New York City Health and Hospitals/Coney Island Hospital Brooklyn, NY, United States
Nikisha Pandya, MD1, Mohammad Choudhry, MD2, Gregory Wagner, DO2, Pawel Szurnicki, MD2, Christopher Chum, DO2, John Trillo, MD2, Vera Platsky, 2 1New York City Health and Hospitals/Coney Island Hospital, Brooklyn, NY; 2Coney Island Hospital, Brooklyn, NY
Introduction: Primary pancreatic lymphoma (PPL) is a rare manifestation of Non-Hodgkin Lymphoma (NHL). PPL presenting as obstructive jaundice and mildly elevated CA 19-9 level is extremely rare, however, to our knowledge no cases in English literature describe PPL with CA 19-9 levels up to 10,000 u/mL. Such pancreatic head masses can be easily confused with pancreatic adenocarcinoma (PA). Both vary significantly in terms of their therapeutic approach and prognostic value making accurate diagnosis crucial.
Case Description/Methods: A 64-year-old male with Diabetes Mellitus presented with abdominal discomfort, jaundice, pale stools for 2 weeks and 40-pound weight loss over 3 months. He had scleral icterus, distended abdomen and jaundiced skin. Labs revealed ALT 192 U/L, AST 157 U/L, total bilirubin 31 mg/dL, direct bilirubin >10 mg/dL and CA19-9 of 10394 u/mL. Dilated intra and extrahepatic bile ducts and common bile duct (CBD) dilation of 2 cm were seen on US of the abdomen. CT scan showed a 5 x 4.4 cm pancreatic head mass with severe peripancreatic, mesenteric, retroperitoneal and axillary lymphadenopathy.
Patient was a poor surgical candidate therefore, ERCP-guided biliary plastic stent was placed for decompression. Biliary brush biopsy was suspicious for malignancy and CT-guided biopsy of the pancreatic mass was done, which showed cells positive for CD45 and CD20 as well as BCL6 breakpoint translocation positivity confirming Diffuse Large B Cell Lymphoma (DLBCL). Plastic stent was exchanged for fully covered metal stent with longer patency and patient was started on R-CHOP (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine, Prednisone) therapy.
Discussion: Though secondary involvement of the pancreas in NHL is documented, primary pancreatic DLBCL is a rare clinical presentation accounting for only 1% of NHL and 0.5% of all pancreatic cancers. No cases of PPL with CA 19-9 levels as high as 10394 u/mL have been reported to date. This can create diagnostic dilemma for clinicians as high CA 19-9 levels and large pancreatic head mass are mostly associated with PA. Histological analysis is important to avoid radical surgeries. This case highlights the significance of keeping DLBCL as a differential for pancreatic masses even in patients with elevated CA 19-9 levels as former has good prognosis with chemotherapy. It also cautions clinicians on blindly placing uncovered biliary stents without definitive diagnosis, as lymphoma can be treated with chemoradiation.
Figure: Figure 1: Pancreatic head mass core biopsy positive for CD20 Figure 2: Pancreatic head mass core biopsy positive for CD45 Figure 3: Pancreatic head mass core biopsy negative for CD10
Disclosures: Nikisha Pandya indicated no relevant financial relationships. Mohammad Choudhry indicated no relevant financial relationships. Gregory Wagner indicated no relevant financial relationships. Pawel Szurnicki indicated no relevant financial relationships. Christopher Chum indicated no relevant financial relationships. John Trillo indicated no relevant financial relationships. Vera Platsky indicated no relevant financial relationships.
Nikisha Pandya, MD1, Mohammad Choudhry, MD2, Gregory Wagner, DO2, Pawel Szurnicki, MD2, Christopher Chum, DO2, John Trillo, MD2, Vera Platsky, 2. P2152 - Diffuse Large B-cell Lymphoma of the Pancreas Presenting as Obstructive Jaundice: A Rare Presentation, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.