PICTURES IN DIGESTIVE PATHOLOGY

 

A diffusely enlarged pancreas: the (un)usual suspect

 

 

Pedro Magalhães-Costa¹, Maria José Brito² and Pedro Pinto-Marques³

¹Department of Gastroenterology. Hospital Egas Moniz. Lisbon, Portugal.
²Department of Pathology. Hospital Garcia de Orta. Lisbon, Portugal.
³Department of Gastroenterology. Hospital Garcia de Orta. Lisbon, Portugal

 

 

Case report

An 81-year-old female presented with obstructive jaundice and a non-specific clinical picture of nausea and appetite loss. Labs demonstrated a conjugated hyperbilirubinemia (7.7 mg/dL), increased aspartate aminotransferase and alanine aminotransferase (10x ULN and 8x ULN, respectively), increased lactate dehydrogenase (10x ULN) and serum lipase (3x ULN). CA 19.9 was 342 U/mL (ref. value < 37 U/mL). There was no evidence of peripheral lymphadenopathy or hepatosplenomegaly. Imaging (Fig. 1 A and B) revealed a marked homogeneous enlargement of the pancreas (without any well-defined mass), dilation of the extra and intra-hepatic bile ducts and ascites. Endoscopic ultrasound (Fig. 1 C and D) identified an enlarged homogeneous hypoechoic pancreas, without any well-defined lesion, no dilation of the main pancreatic duct, and no peripancreatic or celiac enlarged lymph nodes. A fine-needle biopsy was performed yielding, on cytological examination and cell-block technique (Fig. 2 A and B), numerous medium/large sized atypical lymphoid cells that displayed a B-cell lineage immunophenotype (Fig. 2 A-F). Even though further characterization (by flow cytometric immunophenotyping) could not be obtained, a final diagnosis of primary pancreatic lymphoma (PPL) was assumed.

 

 

 

Discussion

Primary pancreatic lymphoma is a remarkably rare tumor of the pancreas, representing approximately 0.5% of all pancreatic neoplasms and < 2% of all lymphomas (1,2). A correct diagnosis is crucial because therapeutic management differs from other pancreatic malignancies (pancreatic ductal adenocarcinoma, neuroendocrine tumor and metastases) (2,3). Two morphologic patterns of PPL are recognized: a focal form (occurring in the pancreatic head in 80% of cases) and a rarer diffuse/infiltrative pattern, as depicted herein, emulating an acute/autoimmune pancreatitis (1).

 

References

1. Battula N, Srinivasan P, Prachalias A, et al. Primary pancreatic lymphoma: Diagnostic and therapeutic dilemma. Pancreas 2006;33:192-4. DOI: 10.1097/01.mpa.0000227910.63579.15.         [ Links ]

2. Du X, Zhao Y, Zhang T, et al. Primary pancreatic lymphoma: A clinical quandary of diagnosis and treatment. Pancreas 2011;40:30-6. DOI: 10.1097/MPA.0b013e3181e6e3e5.         [ Links ]

3. Iglesias García J, Lariño Noia J, Domingues Muñoz JE. Endoscopic ultrasound in the diagnosis and staging of pancreatic cancer. Rev Esp Enferm Dig 2009;101:631-8. DOI: 10.4321/S1130-01082009000900006.         [ Links ]