• 43 years old Male
  • Known case of HIV positive status, presented with severe jaundice for last 1 month
  • CT Scan Abdomen – Mass in the pancreatic head region  with Dilated IHBR
  • EUS – a large hypoechoic mass lesion (5X4 cm) near the head of pancreas which appeared like large
  • lymphnode mass compressing the entire lower CBD upto mid CBD.
  • Multiple Hypoechoic nodes in the porta and peripancreatic region near the body.
  • EUS FNA was then performed from the large mass in the head region and the porta node.
  • Cytological examination followed by histopatholoy and IHC study of the aspirated material revealed it to be a case of B cell Non-Hodgkins lymphoma.
  • Selective cannulation of CBD could be achieved only after pancreatic stent placement and precut sphincterotomy.
  • Cholangiogram revealed a long 10-12 cm stricture involving the entire lower CBD and mid CBD with dilated CHD and IHBR. Biliary sphincterotomy was then extended and with a great difficulty a 10 fr stent could be passed across the stricture. Free flow of bile was seen.
  • Follow-up EUS after 3 months of chemotherapy revealed complete resolution of the lymphomatous lesions and the placed pancreatic and biliary stents were removed.

Expert Comments:

  • Non-Hodgkin lymphoma has been reported to be cause of malignant biliary stenosis in 1-2 % of cases.
  • Case series of such peripancreatic lymphomatous lesion being mistaken for pancreatic neoplasm and getting operated for Whipple’s operation has been reported.
  • EUS guided FNA from such lesion prior to any definitive treatment provides accurate tissue diagnosis as well as locoregional staging of the disease.
  • Preparation of cell blocks from the EUS guided FNA material does enable histological characterization, improves accuracy with advantage of special staining (mucicarmine, Congo red) and Immunohistochemistry studies.

Take Home Message:

  • Lesions of lymphnodal origin (tuberculous granuloma or lymphoma) should be suspected in cases of HIV presenting with peripancreatic mass leading to obstructive jaundice.
  • EUS guided FNA must be done for all such mass lesions prior to any definitive operative intervention.
  • Stenting of the bile duct at the time of diagnosis of such lymphomatous lesion with removal after 3 months should be undertaken to evaluate the response to the chemotherapy treatmen.
  • Covered Self expandable metallic biliary stenting can be considered in cases refractory to treatment with plastic biliary stents.
EUS showing Peripancreatic mass lesion

EUS showing Peripancreatic mass lesion

EUS guided FNA from the mass lesion

EUS guided FNA from the mass lesion

 

 

 

 

 

 

 

 

 

Cholangiogram showing long segment CBD stricture with dilated proximal CBD and CHD

Cholangiogram showing long segment CBD stricture with dilated proximal CBD and CHD

Bile duct stent in situ

Bile duct stent in situ

 

 

 

 

 

 

 

 

 

Fluoroscopy showing CBD stent in situ

Fluoroscopy showing CBD stent in situ

Follow-up EUS showing complete resolution of the lymphnode mass

Follow-up EUS showing complete resolution of the lymphnode mass

 

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