Primary Diffuse Large B Cell Lymphoma of the Common Bile Duct
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Primary Diffuse Large B Cell Lymphoma of the Common Bile Duct Denise L. Wong 1 & Benjamin W. Deschner 1 & Lauren C. King 1 & Evan S. Glazer 1 Received: 28 February 2020 / Accepted: 2 March 2020 # 2020 The Society for Surgery of the Alimentary Tract
Keywords Lymphoma . Diffuse large B cell lymphoma . Common bile duct . Biliary lymphoma . Obstructive jaundice
Clinical Data A previously healthy 32-year-old male presented to his primary care physician with 2 months of nausea, vomiting, weight loss, abdominal pain, and new onset of jaundice. Ultrasound demonstrated intrahepatic and extrahepatic dilation. A computed tomography (CT) scan and a magnetic resonance cholangiopancreatography showed a long-segment common bile duct stricture but no masses, adenopathy, or other abnormalities (Fig. 1a). Endoscopic retrograde cholangiopancreatography (ERCP) revealed a 4–5-cm smooth stricture located in the mid-proximal common bile duct (Fig. 1b). A biliary stent was placed with relief of symptoms. Brushings from ERCP returned benign pathology. The patient then had recurrence of symptoms which necessitated repeat ERCP for stent exchange; concurrent spyglass biopsy and brushings again returned benign pathology. The patient subsequently developed cholangitis, prompting another ERCP and stent exchange. Imaging confirmed a smooth stricture, and repeat brushings were benign. HIV, IgG4, and ANCA were negative, and serum CA 19–9 level was 11.5 U/mL. He had ongoing symptoms and ultimately underwent surgical intervention 2 months after initial presentation. Intraoperatively, the common bile duct felt firm, and a hard plaque was noted extending from the bile duct onto the duodenal serosa (Fig. 2). A shave biopsy of the plaque was sent for frozen section, which was interpreted as a poorly differentiated malignancy, and pancreaticoduodenectomy was performed. As cholangiocarcinoma could not be excluded, multiple sequential sections of the common hepatic duct were sent in an attempt to gain Denise L. Wong and Benjamin W. Deschner contributed equally to this work. * Evan S. Glazer [email protected] 1
Department of Surgery, University of Tennessee Health Science Center, 910 Madison Ave., Suite 300, Memphis, TN 38163, USA
negative margins; however, these were all persistently microscopically positive on frozen section to the level of the liver hilum. Histologic sections and immunohistochemistry (IHC) demonstrated CD20+/PAX5+ diffuse large B cell lymphoma (DLBCL), surrounding the bile duct and encroaching upon the adjacent duodenum (Fig. 3). The DLBCL expressed a germinal center–type immunophenotype (CD10+, BCL-6+) with no expression of MYC or BCL-2 by IHC, and EBER in situ hybridization was negative. Ki-67 proliferation index approached 50%. Fluorescence in situ hybridization identified no BCL2, BCL6, or MYC rearrangements. After recovery from surgery, the patient underwent treatment with R-CHOP and is currently in remission.
Discussion Non-Hodgkin’s lymphoma (NHL) is the 6th and 7th most common cancer in males and females respectivel
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