背景:滤泡性淋巴瘤是非霍奇金淋巴瘤(NHL)的常见类型。表现差异很大,从无症状到无痛性外周淋巴结病到经典B症状。我们介绍了一个不寻常的滤泡性淋巴瘤病例,该患者最初出现急性胰腺炎的体征和症状。这项研究的目的是认识到在诊断腹膜后NHL时面临的挑战以及及时治疗这种疾病的必要性。
方法:一名66岁的西班牙裔女性,有哮喘和高血压治疗史,在右上象限出现腹痛,血清脂肪酶>3000U/L和肝功能检查(LFTs)升高,谷草转氨酶(AST)139U/L,丙氨酸转氨酶(ALT)65U/L,碱性磷酸酶(ALP)122U/L腹部超声发现胆囊壁增厚和胆管扩张。CT扫描显示腹膜后软组织肿块,测量9.3x4.8厘米,包裹在主动脉周围,并将其推离脊柱。经过两天的保守管理,她的疼痛缓解了,脂肪酶水平恢复正常,她已出院,并计划接受门诊内镜超声检查(EUS)并对腹膜后肿块进行活检.第二天,患者出现类似的疼痛,实验室再次显示脂肪酶升高,EUS,肿块细针活检显示CD-10阳性B细胞淋巴瘤。患者在疼痛缓解后出院。初始CT扫描四周后的正电子发射断层扫描(PET)扫描显示肿瘤大小增加,没有任何转移性病变。在等待核心活检时,患者第三次出现腹部疼痛恶化,脂肪酶>3000IU/L,超声显示胆石症伴胆囊炎。患者接受了腹腔镜胆囊切除术。椎旁淋巴结芯针活检示1-2级滤泡性淋巴瘤。最后,患者接受了6个周期的苯达莫司汀和利妥昔单抗化疗,第4个周期后,重复CT扫描显示腹膜后淋巴结肿大消退,残余软组织衰减最小.
结论:NHL很少发生在腹膜后,其诊断具有挑战性。我们的患者表现为腹膜后滤泡性淋巴瘤的原发性和独特发生。她表现为急腹症,脂肪酶和LFTs升高。在做出正确诊断之前,她经历了多次住院和胆囊切除术,直到她接受滤泡性淋巴瘤的治疗。
结论:本研究强调了当患者出现异常疾病时保持警惕的重要性,以便及早诊断和治疗疾病,以降低并发症的风险并减轻不良预后的风险。
BACKGROUND: Follicular lymphomas are a common type of non-Hodgkin\'s lymphomas (NHL). Presentation varies widely from being asymptomatic to painless peripheral lymphadenopathy to classic B symptoms. We present an unusual case of follicular lymphoma where the patient initially presented with signs and symptoms of acute pancreatitis. The aim of this study is to recognize the challenges faced while diagnosing retroperitoneal NHL and the need for timely management of this disease.
METHODS: A 66-year-old Hispanic female with a medical history of treatment compliant asthma and hypertension presented to the ER with complaints of abdominal pain in the right upper quadrant with serum lipase >3000 U/L and elevated liver function tests (LFTs), aspartate aminotransferase (AST) 139 U/L, alanine aminotransferase (ALT) 65 U/L, alkaline phosphatase (ALP) 122 U/L. Abdominal ultrasound identified gall bladder wall thickening and dilation of biliary ducts. CT scan showed soft tissue mass in the retroperitoneum, measuring 9.3x4.8cm which wrapped around the aorta and pushed it off the spine. After two days of conservative management, her pain resolved and lipase levels normalized, she was discharged and scheduled for outpatient endoscopic ultrasound (EUS) with biopsy of the retroperitoneal mass. The next day, the patient presented to the ER with similar pain, and labs again showed elevated lipase, EUS, and fine needle biopsy of mass showed CD-10 positive B-cell lymphoma. The patient was discharged after the resolution of pain. A positron emission tomography (PET) scan four weeks after the initial CT scan showed an increase in tumor size without any metastatic lesions. While awaiting core biopsy, the patient presented to the ER for the third time with worsening abdominal pain, lipase >3000 IU/L, and ultrasound showing cholelithiasis with cholecystitis. The patient underwent laparoscopic cholecystectomy. Core needle biopsy of paraspinal lymph nodes showed grade 1-2 follicular lymphoma. Finally, the patient underwent six cycles of chemotherapy with Bendamustine and Rituximab and after the fourth cycle, a repeat CT scan showed resolution of adenopathy with minimal residual soft tissue attenuation in retroperitoneum.
CONCLUSIONS: NHL rarely occurs in retroperitoneum and its diagnosis is challenging. Our patient presented with the primary and unique occurrence of follicular lymphoma in the retroperitoneum. She presented with symptoms of an acute abdomen with elevated lipase and LFTs. She underwent multiple hospitalization and cholecystectomy before the correct diagnosis was made and until she was treated for follicular lymphoma.
CONCLUSIONS: This study emphasizes the importance of being vigilant when a patient presents with unusual presentations of a disease in order to diagnose and treat the condition early to decrease the risk of complications and to mitigate the risk of poor outcomes.