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.