Presentation
Right upper quadrant pain. Biliary colic?
Patient Data
The pancreas contains several focal lesion in the pancreatic head, body and tail. All 3 lesions enhance. The main pancreatic duct is not dilated.
There is intra and extrahepatic bile duct dilatation with the common bile duct with an abrupt caliber change at the level of the pancreatic head mass. No peripancreatic fluid collection or inflammation.
No focal liver lesion. The hepatic veins, portal veins are patent.
Kidneys, adrenal glands, spleen are normal. No free fluid in the upper abdomen.
Conclusion:
Several pancreatic masses, concerning for a malignant process given the biliary obstruction. Lymphoma and metastases should be considered. Adenocarcinoma is rare in this age group, particularly multifocal and without pancreatic duct obstruction. Multifocal neuroendocrine tumor is a possibility but relative hypoenhancement would be atypical.
The patient went on to have a chest xray.
Likely anterior mediastinal mass. Heart size is within normal limits. Lungs and pleural spaces are normal.
There is a large homogenous soft tissue mass occupying the superior mediastinum extending from the origin of the great vessels to the thoracic inlet. The mass encases without compressing the aorta, pulmonary trunk and the trachea. The mass bulges to the left and mildly displaces the medial left upper lobe, causing some compressive atelectasis with patchy ground glass opacity. There further patchy ground glass opacities in the posterior basal segment of left lower lobe.
Several small left sided pleural plaques identified. A plaque related to the pericardium posterior surface may be calcified.
Conclusion:
Large homogenous soft tissue mass in the superior mediastinum with left pleural disease. Possibilities include lymphoma or less likely thymoma.
Case Discussion
The patient went on to have a mediastinal biopsy.
Histology
MICROSCOPIC DESCRIPTION:
The core biopsy shows a proliferation of atypical lymphoid cells, infiltrating into the fat and skeletal muscle. It forms diffuse sheets. No follicular structures are seen. The atypical lymphocytes are mostly medium in size, though some large ones are also present.
They have enlarged clefted and hyperchromatic nuclei, small nucleoli and scanty cytoplasm. The background is sclerosed. The atypical lymphoid cells are CD20, PAX-5, CD23, bcl-2, bcl-6 and MUM1 positive. The Ki-67 index is about 50%. They are CD3, CD5, CD10, CD30, Cyclin D1, c-Myc, TdT, ALK-1 and EBER-CISH negative. The features are those of diffuse large B-cell lymphoma with activated B-cell-like phenotype.
DIAGNOSIS:
Mediastinal mass biopsy: Diffuse large B-cell lymphoma.
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