Abstract
Background: Follicular lymphomas are a common type of non-Hodgkin’s lymphomas (NHL). Presentation varies widely from being asymptomatic to painless peripheral lymphadenopathy to classic B symptoms. We present an unusual case of follicular lymphoma where the patient initially presented with signs and symptoms of acute pancreatitis. The aim of this study is to recognize the challenges faced while diagnosing retroperitoneal NHL and the need for timely management of this disease.Case report: A 66-year-old Hispanic female with a medical history of treatment compliant asthma and hypertension presented to the ER with complaints of abdominal pain in the right upper quadrant with serum lipase >3000 U/L and elevated liver function tests (LFTs), aspartate aminotransferase (AST) 139 U/L, alanine aminotransferase (ALT) 65 U/L, alkaline phosphatase (ALP) 122 U/L. Abdominal ultrasound identified gall bladder wall thickening and dilation of biliary ducts. CT scan showed soft tissue mass in the retroperitoneum, measuring 9.3x4.8cm which wrapped around the aorta and pushed it off the spine. After two days of conservative management, her pain resolved and lipase levels normalized, she was discharged and scheduled for outpatient endoscopic ultrasound (EUS) with biopsy of the retroperitoneal mass. The next day, the patient presented to the ER with similar pain, and labs again showed elevated lipase, EUS, and fine needle biopsy of mass showed CD-10 positive B-cell lymphoma. The patient was discharged after the resolution of pain. A positron emission tomography (PET) scan four weeks after the initial CT scan showed an increase in tumor size without any metastatic lesions. While awaiting core biopsy, the patient presented to the ER for the third time with worsening abdominal pain, lipase >3000 IU/L, and ultrasound showing cholelithiasis with cholecystitis. The patient underwent laparoscopic cholecystectomy. Core needle biopsy of paraspinal lymph nodes showed grade 1-2 follicular lymphoma. Finally, the patient underwent six cycles of chemotherapy with Bendamustine and Rituximab and after the fourth cycle, a repeat CT scan showed resolution of adenopathy with minimal residual soft tissue attenuation in retroperitoneum.Discussion: NHL rarely occurs in retroperitoneum and its diagnosis is challenging. Our patient presented with the primary and unique occurrence of follicular lymphoma in the retroperitoneum. She presented with symptoms of an acute abdomen with elevated lipase and LFTs. She underwent multiple hospitalization and cholecystectomy before the correct diagnosis was made and until she was treated for follicular lymphoma.Conclusion: This study emphasizes the importance of being vigilant when a patient presents with unusual presentations of a disease in order to diagnose and treat the condition early to decrease the risk of complications and to mitigate the risk of poor outcomes.
Highlights
Presentation and histology of non-Hodgkin lymphoma (NHL) vary widely which makes the diagnosis challenging
There has been a significant rise in the incidence of non-Hodgkin’s lymphomas (NHL) over the past few decades including the subtypes of diffuse large B cell lymphomas (DLBCL) and follicular lymphomas, irrespective of the HIV [1,2]
NHL commonly presents as enlarging and non-tender lymphadenopathy associated with symptoms of immunodeficiency or uncommonly with symptoms of obstruction of GI or respiratory tracts
Summary
Malignant lymphomas are divided into two broad categories - Hodgkin’s lymphomas and non-Hodgkin's lymphomas (NHL). NHL is the most common type of lymphoma and comprises about 90% of the cases [1]. NHL commonly occurs in the retroperitoneum compared to Hodgkin’s lymphomas and presents with varying clinical features [9]. There were two subsequent ER visits and hospitalizations for similar symptoms and cholecystectomy before we could diagnose that her retroperitoneal mass was follicular lymphoma. After doing fine needle aspirations (FNA) with paraspinal lymph node biopsy, which was suggestive of follicular lymphoma, the diagnosis was confirmed with flow cytometry. Though excisional biopsy is the gold standard for the diagnosis of lymphoma, FNA of the mass or involved lymph node is a less invasive and time-saving procedure [9]. Treatment for follicular lymphoma includes radiation therapy, chemotherapy, and stem cell transplant especially in younger patients with relapsing disease. Our patient underwent treatment with six cycles of bendamustine plus rituximab and a CT scan after four cycles of chemotherapy suggested resolution of the mass with the minimal residual disease [4]
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
