Obstructive jaundice as primary presentation of a stage IIE Non-Hodgkin lymphoma: A decision making process between advanced lymphoma and locally advanced/metastatic pancreatic adenocarcinoma.

INTRODUCTION: Secondary pancreatic tumors are uncommon and account for 2-5% of pancreatic cancer. Tumors characterized most commonly with pancreatic involvement are lymphoma, renal cell and lung carcinomas.

PRESENTATION OF CASE: A 76-year-old female patient with obstructive jaundice as the primary symptom and inguinal lymphadenopathy is presented. Imaging revealed a bulky solitary solid pancreatic head mass along with paraaortic and mesenteric lymphadenopathy. The absence of a previous history of malignancy and the presence of a dominant pancreatic mass along with distal lymphadenopathy confined differential diagnosis to advanced secondary pancreatic lymphoma, which is the most common secondary pancreatic tumor, and locally advanced/metastatic pancreatic adenocarcinoma. Pathologic confirmation with excisional biopsy of an enlarged inguinal lymph node and EUS-FNB of the pancreatic head mass confirmed the diagnosis of secondary Non-Hodgkin pancreatic lymphoma allowing initiation of induction chemotherapy.

DISCUSSION: Secondary pancreatic lymphoma can be seen up to 30% of patients with advanced lymphoma; although the head of the pancreas is the most common location, obstructive jaundice is not the predominant symptom as obstruction of the common bile duct is usually absent. In the setting of a solitary nodular type pancreatic mass, key imaging findings highly suggestive of secondary pancreatic lymphoma and not of adenocarcinoma are the absence of vascular invasion, bile and pancreatic duct obstruction, and the presence of lymphadenopathy below the level of the left renal vein.

CONCLUSION: When a secondary pancreatic tumor is highly suspected pathologic confirmation is always needed before initiation of induction or palliative chemotherapy.