic carcinoma, or inadvertant sampling of pancreatic tissue. No evidence of lymphoma is observed.

  2. Kidney: Well-differentiated epithelial tissue consistent with renal epithelium. No evidence of inflammation or neoplasia is observed on this specimen.

So, I am not sure where to go next with this case.  I don’t know if the vomiting and weight loss are due to the crf or due to pancreatic lesion which apparently may be benign or neoplastic.  Chest rads taken later showed a lung nodule.  Since fna was already done, would you go to surgery next and biopsy the left pancreas and GI tract?