Unusual presentation of Hodgkin’s lymphoma

C.T.A.M. Knibbeler-van Rossum, F.J.P. Peters, F.L.G. Erdkamp and L.P. Bos

A 31-year-old women was admitted to our hospital with a 4-week history of progressive upper abdominal pain. Past medical history was non-contributory. Physical examination was unremarkable. Laboratory examination of the blood showed elevated parenchymateous and cholestatic liver function tests: bilirubin 14.0 µmol/l (n = 3–22), alkaline phosphatase 870 U/l (n = 50–125), {gamma}-glutamyltransferase 259 U/l (n = 6–50), aspartate aminotransferase 289 U/l (n = 5–50), alanine aminotransferase 218 U/l (n = 5–40), lactate dehydrogenase 636 U/l (n = 200–450), C-reactive protein 73 mg/l (n <10) and amylase 884 U/l (n = 30–130). Amylase was also elevated in the urine 3190 U/l (n = 50–650). Leucocytes were 14.5 x 109/l (n = 3–12) with normal differentiation, other laboratory findings were normal. Ultrasonographic examination of the abdomen showed a solid multinodular mass in the head of the pancreas 7 x 7 x 8.5 cm, with a normal diameter of the common bile duct. The origin of the mass was not clear; a subsequent computed tomography scan (Figure 1) and magnetic resonance imaging scan of the abdomen did not provide any more information. The differential diagnosis contained a neuro-endocrine tumour, carcinoma or lymphoma. An endoscopic retrograde cholangiopancreatography revealed a normal head of the pancreas and a discontinuation of contrast in the ductus with distension of the ductus pancreaticus in the corpus, probably because of the tumour. Finally, a histological punction from the head of the pancreas revealed a Morbus Hodgkin’s lymphoma of the mixed cellular type.



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Figure 1. Mass in the head of the pancreas.

 
A stent was placed into the ductus hepatocholedochus because of jaundice due to compression of the tumour. Further staging for Hodgkin’s disease revealed no other localisation than in the upper abdomen. We classified the Hodgkin’s lymphoma as an Ann Arbor stage IE disease. ABVD chemotherapy consisting bleomycin 10 mg/m2, doxorubicin 25 mg/m2, dacarbazine 375 mg/m2 and vinblastine 6 mg/m2 on days 1 and 15 every 4 weeks was started. Response evaluation after two courses of chemotherapy showed a >50% reduction of the tumour, and afterwards the ductus choledochus stent was removed.

Lymphoma involving the pancreas is rare compared with pancreatic adenocarcinoma [1]. Among malignant neoplasms of the pancreas, lymphoma have a very low incidence [2] at approximately 1–2%; these are mostly non-Hodgkin’s lymphomas [3]. The dramatic difference in prognosis [4] and treatment between pancreatic carcinoma and lymphoma makes it important to have a correct diagnosis. Currently, >75% of newly diagnosed patients with Hodgkin’s lymphoma are cured with radiation therapy and/or chemotherapy. In contrast with pancreatic carcinoma, which has a 5-year survival of 1–4%. Due to their relatively good prognosis, it is important to consider lymphomas in the differential diagnosis of tumours of the pancreas.

C. T. A. M. Knibbeler-van Rossum1, F. J. P. Peters2, F. L. G. Erdkamp2 & L. P. Bos2

1Department of Internal Medicine, University Hospital Maastricht; 2Department of Internal Medicine, Maasland Hospital Sittard, The Netherlands (E-mail@ Knibbeler-vanrossum@planet.nl)

References

1. Pecorari P, Gorji N, Melato M. Primary non-Hodgkin’s lymphoma of the head of the pancreas: a case report and review of literature. Oncol Rep 1999; 6: 1111–1115.[ISI][Medline]

2. Salvatore JR, Cooper B, Shah I, Kummet T. Primary pancreatic lymphoma: a case report, literature review, and proposal for nomenclature. Med Oncol 2000; 17: 237–247.[ISI][Medline]

3. Aisenberg AC. Problems in Hodgkin’s disease management. Blood 1999; 93: 761–779.[Free Full Text]

4. Rudders RA, Ross ME, DeLellis RA. Primary extranodal lymphoma: response to treatment and factors influencing prognosis. Cancer 1978; 42: 406–416.[ISI][Medline]





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