Current update on primary pancreatic lymphoma

Primary pancreatic peripheral T-cell lymphoma: A case report

BACKGROUND

Primary pancreatic lymphoma (PPL) is an exceedingly rare tumor with limited mention in scientific literature. The clinical manifestations of PPL are often nonspecific, making it challenging to distinguish this disease from other pancreatic-related diseases. Chemotherapy remains the primary treatment for these individuals.

CASE SUMMARY

In this case study, we present the clinical details of a 62-year-old woman who initially presented with vomiting, abdominal pain, and dorsal pain. On further evaluation through positron emission tomography-computed tomography, the patient was considered to have a pancreatic head mass. However, subsequent endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) revealed that the patient had pancreatic peripheral T-cell lymphoma, not otherwise specified (PTCL-NOS). There was a substantial decrease in the size of the pancreatic mass after the patient underwent a cycle of chemotherapy comprised of brentuximab vedotin, gemcitabine, and oxaliplatin (brentuximab vedotin and Gemox). The patient had significant improvement in radiological findings at the end of the first cycle.

CONCLUSION

Primary pancreatic PTCL-NOS is a malignant and heterogeneous lymphoma, in which the clinical manifestations are often nonspecific. It is difficult to diagnose, and the prognosis is poor. Imaging can only be used for auxiliary diagnosis of other diseases. With the help of immunostaining, EUS-FNA could be used to aid in the diagnosis of PPL. After a clear diagnosis, chemotherapy is still the first-line treatment for such patients, and surgical resection is not recommended. A large number of recent studies have shown that the CD30 antibody drug has potential as a therapy for several types of lymphoma. However, identifying new CD30-targeted therapies for different types of lymphoma is urgently needed. In the future, further research on antitumor therapy should be carried out to improve the survival prognosis of such patients.

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.

18F-FDG PET/CT assists the diagnosis of primary pancreatic lymphoma: Two case reports and literature review

Primary pancreatic lymphoma (PPL) is a rare malignancy, which is defined as a mass centered in pancreas with involvement of contiguous lymph nodes and distant spread may exist. Accurate diagnosis of PPL prior to pathological confirmation remains challenging, underscoring the critical significance of preoperative imaging assessments. This case report collected two instances of PPL that underwent initial evaluation via 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) between August 2021 and July 2022. Correspondingly, pertinent literature encompassing 18F-FDG PET/CT data related to PPL was meticulously reviewed. Including our aforementioned pair of cases, a cumulative total of 25 instances of PPL were assembled. The distinctive profile of 18F-FDG PET/CT images of PPL predominantly manifests as hypermetabolic lesions with diminished density. Primarily characterized by singular lesions and comparatively substantial volumetric dimensions, a total of eleven cases revealed contiguous lymph node engagement, with five instances displaying distant dissemination encompassing lymph nodes in multiple locations. Amongst these, ten patients underwent sequential 18F-FDG PET/CT follow-up post-intervention. In comparison to pancreatic carcinoma, PPL lesions exhibited heightened hypermetabolism, augmented volumetric proportions, and distinct patterns of distant metastasis. This study indicates that the pivotal role of 18F-FDG PET/CT in the diagnosis and assessment of therapeutic efficacy in PPL is unequivocal. Combined with the clinical attributes of patients, the integration of 18F-FDG PET/CT augments the differential diagnostic capacity differentiating PPL from pancreatic carcinoma.

Primary pancreatic lymphoma: Report of 4 cases with literature review

Pancreatic cancer (PC) is ranked as the 14th most common cancer and the 7th leading cause of cancer-related deaths. The most common histological type is adenocarcinoma, other type such as primary pancreatic lymphoma (PPL) still very rare. Due to the lack of specific clinical and imaging characteristics, the diagnostic of PPL remains challenging. We report 4 cases of PPL diagnosed and managed at our gastroenterology department between 2019 and 2023. Case 1: A 16-year-old male presented with abdominal pain, jaundice, and weight loss. Imaging revealed an 8 cm tumor in the pancreas, subsequent biopsies confirming Burkitt's lymphoma. Despite chemotherapy, the patient succumbed to the disease. Case 2: A 92-year-old female with no prior medical history presented with abdominal pain, jaundice, pruritus, and weight loss. Imaging revealed a large pancreatic mass, and biopsies identified large B-cell lymphoma. Unfortunately, the patient passed away before treatment initiation. Case 3: A 63-year-old male with a history of tobacco smoking presented with abdominal pain, weight loss, and anorexia. Imaging and biopsies confirmed diffuse large cell B-phenotype lymphoma. The patient achieved complete remission after rituximab, cyclophosphamide, doxorubicin hydrochloride, vincristine, and prednisone (R-CHOP) therapy. Case 4: A 67-year-old man with jaundice, abdominal pain, and weight loss was diagnosed with diffuse large cell B lymphoma through imaging and fine needle aspiration (FNA). The patient responded well to R-CHOP therapy. In conclusion, PPL is an uncommon tumor, with no specific clinical or radiological characteristics. A thorough evaluation of clinical, radiological, biological and histological data is necessary to consider it as a differential diagnosis and ensure accurate and timely management.

Rare Solid Pancreatic Lesions on Cross-Sectional Imaging

Several solid lesions can be found within the pancreas mainly arising from the exocrine and endocrine pancreatic tissue. Among all pancreatic malignancies, the most common subtype is pancreatic ductal adenocarcinoma (PDAC), to a point that pancreatic cancer and PDAC are used interchangeably. But, in addition to PDAC, and to the other most common and well-known solid lesions, either related to benign conditions, such as pancreatitis, or not so benign, such as pancreatic neuroendocrine neoplasms (pNENs), there are solid pancreatic lesions considered rare due to their low incidence. These lesions may originate from a cell line with a differentiation other than exocrine/endocrine, such as from the nerve sheath as for pancreatic schwannoma or from mesenchymal cells as for solitary fibrous tumour. These rare solid pancreatic lesions may show a behaviour that ranges in a benign to highly aggressive malignant spectrum. This review includes cases of an intrapancreatic accessory spleen, pancreatic tuberculosis, solid serous cystadenoma, solid pseudopapillary tumour, pancreatic schwannoma, purely intraductal neuroendocrine tumour, pancreatic fibrous solitary tumour, acinar cell carcinoma, undifferentiated carcinoma with osteoclastic-like giant cells, adenosquamous carcinoma, colloid carcinoma of the pancreas, primary leiomyosarcoma of the pancreas, primary and secondary pancreatic lymphoma and metastases within the pancreas. Therefore, it is important to determine the correct diagnosis to ensure optimal patient management. Because of their rarity, their existence is less well known and, when depicted, in most cases incidentally, the correct diagnosis remains challenging. However, there are some typical imaging features present on cross-sectional imaging modalities that, taken into account with the clinical and biological context, contribute substantially to achieve the correct diagnosis.

Primary Pancreatic Lymphoma Masquerading as Carcinoma on 18F-FDG PET/CT

ABSTRACT

A 76-year-old man with yellowish discoloration of sclera and skin for 2 months was referred to 18F-FDG PET/CT for metabolic characterization of the mass in the pancreas. The images showed intense FDG uptake in the head of the pancreas, as well as a lymph nodal mass in the hepatic hilar region, which was consistent with pancreatic malignancy. Histopathologic findings showed characteristic findings of diffuse large B-cell lymphoma with no evidence of adenocarcinoma.

Primary Pancreatic Lymphoma in the Tail: A Rare Anatomic Presentation

Non-Hodgkin's lymphoma is a common type of cancer, whose most common site of extranodal involvement is the gastrointestinal tract. However, primary presentation in the pancreas remains uncommon. Among cases with pancreatic involvement, the disease is often found in the head and rarely in the tail. Here, we present a case of a 56-year-old male patient with acute epigastric pain, early satiety, and abdominal distention. CT imaging showed a mass of the pancreatic tail with surrounding lymphadenopathy, concerning lymphoma. Endoscopic ultrasound-guided fine needle aspiration (EUS-guided FNA) diagnosed mature B-cell lymphoma, meeting novel diagnostic criteria for the rare diagnosis of primary pancreatic lymphoma (PPL).

Primary hepatopancreatobiliary lymphoma: Pathogenesis, diagnosis, and management

Primary hepatopancreatobiliary lymphoma (PHPBL) is extremely rare, which is defined as a lympho-proliferative disease confined to the hepatobiliary system and pancreas without any involvement of lymph nodes, bone marrow, or other organs. The clinical and imaging manifestations of PHPBL are variable and non-special, which are akin to those of tumors of the hepatobiliary and pancreatic systems. The overall prognosis and management of PHPBL differ from those of other tumors in the hepatobiliary system and pancreas. Proper diagnosis and prompt treatment are essential for improving clinical outcomes. Due to its rarity, the optimal treatment has not been issued. However, combination chemotherapy is considered as a standard treatment for them. This review provides an overview of the pathogenesis, diagnosis, pathology, and management of PHPBL and offers clinicians the diagnosis and management schedule for PHPBL.

18F-FDG PET/CT Findings in HIV-Positive Patient With Primary Pancreas Lymphoma and CMV Pancreatitis

ABSTRACT

A 35-year-old HIV-positive man with abdominal pain was referred to 18F-FDG PET/CT for metabolic characterization of mass in pancreas. PET/CT images showed intense FDG uptake in head of the pancreas, as well as diffuse moderate uptake throughout body and tail of the pancreas. Histopathological results revealed Epstein-Barr virus (EBV) associated large B-cell lymphoma and pancreatitis caused by cytomegalovirus.

Diffuse Large B Cell Lymphoma with Cutaneous and Gastrointestinal Involvement

Diffuse large B cell lymphoma (DLBCL) is the histological subtype of non-Hodgkin's lymphoma, representing approximately 30%. The most common primary extranodal sites of DLBCL are the gastrointestinal (GI) tract, the head and neck, and the skin/soft tissue. We report a case of DLBCL with cutaneous involvement presenting with skin nodules and GI manifestations such as obstructive jaundice and upper GI bleeding. Malignant cystic pancreatic tumor occupying the head and body with invasion to lower end of common bile duct and periampullary region causing biliary obstruction and mesenteric lymphadenopathy were found in abdominal computed tomography and endoscopic ultrasonography. There was also a large gastric ulcer (Forrest IIa) at the greater curvature of body of the stomach. Histopathological results of the skin and stomach were consistent with diffuse large B cell lymphoma; gastric biopsy being negative for leucocyte common antigen. The patient was considered to have disseminated DLBCL. The aim of the present case report was to present the clinical, radiological, and histological characteristics of the patient, which may aid physicians in diagnosing involvement of multiple extranodal sites in DLBCL.

Application of dynamic contrast enhanced ultrasound in distinguishing focal-type autoimmune pancreatitis from pancreatic ductal adenocarcinoma

OBJECTIVE

To explore the value of dynamic contrast enhanced ultrasound (DCE-US) in preoperative differential diagnosis of focal-type autoimmune pancreatitis (AIP) and pancreatic ductal adenocarcinoma (PDAC).

PATIENTS AND METHODS

From May 2016 to March 2020, patients with biopsy and histopathologically confirmed focal-type AIP (n = 9) were retrospectively included. All patients received contrast enhanced ultrasound (CEUS) examinations one week before surgery/biopsy. Dynamic analysis was performed by VueBox® software (Bracco, Italy). Eighteen cases of resection and histopathologically proved PDAC lesions were also included as control group. B mode ultrasound (BMUS) features, CEUS enhancement patterns, time intensity curves (TICs) and CEUS quantitative parameters were obtained and compared between AIP and PDAC lesions.

RESULTS

After injection of ultrasound contrast agents, most focal-type AIP lesions displayed hyper-enhancement (2/9, 22.2%) or iso-enhancement (6/9, 66.7%) during arterial phase of CEUS, while most of PDAC lesions showed hypo-enhancement (88.9%) (P < 0.01). During late phase, most of AIP lesions showed iso-enhancement (8/9, 88.9%), while most of PDAC lesions showed hypo-enhancement (94.4%) (P < 0.001). Compared with PDAC lesions, TICs of AIP lesions showed delayed and higher enhancement. Among all CEUS perfusion parameters, ratio of PE (peak enhancement), WiAUC (wash-in area under the curve), WiR (wash-in rate), WiPI (wash-in perfusion index, WiPI = WiAUC/ rise time), WoAUC (wash-out area under the curve), WiWoAUC (wash-in and wash-out area under the curve) and WoR (wash-out rate) between pancreatic lesion and surrounding normal pancreatic tissue were significantly higher in AIP lesions than PDAC lesions (P < 0.05).

CONCLUSION

DCE-US with quantitative analysis has the potential to make preoperative differential diagnosis between focal-type AIP and PDAC non-invasively.

Features of primary pancreatic lymphoma: A bi-institutional review with an emphasis on typical and atypical imaging features

BACKGROUND

Primary pancreatic lymphoma (PPL) is a rare neoplasm. Being able to distinguish it from other pancreatic malignancies such as pancreatic ductal adenocarcinoma (PDAC) is important for appropriate management. Unlike PDAC, PPL is highly sensitive to chemotherapy and usually does not require surgery. Therefore, being able to identify PPL preoperatively will not only direct physicians towards the correct avenue of treatment, it will also avoid unnecessary surgical intervention.

AIM

To evaluate the typical and atypical multi-phasic computed tomography (CT) imaging features of PPL.

METHODS

A retrospective review was conducted of the clinical, radiological, and pathological records of all subjects with pathologically proven PPL who presented to our institutions between January 2000 and December 2020. Institutional review board approval was obtained for this investigation. The collected data were analyzed for subject demographics, clinical presentation, laboratory values, CT imaging features, and the treatment received. Presence of all CT imaging findings including size, site, morphology and imaging characteristics of PPL such as the presence or absence of nodal, vascular and ductal involvement in these subjects were recorded. Only those subjects who had a pre-treatment multiphasic CT of the abdomen were included in the study.

RESULTS

Twenty-nine cases of PPL were diagnosed between January 2000 and December 2020 (mean age 66 years; 13 males/16 females). All twenty-nine subjects were symptomatic but only 4 of the 29 subjects (14%) had B symptoms. Obstructive jaundice occurred in 24% of subjects. Elevated lactate dehydrogenase was seen in 81% of cases, whereas elevated cancer antigen 19-9 levels were present in only 10% of cases for which levels were recorded. The vast majority (90%) of tumors involved the pancreatic head and uncinate process. Mean tumor size was 7.8 cm (range, 4.0-13.8 cm). PPL presented homogenous hypoenhancement on CT in 72% of cases. Small volume peripancreatic lymphadenopathy was seen in 28% of subjects. Tumors demonstrated encasement of superior mesenteric vessels in 69% of cases but vascular stenosis or occlusion only manifested in 5 out of the twenty-nine individuals (17%). Mild pancreatic duct dilatation was also infrequent and seen in only 17% of cases, whereas common bile duct (CBD) dilation was seen in 41% of subjects. Necrosis occurred in 10% of cases. Size did not impact the prevalence of pancreatic and CBD dilation, necrosis, or mesenteric root infiltration (P = 0.525, P = 0.294, P = 0.543, and P = 0.097, respectively). Pancreatic atrophy was not present in any of the subjects.

CONCLUSION

PPL is an uncommon diagnosis best made preoperatively to avoid unnecessary surgery and ensure adequate treatment. In addition to the typical CT findings of PPL, such as homogeneous hypoenhancement, absence of vascular stenosis and occlusion despite encasement, and peripancreatic lymphadenopathy, this study highlighted many less typical findings, including small volume necrosis and pancreatic and bile duct dilation.

Pancreatic follicular lymphoma: a report of two cases and literature review

Primary pancreatic lymphomas are extremely rare, accounting for 0.1–0.5% of malignant lymphomas and about 0.2% of primary pancreatic tumors. They occur most commonly in the pancreatic head of elderly males, with diffuse large B-cell lymphoma being the most common subtype. Primary pancreatic follicular lymphoma is the most commonly reported primary pancreatic indolent lymphoma, accounting for 9–14% of primary pancreatic lymphomas. We report two cases of primary pancreatic follicular lymphoma treated with obinutuzumab, a second-generation humanized anti-CD20 monoclonal antibody, and bendamustine. One was diagnosed by endoscopic ultrasound-guided fine-needle aspiration, while the other required laparoscopic lymph node sampling to reach a diagnosis. Both achieved complete response with induction therapy and opted for maintenance therapy with obinutuzumab. We also conducted a literature review of primary pancreatic follicular lymphoma cases reported over the last 30 years.

Primary Pancreatic Lymphoma: Recommendations for Diagnosis and Management

BACKGROUND

Primary pancreatic lymphoma (PPL) is a rare disease representing 0.1% of all malignant lymphomas, which lacks well-defined diagnostic and therapeutic protocols. We conducted a systematic review to analyze demographic, diagnostic and therapeutic features of PPL.

METHODS

This review identified small series and single case reports. Sources were MEDLINE, PubMed, and the Cochrane library from January 2001 to December 2020. Data were screened, extracted and the risk of bias analyzed by three independent reviewers.

RESULTS

A total of 107 eligible papers (17 small series, 90 single case reports) describing 266 patients were identified. Patients had a median age of 53.1 (range 3-86) years and were males in 64.6% of cases. Abdominal pain and jaundice were the most common presenting symptoms, affecting 75.3% and 41.8% of patients, respectively. PPL had a median size of 60.6 mm (range 16-200) and it was localized in the pancreatic head in 63.7% of cases. At diagnosis most patients underwent ultrasonography followed by computed tomography. PPL typically showed low echogenicity, and lower contrast enhancement than solid tumors. Histopathological specimens were obtained by percutaneous or endoscopic biopsies in 47.7% of patients; abdominal surgery was performed in 33.5% of cases. Overall, diffuse large B-cell lymphoma was the most frequent histological diagnosis (53.6%). However, patients aged <18 years were affected by Burkitt lymphoma in 52.4% of cases. Most patients (53.6%) received immunochemotherapy (IC) or IC plus radiotherapy (14%). Demolitive surgery appeared to be associated with impaired survival. Central nervous system (CNS) relapse or progression was observed in 20% of patients.

CONCLUSION

PPL is a rare entity, with some peculiar features at modern imaging. For diagnostic purposes percutaneous or endoscopic biopsies might be preferable, as opposed to surgery. No definite data is available about the optimal treatment, which should be tailored on the histological type and associated with CNS prophylaxis.

Primary Pancreatic Lymphoma on FDG PET/CT

A 69-year-old man underwent FDG PET/CT to evaluate a right upper abdominal mass. The images showed peripherally increased activity with central photopenic region in the head of the pancreas, which was consistent with pancreatic malignancy. Histopathologic findings showed characteristic findings of diffuse large B-cell lymphoma. The activity was diminished on follow-up PET/CT after 8 courses of chemotherapy.

Primary Pancreatic Large B-Cell Lymphoma Presenting as Acute Pancreatitis

Primary pancreatic lymphoma (PPL) is an extremely rare form of extranodal malignant lymphoma. The most common histological subtype of PPL is diffuse large B-cell lymphoma (DLBCL). Clinical and imaging features of PPL may often overlap with pancreatic adenocarcinoma. Therefore, it is very important to obtain a preoperative cytohistology diagnosis of pancreatic tumors to avoid unnecessary surgeries in cases with a diagnosis of PPL.

Herein, we report a 71-year-old male who was admitted to our hospital with a diagnosis of acute pancreatitis after he presented with complaints of nausea, vomiting, and epigastric abdominal pain. MRI of the abdomen revealed a pancreatic head mass, and histopathology and immunohistochemical assessment of the pancreatic lesion established the diagnosis of DLBCL. The patient achieved remission after six cycles of rituximab-cyclophosphamide, doxorubicin (hydroxydaunomycin), vincristine (oncovin), prednisolone (R-CHOP) chemotherapy.

Imaging diagnosis and staging of pancreatic ductal adenocarcinoma: a comprehensive review

Pancreatic ductal adenocarcinoma (PDAC) has continued to have a poor prognosis for the last few decades in spite of recent advances in different imaging modalities mainly due to difficulty in early diagnosis and aggressive biological behavior. Early PDAC can be missed on CT due to similar attenuation relative to the normal pancreas, small size, or hidden location in the uncinate process. Tumor resectability and its contingency on the vascular invasion most commonly assessed with multi-phasic thin-slice CT is a continuously changing concept, particularly in the era of frequent neoadjuvant therapy. Coexistent celiac artery stenosis may affect the surgical plan in patients undergoing pancreaticoduodenectomy. In this review, we discuss the challenges related to the imaging of PDAC. These include radiological and clinical subtleties of the tumor, evolving imaging criteria for tumor resectability, preoperative diagnosis of accompanying celiac artery stenosis, and post-neoadjuvant therapy imaging. For each category, the key imaging features and potential pitfalls on cross-sectional imaging will be discussed. Also, we will describe the imaging discriminators of potential mimickers of PDAC.

Differential diagnosis of solid pancreatic masses

Solid pancreatic lesions include mainly adenocarcinoma, neuroendocrine tumors pancreatic cystic neoplasms with solid component, solid pseudopapillary tumor, pancreatoblastoma, pancreatic lymphoma, and pancreatic metastasis. The most frequent pancreatic lesion is the adenocarcinoma, representing between 70% and 95% of all solid pancreatic neoplasm. The diagnosis of these lesions can be a challenge and currently, there are different imaging techniques such as CT scan, EUS and MRI with high sensitivity and specificity. The most widely used technique for the initial evaluation is the CT scan with a sensitivity between 76% and 92% for the diagnosis of pancreatic cancer. The EUS has a sensitivity for the detection of pancreatic lesions of around 98% and is accepted to be the most sensitive technique for the detection of small pancreatic tumors (<2 cm). The MRI, with a very high soft-tissue contrast resolution, provides an accuracy in the detection and staging of adenocarcinoma of 90-100%. A multimodality approach is usually necessary in patients with clinical suspicion of pancreatic lesion. The EUS is required for the local evaluation of the relation of the lesion with vessels and for tissue acquisition and the CT scan and/or MRI is usually required for the local and distance staging in case of pancreatic cancer. The purpose of this review is to provide an overview of solid pancreatic lesions and the role of the different imaging techniques in their evaluation.

Burkitt's Lymphoma Involving Multiple Hormone-Producing Organs on FDG PET/CT

Lymphoma involving many different organs can be occasionally observed. However, lymphoma involvement of multiple hormone-producing organs is rare. In this report, we described our FDG PET/CT findings in a 21-year-old man whose Burkitt's lymphoma involved not only lymph nodes, the spleen, the brain, and the bones, but also 4 organs in the endocrine system, including the thyroid, right adrenal, the pancreas, and the right testicle.

Two-dimensional Texture Analysis Based on CT Images to Differentiate Pancreatic Lymphoma and Pancreatic Adenocarcinoma: A Preliminary Study

OBJECTIVE

To retrospectively assess the diagnostic performance of texture analysis and characteristics of CT images for the discrimination of pancreatic lymphoma (PL) from pancreatic adenocarcinoma (PA).

METHODS

Fifteen patients with pathologically proved PL were compared with 30 age-matched controls with PA in a 1:2 ratio. Patients underwent a CT scan with three phases including the precontrast phase, the arterial phase, and the portal vein phase. The regions of interest of PA and PL were drawn and analyzed to derive texture parameters with MaZda software. Texture features and CT characteristics were selected for the discrimination of PA and PL by the least absolute shrinkage and selection operator and logistic regression analysis. Receiver operating characteristic analysis was performed to assess the diagnostic performance of texture analysis and characteristics of CT images.

RESULTS

Sixty texture features were obtained by MaZda. Of these, four texture features were selected by least absolute shrinkage and selection operator. Following this, three texture features and nine CT characteristics were excluded by logistic regression analysis. Finally, "S(5, -5)SumAverg" (texture feature) and "Size" (CT characteristic) were selected for the receiver operating characteristic analysis. The AUC of "S(5, -5)SumAverg" and "Size" were to be 0.704 and 0.821, respectively, with no significance between them (p = 0.3064).

CONCLUSION

Two-dimensional texture analysis is a quantitative method for differential diagnosis of PL from PA. The diagnostic performance of both texture analysis and CT characteristics was similar.

[Extranodal abdominal lymphomas]

BACKGROUND

Extranodal manifestations occur in up to 40% of non-Hodgkin lymphomas. The prevalence of extranodal involvement has increased.

OBJECTIVES

A comprehensive overview on lymphoma involvement in the parenchymatous abdominal organs, the gastrointestinal tract, and the peritoneal cavity under due consideration of clinical implications is given.

MATERIALS AND METHODS

A selective literature search with analysis of dedicated original research articles and reviews was carried out. Clinical guidelines are discussed.

RESULTS

Extranodal abdominal lymphoma involvement usually occurs secondarily in advanced disease. Sites involved most frequently are the liver and the gastrointestinal tract. Extranodal abdominal lymphoma involvement is more common in the immunocompromised patient.

CONCLUSION

Imaging findings of extranodal abdominal lymphoma are variable. Lymphoma is an important differential diagnosis to be considered in unclear tumor diseases.

[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.

Nonepithelial Neoplasms of the Pancreas, Part 2: Malignant Tumors and Tumors of Uncertain Malignant Potential From the Radiologic Pathology Archives

Almost all neoplasms of the pancreas are derived from pancreatic epithelial components, including the most common pancreatic mass, primary pancreatic ductal adenocarcinoma (PDAC). Nonepithelial neoplasms comprise only 1%-2% of all pancreatic neoplasms. Although some may arise directly from intrapancreatic elements, many originate from mesenchymal, hematopoietic, or neural elements in the retroperitoneal peripancreatic space and grow into the pancreas. Once these tumors reach a certain size, it can be challenging to identify their origin. Because these manifest at imaging as intrapancreatic masses, awareness of the existence and characteristic features of these nonepithelial neoplasms is crucial for the practicing radiologist in differentiating these tumors from primary epithelial pancreatic tumors, an important distinction given the vastly different management and prognosis. In part 1 of this article, the authors reviewed benign nonepithelial neoplasms of the pancreas. This article focuses on malignant nonepithelial neoplasms and those of uncertain malignant potential that can be seen in the pancreas. The most common malignant or potentially malignant nonepithelial pancreatic tumors are of mesenchymal origin and include soft-tissue sarcomas, solitary fibrous tumor, and inflammatory myofibroblastic tumor. These tumors commonly manifest as large heterogeneous masses, often containing areas of necrosis and hemorrhage. The clinical features associated with these tumors and the imaging characteristics including enhancement patterns and the presence of fat or calcification help distinguish these tumors from PDAC. Hematopoietic tumors, including lymphoma and extramedullary plasmacytoma, can manifest as isolated pancreatic involvement or secondarily involve the pancreas as widespread disease. Hyperenhancing paragangliomas or hypervascular metastatic disease can mimic primary pancreatic neuroendocrine tumors or vascular anomalies.

Obstructive jaundice as primary presentation of a stage IIE Non-Hodgkin lymphoma: A decision making process between advanced lymphoma and locally advanced/metastatic pancreatic adenocarcinoma

INTRODUCTION

Secondary pancreatic tumors are uncommon and account for 2-5% of pancreatic cancer. Tumors characterized most commonly with pancreatic involvement are lymphoma, renal cell and lung carcinomas.

PRESENTATION OF CASE

A 76-year-old female patient with obstructive jaundice as the primary symptom and inguinal lymphadenopathy is presented. Imaging revealed a bulky solitary solid pancreatic head mass along with paraaortic and mesenteric lymphadenopathy. The absence of a previous history of malignancy and the presence of a dominant pancreatic mass along with distal lymphadenopathy confined differential diagnosis to advanced secondary pancreatic lymphoma, which is the most common secondary pancreatic tumor, and locally advanced/metastatic pancreatic adenocarcinoma. Pathologic confirmation with excisional biopsy of an enlarged inguinal lymph node and EUS-FNB of the pancreatic head mass confirmed the diagnosis of secondary Non-Hodgkin pancreatic lymphoma allowing initiation of induction chemotherapy.

DISCUSSION

Secondary pancreatic lymphoma can be seen up to 30% of patients with advanced lymphoma; although the head of the pancreas is the most common location, obstructive jaundice is not the predominant symptom as obstruction of the common bile duct is usually absent. In the setting of a solitary nodular type pancreatic mass, key imaging findings highly suggestive of secondary pancreatic lymphoma and not of adenocarcinoma are the absence of vascular invasion, bile and pancreatic duct obstruction, and the presence of lymphadenopathy below the level of the left renal vein.

CONCLUSION

When a secondary pancreatic tumor is highly suspected pathologic confirmation is always needed before initiation of induction or palliative chemotherapy.

CT imaging of primary pancreatic lymphoma: experience from three referral centres for pancreatic diseases

Purpose

To describe CT characteristics of primary pancreatic lymphoma (PPL), a rare disease with features in common with adenocarcinoma.

Materials and methods

Fourteen patients were enrolled. CT: unenhanced scan, contrast-enhanced pancreatic and venous phases. Image analysis: tumour location; peri-pancreatic vessel encasement; necrosis; enlarged lymph nodes; fat stranding; enlarged bile duct and pancreatic duct; neoplasm longest dimension, volume and density.

Results

Histopathological diagnoses: follicular non-Hodgkin lymphoma (5/14), diffuse large B-cell lymphoma (6/14) and high-grade B-cell lymphoma not otherwise specified (3/14). Six of 14 PPLs were located in the pancreatic head and 7/14 in the body-tail; 1/14 involved the whole gland. In 5/14 cases the superior mesenteric artery and vein were encased; splenic vein and artery encasement was depicted in 2 PPLs. Necrosis was present in 2/14. Enlarged retroperitoneal lymph nodes were found in 11 cases and fat stranding in all patients. The bile duct was dilated in six cases and the pancreatic duct in five. Mean neoplasm longest diameter and volume were 8.05 cm and 210.8 cm³. Mean tumour attenuation values were 39.1 HU at baseline, 60.6 HU in the pancreatic phase and 71.4 HU in the venous phase.

Conclusions

PPL presents as a large mass lesion with delayed homogeneous enhancement; peri-pancreatic fat stranding and vessel encasement are present, without vascular infiltration. Pancreatic duct dilatation is rare.

Key points

• Primary pancreatic lymphoma (PPL) is a rare haematological disease

• PPL presents imaging features in common with pancreatic carcinoma but also some distinctive findings

• The majority of PPLs are large lesions with delayed homogeneous enhancement

• Peri-pancreatic fat stranding and vessel encasement are common in PPL

• Vascular infiltration and pancreatic duct dilatation are rare in PPL

Present status and perspectives of endosonography 2017 in gastroenterology

Endoscopic ultrasound has become an essential tool in modern gastroenterology and abdominal surgery. Compared with all other endoscopic methods, it has the most potential for innovation and its future looks bright. Thus, we compiled this summary of established and novel applications of endoscopic ultrasound methods to inform the reader about what is already possible and where future developments will lead in improving patient care further. This review is structured in four parts. The first section reports on developments in diagnostic endoscopic ultrasound, the second looks at semi-invasive endoscopic ultrasound, and the third discusses advances in therapeutic endoscopic ultrasound. An overview on the future prospects of endoscopic ultrasound methods concludes this article.

Rare Tumors and Lesions of the Pancreas

There are a few entities that account for most solid and cystic masses of the pancreas. The pancreas harbors a wide array of diseases, including adenocarcinoma, and its variants, such as anaplastic and adenosquamous carcinoma. Other neoplasms include acinar cell carcinoma, solid pseudopapillary tumor, and sarcomas. Benign lesions include hamartomas, hemangiomas, lymphangioma, and plasmacytoma. Isolated metastases include renal cell carcinoma, melanoma, and other carcinomas. Benign inflammatory conditions, such as autoimmune pancreatitis and groove pancreatitis can also mimic solid neoplasms of the pancreas.

Autoimmune Pancreatitis

Autoimmune pancreatitis (AIP) is a rare and underdiagnosed fibrosclerosing inflammatory variant of chronic pancreatitis. Its true incidence and prevalence in the general population is still not confirmed despite advances in medicine. Differentiating it from pancreatic cancer is of paramount importance. In this imaging review, we highlight the imaging findings of this intriguing entity.