Two cases of cystic lymphangioma of the pancreas: a rare finding in endoscopic ultrasonography

Cystic lymphangioma of the pancreas is a rare, benign neoplasm classically diagnosed at surgery. We report here on two patients diagnosed using endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA).

A 70-year-old man and a 63-year-old woman both underwent computed tomography (CT) scans for evaluation of nonspecific abdominal complaints. The physical examination and laboratory evaluation were unremarkable in both. The CT scans revealed a 4.6-cm cystic lesion in the head of the pancreas in the first patient and a 3.0-cm mass near the uncinate process in the second (Figure [1]).

EUS was carried out in both patients. The first patient had a septated cystic lesion 4.6 × 2.7 cm in size in the pancreatic head (Figure [2 a]). The second patient had a septated cystic mass measuring 3.7 × 2.6 cm near the uncinate process (Figure [2 b]). The rest of the examination was normal in both patients (Figure [3]). At FNA, a thin, milky fluid was aspirated in both cases (Figure [4]). Laboratory analysis revealed a triglyceride level of > 5000 mg/dl in both cases. No disease progression or complications such as cyst infections were evident after a follow-up period of 5 months. In both cases, the chylous aspirate with a markedly elevated triglyceride level was diagnostic.

Figure 1 Computed tomograms from patient 1 (a) and patient 2 (b), showing the pancreatic cysts.

Figure 2 Radial endoscopic ultrasound images from patient 1 (a) and patient 2 (b), showing measurements of the septated cyst (cross-hairs).

Figure 3 Radial endoscopic ultrasound image from patient 1, showing the cyst in relation to the common bile duct (CBD), pancreatic duct (PD) and portal vein (PV).

Figure 4 A syringe filled with the chylous cyst aspirate.

Lymphangiomas are rare benign neoplasms that can arise in most organs. The largest reported series, including 10 surgical cases, suggested that they represent 0.2 % of pancreatic neoplasms. Many patients have been asymptomatic, with the lesion being discovered incidentally on imaging studies [1].

Most previously reported cases have been diagnosed at surgery, since imaging examinations have not been sufficient to exclude malignancy. With EUS-FNA, many cystic neoplasms can now be reliably diagnosed without surgery [2] [3] [4] [5]. Since lymphangiomas are generally believed to be benign, nonsurgical management may be reasonable if a definitive diagnosis is made [1]. In the absence of significant symptoms attributable to the cystic lymphangioma, surgical resection may be unnecessary.

Endoscopy_UCTN_Code_CCL_1AF_2AZ_3AB

References

• 1 Paal E, Thompson L D, Heffess C S. A clinicopathologic and immunohistochemical study of ten pancreatic lymphangiomas and a review of the literature.  Cancer. 1998;  82 2150-2158
• 2 Brugge W R. The role of EUS in the diagnosis of cystic lesions of the pancreas.  Gastrointest Endosc. 2000;  52 (6 Suppl) S18-S22
• 3 Hernandez L V, Mishra G, Forsmark C. et al . Role of endoscopic ultrasound (EUS) and EUS-guided fine needle aspiration in the diagnosis and treatment of cystic lesions of the pancreas.  Pancreas. 2002;  25 222-228
• 4 Jacobson B C, Baron T H, Adler D G. et al . ASGE guideline: the role of endoscopy in the diagnosis and the management of cystic lesions and inflammatory fluid collections of the pancreas.  Gastrointest Endosc. 2005;  61 363-370
• 5 Song M H, Lee S K, Kim M H. et al . EUS in the evaluation of pancreatic cystic lesions.  Gastrointest Endosc. 2003;  57 891-896