Mantle cell lymphoma masked by posttraumatic pancreatic hematoma

Pelvic computed tomography revealed a 15-cm peripancreatic mass in a 73-year-old man undergoing an operation for appendicitis associated with a periappendiceal abscess. The patient had been hospitalized 18 months previously for blunt abdominal trauma sustained during a motor vehicle collision. At that time, hemoperitoneum and a peripancreatic hematoma were diagnosed ([Fig. 1 a]). The hematoma decreased in size within 1 week, and there was no evidence of major pancreatic duct injury; thus, he was managed conservatively. The lesion continued to shrink for 6 months after the injury ([Fig. 1 b]), but the volume had increased at the time of the appendectomy, as shown by computed tomography ([Fig. 1 c]). Endoscopic ultrasound-guided biopsy with a 19-gauge needle (ProCore; Cook Medical, Bloomington, Indiana, USA) was used to identify the lesion. Pathologic examination and immunohistochemical staining of the specimen yielded a diagnosis of mantle cell lymphoma ([Fig. 2 a – c]).

Fig. 1 Evolving peripancreatic lesion. a Abdominal computed tomography immediately after a car accident shows an enhancing peripancreatic mass. b After 6 months, the lesion has shrunk. c A huge peripancreatic mass is incidentally identified following appendectomy 18 months after the injury.

Fig. 2 Pathologic examination and immunohistochemical staining of mantle cell lymphoma. a The specimen contains small lymphocytes with irregular nuclei. b, c Immunohistochemical staining reveals positivity for cyclin D1 and CD5.

Pancreatic injury, which occurs in approximately 5 % of patients who sustain blunt abdominal trauma, is associated with a morbidity rate of up to 45 % and a mortality rate of up to 30 % [1]. Low grade blunt injuries without main pancreatic ductal damage are initially managed nonoperatively rather than through operative exploration and repair [2]. The differentiation between an organizing hematoma and a mass like a lymphoma is not always straightforward [3] [4]. Notably, the mass in this case became smaller during the first 6 months. The mantle cell lymphoma, which presented as a slowly growing mass, was stationary in the early stage, and absorption of the hematoma occurred more quickly than growth of the lymphoma [5].

This case highlights the fact that clinicians should continue observation until a hematoma that has arisen at an unusual site completely disappears. If the behavior of a lesion does not correspond to the patient’s clinical presentation or exhibits an unusual course, the patient must be evaluated to establish the correct diagnosis.

Endoscopy_UCTN_Code_CCL_1AZ_2AO

Competing interests: None

Acknowledgment

This study was supported by a grant from the Korea Healthcare Technology R&D Project, Ministry of Health & Welfare, Republic of Korea (A100054). The source of the grant had no role in the design, practice, or analysis of the study.

• References

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