CASE REPORT

A 18-year-old man presented with epigastric pain and progressive jaundice. His past medical history was remarkable for the diagnosis of nodular sclerosing Hodgkin’s lymphoma (stage IIa – cervical and mediastinum) 10 months before, for which he underwent chemoradiation therapy. Of note, he was in remission for the last 2 months before the current symptoms. Computed tomography imaging revealed a heterogeneous 30 mm pancreatic head mass, causing dilation of both the common bile duct and pancreatic duct (Figure 1).

Figure 1: (Left) Computed tomography scan showing a heterogeneous 30 mm tumor in the pancreatic head. (Right) Pancreatic head mass evaluated by endoscopic ultrasonography.

These findings were replicated on endoscopic ultrasonography, with no other significant findings, namely mediastinal or abdominal adenopathies. Fine-needle aspiration was performed using a 22-gauge ProCore needle. The samples were sent to pathological examination and flow cytometry. The results of the analysis were surprising as they unveiled a high-grade B-cell non-Hodgkin lymphoma (Figure 2). This cast doubt on the previous diagnosis of Hodgkin’s lymphoma, which was reviewed and confirmed.

Figure 2: (Left) Flow cytometry analysis: B cells identified by bright expression of CD19 and CD20. These cells were large, CD38+, CD79b+, CD81+, CD200+, CD10- (data not shown). These results suggested B-cell non-Hodgkin lymphoma, as evidenced by the immunophenotype and Lambda surface immunoglobulin light chain restriction (center). (Right) Large lymphoid cells with crush artefact. May-Grünwald-Giemsa, x600.

Commentary 

The occurrence of a metachronous form of non-Hodgkin lymphoma in a patient with Hodgkin’s lymphoma is exceedingly rare, especially the extranodal involvement in the absence of nodal disease. (1) Moreover, in a setting of Hodgkin’s lymphoma, echoendoscopists do not regularly send samples for flow cytometry, as this analysis has not proved useful in the detection of the Reed-Sternberg cells. (2) However, given the clinical context putting forth the hypothesis of secondary pancreatic involvement by lymphoma as well as a previous report of missed non-Hodgkin lymphoma diagnosis in a background of Hodgkin’s lymphoma, flow cytometry was performed. (3) In a difficult case with broad spectrum differential, this proved to be invaluable by rapidly pointing to a non-Hodgkin lymphoma and by improving the diagnostic certainty of the pathology analysis obtained later on. It raises the question as to whether echoendoscopists should systematically obtain flow cytometry samples in patients with Hodgkin’s lymphoma.

References:

1. Pileri SA, Ascani S, Leoncini L, Sabattini E, Zinzani PL, Piccaluga PP, et al. Hodgkin’s lymphoma: the pathologist’s viewpoint. J Clin Pathol 2002;55:162-76.

2. Stacchini A, Carucci P, Pacchioni D, Accinelli G, Demurtas A, Aliberti S, et al. Diagnosis of deep-seated lymphomas by endoscopic ultrasound-guided fine needle aspiration combined with flow cytometry. Cytopathology 2012;23:50-6.

3. Ribeiro A, Pereira D, Escalon MP, Goodman M, Byrne GE, Jr. EUS-guided biopsy for the diagnosis and classification of lymphoma. Gastrointest Endosc 2010;71:851-5.

Pedro Figueiredo1; Pedro Pinto-Marques1,2; Maria Arroz3; Evelina Mendonça4; Nuno Ladeira5; Inês Mendonça2

1 Department of Gastroenterology, Hospital Garcia de Orta, Almada, Portugal

2 Department of Gastroenterology, Hospital da Luz, Lisboa, Portugal

3 Department of Clinical Pathology, Hospital Egas Moniz, Lisboa, Portugal

4 Department of Pathology, Hospital da Luz, Lisboa, Portugal

5 Department of Gastroenterology, Hospital Central do Funchal, Funchal, Portugal