Primary pancreatic peripheral T-cell lymphoma: A case report

BACKGROUND

Primary pancreatic lymphoma (PPL) is an exceedingly rare tumor with limited mention in scientific literature. The clinical manifestations of PPL are often nonspecific, making it challenging to distinguish this disease from other pancreatic-related diseases. Chemotherapy remains the primary treatment for these individuals.

CASE SUMMARY

In this case study, we present the clinical details of a 62-year-old woman who initially presented with vomiting, abdominal pain, and dorsal pain. On further evaluation through positron emission tomography-computed tomography, the patient was considered to have a pancreatic head mass. However, subsequent endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) revealed that the patient had pancreatic peripheral T-cell lymphoma, not otherwise specified (PTCL-NOS). There was a substantial decrease in the size of the pancreatic mass after the patient underwent a cycle of chemotherapy comprised of brentuximab vedotin, decitabine, and oxaliplatin (brentuximab vedotin and Gemox). The patient had significant improvement in radiological findings at the end of the first cycle.

CONCLUSION

Primary pancreatic PTCL-NOS is a malignant and heterogeneous lymphoma, in which the clinical manifestations are often nonspecific. It is difficult to diagnose, and the prognosis is poor. Imaging can only be used for auxiliary diagnosis of other diseases. With the help of immunostaining, EUS-FNA could be used to aid in the diagnosis of PPL. After a clear diagnosis, chemotherapy is still the first-line treatment for such patients, and surgical resection is not recommended. A large number of recent studies have shown that the CD30 antibody drug has potential as a therapy for several types of lymphoma. However, identifying new CD30-targeted therapies for different types of lymphoma is urgently needed. In the future, further research on antitumor therapy should be carried out to improve the survival prognosis of such patients.

A case report of primary pancreatic lymphoma revealed by an acute pancreatitis

INTRODUCTION

Primary pancreatic lymphoma (PPL) is a rare malignancy. Diffuse large B-cell lymphoma is the predominant subtype, often affecting the pancreatic head in elderly males. Due to its rarity and nonspecific symptoms, PPL is frequently misdiagnosed, leading to unnecessary surgeries. This case report discusses the diagnosis and management of PPL in a 47-year-old female, emphasizing the challenges in its identification.

CASE PRESENTATION

A 47-year-old female with no medical history presented with severe epigastric pain and jaundice. Diagnosed initially as acute pancreatitis. The abdominal CT scan showed a tumor in the head of the pancreas suggesting pancreatic adenocarcinoma invading the vessels, making it minimally borderline. However, due to the presence of large intra- and retroperitoneal lymph nodes casting doubt on the diagnosis, we further investigated with an MRI and Endoscopic Ultrasound with fine-needle aspiration, which ruled out adenocarcinoma and confirmed a pancreatic diffuse large B-cell lymphoma. The patient underwent chemotherapy with CHOP, showing significant improvement after six cycles.

DISCUSSION

Primitive pancreatic lymphoma (PPL) is a rare form of non-Hodgkin lymphoma, often mimicking other pancreatic diseases. B-cell lymphomas, especially diffuse large B-cell lymphoma (DLBCL), are common in PPL. Diagnostic criteria include the bulk of disease in the pancreas, no splenic or hepatic involvement, and normal white blood cell count. Imaging modalities aid in diagnosis, but histopathological evaluation is essential. Treatment options include chemotherapy, radiation therapy, and surgery, with rituximab-based regimens being common for DLBCL.

CONCLUSIONS

B-cell pancreatic lymphoma poses diagnostic challenges due to nonspecific symptoms. A definitive diagnosis requires histopathological evidence, often obtained through minimally invasive procedures like endosonography-guided biopsy. Treatment involves chemotherapy, immunotherapy, and radiation, with early detection correlating with improved outcomes. Surgery's role is limited due to the diffuse nature of the disease. This case underscores the importance of considering PPL in the differential diagnosis of pancreatic masses, especially in atypical clinical presentations.

Primary Pancreatic Lymphoma Evaluated by Fine-Needle Aspiration

OBJECTIVES

Primary pancreatic lymphoma (PPL) is rare, mimicking pancreatic ductal adenocarcinoma (PDAC) clinically and radiologically. The aim of this study is to evaluate the clinical, radiologic, and pathological characteristics of PPL diagnosed by fine-needle aspiration (FNA) in our institution.

METHODS

Patient clinical, radiologic, and pathological information was collected from the electronic health record system.

RESULTS

In total, 11 of 4,353 pancreatic FNAs met the criteria. The most common clinical symptom was jaundice, followed by abdominal pain, weight loss, and diarrhea. Abnormal laboratory findings included elevated alkaline phosphatase, total bilirubin, lactate dehydrogenase, and cancer antigen 19-9. Abnormal radiologic findings included pancreatic mass, biliary dilatation, vessel encasement, and common bile duct encasement and thickening. Five patients underwent more than 1 tissue sampling procedure before the final diagnosis of lymphoma. Final pathologic diagnosis included 7 large B-cell lymphomas and 4 follicular lymphomas. Flow cytometric analysis was performed on 9 specimens, and all demonstrated an aberrant monoclonal B-cell population.

CONCLUSIONS

PPL mimics PDAC clinically and radiologically and could be a challenge for pathologic diagnosis if lymphoma is not included in the differential diagnosis during immediate evaluation. If lymphoma is suspected during immediate evaluation, PPL could be reliably diagnosed by FNA with the aid of ancillary studies.

Primary pancreatic mucosa-associated lymphoid tissue lymphoma transformed into diffuse large B-cell lymphoma: a case report and literature review

Primary pancreatic lymphoma (PPL) is an extremely rare malignant tumor that accounts for less than 2% of extranodal malignant lymphomas and 0.5% of pancreatic tumors. The most common symptoms of PPL are abdominal pain (83%), abdominal mass (58%), and weight loss (50%). The final diagnosis of PPL is based on cell histology, and the most common histological subtype is diffuse large B-cell lymphoma (DLBCL). The number of reported cases of primary pancreatic mucosa-associated lymphoid tissue (MALT) lymphoma is limited. The conversion rate of MALT lymphoma varies between 3% and 12%. However, the transformation of primary pancreatic MALT lymphoma to DLBCL has not been reported. We present a case of a 58-year-old man whose main symptoms were nausea and vomiting. Magnetic resonance imaging of the abdomen showed space-occupying lesions in the neck and body of the pancreas. Histopathological examination after surgical resection was diagnosed as primary pancreatic MALT lymphoma. Local radiotherapy was recommended and rejected by the patient's family. The disease progressed in a short time. Left supraclavicular lymph node resection biopsy and pathological examination showed DLBCL. After the initiation of chemotherapy, glaucoma appeared in the right eye during treatment, and chemotherapy was suspended. The disease progressed rapidly and the patient eventually died.

Primary Pancreatic Mantle Cell Lymphoma Diagnosed via Endoscopic Ultrasound-Guided Fine-Needle Aspiration

Primary pancreatic lymphomas (PPLs) are rare, and the histological classification of these tumors is difficult. To accurately diagnose and determine the appropriate treatment for PPLs, sufficient sample amounts are necessary. Here, we report a 73-year-old man with a primary pancreatic mantle cell lymphoma. Histological samples were obtained via endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). The tumor cells predominantly composed of atypical small to medium round cells, with diffuse immunoreactivity of CD20 and cyclin D1. In addition, immunoglobulin gene H chain rearrangement was detected. The patient underwent chemotherapy, resulting in complete remission. Eight years after the initiation of chemotherapy, the patient was still alive. EUS-FNA could be a useful and safe diagnostic modality for PPLs by providing enough samples for testing.

Features of primary pancreatic lymphoma: A bi-institutional review with an emphasis on typical and atypical imaging features

BACKGROUND

Primary pancreatic lymphoma (PPL) is a rare neoplasm. Being able to distinguish it from other pancreatic malignancies such as pancreatic ductal adenocarcinoma (PDAC) is important for appropriate management. Unlike PDAC, PPL is highly sensitive to chemotherapy and usually does not require surgery. Therefore, being able to identify PPL preoperatively will not only direct physicians towards the correct avenue of treatment, it will also avoid unnecessary surgical intervention.

AIM

To evaluate the typical and atypical multi-phasic computed tomography (CT) imaging features of PPL.

METHODS

A retrospective review was conducted of the clinical, radiological, and pathological records of all subjects with pathologically proven PPL who presented to our institutions between January 2000 and December 2020. Institutional review board approval was obtained for this investigation. The collected data were analyzed for subject demographics, clinical presentation, laboratory values, CT imaging features, and the treatment received. Presence of all CT imaging findings including size, site, morphology and imaging characteristics of PPL such as the presence or absence of nodal, vascular and ductal involvement in these subjects were recorded. Only those subjects who had a pre-treatment multiphasic CT of the abdomen were included in the study.

RESULTS

Twenty-nine cases of PPL were diagnosed between January 2000 and December 2020 (mean age 66 years; 13 males/16 females). All twenty-nine subjects were symptomatic but only 4 of the 29 subjects (14%) had B symptoms. Obstructive jaundice occurred in 24% of subjects. Elevated lactate dehydrogenase was seen in 81% of cases, whereas elevated cancer antigen 19-9 levels were present in only 10% of cases for which levels were recorded. The vast majority (90%) of tumors involved the pancreatic head and uncinate process. Mean tumor size was 7.8 cm (range, 4.0-13.8 cm). PPL presented homogenous hypoenhancement on CT in 72% of cases. Small volume peripancreatic lymphadenopathy was seen in 28% of subjects. Tumors demonstrated encasement of superior mesenteric vessels in 69% of cases but vascular stenosis or occlusion only manifested in 5 out of the twenty-nine individuals (17%). Mild pancreatic duct dilatation was also infrequent and seen in only 17% of cases, whereas common bile duct (CBD) dilation was seen in 41% of subjects. Necrosis occurred in 10% of cases. Size did not impact the prevalence of pancreatic and CBD dilation, necrosis, or mesenteric root infiltration (P = 0.525, P = 0.294, P = 0.543, and P = 0.097, respectively). Pancreatic atrophy was not present in any of the subjects.

CONCLUSION

PPL is an uncommon diagnosis best made preoperatively to avoid unnecessary surgery and ensure adequate treatment. In addition to the typical CT findings of PPL, such as homogeneous hypoenhancement, absence of vascular stenosis and occlusion despite encasement, and peripancreatic lymphadenopathy, this study highlighted many less typical findings, including small volume necrosis and pancreatic and bile duct dilation.

Migration of a pancreatic duct stent into the peritoneal cavity during chemotherapy for pancreatic malignant lymphoma

A 68-year-old man with epigastric pain was admitted for acute pancreatitis and obstructive jaundice caused by Primary pancreatic malignant lymphoma. Computed tomography showed diffuse enlargement of the whole pancreas and dilation of the main pancreatic duct and bile duct. Endoscopic retrograde cholangiopancreatography was performed to decompress these dilated ducts. After two courses of chemotherapy, follow-up computed tomography incidentally revealed migration of the pancreatic duct stent, which had perforated the contralateral duodenal wall to enter the peritoneal cavity. In the present case, pancreatic duct stent deviation was attributed to tumor shrinkage resulting from chemotherapy. In addition, stent migration into the peritoneal cavity occurred due to repeated mechanical manipulation of the pancreatic duct stent, presumably leading to partial ulceration of the duodenal wall and delayed wound healing during chemotherapy. This case may provide valuable information on the migration of pancreatic duct stents as a rare, stent-related late complication during chemotherapy.

Pancreatic Non-Hodgkin Lymphoma, a rare cause for obstructive jaundice. A Case reports

INTRODUCTION

Primary pancreatic lymphoma (PPL) is an uncommon condition. Clinical features of PPL are nonspecific & likely to be misrecognized as pancreatic malignancy.

CASE PRESENTATION

71 years old male patient presented with upper abdominal pain with obstructive jaundice.

CLINICAL FINDINGS AND INVESTIGATIONS

Examination reveals RHC tenderness and deep icteric. CT shows a large pancreatic head and uncinate process mass. Final diagnosis made with USS guided core biopsy which confirmed B cell, Non-Hodgkin Lymphoma (NHL).

INTERVENTION AND OUTCOME

Complete remission of PPL occurred following six cycles of chemotherapy with R-CHOP regimen.

RELEVANCE AND IMPACT

PPL is rare condition, accounts 1% of extra nodal lymphomas and 0.5% of malignant pancreatic neoplasm. Ultrasonography, Endoscopic ultrasonography, CT and MRI are the imaging modalities use to diagnose the pancreatic neoplasm. Biopsy of all pancreatic lesion is crucial which can diagnose curable condition such as PPL. Combined therapy with chemotherapy and radiotherapy without surgery is advisable for PPL.

Double-hit pancreatic B-lymphoblastic lymphoma with a variant translocation t(2;18)(p11;q21)

Double-hit lymphoma is typically categorized as "high-grade B-cell lymphoma, with MYC and BCL2 and/or BCL6 rearrangements", but in infrequent cases in which terminal deoxynucleotidyl transferase (TdT) expression is positive, it is categorized as B-lymphoblastic lymphoma (B-LBL). BCL2 rearrangements are usually caused by t(14;18)(q32;q21); variant translocations are very rare. Here, we describe an unusual case of double-hit pancreatic B-LBL with a variant translocation t(2;18)(p11;q21). A 69-year-old man was admitted because of an abdominal mass. Computed tomography scans demonstrated a diffusely enlarged pancreas and massive ascites. Cell block preparations of ascites cells revealed marked proliferation of blastic lymphoid cells positive for CD19, CD10, CD79a, PAX5, and TdT, indicating a diagnosis of B-LBL. G-banding and spectral karyotyping showed 45,XY,+X,t(2;18)(p11;q21),-4,der(5)t(1;5)(q12;p15),der(6)t(6;21)(q21;q?),t(8;14)(q24;q32),-15. Fluorescence in situ hybridization detected split BCL2 and IGH/MYC fusion signals. Almost all ascites cells were diffusely and strongly positive for MYC and BCL2. The patient died of progressive disease 20 days after admission. To our knowledge, this is the first reported case of MYC and BCL2 double-hit B-LBL with t(2;18)(p11;q21). High coexpression of MYC by t(8;14) and BCL2 by t(2;18) may be implicated in the development of B-LBL. Furthermore, double-hit B-LBL may be associated with a less favorable outcome compared with typical B-LBL.

Knife wielding radiologist: A case report of primary pancreatic lymphoma

Majority of malignant pancreatic neoplasms are epithelial in origin and mostly arise from exocrine gland. Ductal adenocarcinoma compromises the major histological type of such tumors. Primary non-epithelial tumors of exocrine pancreatic gland are extremely rare and incorporate lymphoma and sarcoma. Primary pancreatic lymphoma compromises less than 0.5% of pancreatic malignancies. Primary pancreatic lymphoma can be difficult to differentiate from pancreatic adenocarcinoma and other neoplasms on imaging, and a correct diagnosis is crucial for appropriate patient management.

Rare Tumors and Lesions of the Pancreas

There are a few entities that account for most solid and cystic masses of the pancreas. The pancreas harbors a wide array of diseases, including adenocarcinoma, and its variants, such as anaplastic and adenosquamous carcinoma. Other neoplasms include acinar cell carcinoma, solid pseudopapillary tumor, and sarcomas. Benign lesions include hamartomas, hemangiomas, lymphangioma, and plasmacytoma. Isolated metastases include renal cell carcinoma, melanoma, and other carcinomas. Benign inflammatory conditions, such as autoimmune pancreatitis and groove pancreatitis can also mimic solid neoplasms of the pancreas.

Clinicopathological characteristics of primary pancreatic lymphoma: report of two cases

Primary pancreatic lymphoma (PPL), originating from the pancreatic parenchyma, is a rare type of lymphoma. The symptoms and radiographic findings of PPL are quite similar to pancreatic adenocarcinoma (PAC), and thus it is often misdiagnosed. In this study, we described the clinical features, radiographic findings, histological and immunohistochemical analysis, molecular detection and clinical treatment of two cases of PPL, aiming to distinguish PPL from PAC. The two cases were both low-grade PPL. One was follicular lymphoma and the other was small lymphocytic lymphoma. Imaging examination of the two cases both showed solid mass, thus highly suspecting of PAC. However, after surgery, PPL was diagnosed by the pathologists through histopathological observation, immunohistochemistry (IHC) assay and clonality analysis. Therefore, accurately diagnosing and classifying of PPL is essential for patient management, since PPL is a treatable malignant tumor.

Pancreatic T/histiocyte-rich large B-cell lymphoma: A case report and review of literature

Primary pancreatic lymphoma (PPL) is an extremely rare form of extranodal malignant lymphoma. The most common histological subtype of PPL is diffuse large B cell lymphoma (DLBCL). In rare cases, PPL can also present as follicular lymphoma, small lymphocytic lymphoma, and T cell lymphoma either of non-Hodgkin’s lymphoma or of Hodgkin’s lymphoma. T-cell/histiocyte-rich large B-cell lymphoma (T/HRBCL) is an uncommon morphologic variant of DLBCL with aggressive clinical course, it is predominantly a nodal disease, but extranodal sites such as bone marrow, liver, and spleen can be involved. Pancreatic involvement of T/HRBCL was not presented before. Herein, we report a 48-year-old male who was hospitalized with complaints of jaundice, dark brown urine, pale stools, and nausea. The radiological evaluation revealed a pancreatic head mass and, following operative biopsy, the tumor was diagnosed as T/HRBCL. The patient achieved remission after six cycles of CHOP chemotherapy. Therefore, T/HRBCL can be treated similarly to the stage-matched DLBCL and both of them get equivalent outcomes after chemotherapy.

A Man with Pancreatic Head Mass Lesion on Endoscopic Ultrasound and Granuloma on Cytopathology

Primary pancreatic lymphoma is an unlikely malignancy accounting for less than 0.5% of pancreatic tumors. Clinical presentation is often nonspecific and may be clinically misdiagnosed as pancreatic adenocarcinoma. Here we present an Iranian case of primary pancreatic lymphoma in a 47-year-old male suffering from jaundice and 20% weight loss. Endoscopic ultrasound revealed a mixed echoic mass lesion at the head of pancreas. The patient underwent endoscopic ultrasound-guided fine needle aspiration of solid pancreatic mass and histopathologic diagnosis revealed granuloma. Computed tomography-guided core needle biopsy was performed and eventually histological examination showed granuloma that was coherent with the diagnosis of primary pancreatic lymphoma. Primary pancreatic lymphoma is a rare entity presenting with nonspecific symptoms, laboratory and radiological findings. Computed tomography results in combination with clinical and radiological studies generally provide guidance for appropriate investigation.

Frequency of occurrence and characteristics of primary pancreatic lymphoma during endoscopic ultrasound guided fine needle aspiration: a retrospective study

BACKGROUND

Primary pancreatic lymphoma is a rare tumour of the pancreas. Data on the role of endoscopic ultrasound guided fine needle aspiration for its diagnosis are scant.

AIM

To identify the frequency of occurrence, sonographic characteristics and cytological findings that are predictive of primary pancreatic lymphoma.

METHODS

Pancreatic lymphoma cases were identified by retrospective review of solid pancreatic masses over 10-year period.

RESULTS

12/2397 (0.5%) lesions were identified. Patients were predominantly white (92%) and male (58%). Mean largest dimension was 47.5mm and 83.3% were located in the head. The mass appeared heterogeneous in 75% and peripancreatic lymphadenopathy was noted in 58%. None of the patients showed features of chronic pancreatitis or pancreatic ductal dilation. Rapid onsite analysis revealed atypical lymphocytes in 92%. Flow cytometry confirmed diagnosis in 75% of cases.

CONCLUSIONS

Primary pancreatic lymphoma is encountered in 0.5% of patients undergoing endoscopic ultrasound guided fine needle aspiration. A large heterogeneous mass, in the absence of chronic pancreatitis or pancreatic duct dilation that reveals atypical lymphocytes on fine needle aspiration is suggestive.

Clues for diagnosing primary pancreatic lymphoma

Primary pancreatic lymphoma (PPL), a localized lymphoma in the pancreas, accounts for <0.5% of all pancreatic masses and presents with symptoms favoring the more common adenocarcinoma. It is important to differentiate PPL from adenocarcinoma since treatment and prognosis differ considerably. PPL is potentially curable with chemotherapy, especially if it is diagnosed at early stages. A definitive diagnosis can only be based on histopathological findings. Endoscopic ultrasound-guided fine needle aspiration (EUS-guided FNA) is a reliable, minimally invasive and cost-effective method for this purpose. Even though there are neither typical clinical features nor specific biomarker for the diagnosis of PPL, certain common presentations have been observed which may indicate PPL. We herein present the case of a 43-year-old man who was successfully diagnosed with PPL by EUS-guided FNA. His clinical, laboratory and radiographic findings supported PPL over adenocarcinoma as well. This case demonstrates that high clinical suspicion based on clinical, laboratory and imaging features is critical in PPL diagnosis and management.

Curative Chemoradiotherapy of Primary Pancreatic Lymphoma with Vertebral Metastasis: Palliation of Persistent Biliary Stricture by Roux-en-Y Hepaticojejunostomy

Primary pancreatic lymphoma (PPL) is a rare tumor that usually presents with the clinical picture of advanced adenocarcinoma but has a much better prognosis. A 38-year-old man was referred after percutaneous transhepatic external biliary drainage for obstructive jaundice. Abdominal magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography had revealed a 5-cm pancreatic head mass that caused biliary tract dilation. Computed tomography angiography showed that the mass encased the celiac trunk as well as the common hepatic and splenic arteries. MRI also revealed a metastatic lesion at the third lumbar vertebra. Serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels were within normal range. The initial diagnosis was inoperable pancreatic adenocarcinoma; however, Tru-Cut pancreatic biopsy showed a large B cell lymphoma. After 6 sessions of chemotherapy and 21 sessions of radiotherapy, both the pancreatic mass and the vertebral metastasis had disappeared. However, he had persistent distal common bile duct stricture that could not be negotiated by either the endoscopic or percutaneous route. A Roux-en-Y hepaticojejunostomy was performed. The patient stayed alive without recurrence for 52 months after the initial diagnosis and 45 months after completion of oncologic treatment. In conclusion, a large pancreatic mass with grossly involved peripancreatic lymph nodes, without ascites, liver or splenic metastasis, should alert the clinician to the possibility of PPL. Cure is possible by chemoradiotherapy even in the presence of vertebral metastasis. Persistent stricture in the distal common bile duct may require a biliodigestive anastomosis.

Primary pancreatic low-grade mucosa-associated lymphoid tissue lymphoma presenting with multiple masses

The case concerns a 55-year-old Japanese man with multiple pancreatic tumors that were incidentally detected by ultrasonography (US) in a routine medical examination. He consulted a doctor since either neuroendocrine tumors or metastases of small-cell lung carcinoma were suspected, because he had an abnormal shadow in the lung. Then he was transferred to our hospital. Imaging studies showed multiple pancreatic tumors of 3.0-cm diameter in the head, 1.0 cm in the body and 1.5 cm in the tail, respectively. Specimen by endoscopic ultrasonography fine-needle aspiration cytology (EUS-FNAC) revealed numerous B-cell lymphocytes, but a definite diagnosis of malignant lymphoma could not be obtained. Therefore, a segmental pancreatic body resection was performed to clarify the features of the tumor for appropriate therapy. Consequently, the final diagnosis was obtained as a low-grade B-cell lymphoma having a lymphoepithelial lesion, which indicated mucosa-associated lymphoid tissue (MALT) lymphoma. Radiation therapy with 31 Gy successfully resulted in complete remission. We report here for the first time on primary pancreatic low-grade MALT lymphoma presenting with multiple pancreatic masses.

Primary pancreatic anaplastic large cell lymphoma, ALK negative: A case report

We present the fourth case of a primary pancreatic anaplastic large cell lymphoma (ALCL), ALK-. An 80-year-old man was admitted to our clinic for further investigation of a fever of unknown origin. He noted anorexia, weight loss and fatigue. His laboratory tests showed anemia and a great elevation of ESR, LDH, and β₂ microglobulin. In CT and MRI scan, a soft tissue mass in the pancreas was observed. A repeated endoscopy after his admission revealed an ulcerated mass-like deformity of the duodenal bulb. Explorative laparotomy confirmed a diffuse spread of an unresectable malignant pancreatic mass extending to the adjacent organs. Duodenal and surgical biopsies identified an ALCL of T-cell lineage, ALK-. The patient died in the Intensive Care Unit due to hemodynamic instability. Our case is the first one indicating that primary pancreatic lymphoma should be suspected in a patient with pancreatic mass and elevated serum LDH and β₂ microglobulin.