Imaging Characteristics, Role of EUS-FNA and Prognosis in Patients With Pancreatic Lymphoma

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Introduction: Lymphoma involving the pancreas has a prevalence of 2% of all pancreatic malignancy. The prognosis and management of pancreatic lymphoma differ from those of primary pancreatic cancer. The purpose of the study was to identify the clinical, imaging, and cytopathology characteristics, and role of endoscopic ultrasound with fine-needle aspiration (EUS-FNA) in the diagnosis of pancreatic lymphoma.Table 1: Patient CharacteristicsMethods: The study was approved by the institutional review board. All patients who had EUS-FNA with confirmation of pancreatic lymphoma via cytology, flow cytometry, and/or immunocytochemistry during 2003-2013 were included. Results: A total of 18 patients [median age: 54 years; range: 50-83; 10 males (55%); 15 Caucasian, 1 Asian, 1 African American, and 1 Hispanic] with pancreatic lymphoma were followed for a median of 13.5 months (range: 0.5-124). A total of 7 patients (39%) died during the follow-up; all of them had high-grade lymphoma with stage IV disease. All patients were symptomatic presenting with abdominal pain (61%), weight loss (22%), jaundice (55%), and itching (11%). A total of 18 pancreatic masses (17 in the head and 1 in the tail) were identified with a median size of 4.75 cm (range: 2-8) on CT scan in 18 patients who subsequently underwent EUS-guided FNA. PET scan showed increased uptake in 14 of the 18 masses. Biliary dilation was seen in 14 patients (77%), with a mass in the head and required placement of biliary stents. Mild pancreatic duct dilation was seen in 3 patients (16%). A median of 3 passes (range: 2-7) per mass lesion were performed. Rapid onsite evaluation was available for all cases. Flow cytometry could be performed in 15 of 18 patients and was diagnostic in all cases. Fourteen patients (78%) had diffuse large B-cell lymphoma (DLBCL) and molecular testing for BCL2 and MYC could be performed on 8 of 14 samples. See Table 2 for details of further subclassification of DLBCL. Four patients (22%) had follicular cell lymphoma (3 low grade and 1 high grade). Cellblock or cytostain with immunohistochemistry could be performed on all 18 samples, thus differentiating high-grade from low-grade lymphoma. Conclusion: Pancreatic lymphomas predominantly involve the head of the pancreas with most patients presenting with symptoms of biliary obstruction. Pancreatic duct dilation is uncommon. Most pancreatic lymphomas are DLBCL. EUS-FNA with flow cytometry has a high diagnostic yield in pancreatic lymphoma and should be employed in all cases where pancreatic lymphoma is suspected.