PICTURES IN DIGESTIVE PATHOLOGY

 

Usefulness of endoscopic ultrasound in the evaluation of a lymphoma with multiple gastric and pancreatic lesions

Utilidad de la ecografía en la evolución de un linfoma con múltiples lesiones gástricas y pancreáticas

 

 

Ramiro Rodríguez-Pérez¹, Julio Iglesias-García^2,3, Matilde Álvarez-del-Castillo^2,3, José Lariño-Noia^2,3, José Iglesias-Canle^2,3 and J. Enrique Domínguez-Muñoz^2,3

¹Department of Gastroenterology. Hospital Universitario de Gran Canaria "Doctor Negrin". Las Palmas de Gran Canaria, Spain
²Department of Gastroenterology. Hospital Universitario de Santiago de Compostela. Santiago de Compostela, A Coruña. Spain
³Foundation for Research in Digestive Diseases. Hospital Universitario de Santiago de Compostela. Santiago de Compostela, A Coruña. Spain

 

 

Case report

A 22-years-old woman, without relevant medical history, was hospitalized with a 10-days history of jaundice and epigastric pain. Laboratory test revealed 5,920 leukocytes/mm³, 448,000 platelets/mm³, bilirubin 3.4 mg/dL, aspartate aminotransferase 153 IU/L, alanine aminotransferase 405 IU/L, gamma-glutamyl transferase 188 IU/L, alkaline phosphatase 486 IU/L. A linear EUS was performed with Pentax EG-3870UTK^® and HITACHI-Preirus^®, demonstrating numerous pancreatic homogeneous hypoechoic lesions (Fig. 1), measuring from 4 to 20 mm, with a homogenous blue elastographic pattern and a strain ratio of 35.33 (Fig. 2). Microcholedocholitiasis and an upstream dilated common biliary duct due to an extrinsic compression by a pancreatic mass were also detected. Several subepithelial gastric lesions, with a central scar (Fig. 3), well-limited, homogeneous and hypoechoic, originated from mucosa and muscularis mucosae layer were also identified (Fig. 4). Biopsies were taken from these subepithelial lesions, giving the diagnosis of a diffuse large B-cell lymphoma. A multidetector-CT-scan confirmed previous finding. An endoscopic retrograde cholangiopancreatography (ERCP) was performed, and a 5 cm-10Fr plastic biliary stent was placed. The patient was submitted to Hematology Department, and started with a specific chemotherapy strategy.

 

 

 

 

 

Discussion

Endoscopic ultrasound (EUS) is considered as the most accurate method for the diagnosis and staging of pancreatic and gastro-esophageal lesions. EUS can also guide tissue sampling from both gut wall (by using standard forceps biopsies) and pancreatic solid lesions (by guiding fine needle aspiration (FNA) (1-3). Nowadays, new tools associated to EUS, like elastography, add relevant information to the standard B-mode image, helping in the differential diagnosis of solid pancreatic masses (4,5). In the present case, biopsies were obtained from a gastric lesion, giving the final diagnosis of a diffuse large B-cell lymphoma. When analyzing the multiple pancreatic solid masses, the strain ratio measured by EUS-guided elastography was 35.33, which has been associated in our previous studies to malignancy (5).

 

References

1. Dye CE, Waxman I. Endoscopic Ultrasound. Gastroenterol Clin North Am 2002; 31:863-79.         [ Links ]

2. Iglesias-García J, Lariño-Noia J, Domínguez-Muñoz JE. Endoscopic ultrasound in the diagnosis and staging of pancreatic cancer. Rev Esp Enferm Dig 2009;101:631-8.         [ Links ]

3. Dumonceau JM, Polkowski M, Larghi A, Vilmann P, Giovannini M, Frossard JL, et al. Indications, results, and clinical impact of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) clinical Guideline. Endoscopy 2011;43:897-912.         [ Links ]

4. Iglesias-García J, Lariño-Noia J, Abdulkder I, Forteza J, Domínguez-Muñoz JE. EUS elastography for the characterization of solid pancreatic masses. Gastrointest Endosc 2009;70:1101-8.         [ Links ]

5. Iglesias-García J, Lariño-Noia J, Abdulkader I, Forteza J, Domínguez-Muñoz JE. Quantitative endoscopic ultrasound elastography: an accurate method for the differentiation of solid pancreatic masses. Gastroenterology 2010;139:1172-80.         [ Links ]