Case report
A 47 year old lady without any co morbidities presented with pain
abdomen, dyspepsia and 8 kilogram weight loss of 3 months duration. She
did not report any symptoms of fever, night sweats, pruritis, chest
symptoms, and bowel and bladder disturbances. Clinical examination was
unremarkable but for mild pallor. There was no lymphadenopathy and
organomegaly. She was hemodynamically stable. Initial imaging done
elsewhere with Computerised Tomography (CT) of abdomen was suggestive of
a 34 x 57 x 66 mm pancreatic head lesion, with loss of fat planes with
stomach. Also noted was lymphadenopathy involving peripancreatic,
periportal and portocaval regions. CA 19.9 was normal (0.760 units/ml).
Complete blood picture, renal, liver function tests and LDH was normal.
Viral markers were negative. An endoscopic ultrasound (EUS) was
suggestive of gastric antral ulcer and a pancreatic body and tail mass.
EUS guided fine needle aspiration cytology (FNAC) was done which
suggested a poorly differentiated neoplasm. Immunohistochemistry (IHC)
was done to further characterize the lesion which showed positivity for
LCA, CD 20, BCL2, BCL6, CD 45 and CD 10 with KI-67 of 50%. The lesion
was negative for Pan CK, Chromogranin and CA 19.9 leading to a diagnosis
of B cell NHL (non Hodgkin’s lymphoma). Fluorescence in situ
Hybridisation (FISH) done for BCL-2, BCL-6 and c-myc expression and
rearrangement were negative ruling out a possibility of double hit
lymphoma.
PET CT(Positron Emission Tomography Computerised Tomography) scan was
done for baseline staging. PET CT was suggestive of a metabolically
active locally advanced primary pancreatic head lesion infiltrating the
pyloric antrum with adjacent peripancreatic nodes. Also seen were
metabolically active Index score was 2 which is low intermediate. A
diagnosis of Stage III BE Non Hodgkin’s lymphoma was made. Considering
the prognosis and available options for treatment, she was offered R-
CHOP (Rituximab-Cyclophosphamide, Doxorubicin, Vincristine and
prednisolone) based chemotherapy. After three cycles,an interim PET-CT
done suggested a complete metabolic response. She received a total of
six cycles and continues to be in remission.