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Segaran N, Sandrasegaran K, Devine C, Wang MX, Shah C, Ganeshan D. Features of primary pancreatic lymphoma: A bi-institutional review with an emphasis on typical and atypical imaging features. World J Clin Oncol 2021; 12:823-832. [PMID: 34631445 PMCID: PMC8479350 DOI: 10.5306/wjco.v12.i9.823] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/29/2021] [Accepted: 08/10/2021] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Nicole Segaran
- Department of Radiology, Mayo Clinic Arizona, Phoenix, AZ 85054, United States
| | | | - Catherine Devine
- Department of Diagnostic Imaging, University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States
| | - Mindy X Wang
- Department of Diagnostic Imaging, University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States
| | - Chintan Shah
- Department of Diagnostic Imaging, University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States
| | - Dhakshinamoorthy Ganeshan
- Department of Diagnostic Imaging, University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States
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Facchinelli D, Boninsegna E, Visco C, Tecchio C. Primary Pancreatic Lymphoma: Recommendations for Diagnosis and Management. J Blood Med 2021; 12:257-267. [PMID: 33981170 PMCID: PMC8107008 DOI: 10.2147/jbm.s273095] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 04/16/2021] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
| | - Enrico Boninsegna
- Department of Radiology, Azienda Socio Sanitaria Territoriale, Mantova, Italy
| | - Carlo Visco
- Hematology and Bone Marrow Transplant Unit, Department of Medicine, University of Verona, Verona, Italy
| | - Cristina Tecchio
- Hematology and Bone Marrow Transplant Unit, Department of Medicine, University of Verona, Verona, Italy
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Savari O, Al-Duwal Z, Wang Z, Ganesan S, Danan-Rayes R, Ayub S. Pancreatic lymphoma: A cytologic diagnosis challenge. Diagn Cytopathol 2019; 48:350-355. [PMID: 31774250 DOI: 10.1002/dc.24349] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 10/26/2019] [Accepted: 11/14/2019] [Indexed: 11/07/2022]
Abstract
Very rarely lymphoma primarily or secondarily involves the pancreas. Involvement of the pancreatic parenchyma with lymphoma clinically may mimic pancreatic ductal adenocarcinoma (PDA) and other mass-forming pancreatic lesions. Endoscopic ultrasound fine needle aspiration (EUS-FNA) is the first step in the diagnostic pathway of managing these patients by providing a cytology specimen. Cytologically, lymphoma of pancreas can be misdiagnosed for a wide variety of pancreatic neoplastic and non-neoplastic lesions. Cytological differential diagnosis includes well-differentiated adenocarcinoma, acinar cell carcinoma, well differentiated neuroendocrine tumor, and autoimmune pancreatitis. Gastroenterologist's skills in providing adequate sample for preparing smears, cell blocks and/or performing flow cytometry, and also cytopathologist's skills in detecting atypical lymphocytic population are crucial factors. Although cytology examination has limitations to subclassify lymphoma, it plays a key role to redirect clinicians into the right patient-care pathway. In this article, we present two cases of pancreatic lymphoma with emphasis on the discriminating cytomorphological features, and we also review literatures with reports of primary pancreatic lymphoma (PPL) to better understand the characteristics of this rare lesion.
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Affiliation(s)
- Omid Savari
- Department of Pathology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Zaynab Al-Duwal
- Department of Pathology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Zijian Wang
- Department of Pathology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Santhi Ganesan
- Department of Pathology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Rania Danan-Rayes
- Department of Pathology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Salman Ayub
- Department of Pathology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
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Rodríguez-Infante A, Fernández-Martínez D, Iglesias-García E, García-Flórez L. Primary pancreatic lymphoma as a cause of obstructive jaundice. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2019. [DOI: 10.1016/j.rgmxen.2018.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Rodríguez-Infante A, Fernández-Martínez D, Iglesias-García E, García-Flórez LJ. Primary pancreatic lymphoma as a cause of obstructive jaundice. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2018; 84:114-115. [PMID: 29615287 DOI: 10.1016/j.rgmx.2018.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 01/24/2018] [Accepted: 01/24/2018] [Indexed: 10/17/2022]
Affiliation(s)
- A Rodríguez-Infante
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario San Agustín, Avilés, Asturias, España.
| | - D Fernández-Martínez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario San Agustín, Avilés, Asturias, España
| | - E Iglesias-García
- Servicio de Anatomía Patológica, Hospital Universitario San Agustín, Avilés, Asturias, España
| | - L J García-Flórez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario San Agustín, Avilés, Asturias, España
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Abstract
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.
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Affiliation(s)
- Deepa Anand
- Abdominal Imaging, Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Pickens Academic Tower, 1400 Pressler Street, Unit 1473, Houston, TX, 77030-4009, USA.
| | - Chandana Lall
- Abdominal Imaging, Department of Radiology, University of California, Irvine, 101 The City Dr South Suite 0115, Orange, CA, 92868, USA
| | - Priya Bhosale
- Abdominal Imaging, Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Pickens Academic Tower, 1400 Pressler Street, Unit 1473, Houston, TX, 77030-4009, USA
| | - Dhakshinamoorthy Ganeshan
- Abdominal Imaging, Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Pickens Academic Tower, 1400 Pressler Street, Unit 1473, Houston, TX, 77030-4009, USA.
| | - Aliya Qayyum
- Abdominal Imaging, Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Pickens Academic Tower, 1400 Pressler Street, Unit 1473, Houston, TX, 77030-4009, USA
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Nelsen EM, Buehler D, Soni AV, Gopal DV. Endoscopic ultrasound in the evaluation of pancreatic neoplasms-solid and cystic: A review. World J Gastrointest Endosc 2015; 7:318-327. [PMID: 25901210 PMCID: PMC4400620 DOI: 10.4253/wjge.v7.i4.318] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Revised: 10/31/2014] [Accepted: 01/20/2015] [Indexed: 02/05/2023] Open
Abstract
Pancreatic neoplasms have a wide range of pathology, from pancreatic adenocarcinoma to cystic mucinous neoplasms. Endoscopic ultrasound (EUS) with or without fine needle aspiration (FNA) is a helpful diagnostic tool in the work-up of pancreatic neoplasms. Its utility in pancreatic malignancy is well known. Over the last two decades EUS-FNA has become a procedure of choice for diagnosis of pancreatic adenocarcinoma. EUS-FNA is highly sensitive and specific for solid lesions, with sensitivities as high as 80%-95% for pancreatic masses and specificity as high as 75%-100%. Multiple aspects of the procedure have been studied to optimize the rate of diagnosis with EUS-FNA including cytopathologist involvement, needle size, suctioning and experience of endoscopist. Onsite pathology is one of the most important elements in increasing diagnostic yield rate in EUS-FNA. EUS-FNA is valuable in diagnosing rare and atypical pancreatic neoplasms including neuroendocrine, lymphoma and metastatic disease. As more and more patients undergo cross sectional imaging, cystic lesions of the pancreas are becoming a more common occurrence and EUS-FNA of these lesions can be helpful for differentiation. This review covers the technical aspects of optimizing pancreatic neoplasm diagnosis rate, highlight rare pancreatic neoplasms and role of EUS-FNA, and also outline the important factors in diagnosis of cystic lesions by EUS-FNA.
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Johnson EA, Benson ME, Guda N, Pfau PR, Frick TJ, Gopal DV. Differentiating primary pancreatic lymphoma from adenocarcinoma using endoscopic ultrasound characteristics and flow cytometry: A case-control study. Endosc Ultrasound 2014; 3:221-5. [PMID: 25485269 PMCID: PMC4247529 DOI: 10.4103/2303-9027.144530] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 05/12/2014] [Indexed: 12/14/2022] Open
Abstract
Background: Primary pancreatic lymphoma (PPL) is a rare pancreatic neoplasm that is difficult to diagnose. PPL has a vastly different prognosis and treatment regimen than other pancreatic tumors; therefore, accurate diagnosis is vital. In this article, we describe the characteristic presentation, endoscopic ultrasound (EUS) features, and the role of fine-needle aspiration (FNA) in the diagnosis of PPL compared with pancreatic adenocarcinoma. Materials and Methods: This was a retrospective case-control study of 11 patients diagnosed with PPL via EUS between 2002 and 2011. The clinical and EUS features of the cases were then compared with age-matched controls with adenocarcinoma in a 1:3 ratio. Results: There were 11 patients with PPL and 33 with adenocarcinoma. At last follow-up, 7 of 11 PPL patients were alive, and 3 of 33-adenocarcinoma patients were alive (P < 0.001). The most common presenting symptoms for PPL were pain 73%, weight loss 45%, and jaundice 18%, while patients with adenocarcinoma presented with pain 52% (P = 0.3), weight loss 30% (P = 0.47) and jaundice 76% (P = 0.001). The EUS appearance was similar in the two groups in that ultrasound imaging of the pancreas lesions tended to be hypoechoic and heterogenous, but the PPL group was more likely to have peripancreatic lymphadenopathy (LAD) (64% vs. 18%, P = 0.008) and were larger (4.8 cm × 5.3 cm vs. 3.2 cm × 3.1 cm, P < 0.001). The PPL group was less likely to have vascular invasion (18% vs. 55%, P = 0.045) and less likely to be found in the head of the pancreas (36% vs. 85%, P = 0.004). FNA and cytology (without flow cytometry [FC]) made the diagnosis in 28% of PPL patients compared with 91% of adenocarcinoma patients (P = 0.002). In the PPL group, 7 of 11 FNA samples were sent for FC. If FC was added, then the diagnosis of PPL was increased to 100%. Conclusions: Compared with adenocarcinoma, pancreatic lymphoma has a better prognosis, is less likely to present with jaundice and less likely to have vascular invasion. PPL is more likely to be located outside the head of the pancreas and to include peripancreatic LAD, and is less likely to be diagnosed with cytology. The diagnostic accuracy of FNA for PPL is improved greatly with the addition of FC.
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Affiliation(s)
- Eric A Johnson
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Wisconsin, School of Medicine and Public Health, Madison, USA
| | - Mark E Benson
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Wisconsin, School of Medicine and Public Health, Madison, USA
| | - Nalini Guda
- GI Associates - Aurora St. Luke's Medical Center, Milwaukee, WI, USA
| | - Patrick R Pfau
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Wisconsin, School of Medicine and Public Health, Madison, USA
| | - Terrence J Frick
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Wisconsin, School of Medicine and Public Health, Madison, USA
| | - Deepak V Gopal
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Wisconsin, School of Medicine and Public Health, Madison, USA
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9
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Primary pancreatic lymphoma: a population-based analysis using the SEER program. Am J Clin Oncol 2013; 36:38-43. [PMID: 22134518 DOI: 10.1097/coc.0b013e3182354bbb] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Primary pancreatic lymphoma (PPL) is a rare disease, accounting for only 0.5% of all pancreatic masses. A paucity of literature exists on the epidemiology and outcomes of PPL. Here, we present a series of 523 cases of PPL obtained from the Surveillance, Epidemiology, and End Results database. METHODS Patients diagnosed with a PPL from 1973 to 2007 were identified. Data on patient and tumor characteristics as well as initial treatment with surgery or radiation were extracted. Survival rates were calculated using the Kaplan-Meier method. A multivariate analysis was performed to determine independent prognostic factors predicting mortality hazard ratios using Cox proportional hazards modeling. RESULTS Fifty-eight percent of patients identified were male. The median age range at diagnosis was 65 to 69 years. The most common histologic subtype in the present series was diffuse large B-cell lymphoma, which accounted for 56% of all patients. The 5-year overall survival for the group was 45%. Multivariate analysis suggests that age more than 60 years at diagnosis, race of "other" (compared with "white"), and marital status of single or widowed were predictive of increased all-cause mortality (P<0.05). CONCLUSIONS This represents the largest published series of patients with PPL. Age more than 60 years, female sex, and marital status of married were identified as independent prognostic factors predicting for decreased all-cause mortality.
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Krishna SG, Lee JH. Endosonography in solid and cystic pancreatic tumors. JOURNAL OF INTERVENTIONAL GASTROENTEROLOGY 2011; 1:193-201. [PMID: 22586537 DOI: 10.4161/jig.1.4.19971] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 09/04/2011] [Accepted: 12/23/2011] [Indexed: 12/12/2022]
Abstract
Pancreatic tumors being either benign or malignant can be solid or cystic. Although diverse in presentation, their imaging features share commonalities and it is often difficult to distinguish these tumors. Endoscopic ultrasonography (EUS) is the most sensitive of the imaging procedures currently available for characterizing pancreatic tumors, and is especially good in identifying the smaller sized tumors. Additional applications inclusive of EUS-guided fine needle aspiration (EUS-FNA) are useful in tissue sampling and preoperative staging of pancreatic tumors.Although diagnostic capabilities have greatly evolved with advances in EUS and tissue processing technology (cytology, tumor markers, DNA analysis), differentiation of benign and malignant neoplasms, neoplastic and non-neoplastic (chronic pancreatitis) conditions, continues to be challenging.Recent innovative applications include contrast-enhanced EUS with Doppler mode, contrast-enhanced harmonic EUS, 3-dimensinal EUS, and EUS elastography. Incorporation of these methods has improved the differential diagnosis of pancreatic tumors. Finally, a multi-disciplinary approach involving radiology, gastroenterology and surgical specialties is often necessary for accurate diagnosis and management of solid and cystic pancreatic tumors.
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Affiliation(s)
- Somashekar G Krishna
- Deptment of Gastroenterology, Hepatology, and Nutrition, MD Anderson Cancer Center, Houston, Texas, USA
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Haji AG, Sharma S, Majeed KA, Vijaykumar DK, Pavithran K, Dinesh M. Primary pancreatic lymphoma: Report of three cases with review of literature. Indian J Med Paediatr Oncol 2011; 30:20-3. [PMID: 20668602 PMCID: PMC2902210 DOI: 10.4103/0971-5851.56331] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- Altaf Gauhar Haji
- Department of Surgical Oncology, Amrita Institute of Medical Sciences and Research Center, Ernakulam, Kerala, India
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12
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Mason K, Higgs SM, Norton SA. Endoscopic ultrasound in the assessment of solid and cystic pancreatic lesions. Br J Hosp Med (Lond) 2011; 72:78-85. [PMID: 21378613 DOI: 10.12968/hmed.2011.72.2.78] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Pancreatic masses can be solid or cystic, benign or malignant. Rapid and accurate diagnosis is essential for optimal management. Clinical presentation and radiological appearance are often inadequate for a definitive diagnosis. Endoscopic ultrasound allows more detailed assessment of the pancreas than traditional imaging techniques.
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Affiliation(s)
- Karen Mason
- Department of Radiology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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13
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Rossi ED, Larghi A, Verna EC, Martini M, Galasso D, Carnuccio A, Larocca LM, Costamagna G, Fadda G. Endoscopic ultrasound-guided fine-needle aspiration with liquid-based cytologic preparation in the diagnosis of primary pancreatic lymphoma. Pancreas 2010; 39:1299-302. [PMID: 20944491 DOI: 10.1097/mpa.0b013e3181dc694e] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The diagnosis subtyping of lymphoma on specimens collected by endoscopic ultrasound fine-needle aspiration (EUS-FNA) can be extremely difficult. When a cytopathologist is available for the on-site evaluation, the diagnosis may be achieved by applying flow cytometric techniques. We describe our experience with immunocytochemistry (ICC) and molecular biology studies applied on EUS-FNA specimens processed with a liquid-based cytologic (LBC) preparation for the diagnosis of primary pancreatic lymphoma (PPL). METHODS Three patients with a pancreatic mass underwent EUS-FNA. The collected specimens were processed with the ThinPrep method for the cytologic diagnosis and eventual additional investigations. RESULTS A morphologic picture consistent with PPL was found on the LBC specimens of the 3 patients. Subsequent ICC and molecular biology studies for immunoglobulin heavy chain gene rearrangement established the diagnosis of pancreatic large B-cell non-Hodgkin lymphoma in 2 patients and a non-Hodgkin lymphoma with plasmoblastic/immunoblastic differentiation in the remaining one. CONCLUSIONS An LBC preparation can be used to diagnose and subtype PPL by applying ICC and molecular biology techniques to specimens collected with EUS-FNA. This method can be an additional processing method for EUS-FNA specimens in centers where on-site cytopathologist expertise is not available.
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14
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Gimeno-García AZ, Alonso MM, García Castro C, Nicolás Pérez D, Quintero E. [Primary pancreatic lymphoma diagnosed by endoscopic ultrasound-guided fine needle aspiration biopsy]. GASTROENTEROLOGIA Y HEPATOLOGIA 2010; 33:638-42. [PMID: 20932603 DOI: 10.1016/j.gastrohep.2010.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2010] [Revised: 07/30/2010] [Accepted: 08/05/2010] [Indexed: 11/28/2022]
Abstract
Although primary pancreatic lymphoma (PPL) is a rare malignant tumor, the correct diagnosis is essential since their therapeutic management differs from other pancreatic tumors. The fine needle aspiration cytology guided by endoscopic ultrasonography (EUS-FNA) is currently the preferred technique for the diagnosis of neoplasms of the pancreas, being of particular interest in those pancreatic lesions with atypical characteristics or presentation. However, the usefulness of EUS-FNA in the PPL has been poorly studied because of the rarity of this entity. We report a case of a patient with HIV infection and PPL diagnosed by EUS-FNA.
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Affiliation(s)
- Antonio Z Gimeno-García
- Servicio de Aparato Digestivo, Hospital Universitario de Canarias, La Laguna, Tenerife, España.
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Abe Y, Tamura K, Sakata I, Ishida J, Mukai M, Ohtaki M, Nakamura M, Machida K. Unique intense uptake demonstrated by (18)F-FDG positron emission tomography/computed tomography in primary pancreatic lymphoma: A case report. Oncol Lett 2010; 1:605-607. [PMID: 22966351 DOI: 10.3892/ol_00000107] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2010] [Accepted: 04/21/2010] [Indexed: 11/06/2022] Open
Abstract
Patients with primary pancreatic lymphoma (PPL), which is rare, require a different therapeutic approach and have a better prognosis than those with pancreatic cancer. However, conventional imaging modalities alone are not able to differentiate between pancreatic cancer and other rare tumors such as PPL, although the accurate diagnosis of PPL is crucial. The development of new modalities such as F-18 2'-deoxy-2fluoro-D-glucose (FDG) positron emission tomography combined with computed tomography (PET/CT) contributes to the evaluation of lymphoma staging. However, few reports are currently available regarding PET/CT findings in PPL. In this study, a 56-year old man with PPL was examined using FDG PET/CT imaging, which showed the unique intense uptake of FDG in the pancreas with atypical findings of malignancy in the CT scan and magnetic resonance images.
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Affiliation(s)
- Yoshiyuki Abe
- Tokorozawa PET Diagnostic Imaging Clinic, Saitama 359-1124
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Nakamura T, Ito T, Abe Y, Izutsu K, Gibo J, Itaba S, Kawabe K, Oono T, Igarashi H, Yamaguchi K, Ohshima K, Takayanagi R. Primary pancreatic low-grade mucosa-associated lymphoid tissue lymphoma presenting with multiple masses. Clin J Gastroenterol 2008; 1:168-173. [PMID: 26193698 DOI: 10.1007/s12328-008-0028-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2008] [Accepted: 08/04/2008] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Taichi Nakamura
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Tetsuhide Ito
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Yasunobu Abe
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Kensaku Izutsu
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Junya Gibo
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Souichi Itaba
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Ken Kawabe
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Takamasa Oono
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Hisato Igarashi
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Koji Yamaguchi
- Department of Cancer Therapy and Research, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kouichi Ohshima
- Division of Pathophysiological and Experimental Pathology, Department of Pathology, Graduate School of Medical Sciences, Kurume University, Fukuoka, Japan
| | - Ryoichi Takayanagi
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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Abstract
AIM: To heighten recognition of primary pancreatic lymphoma (PPL) in clinical practice.
METHODS: A retrospective review of the clinical presentation, imaging characteristics and pathological features of PPL patients were presented, as well as their diagnosis and treatment, in combination with literature review.
RESULTS: Histological diagnosis was made in four patients by surgery and in two patients by EUS-FNA. The six PPL patients (5 males and 1 female; age range, 16-65 years; mean age, 46 years) had the duration of symptoms for two weeks to three months. The primary presenting symptoms, though not characteristic, were abdominal pain, abdominal masses, weight loss, jaundice, nausea and vomiting. One of the patients developed acute pancreatitis. In one patient, the level of serum CA19-9 was 76.3 μg/L. Abdominal CT scan showed that three of the six tumors were located in the head of pancreas, two in the body and tail, and one throughout the pancreas. Diameter of the tumors in the pancreas in four cases was more than 6 cm, with homogeneous density and unclear borders. Enhanced CT scan showed that only the tumor edges were slightly enhanced. The pancreatic duct was irregularly narrowed in two cases whose tumors were located in the pancreatic head and body, in which endoscopic retrograde cholangiopancreatography (ERCP) showed that the proximal segment was slightly dilated. Two patients underwent Whipple operation, one patient underwent pancreatectomy, and another patient underwent operative biliary decompression. PPL was in stageIE in 2 patients and in stage II E in 4 patients according to the Ann Arbor classification system. The diagnosis of B-cell non-Hodgkin’s lymphoma was made in all patients histopathologically. All six patients underwent systemic chemotherapy, one of whom was also treated with gamma radiometry. One patient died two weeks after diagnosis, two patients lost follow-up, two patients who received chemotherapy survived 49 and 37 mo, and the remaining patient is still alive 21 mo, after diagnosis and treatment.
CONCLUSION: PPL is a rare form of extranodal lymphoma originating from the pancreatic parenchyma. Clinical and imaging findings are otherwise not specific in the differentiation of pancreatic lymphoma and pancreatic cancer, which deserves attention. EUS-guided fine-needle aspiration (EUS-FNA) of the pancreas requires experienced cytopathologists as well as advanced immunohistochemical assays to obtain a final diagnosis on a small amount of tissue. Surgery and adjuvant chemotherapy or radiotherapy can produce fairly good outcomes.
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Affiliation(s)
- Hai Lin
- Department of Gastroentology, Zhejiang Qu-Hua Hospital, Quzhou, China
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Meier C, Kapellen T, Tröbs RB, Hirsch W, Parwaresch R, Kiess W, Körholz D. Temporary diabetes mellitus secondary to a primary pancreatic Burkitt lymphoma. Pediatr Blood Cancer 2006; 47:94-6. [PMID: 16411197 DOI: 10.1002/pbc.20752] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Primary pancreatic lymphoma (PPL) is a rare form of extranodal lymphoma. So far, only in adults has a coincidence with diabetes mellitus (DM) been described. We report a nearly 9-year-old German boy presenting with a Burkitt lymphoma associated with a temporary insulin-dependent DM and exocrine insufficiency of the pancreas. After the patient went into remission, a spontaneous recovery of the endocrine pancreatic function was observed. On immunophenotyping, the lymphoma cells revealed expression of FasL suggesting a potentially apoptotic effect on pancreatic tissue. Beta cell impairment may have been caused by FasL resembling autoimmune diabetes.
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Affiliation(s)
- Constance Meier
- Hospital for Children and Adolescents, University of Leipzig Medical Center, Leipzig, Germany
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Wang YJ, Jeng CM, Wang YC, Chang PP, Wang TH. Primary pancreatic Burkitt's lymphoma mimicking carcinoma with obstructive jaundice and very high CA19-9. Eur J Gastroenterol Hepatol 2006; 18:537-40. [PMID: 16607151 DOI: 10.1097/00042737-200605000-00014] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Primary pancreatic lymphoma is a rare neoplasm. We report the case of a 49-year-old man who presented with biliary obstruction due to a neoplasm involving the pancreatic head. Initial computed tomography revealed a suspicious periampullary mass. Consequently, magnetic resonance imaging was performed 16 days later, showing a relatively clearly defined and homogeneous signal mass in the pancreatic head with biliary dilatation on enhanced study. In combination with high tumour marker associated antigen CA19-9 levels (1872 and 2110 U/ml), these findings were highly suggestive of a pancreatic carcinoma. He underwent Whipple's procedure. Examination of the surgical specimen revealed a Burkitt's lymphoma. This case demonstrates that lymphoma can present with features mimicking pancreatic head carcinoma on imaging, clinical and laboratory studies. Neither clinical nor imaging nor laboratory methods indicate correct diagnosis, but a relatively clearly defined and homogeneous mass should prompt the physician to include lymphoma in a differential diagnosis of a pancreatic mass.
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Affiliation(s)
- Yu Jen Wang
- Department of Radiology, Cathay General Hospital, 18 Hsinhai Road, Pan Chiao City, Taipei Hsien 220, Taiwan, ROC.
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Alldinger I, Peiper M, Diallo R, Poll L, Kündgen A, Germing U, Knoefel WT. Primary pancreatic lymphoma—a rare cause of cholestasis leading to surgical treatment. Ann Hematol 2006; 85:485-6. [PMID: 16568321 DOI: 10.1007/s00277-006-0102-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2006] [Accepted: 02/14/2006] [Indexed: 10/24/2022]
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Nayer H, Weir EG, Sheth S, Ali SZ. Primary pancreatic lymphomas: a cytopathologic analysis of a rare malignancy. Cancer 2004; 102:315-21. [PMID: 15386314 DOI: 10.1002/cncr.20488] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Hassan Nayer
- Department of Pathology, The Johns Hopkins Hospital, Baltimore, Maryland 21287, USA
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Abstract
The usefulness of F-18 2'-deoxy-2-fluoro-D-glucose (FDG) positron emission tomography (PET) has been well established for lymphoma staging. Although involvement of the pancreas occurs in more than one third of patients with non-Hodgkin lymphoma, primary lymphoma of the pancreas accounts for less than 1% of extranodal non-Hodgkin lymphomas. Because patients with primary pancreatic lymphoma require a different therapeutic approach and have a better prognosis than those with pancreatic adenocarcinoma, the accurate diagnosis is important. However, conventional imaging modalities cannot differentiate between adenocarcinoma and other less common neoplasms such as lymphoma. We report a 67-year-old man who had a primary pancreatic lymphoma in which FDG PET imaging revealed round, intense FDG uptake in the center of the midabdomen.
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Affiliation(s)
- Seok-Nam Yoon
- Department of Nuclear Medicine, School of Medicine, Ajou University, Suwon, Korea.
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23
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Puvanachandra N, Rene C. A unique case of mistaken identity. Eye (Lond) 2004; 19:108-10. [PMID: 15094727 DOI: 10.1038/sj.eye.6701407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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