Primary pancreatic lymphoma—a rare cause of cholestasis leading to surgical treatment

Primary Pancreatic Lymphoma: Recommendations for Diagnosis and Management

BACKGROUND

Primary pancreatic lymphoma (PPL) is a rare disease representing 0.1% of all malignant lymphomas, which lacks well-defined diagnostic and therapeutic protocols. We conducted a systematic review to analyze demographic, diagnostic and therapeutic features of PPL.

METHODS

This review identified small series and single case reports. Sources were MEDLINE, PubMed, and the Cochrane library from January 2001 to December 2020. Data were screened, extracted and the risk of bias analyzed by three independent reviewers.

RESULTS

A total of 107 eligible papers (17 small series, 90 single case reports) describing 266 patients were identified. Patients had a median age of 53.1 (range 3-86) years and were males in 64.6% of cases. Abdominal pain and jaundice were the most common presenting symptoms, affecting 75.3% and 41.8% of patients, respectively. PPL had a median size of 60.6 mm (range 16-200) and it was localized in the pancreatic head in 63.7% of cases. At diagnosis most patients underwent ultrasonography followed by computed tomography. PPL typically showed low echogenicity, and lower contrast enhancement than solid tumors. Histopathological specimens were obtained by percutaneous or endoscopic biopsies in 47.7% of patients; abdominal surgery was performed in 33.5% of cases. Overall, diffuse large B-cell lymphoma was the most frequent histological diagnosis (53.6%). However, patients aged <18 years were affected by Burkitt lymphoma in 52.4% of cases. Most patients (53.6%) received immunochemotherapy (IC) or IC plus radiotherapy (14%). Demolitive surgery appeared to be associated with impaired survival. Central nervous system (CNS) relapse or progression was observed in 20% of patients.

CONCLUSION

PPL is a rare entity, with some peculiar features at modern imaging. For diagnostic purposes percutaneous or endoscopic biopsies might be preferable, as opposed to surgery. No definite data is available about the optimal treatment, which should be tailored on the histological type and associated with CNS prophylaxis.

The spectrum of hematologic malignancies involving the pancreas: potential clinical mimics of pancreatic adenocarcinoma

Hematologic malignancies often involve the pancreas, causing potential diagnostic pitfalls and, rarely, potentially avoidable surgical resection. We review the spectrum of hematologic malignancies involving the pancreas and describe features useful in preoperative distinction from adenocarcinoma. Archived clinical, pathologic, and radiologic data (1965 to present) for hematologic malignancies involving the pancreas were reviewed and compared with the data for 157 surgically resected pancreatic adenocarcinomas. Of 42 cases, 27 (64%) were clinically "suspicious" for hematologic malignancies. Of the remaining 15 cases, 4 patients underwent resection for presumed pancreatic adenocarcinoma. Isolated pancreatic masses proved most difficult to identify clinically. Significant factors in distinguishing hematologic malignancies from adenocarcinoma included history of hematologic malignancy, young age, large tumor size, low CA19-9 level, B symptoms, and lack of jaundice or diabetes mellitus. Various hematologic malignancies involve the pancreas, most commonly diffuse large B-cell lymphoma. Pancreatic masses are usually correctly identified clinically. Preoperative and operative sampling is strongly recommended when hematologic malignancies cannot be excluded.