Primary pancreatic lymphoma: a case report, literature review, and proposal for nomenclature

Acute Pancreatitis Revealing a Diagnosis of Diffuse Large B-Cell Lymphoma

Acute pancreatitis is a common gastroenterological condition that can occur due to several causes. While not required for diagnosis, imaging is often performed and may reveal unexpected findings such as pancreatic masses. Malignancies such as lymphoma are uncommon causes of acute pancreatitis, especially as the initial presentation of malignancy. We present a case of a young patient with acute pancreatitis caused by diffuse large B-cell lymphoma with extranodal disease secondarily involving the pancreas. Our case highlights the importance of keeping a broad differential for acute pancreatitis and considering rare etiologies such as pancreatic lymphoma in patients without another obvious culprit.

The Diagnostic Challenge of Evaluating Small Biopsies from the Pancreatobiliary System

Examination of fine needle aspirations and small core biopsies of the pancreas can be an extremely difficult and treacherous area for the diagnostic pathologist. The pancreas often yields small and often fragmented specimens, which, in combination with the morphologic overlap between numerous neoplastic and nonneoplastic mimickers, generate multiple potential diagnostic pitfalls. The authors review this challenging topic and provide insight into resolving these pitfalls using morphologic pattern recognition and ancillary testing.

Primary extranodal lymphoma of the glands. Literature review and options for best practice in 2019

Primary extranodal non-Hodgkin's lymphomas (EN-NHL) are a heterogeneous group of malignancies that involve numerous entities with significant difference in terms of tumor site locations, prognostic factors, biology expression, and therapeutic options. In the literature, many EN-NHL types were reported from limited series which only allowed narrow views for elucidating prognostic factors and defining the role of loco-regional therapies in the era of new systemic and biologically targeted therapies. The Rare Cancer Network (RCN), an international multidisciplinary consortium, has published a number of reports on several EN-NHL sites which included many gland locations. In this review, we will focus on the recent literature for a selected number of EN-NHL types in both exocrine and endocrine gland locations. We aim to provide renewed and clear messages for the best practice in 2019 for diagnosis, histopathology, treatments, and also their prognostic implications. We believe that better understanding of molecular and genetic characteristics of these particular diseases is crucial for an appropriate management in the era of personalized treatment developments.

[Epigastralgia revealing primary pancreatic large B-cell lymphoma in a young patient: about a case]

Le lymphome malin non hodgkinien (LMNH) primitif du pancréas est une localisation extrêmement rare des LMNH extraganglionnaires représentant moins de 0,7% de tous les LMNH et moins de 0,5% des tumeurs malignes pancréatiques, touchant essentiellement le sujet âgé et très rarement le sujet jeune (l'intérêt de notre cas). Son diagnostic est difficile simulant cliniquement l'adénocarcinome de pancréas et les pancréatites chroniques. Nous rapportons le cas d'un patient de 25ans, suivi pour lymphome non hodgkinien (LNH) diffus à grandes cellules B de localisation pancréatique primitive révélé par des épigastralgies avec ictère foudroyant d'installation brutale dans un contexte d'altération de l'état général et diagnostiqué sur une biopsie de la loge duodéno-pancréatique. Le diagnostic et la prise en charge précoce de ces tumeurs agressives permettent d'améliorer significativement leur pronostic.

Primary Pancreatic Lymphoma

Aims and backgrounds

Primary pancreatic lymphoma is non-Hodgkin lymphoma primarily involving the pancreas, which is rare in pancreatic diseases. The aim of this work is to summarize the diagnostic and therapeutic experience of primary pancreatic lymphoma.

Methods

We retrospectively reviewed the clinical data of 7 cases of primary pancreatic lymphoma admitted to Huashan Hospital in the past 3 years. Available English literature was also reviewed using the following terms: primary pancreatic lymphoma and pancreatic lymphoma.

Results

The literature review identified 157 additional cases, and a total of 164 cases had been analyzed. In this series, only 30% had a successful non-operative diagnosis. The curative rate of the surgery-adjuvant chemotherapy group was higher than that of the chemotherapy alone group.

Conclusions

Obtaining specimens through surgery is an effective diagnostic tool. Surgical resection in combination with postoperative chemotherapy plays a therapeutic role.

Primary pancreatic lymphoma: two case reports and a literature review

Primary pancreatic lymphoma (PPL) is an extremely rare disease, with only a few cases reported in the literature. Clinical manifestations of PPL are often nonspecific and may mimic other pancreatic diseases. Because of the limited experience of PPL, clinicopathological features, differential diagnosis, optimal therapy, and outcomes are not well defined. We described two cases diagnosed as PPL and confirmed by histological examination and immunohistochemical analysis. Case 1 was a young man with obstructive jaundice and upper abdominal malaise mimicking a pancreatic adenocarcinoma. A computed tomography (CT) scan revealed a diffuse heterogeneous mass in the head of the pancreas along with dilated bile ducts, no dilated pancreatic duct, no liver or splenic involvement, or evident retroperitoneal adenopathies. The patient underwent a pancreatico-duodenectomy, and the postoperative histopathology confirmed diffuse large B-cell non-Hodgkin lymphoma. Postoperatively, he received six courses of the CHOP regimen (cyclophosphamide, doxorubicin, vincristine, and prednisolone). Case 2 was an older man with left flank pain. A CT confirmed a mass with irregular margins at the tail of the pancreas and the hilum of the spleen. The mass was heterogeneous, with no clear boundary between lesions, spleen, stomach, and pancreas, with nearby blood vessels wrapped around it, and multiple enlarged lymph nodes in the abdominal cavity. A CT-guided biopsy was performed. The immunohistological findings of the specimen revealed a diffuse large B-cell lymphoma. The size of the tumor was significantly reduced after four cycles of the CHOP chemotherapy regimen. These two cases were different in clinical manifestation, location, and treatment. We reviewed the literature and discussed the clinicopathological features, differential diagnosis, optimal therapy, and outcomes of this neoplasm.

A Man with Pancreatic Head Mass Lesion on Endoscopic Ultrasound and Granuloma on Cytopathology

Primary pancreatic lymphoma is an unlikely malignancy accounting for less than 0.5% of pancreatic tumors. Clinical presentation is often nonspecific and may be clinically misdiagnosed as pancreatic adenocarcinoma. Here we present an Iranian case of primary pancreatic lymphoma in a 47-year-old male suffering from jaundice and 20% weight loss. Endoscopic ultrasound revealed a mixed echoic mass lesion at the head of pancreas. The patient underwent endoscopic ultrasound-guided fine needle aspiration of solid pancreatic mass and histopathologic diagnosis revealed granuloma. Computed tomography-guided core needle biopsy was performed and eventually histological examination showed granuloma that was coherent with the diagnosis of primary pancreatic lymphoma. Primary pancreatic lymphoma is a rare entity presenting with nonspecific symptoms, laboratory and radiological findings. Computed tomography results in combination with clinical and radiological studies generally provide guidance for appropriate investigation.

Pancreatic Follicular Lymphoma Presenting as Acute Pancreatitis: Report of a Case

Pancreatic B-cell lymphoma is rare; it accounts for 0.2% to 2.0% of extranodal non-Hodgkin lymphoma, and constitutes less than 0.5% of all pancreatic malignancies. Most histologic types of the pancreatic lymphoma are diffuse large B-cell lymphoma, and follicular lymphoma is quite rare. We report here a case of pancreatic follicular lymphoma that was initially detected by acute pancreatitis. This is the first reported case of pancreatic follicular lymphoma presenting with acute pancreatitis. A 71-year-old woman had epigastric and left upper quadrant abdominal pain. Computed tomography (CT) revealed features of acute pancreatitis. After standard therapy for pancreatitis, enhanced CT showed a pancreatic tumor (50 × 35 mm) in the body of the pancreas with gradual enhancement. Endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography showed a complete interruption of the pancreatic duct in the body, with mild dilation of the duct in the tail of the pancreas. Endoscopic ultrasonography revealed hypervascularity of the pancreatic tumor. The patient underwent distal pancreatectomy to remove the cause of pancreatitis and to disclose the diagnosis. Histologic examination revealed follicular lymphoma of pancreas. Despite recent improvement in clinical strategies, differential diagnosis between pancreatic lymphoma and pancreatic cancer is still difficult without histologic information. Pancreatic lymphoma should be considered as a differential diagnosis in a patient who initially presents with acute pancreatitis.

Current update on primary pancreatic lymphoma

OBJECTIVE

This article reviews the computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) CT findings of primary and secondary pancreatic lymphomas and discusses the role of endoscopic ultrasound-guided fine needle aspiration in diagnosis and management.

CONCLUSION

Pancreatic lymphoma has certain characteristic imaging features which may help distinguish it from the more common pancreatic adenocarcinoma. It is critical to make an accurate diagnosis, as the management of these two conditions is vastly different.

Pancreatic involvement by plasma cell neoplasms

INTRODUCTION

Pancreatic involvement by plasma cell neoplasms is an extremely rare event, with only 50 cases described in the literature. They can present as a primary solitary extramedullary plasmacytoma or plasmacytoma secondary to a plasma cell myeloma. Clinical manifestations are due to the presence of a pancreatic mass usually in the pancreas head, which causes extra-biliary obstruction and abdominal pain.

METHODS

Abdominal imaging including CT scan or endoscopic ultrasound with fine-needle aspiration tissue sampling is essential for the initial diagnostic procedure. However, immunohistochemical analysis of the biopsy specimen or flow cytometry of the aspirated material is crucial to prove the monoclonality and the final diagnosis of a plasma cell neoplasm.

DISCUSSION

Management of these situations include radiotherapy, chemotherapy, surgery or combined therapy. Novel medications including the immunomodulatory drugs or the proteasome inhibitors followed by consolidation with intensive chemotherapy and haematopoietic stem cell transplantation are nowadays used as upfront treatment in the cases associated to a plasma cell myeloma.

CONCLUSION

Despite the rarity, plasma cell neoplasms should be considered in the differential diagnosis of obstructive jaundice and pancreatic neoplasms since they are potentially treatable situations.

A patient with chronic hepatitis C and a pancreatic mass in endoscopic ultrasound

We report a rare case of pancreas tumor (lymphoma) in a patient with a history of chronic hepatitis C virus (HCV) infection without treatment, with a high viral load (20,199,805 IU/ml). He presented with abdominal pain, jaundice, weight loss and sweating. Computed tomography showed a hypodense mass located in the head of the pancreas, and immunohistochemistry of a specimen obtained by endoscopic ultrasound-guided fine needle aspiration revealed non-Hodgkin's lymphoma of the pancreas, B cell type. An association of HCV infection with pancreatic lymphoma has only been reported rarely in the literature and its clinical significance is uncertain.

The spectrum of hematologic malignancies involving the pancreas: potential clinical mimics of pancreatic adenocarcinoma

Hematologic malignancies often involve the pancreas, causing potential diagnostic pitfalls and, rarely, potentially avoidable surgical resection. We review the spectrum of hematologic malignancies involving the pancreas and describe features useful in preoperative distinction from adenocarcinoma. Archived clinical, pathologic, and radiologic data (1965 to present) for hematologic malignancies involving the pancreas were reviewed and compared with the data for 157 surgically resected pancreatic adenocarcinomas. Of 42 cases, 27 (64%) were clinically "suspicious" for hematologic malignancies. Of the remaining 15 cases, 4 patients underwent resection for presumed pancreatic adenocarcinoma. Isolated pancreatic masses proved most difficult to identify clinically. Significant factors in distinguishing hematologic malignancies from adenocarcinoma included history of hematologic malignancy, young age, large tumor size, low CA19-9 level, B symptoms, and lack of jaundice or diabetes mellitus. Various hematologic malignancies involve the pancreas, most commonly diffuse large B-cell lymphoma. Pancreatic masses are usually correctly identified clinically. Preoperative and operative sampling is strongly recommended when hematologic malignancies cannot be excluded.

Curative Chemoradiotherapy of Primary Pancreatic Lymphoma with Vertebral Metastasis: Palliation of Persistent Biliary Stricture by Roux-en-Y Hepaticojejunostomy

Primary pancreatic lymphoma (PPL) is a rare tumor that usually presents with the clinical picture of advanced adenocarcinoma but has a much better prognosis. A 38-year-old man was referred after percutaneous transhepatic external biliary drainage for obstructive jaundice. Abdominal magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography had revealed a 5-cm pancreatic head mass that caused biliary tract dilation. Computed tomography angiography showed that the mass encased the celiac trunk as well as the common hepatic and splenic arteries. MRI also revealed a metastatic lesion at the third lumbar vertebra. Serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels were within normal range. The initial diagnosis was inoperable pancreatic adenocarcinoma; however, Tru-Cut pancreatic biopsy showed a large B cell lymphoma. After 6 sessions of chemotherapy and 21 sessions of radiotherapy, both the pancreatic mass and the vertebral metastasis had disappeared. However, he had persistent distal common bile duct stricture that could not be negotiated by either the endoscopic or percutaneous route. A Roux-en-Y hepaticojejunostomy was performed. The patient stayed alive without recurrence for 52 months after the initial diagnosis and 45 months after completion of oncologic treatment. In conclusion, a large pancreatic mass with grossly involved peripancreatic lymph nodes, without ascites, liver or splenic metastasis, should alert the clinician to the possibility of PPL. Cure is possible by chemoradiotherapy even in the presence of vertebral metastasis. Persistent stricture in the distal common bile duct may require a biliodigestive anastomosis.

Large platelet aggregates in endoscopic ultrasound-guided fine-needle aspiration of the pancreas and peripancreatic region: a clue for the diagnosis of intrapancreatic or accessory spleen

Intrapancreatic and intraabdominal accessory spleens (IPIASs) are rarely encountered in endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) biopsies. However, as incidentally discovered IPIAS can mimic a benign or malignant pancreatic neoplasm on imaging studies, a definitive diagnosis made by EUS-FNA can avert an unnecessary surgical intervention or additional radiologic follow-up. We report five cases of intrapancreatic splenules and one case of accessory spleen (AS) in which a definitive diagnosis was made on EUS-FNA. Previously recognized FNA cytomorphologic features of splenic tissue, including ASs and splenosis, are endothelial cells and polymorphous lymphocytes admixed with neutrophils, eosinophils, plasma cells, histiocytes, and lymphoglandular bodies. We describe the additional finding of abundant large platelet aggregates as another distinguishing feature of splenic tissue on FNA. In all six cases, large platelet aggregates were identified along with polymorphous lymphoid cells, lymphoglandular bodies, loose aggregates of endothelial cells and scattered or aggregated bland spindle cells. A review of 10 consecutive cases of EUS-FNA-sampled benign intraabdominal lymph nodes showed that the presence of large platelet aggregates, three-dimensional aggregates of lymphoid cells and of bland slender spindle cells and the absence of follicular germinal cell components (tingible body macrophages and lymphohistiocytic aggregates) are useful in differentiating IPIASs from reactive lymph nodes. Immunoperoxidase stains were useful to confirm a suspected IPIASs by showing CD31-positive acellular flocculent material, consistent with large platelet aggregates and a rich CD8-positive endothelial cell network between CD45-positive lymphoid cells and CD68-positive histiocytes in all six cases.

Primary pancreatic lymphoma: a clinical quandary of diagnosis and treatment

OBJECTIVE

To investigate the clinical feature and treatment strategy of primary pancreatic lymphoma.

METHODS

Thirty-nine cases of primary pancreatic lymphoma reported in China were reviewed retrospectively with their clinical characters, treatment, and outcome, as well as a literature review of worldwide reports.

RESULTS

The major clinical presentations included discomfort or pain in the upper abdomen and jaundice without specificity. Only 2 cases were identified correctly by computed tomography, and 5 cases obtained a positive finding in a biopsy before operation. Thirty-two patients accepted operation; 13 pancreatoduodenectomy and 6 distal pancreatectomy were performed. Thirty-one patients accepted postoperative chemotherapy. Until now, 26 patients are still alive at a range of 3 to 72 months; 5 patients died at 5 to 24 months after operation. Literature review revealed 85 additional cases of pancreatic lymphoma in English reports. Their diagnosis and treatment methods varied.

CONCLUSIONS

Primary pancreatic lymphoma was misdiagnosed as pancreatic adenocarcinoma frequently. Fine needle aspiration biopsy is the most valuable method in preoperative diagnosis. The cyclophosphamide, doxorubicin, vincristine, and prednisone scheme was still the most commonly used regimen of chemotherapy. The value of surgery and radiotherapy remains controversial; an operation combining chemotherapy seems to be an appropriate method of treatment for a patient in whom malignancy cannot be ruled out.

Primary pancreatic low-grade mucosa-associated lymphoid tissue lymphoma presenting with multiple masses

The case concerns a 55-year-old Japanese man with multiple pancreatic tumors that were incidentally detected by ultrasonography (US) in a routine medical examination. He consulted a doctor since either neuroendocrine tumors or metastases of small-cell lung carcinoma were suspected, because he had an abnormal shadow in the lung. Then he was transferred to our hospital. Imaging studies showed multiple pancreatic tumors of 3.0-cm diameter in the head, 1.0 cm in the body and 1.5 cm in the tail, respectively. Specimen by endoscopic ultrasonography fine-needle aspiration cytology (EUS-FNAC) revealed numerous B-cell lymphocytes, but a definite diagnosis of malignant lymphoma could not be obtained. Therefore, a segmental pancreatic body resection was performed to clarify the features of the tumor for appropriate therapy. Consequently, the final diagnosis was obtained as a low-grade B-cell lymphoma having a lymphoepithelial lesion, which indicated mucosa-associated lymphoid tissue (MALT) lymphoma. Radiation therapy with 31 Gy successfully resulted in complete remission. We report here for the first time on primary pancreatic low-grade MALT lymphoma presenting with multiple pancreatic masses.

[Primary pancreatic lymphoma in pediatric patients]

Primary involvement of the pancreas in non-Hodgkin's lymphoma is extremely rare in children and adolescents. Indeed, we have only found three cases of primary pancreatic lymphoma in this population published in the English literature. We report the case of a 13-year-old girl diagnosed with primary pancreatic lymphoma. We describe the ultrasonography and computed tomography findings, discuss the differential diagnosis with other pancreatic tumors that affect pediatric patients, and review the literature.

Primary pancreatic lymphoma: diagnostic and therapeutic dilemma

OBJECTIVES

Non-Hodgkin lymphoma predominantly involving the pancreas is a rare tumor and accounts for less than 0.7% of all pancreatic malignancies and 1% of extranodal lymphomas. Diagnosis of primary pancreatic lymphoma can be difficult because it may mimic carcinoma. The principal aims of this review were to highlight the difficulties encountered in making a diagnosis and to identify the role of surgery.

METHODS

A PubMed search was conducted using the following terms: primary pancreatic lymphoma and non-Hodgkin lymphoma of the pancreas. Additional references were sourced from key articles.

RESULTS

A total of 89 reported cases of pancreatic lymphoma between 1951 and 2005 were reviewed. An accurate preoperative diagnosis of primary pancreatic lymphoma is not always possible. A complete response rate of 100% and a long-term survival rate of 94% have been reported with surgery and adjuvant chemotherapy when compared with a 5-year survival rate of less than 50% and an overall 3-year disease-free survival rate of 44% with current chemotherapy, radiotherapy, or combined methods.

CONCLUSION

Pancreaticoduodenectomy may have a therapeutic role in association with chemotherapy.

A case of primary pancreatic non-Hodgkin's lymphoma

Primary pancreatic lymphoma is rare, comprising 0.2-4.9% of all pancreatic malignancies and less than 1% of cases of non-Hodgkin's lymphoma. Many patients are diagnosed with lymphoma after radical resection. We report a rare presentation of diffuse large B cell lymphoma, appearing as a primary tumor of the pancreas. A 61-year old female was admitted to the hospital with the complaint of right upper abdominal pain. Computed tomography of the abdomen showed a well defined mass located at the head of the pancreas. A frozen section of pancreas, during laparotomy, revealed lymphoma. The patient received 6 cycles of chemotherapy and is currently in complete remission. This case underscores the importance of differentiating primary lymphoma from the more common adenocarcinoma of the pancreas as treatment and prognosis differ significantly. Primary pancreatic lymphoma should be considered in the differential diagnosis of pancreatic tumors and an attempt to obtain a tissue diagnosis is always necessary before proceeding to radical surgery, especially on young patients.

Less common neoplasms of the pancreas

Recently, there has been an increased recognition of neoplasms of the pancreas other than ductal adenocarcinoma. Although not as well studied or characterized as pancreatic adenocarcinoma there are many distinct lesions which exhibit diverse biological behaviors and varying degrees of malignancy. These lesions include: endocrine neoplasms, cystic tumors, solid pseudopapillary tumors, acinar cell carcinoma, squamous cell carcinoma, primary lymphoma of the pancreas, and metastatic lesions to the pancreas. These less common neoplasms are being diagnosed more frequently as the number and sensitivity of diagnostic imaging studies increase. This review article discusses the clinical course, diagnosis, and treatment of these less common, but quite relevant, neoplasms of the pancreas.

Primary pancreatic lymphomas: a cytopathologic analysis of a rare malignancy

BACKGROUND

Primary pancreatic lymphomas (PPL) are extremely rare. Clinically, PPL usually present with symptoms of carcinoma of the pancreatic head. An accurate cytopathologic diagnosis by fine-needle aspiration (FNA) is imperative because the primary treatment is nonsurgical, based on a combination of chemotherapy and radiation therapy.

METHODS

Eight cases of PPL were identified from the pathology files of The Johns Hopkins Hospital over a 14-year period (1989-2003). All cases were diagnosed on FNA performed under radiologic guidance. Needle rinses were used to perform flow cytometric (FC) analysis. No tissue studies were performed after the FNA diagnosis was made.

RESULTS

A strong male predominance (male-to-female ratio of 7:1) was noted. The patients ranged in age from 35-75 years (mean age, 55 years). The tumors varied in size from 2-14 cm, as evaluated on the radiologic scans (mean dimension of 8.0 cm). Abdominal pain was the most common presenting symptom (six patients) followed by jaundice, acute pancreatitis, small bowel obstruction, and diarrhea. The cytomorphologic features included hypercellularity with discohesive cells with round nuclei, often prominent nucleoli, mitoses, and karyorrhexis. By FC analysis, all eight cases demonstrated a monoclonal pattern of immunoglobulin light chain expression. The patients were treated with either chemotherapy alone or in conjunction with radiation therapy or stem cell transplantation.

CONCLUSIONS

PPL is an extremely rare pathologic entity. FNA coupled with FC analysis appears to be highly accurate in the diagnosis of PPL and is the sole diagnostic modality used clinically. Based on cytomorphology, the main differential diagnoses of PPL involve secondary lymphoma, pancreatic endocrine neoplasm, and florid chronic pancreatitis. An accurate FNA diagnosis of PPL is critical for timely, nonsurgical management and obviates the need for an exploratory laparotomy.

Immunoblastic large B-cell lymphoma of the peripancreatic head region: MR findings

We report the magnetic resonance (MR) appearance of a large B-cell lymphoma in the peripancreatic head region, in a 38-year-old male who presented with a 1-month history of pruritus and jaundice. Routine laboratory examination at presentation revealed an elevated bilirubin. The tumor was a large, solitary well-defined mass with no evidence of necrosis, which showed mild diffuse heterogeneous enhancement. The tumor was closely applied to the lateral margin of the head of the pancreas. The constellation of MR findings was interpreted as consistent with the correct eventual diagnosis of lymphoma.

Imaging of uncommon tumors of the pancreas

In this article, the radiological manifestations of a variety of uncommon tumors of the pancreas are illustrated, with emphasis placed on their appearance at helical CT. Islet cell tumors, because of their vascularity, typically present as masses that are hyperattenuating to the normal pancreas at dual-phase helical CT. Lymphomas appear as hypoattenuating focal lesions or can diffusely infiltrate the gland. Absence of biliary tree dilatation, despite the presence of a bulky tumor, or associated extensive retroperitoneal adenopathy should offer clues to the diagnosis. Pancreatic metastases are usually seen in patients with advanced cancers, although isolated metastases from renal cell carcinoma can occurs years after the original tumor; such patients may benefit from surgical resection. Finally, the appearance of some rare neoplasms of mesenchymal origin is discussed.