Primary pancreatic lymphoma: endoscopic ultrasound-guided Trucut biopsy to the rescue!

A 64-year-old diabetic woman presented with a 1-week history of abdominal pain and cholestatic jaundice. Her laboratory tests showed: leukocyte count 7.2 × 10⁹/L (normal range 3.5 – 10.5 × 10⁹/L), total bilirubin 10.5 μg/dL (0.1 – 1.0 μg/dL), aspartate aminotransferase (AST) 337 U/L (12 – 31 U/L), alanine aminotransferase (ALT) 624 U/L (9 – 29 U/L), alkaline phosphatase 724 U/L (50 – 130 U/L), lipase 24 U/L (10 – 73 U/L), CA 19 – 9 28 units/mL (< 55 units/mL) and IgG4 137 mg/dL (8 – 140 mg/dl). Abdominal computed tomography revealed a pancreatic head mass that was encasing the portal vein and common hepatic artery but sparing the superior mesenteric artery, with evidence of peripancreatic and portal lymphadenopathy; there was no evidence of hepatic or splenic involvement ([Fig. 1]). Her chest radiograph was normal. Endoscopic ultrasound (EUS) revealed a 4.3-cm, echo-poor pancreatic head mass and a 1.4-cm (short axis) peripancreatic lymph node ([Fig. 2], [3]). EUS-guided fine-needle aspiration (EUS-FNA) of the pancreatic head and of the peripancreatic lymph node was performed.

Fig. 1 Biphasic abdominal computed tomographic images revealed a poorly defined mass at the junction of the body and the head of the pancreas that measured 4.5 cm in diameter, and an incidental hepatic cyst.

Fig. 2 Linear endoscopic ultrasound revealed a solid, echo-poor mass involving the pancreatic head and body.

Fig. 3 Linear endoscopic ultrasound image of a large (1.4 cm) peripancreatic lymph node.

The patient was diagnosed with primary pancreatic lymphoma. EUS-FNA of the pancreatic mass revealed very unusual atypical large lymphocytes, an appearance suspicious of but not diagnostic for large B-cell lymphoma ([Fig. 4]). A Trucut biopsy of a cytologically suspicious peripancreatic node confirmed the diagnosis ([Fig. 5]). Immunoperoxidase studies of the Trucut biopsy tissue demonstrated large atypical lymphoid cells that were positive for CD45 and CD20 ([Fig. 6]). The patient’s bone marrow examination was normal.

Fig. 4 A pancreatic fine-needle aspiration smear showing large, atypical, malignant lymphoid cells with scattered small lymphocytes (Papanicolaou stain, original magnification × 400).

Fig. 5 Histological examination of the Trucut biopsy of the lymph node showed sheets of non-cohesive, large neoplastic cells with necrosis (on the left of the image) (hematoxylin and eosin stain, original magnification × 400).

Fig. 6 Immunohistochemical staining showed the malignant cells to be positive for CD20 (original magnification × 400).

Primary pancreatic lymphoma accounts for less than 1 % of extranodal non-Hodgkin’s lymphomas, of which 58 % are of the large-cell type [1]. Diagnosis and subtyping can be achieved by EUS-FNA with adjuvant flow cytometry [2] [3] [4]. As EUS-FNA can fail to establish a definitive diagnosis of lymphoma, a Trucut biopsy can yield useful diagnostic and prognostic information, excluding carcinoma for example [5]. This case serves as a reminder that EUS Trucut biopsies can be useful as an adjunctive rescue technique when standard cytological techniques are inconclusive.

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References

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• 2 Saif M W. Primary pancreatic lymphomas.  JOP. 2006;  7 262-273
• 3 Volmar K E, Routbort M J, Jones C K, Xie H B. Primary pancreatic lymphoma evaluated by fine-needle aspiration: findings in 14 cases.  Am J Clin Pathol. 2004;  121 898-903
• 4 Nayer H, Weir E G, Sheth S, Ali S Z. Primary pancreatic lymphomas: a cytopathologic analysis of a rare malignancy.  Cancer. 2004;  102 315-321
• 5 Gines A, Wiersema M J, Clain J E. et al . Prospective study of a Trucut needle for performing EUS-guided biopsy with EUS-guided FNA rescue.  Gastrointest Endosc. 2005;  62 597-601