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IMAGE IN EUS
Year : 2015  |  Volume : 4  |  Issue : 2  |  Page : 160-161

Contrast-enhanced harmonic endoscopic ultrasound in the diagnosis of primary pancreatic B-cell non-Hodgkin's lymphoma


Department of Endoscopy, Instituto Ecuatoriano de Enfermedades Digestivas, University Hospital Omni, Guayaquil, Ecuador

Date of Submission11-Oct-2014
Date of Acceptance29-Oct-2014
Date of Web Publication8-May-2015

Correspondence Address:
Carlos Robles-Jara
Department of Endoscopy, Instituto Ecuatoriano de Enfermedades Digestivas, University Hospital Omni, Guayaquil
Ecuador
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2303-9027.156762

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How to cite this article:
Hwang HJ, Robles-Jara C, Largacha M, Robles-Medranda C. Contrast-enhanced harmonic endoscopic ultrasound in the diagnosis of primary pancreatic B-cell non-Hodgkin's lymphoma. Endosc Ultrasound 2015;4:160-1

How to cite this URL:
Hwang HJ, Robles-Jara C, Largacha M, Robles-Medranda C. Contrast-enhanced harmonic endoscopic ultrasound in the diagnosis of primary pancreatic B-cell non-Hodgkin's lymphoma. Endosc Ultrasound [serial online] 2015 [cited 2019 Sep 17];4:160-1. Available from: http://www.eusjournal.com/text.asp?2015/4/2/160/156762

A 71-year-old male with a history of non-Hodgkin's lymphoma 26 years ago and considered in remission was presented with abdominal pain and bloating of 4 months duration, jaundice and weight loss of 15 pounds in the last 2 months. His total serum bilirubin was 24 mg/dL (direct bilirubin: 21 mg/dL), associated to elevated transaminases 3 times over the upper limit of normal value. Other laboratory data were normal. Contrast-enhanced computerized tomography scan showed a mass in the head of the pancreas with gastric and duodenal infiltration, abdominal lymphadenopathy, bile and pancreatic duct dilated and ascites. Endoscopic ultrasonography (EUS) showed a 60 mm hypoechoic mass in the head of the pancreas with common bile duct and portal vein infiltration. EUS also found lymphadenopathy, ascites, with dilation of the main pancreatic duct and common biliary duct. Initially, EUS-fine needle aspiration (EUS-FNA) was not conclusive in spite that quantitative and qualitative elastography were suspected for malignancy (mean strain ratio: 37). We performed a new EUS using contrast-enhanced harmonic EUS (CH-EUS, pentax-hitachi) with sonovue (2.4 mL) that showed a hypoenhanced pattern of the pancreatic mass. EUS-FNA with a 19-gage needle (expect needle, boston scientific) obtained sample of the pancreatic mass for histology and a diffuse large B-cell immunophenotype non-Hodgkin's lymphoma was diagnosed [Figure 1], [Figure 2] and [Figure 3].
Figure 1. Endoscopic ultrasonography elastography showing the heterogeneous mass in the head of the pancreas (Strain Ratio: 30)

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Figure 2. Contrast-enhanced harmonic-endoscopic ultrasonography with a linear array ultrasound endoscope shows a hypoenhanced mass after contrast sonovue (Bracco) injection

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Figure 3. Histology showing a diffuse large B-cell immunophenotype non-Hodgkin's lymphoma

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Primary pancreatic lymphoma (PPL) is a rare tumor of the pancreas. Although it is a rare malignant tumor, the correct diagnosis is essential since their therapeutic management differs from other pancreatic tumors. In a retrospective study, it was encountered in 0.5% of patients with solid pancreatic masses, usually located in the head and appeared as a heterogeneous mass. [1] Endoscopic ultrasonography is the best modality for pancreatic lesion evaluation, although differentiating malignant lesions (adenocarcinoma, neuroendocrine tumor, primary lymphoma, metastases) remains a challenge. EUS-FNA is currently the preferred technique for the diagnosis of neoplasms of the pancreas. [2] Recently, CH-EUS has been reported as an adjunct in the diagnosis of pancreatic neoplasms. [3] However, the usefulness of CH-EUS in the PPL has been poorly studied because of the rarity of this entity. In a recent study, a case with metastatic pancreatic lymphoma CH-EUS appeared hyperenhancing. [4] We present a case of PPL in which CH-EUS showed as an hypoenhancing pattern.

 
  References Top

1.
Ramesh J, Hebert-Magee S, Kim H, et al. Frequency of occurrence and characteristics of primary pancreatic lymphoma during endoscopic ultrasound guided fine needle aspiration: A retrospective study. Dig Liver Dis 2014;46:470-3.  Back to cited text no. 1
    
2.
Gimeno-García AZ, Alonso MM, García Castro C, et al. Primary pancreatic lymphoma diagnosed by endoscopic ultrasound-guided fine needle aspiration biopsy. Gastroenterol Hepatol 2010;33:638-42.  Back to cited text no. 2
    
3.
Kwek BE, Ang TL, Seo DW, et al. Contrast-enhanced harmonic endoscopic ultrasonography of solid pancreatic lesions. Endosc Ultrasound 2013;2:142-7.  Back to cited text no. 3
    
4.
Fusaroli P, D'Ercole MC, De Giorgio R, et al. Contrast harmonic endoscopic ultrasonography in the characterization of pancreatic metastases (with video). Pancreas 2014;43:584-7.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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