A 42-year-old male presented to our institution with a 2-month history of several episodes of confusion, double vision, headache, and loss of consciousness. The blood glucose levels measured during these episodes were in the range of 30-40 mg/dl, but randomly drawn blood samples showed normal glucose levels. Further workup showed a fasting blood glucose level of 34 mg/dl at 60 hours and elevated proinsulin levels, while insulin and C-peptide levels were normal. Serum levels of chromogranin A, pancreatic polypeptide, sulfonylurea, human growth hormone, cortisol, TSH, calcium, and creatinine were within normal limits. Computed tomography scan of the head, thorax and abdomen demonstrated no abnormal findings. The patient underwent endoscopic ultrasound evaluation, which showed a round, hypoechoic lesion measuring 14 3 13 mm in the body of the pancreas. Three transgastric EUS-FNA passes of the pancreatic lesion were performed using a 22 gauge needle. The aspirated material was used for the preparation of three airdried rapid Romanowsky (Diff-Quik V R ) stained smears, three paired fixed smears, to be later stained with the Papanicolaou stain, and the remaining material was placed in 10% formalin for cell block preparation. The FNA samples were deemed adequate during rapid onsite evaluation of the Diff-Quik V R -stained smears but a specific diagnosis was deferred to the examination of the alcoholfixed Papanicolaou-stained smears and hematoxylin and eosin stained cell block sections.The smears were hypocellular, but showed abundant large (0.2-0.6 mm) arborizing fragments of amorphous material in a "dirty" background composed of fragments of amorphous debris, red blood cells, proteinaceous material, wisps of mucus and occasional single cells and naked nuclei (Fig. C-1). In Diff-Quik V R -stained smears