Purpose: A 19 year old female presented to the emergency room with acute onset of abdominal pain and bilious vomiting. Abdominal exam was significant for right upper quadrant tenderness without rebound or guarding. Laboratory tests: T. bili 3.8 mg/dl (direct 1.8), ALT 250 IU/L, AST 170 IU/L, alk phos 146 IU/L, lipase 393 IU/L (nl <52). Two 1.6 × 1.5 cm pancreatic masses were seen on CT, one in the head causing biliary obstruction and the second in the body. MRI characterization defined two heterogeneous masses, hypointense on T1 and hyperintense on T2 with peripheral contrast enhancement. There was no peripancreatic inflammation or intraabdominal adenopathy. An ERCP was performed to manage biliary obstruction; biliary cytology was nondiagnostic. CA 19-9, CEA, ACE and LDH were normal. An EUS described solid masses with cystic components, consistent with solid pseudopapillary tumor versus cystic malignancy. Fine needle aspiration was non-diagnostic as was a second EUS-guided aspiration. Surgical exploration with frozen section biopsy revealed atypical cells concerning for epithelial malignancy. An extended Whipple procedure, to include the proximal body of the pancreas, was performed. Final histology and flow cytometry was diagnostic for B-cell lymphoma. Discussion: To our knowledge PPL presenting as two pancreas masses has not been previously described in this age group. PPL is an uncommon extranodal manifestation of non-Hodgkin's lymphoma, representing only 0.5% of all pancreatic masses. PPL must be differentiated from epithelial neoplasia as resection is not indicated for lymphoma. The presentation of a solid-cystic mass in a young woman would more commonly be a solid-pseudopapillary neoplasm. This tumor, like PPL, usually presents as an isolated mass rather than with multifocal lesions as seen in our patient. Treatment of PPL is treated with chemotherapy and radiation with cure rates that do not exceed 30%. Had the diagnosis been established either preoperatively or intraoperatively, she could have been spared pancreaticoduodenectomy. Unfortunately, it is not uncommon that histology is non-specific and flow cytometric analysis is required for diagnosis.Figure: T1 MRI image demonstrating the head of pancreas mass. Second mass seen in a different axial image.