Madhuri Badrinath, MBBS1, Rachana Mandru, MBBS1, Sheikh A. Saleem, MBChB2, David Heisig, MD1
1SUNY Upstate Medical Center, Syracuse, NY; 2Upstate Medical University, Syracuse, NY
Introduction: Primary pancreatic lymphomas (PPL) are very rare and mimic pancreatic head cancer. We present a case of a man who presented with a pancreatic mass and chylous ascites, and was found to have PPL.
Case Description/Methods: A 69 year old man presented with 2 months of anorexia, abdominal pain and distension. He denied fever,chills or weight loss. Abdomen was distended,soft,non-tender with shifting dullness and fluid thrill. Laboratory tests were noncontributory except for mildly elevated LDH 254 U/L. Abdominal computed tomography (CT) showed a 20x10x17cm soft tissue mass impinging the distal duodenum, replacing the proximal pancreatic parenchyma,encasing the celiac and superior mesenteric arteries; ascites,lymphadenopathy and multiple omental nodules were seen. No cirrhosis or hepatomegaly noted. 2.5L of grossly chylous fluid was drained with lymphocytic predominance,high triglycerides 980 mg/dL and negative cytology.Endoscopic ultrasound(EUS) showed an irregular hypoechoic mass.Fine needle aspiration(FNA) showed lymphoid cells with irregular nuclear membrane contours strongly positive for CD20,consistent with B cell lymphoma.PET-CT scan confirmed a metabolically active pancreatic mass with inguinal, aortocaval, juxtadiaphrgamatic and inframammary lymphadenopathy. Diagnostic laparoscopic biopsy confirmed diffuse B-cell lymphoma of germinal center origin positive for CD10, BCL6, BCL2 and CD45. Patient received 6 cycles of R-CHOP (rituximab,cyclophosphamide,doxorubicin,vincristine,prednisolone) which he tolerated well. Follow-up PET CT scan showed reduction in size of pancreatic mass and lymph nodes without areas of new/worsening lymphoma.
Discussion: PPLs comprise 0.5% of all pancreatic masses.Diagnostic criteria include dominant pancreatic mass,without superficial or mediastinal lymphadenopathy,absent hepatosplenic involvement and a normal blood leukocyte count. Clinical presentation is non-specific without classic symptoms of nodal lymphoma.Abdominal pain is the most common symptom (83%),followed by abdominal mass and weight loss.High tumor burden,β2-microglobulin levels >2 mg/l and high LDH levels are poor prognostic markers.Definitive diagnosis requires histologic confirmation,EUS-guided sampling is highly accurate. Treatment options include surgery, chemotherapy, radiation, alone or in combination. Cure rates upto 30% have been reported. Long term remission can be obtained with CHOP chemotherapy alone in majority of patients. Addition of rituximab results in overall improvement in patient survival.
Citation: Madhuri Badrinath, MBBS; Rachana Mandru, MBBS; Sheikh A. Saleem, MBChB; David Heisig, MD. P1877 - RARE PRESENTATION OF LARGE PANCREATIC MASS WITH CHYLOUS ASCITES. Program No. P1877. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.