IMAGING IN PANCREATIC LYMPHANGIOMA
Sujata Ojha, BSc, Muhammad Darwish, MBBS, D. Rohan Jeyarajah, MD FACS
Presenter: Sujata Ojha, BS, Methodist Richardson Medical Center
Introduction/Objective: Lymphangiomas are rare, benign, tumors of the lymphatic system. They are formed through congenital malformation leading to lymphangiectasias. Thus, lymphangiomas are mostly seen in children and infants. This study reports a rare presentation of a lymphangioma in the pancreas.
Case Presentation: A 65-year-old female presented to our clinic with nausea and occasional abdominal pain. She had a past medical history of an incidentally diagnosed 7-cm lesion on her pancreas during workup for chest pain several years ago. An abdominal CT was obtained that showed an 8.1 x 4.5 x 5.6 cm cystic mass demonstrating few small septations and associated with the superior and anterior pancreatic body without evidence of adjacent soft tissue invasion or any significant vascular encasement [Figures 1 & 2]. The patient had no history of heavy alcohol use or previous attacks of pancreatitis. Laboratory findings were all within normal limits. Carbohydrate Antigen 19-9 (CA 19-9) was negative (4.27 U/mL). An EGD/EUS was performed revealing an 8-cm cystic lesion with septations but without nodules spanning from the head to the body of the pancreas. Fine-needle aspiration (FNA) showed a Carcinoembryonic Antigen (CEA) level of 93.9 ng/mL and an Amylase level of 222.5 IU/L, both low, decreasing the likelihood of malignancy. Since the patient was mostly asymptomatic, follow up with routine imaging was recommended. An MRI scan 3 months later showed an interval decrease in size to 6.1 x 4.3 x 5.3 cm. The cyst was a lobulated, macrocystic mass extending superiorly from the anterior pancreas body and draping over the portal vein and common hepatic artery while exerting a mass effect on the posterior wall of the gastric antrum. The cyst wall demonstrated irregular enhancement with regions of restricted diffusion [Figure 3]. The patient was advised to continue follow up with imaging. However, future need for a pancreatoduodenectomy to address worsening symptoms if they occur was discussed with the patient.
Discussion: A diagnosis of lymphangioma is generally made based on clinical findings and imaging studies. Diagnostic imaging techniques include computed tomography (CT), magnetic resonance imaging (MRI), and endoscopic ultrasound (EUS) combined with fine-needle aspiration (FNA). Typical presentations are a multilocular lesion with homogenous serous composition which appears anechoic on ultrasound. These lesions show a low signal intensity on T1-weighted images and very high signal intensity on heavily T2-weighted images. Furthermore, CT demonstrates fluid attenuation. These imaging findings were consistent with a lymphangioma of the pancreas.
Conclusion: Lymphangiomas are benign tumors of the lymphatic system. Pancreatic lymphangioma is a rare clinical finding in adults. They often present asymptomatically and are discovered incidentally through intraoperative or imaging methods. This case demonstrates the classic imaging findings of a lymphangioma in an unusual organ.
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