1130-0108/2016/108/12/809-811
Revista Española de Enfermedades Digestivas
© Copyright 2016. SEPD y © ARÁN EDICIONES, S.L.
Rev Esp Enferm Dig
2016, Vol. 108, N.º 12, pp. 809-811
PICTURES IN DIGESTIVE PATHOLOGY
A diffusely enlarged pancreas: the (un)usual suspect
Pedro Magalhães-Costa1, Maria José Brito2 and Pedro Pinto-Marques3
Department 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
1
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 aminotransfer-
ase 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
Fig. 1. A-B. Imaging studies revealed a diffuse enlargement of the pancreatic gland. The pancreatic parenchyma was hipoechoic and surrounded by an
enhanced peripancreatic fat layer. Also the extra-hepatic and intra-hepatic bile ducts were dilated. The examiner did not notice any dilation of the main
pancreatic duct. C-D. Endoscopic ultrasound identified an enlarged homogeneous hypoechoic pancreas, without any well-defined lesion, and no peripancreatic or celiac enlarged lymph nodes.
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P. MAGALHÃES-COSTA ET AL.
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.
Rev Esp Enferm Dig
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).
Fig. 2. Cytological examination (A: Giemsa staining, 20x) and cell-block technique (B: hematoxylin & eosin staining, 40x) showed the presence of numerous
medium/large sized atypical lymphoid cells. Those cells were positive for CD20 (C), CD10 (D), BCL2 (E) and BCL6 (F) and negative for CD3, CD5, CD21,
CD23 and cyclin D1.
Rev Esp Enferm Dig 2016;108(12):809-811
2016, Vol. 108, N.º 12
A DIFFUSELY ENLARGED PANCREAS: THE (UN)USUAL SUSPECT
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
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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
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/S113001082009000900006