Abdominal imagingCase Type
Mariia Shantarevich, Ivan Gruzdev, Valeriya Tikhonova, Nataliya Karelskaya, Evgeny Kondratiev, Grigory KarmazanovskyPatient
48 years, male
A 48-year-old man was admitted with the complaints of pullingpain in the left hypochondrium over the past 3 months. At the physical examination of the abdomen no abnormality was found. Abdominal ultrasound examination revealed a splenic neoplasm.
Abdominal MDCT with administration of iodinated contrast medium were obtained. MDCT revealed a 10 cm hypovascular heterogeneous lesion with infiltrative growth in the pancreatic tail (fig. 1) and severe lymphadenopathy (fig.2). Infiltrative changes extended to splenic vessels and spleen parenchyma. MRI revealed a hypovascular heterogeneous lesion with infiltrative growth and severe lymphadenopathy. The solid tumor in splenic hilum and lesion in the right half of Th12 vertebral body and pedicle restrict diffusion according to DWI, ADC is very low (fig.3). No liver metastasis were detected.
Pancreatic lymphoma is more common in patients with a mean age of 55 years old and more prevalent in immunocompromised patients . Pancreatic lymphoma demonstrates distinct male predominance . The most frequently reported symptoms are abdominal pain (83%), followed by abdominal mass (58%), weight loss (50%), jaundice (37%), acute pancreatitis (12%), small-bowel obstruction (12%) and diarrhea (12%) .
It is classified as either primary or secondary: primary pancreatic lymphoma is a rare extranodal manifestation of any histopathologic subtype of B-cell non-Hodgkin's lymphoma, representing <2% of extranodal lymphomas and 0.5% of pancreatic tumors. Secondary lymphoma found in 30% of non-Hodgkin lymphoma patients with widespread disease, it is the dominant form and is the result of direct extension from peripancreatic lymphadenopathy [1, 4]. Extranodal lymphoma is classified as primary if the involvement is confined to a single organ and the adjacent lymph nodes, whereas it is classified as secondary if there is involvement of nodes other than those in close proximity to the primary organ or the involvement of more than one extranodal site . Primary pancreatic lymphoma can present as an isolated mass mimicking pancreatic carcinoma .
CT imaging may show minimal enhancement, peripancreatic lymph node enlargement. It typically has uniform low attenuation, diffuse enlargement (diffuse form) may simulate acute pancreatitis, encasement of the peripancreatic vessels may occur; vascular invasion is less common in lymphoma than in adenocarcinoma [1, 4]. MR imaging may show low signal intensity on T1-weighted images and intermediate signal intensity on T2-weighted images (slightly higher signal intensity than the pancreas but lower signal intensity than fluid), and shows faint contrast enhancement for focal form. The diffuse form usually exhibits low signal intensity on T1- and T2-weighted MR images and homogenous contrast enhancement, although small foci of reduced or absent enhancement can be observed in some cases.
In accordance with CT and MRI findings (the presence of huge hypovascular heterogeneous lesion in the pancreatic tail with infiltrative growth, low ADC values, severe lymphadenopathy, the lesion in the right pedicle of Th12 and absence of liver metastasis), pancreatic lymphoma was suspected.
To establish the diagnosis percutaneous core biopsy should be performed . Pancreatic lymphoma carries a more favorable prognosis than adenocarcinoma, because first-line chemotherapy treatment is generally effective for producing long-term disease regression or remission. In most of the cases surgery is not required . Using complex treatment approaches, cure rates of up to 30% are reported for patients with primary pancreatic lymphoma.
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