Clinical features and images of malignant lymphoma localized in the pancreatic head to differentiate from pancreatic ductal adenocarcinoma: a case series study

BACKGROUND

Pathological examination by endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) has been reported to be useful in diagnosing pancreatic malignant lymphoma (ML), but some ML cases are difficult to be differentiated from pancreatic ductal adenocarcinoma (PDAC).

METHODS

This retrospective study included 8 patients diagnosed with ML that had a pancreatic-head lesion at initial diagnosis and 46 patients with resected PDAC in the pancreatic head between April 2006 and October 2021 at our institute. ML and PDAC were compared in terms of patients' clinical features and imaging examinations.

RESULTS

The median tumor size was larger in ML than in PDAC (45.8 [24-64] vs. 23.9 [8-44] mm), but the median diameter of the caudal main pancreatic duct (MPD) was larger in PDAC (2.5 [1.0-3.5] vs. 7.1 [2.5-11.8] mm), both showing significant differences between these malignancies (both, P < 0.001). In the analysis of covariance, MLs showed a smaller caudal MPD per tumor size than PDACs, with a statistical difference (P = 0.042). Sensitivity and specificity using sIL-2R ≥ 658 U/mL plus CA19-9 < 37 U/mL for the differentiation of ML from PDAC were 80.0% and 95.6%, respectively.

CONCLUSIONS

Diagnosing pancreatic ML using cytohistological examination through EUS-FNA can be difficult in some cases. Thus, ML should be suspected if a patient with a pancreatic tumor has a small MPD diameter per tumor size, high serum sIL-2R level, normal CA19-9 level. If the abovementioned features are present and still cannot be confirmed as PDAC, re-examination should be considered.

[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.

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.

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.

Primary pancreatic lymphoma: Report of three cases with review of literature

Background:

Primary pancreatic lymphoma (PPL) is an extremely rare neoplasm, which may be confused with pancreatic adenocarcinoma. So far only about 150 cases of PPL have been reported.

Materials and Methods:

We present our experience of 3 cases of PPL over a 4-year period.

Results:

All the patients presented with vague abdominal pain of duration ranging from 1½ months to 3 months. Two patients had diagnosis confirmed histologically by CT-guided core biopsy or Fine needle aspiration procedure. We were able to avoid unnecessary laparotomy in 2 patients using preoperative guided Fine needle aspiration Cytology, although the third patient did undergo a Whipple′s procedure as the diagnosis of PPL was not considered during the initial workup.

Conclusions:

There is no significant difference noted with regard to patient′s age or duration of symptoms between patients with either pancreatic adenocarcinoma or PPL. The differential diagnosis of PPL includes pancreatic adenocarcinoma and secondary involvement of pancreas from extra-nodal lymphoma. Combination of two things is suggestive of Pancreatic lymphoma: (1) Bulky localized tumor in pancreatic head (2) Absence of significant dilatation of main pancreatic duct strengthens a diagnosis of pancreatic lymphoma over adenocarcinoma. Majority of patients can be managed with chemotherapy with much better prognosis compared to patients with pancreatic adenocarcinoma. Larger series of patients are needed to evaluate whether chemotherapy, eventually followed by involved-field radiation therapy, is the treatment of choice for PPL.

Value of ultrasound examination in differential diagnosis of pancreatic lymphoma and pancreatic cancer

AIM: To investigate the value of clinical manifestations and ultrasound examination in the differential diagnosis of pancreatic lymphoma and pancreatic cancer.

METHODS: The clinical and ultrasonic characteristics of 12 cases of pancreatic lymphoma and 30 cases of pancreatic cancer were retrospectively analyzed.

RESULTS: Statistically significant differences were found in the course of disease, back pain, jaundice, carcino-embryonic antigen (CEA) and CA19-9 increase, palpable abdominal lump, superficial lymph node enlargement, fever and night sweats, lesion size, bile duct expansion, pancreatic duct expansion, vascular involvement, retroperitoneal (below the renal vein level) lymph node enlargement, and intrahepatic metastasis between pancreatic lymphoma and pancreatic cancer. There were no significant differences in age of onset, gender ratio, weight loss, nausea and vomiting, lesion position, the echo of the lesion, and the blood flow of the lesion.

CONCLUSION: Pancreatic lymphoma should be considered for patients with long lasting symptoms, superficial lymph node enlargement, palpable abdominal lump, fever and night sweats, relatively large lesions, and retroperitoneal (below the level of the renal vein) lymph node enlargement. A diagnosis of pancreatic cancer should be considered more likely in the patients with relatively short disease course, jaundice, back pain, CEA and CA19-9 increase, relatively small lesions, bile duct expansion, obvious pancreatic duct expansion, peripheral vascular wrapping and involvement, or intrahepatic metastases.