Diffuse Large B-Cell Lymphoma Presenting as Acute Pancreatitis and Mediastinal Mass

Abstract

SESSION TITLE: Disorders of the Mediastinum 2 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Acute pancreatitis is an extremely rare presentation of diffuse large B-cell lymphoma (DLBCL). We present the case of a 19 year old female with recurrent pancreatitis secondary to DLBCL. CASE PRESENTATION: A 19 year old female with a prior history of cholecystectomy and no alcohol use presented to the emergency department with epigastric pain and vomiting. She had recently been admitted twice for acute pancreatitis with no etiology identified. Lipase was 3,334 U/L (normal 23-300 U/L). Ultrasound showed no biliary duct dilation. Magnetic resonance cholangiopancreatography five days prior had shown pancreatic edema but no common bile duct obstruction. A CT had shown only pancreatic edema. Extensive workup for the etiology of her pancreatitis was done: calcium, triglycerides, hepatitis panel, EBV, CMV and HIV serology, alpha-1 antitrypsin, ANA, and IgG4 levels were normal. On review of systems, she had a one-month history of dry cough and dyspnea on exertion. Chest X-ray revealed a right upper lobe (RUL) infiltrate. CT chest/abdomen/pelvis was done and showed a 13 x 3.4 cm mediastinal mass (Fig. 1) causing compression of the superior vena cava and RUL bronchus, right hilar adenopathy, and pericardial and bilateral pleural effusions. The pancreas was diffusely swollen with peripancreatic induration and retroperitoneal adenopathy. Pathology from CT-guided biopsy of the mediastinal mass revealed DLBCL. She was treated with 6 cycles of R-CHOP and has been in remission for five years with no further episodes of pancreatitis. DISCUSSION: Primary pancreatic lymphoma often presents as pancreatitis, but it is very rare for DLBCL to present as acute pancreatitis from secondary involvement of the pancreas. Our case is even more unusual as there was no discrete pancreatic mass on imaging. To our knowledge, only two other cases of DLBCL involving the pancreas have been reported in which there was no discrete mass1,2. Notably, in all cases reported in the literature, imaging has demonstrated either lymphadenopathy or masses involving other organs in addition to the pancreas. Therefore, these findings should raise suspicion for malignant etiologies in the patient with otherwise routine-appearing pancreatitis. Our case demonstrates the value of repeat imaging upon recurrent episodes of pancreatitis when no etiology has been found, as her lymphadenopathy and masses did not appear on initial imaging. CONCLUSIONS: Lymphoma must be considered in the differential diagnosis of acute pancreatitis after the usual causes are excluded. Repeat imaging is valuable in cases of recurrent pancreatitis of unknown etiology since new findings may develop rapidly and lead to the diagnosis. Reference #1: To C, et. al. Masquerade without a mass: an unusal cause of severe acute pancreatitis. J Gastrointest Oncol 2013;4(1):114-117. Reference #2: Saif M, et al. Secondary pancreatic involvement by a diffuse large B-cell lymphoma presenting as acute pancreatitis. World J Gastroenterol 2007;13(36):4909-4911. DISCLOSURE: The following authors have nothing to disclose: Zachary Wolfe, Lydia Winnicka, Bradley Lash No Product/Research Disclosure Information