A Case of Non-Hodgkin’s Lymphoma Mimicking Cholangiocarcinoma Diagnosed by Endoscopic Ultrasound-Guided FNA

Case Report

Ann Hematol Oncol. 2015; 2(10): 1066.

A Case of Non-Hodgkin’s Lymphoma Mimicking Cholangiocarcinoma Diagnosed by Endoscopic Ultrasound-Guided FNA

Ishikawa T and Belletrutti PJ*

Department of Medicine, University of Calgary, Canada

*Corresponding author: Paul J Belletrutti, Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Room 6D23, Research and Wellness Building, 3280 Hospital Drive Northwest, Calgary, T2N 4Z6, Alberta, Canada

Received: September 11, 2015; Accepted: November 28, 2015; Published: November 30, 2015


Lymphoma is a rare cause of biliary obstruction and may mimic other malignant causes of jaundice. A 64-year-old man was admitted to hospital with painless jaundice and pruritus. Transabdominal ultrasound revealed biliary dilatation with a mass in the distal Common Bile Duct (CBD). CT and MRI confirmed intra- and extra hepatic biliary dilation, an abrupt caliber change in the CBD at the level of the mass in the porta-hepatis, and regional lymphadenopathy. Endoscopic retrograde cholangiogram demonstrated a severe stricture in the mid-CBD. Although brush cytology was negative for malignancy, the imaging findings favored a diagnosis of cholangiocarcinoma. Surgical resection was deferred due to the presence of lymphadenopathy. A biliary stent was placed and the patient was referred to our institution for a second attempt at a tissue diagnosis via Endoscopic Ultrasound (EUS)-guided Fine Needle Aspiration (FNA). The cytopathology combined with flow cytometry of the FNA specimen, however, was diagnostic of a large B-cell lymphoma. The patient was started on R-CHOP chemotherapy. EUS makes it possible to perform FNA of lesions that are inaccessible by other image-guided techniques. When FNA is performed, lymphoma should be considered as an alternate diagnosis, thus cytology should be combined with flow cytometry.

Keywords: Lymphoma; Endoscopic ultrasound; Flow cytometry

Case Presentation

A 64-year-old man was admitted to a regional hospital with painless jaundice and pruritus. He had noted dark colored urine, light colored stools and itchiness. He denied weight loss, fever, night sweats or loss of appetite. Past medical history included type-2 diabetes, hypertension, dyslipidemia, osteoarthritis and gastroesophageal reflux disease. He is an active smoker of 50 pack-years. He only drinks alcohol occasionally. He is a retired farmer but had no recalled exposure to environmental toxins or radiation. His family history is unremarkable for solid or hematological malignancies. Physical examination revealed jaundice but there were no palpable abdominal masses, hepatosplenomegaly or lymphadenopathy. He was afebrile and the remainder of his exam was unremarkable. Laboratory parameters included normal platelet count, WBC, hemoglobin, creatinine, calcium and total protein concentrations. However, total bilirubin was elevated at 206 umol/L (normal range <21) with ALP 382 U/L (normal range 55-170), GGT 1253 U/L (normal range 15- 90), LDH 228 umol/L (normal range 100-245) and ALT 181 U/L (normal range <60).

Transabdominal ultrasound demonstrated a hypoechoic mass centered on the distal Common Bile Duct (CBD) and significant upstream biliary dilation (Figure 1). CT and MR imaging both confirmed the findings of intra- and extra hepatic biliary dilation, an abrupt change in the caliber of the CBD at the level of the mass in the peri-portal region, and porta-hepatis lymphadenopathy (Figure 2). MR Cholangiopancreatography sequences demonstrated a tapering obstruction of the CBD with upstream dilation (Figure 3). Endoscopic Retrograde Cholangiogram (ERC) revealed a severe stricture in the mid-CBD (Figure 4). Intraductal brush specimens were obtained and sent for cytopathology and a plastic biliary stent was placed to relieve the obstruction. Although the cytology was nondiagnostic for malignancy, based on the presentation and imaging findings, the most likely diagnosis was felt be a cholangiocarcinoma. Surgical intervention was deferred due to the presence of regional lymphadenopathy. A repeat ERC was therefore performed and a permanent uncovered metal stent was placed for more reliable palliation. He was referred to our institution to obtain a pathological diagnosis with endoscopic ultrasound-guided FNA. On EUS, a 3cm well-defined hypoechoic mass was found in the periportal region more consistent with an enlarged lymph node as opposed to a CBD mass. Targeted FNA was performed of this lesion. A 25 gauge needle (Expect, M00550021, Boston Scientific, Natick, MA) was used and 3 separate specimens were obtained (Figure 5). Thin prep of the specimen showed scattered individual and aggregate lymphoid cells predominantly composed of atypical large cells (Figure 6). The atypical B-cells were positive for CD20 and CD45 (Figure 7). Partial expression of BCL2 by B-cells was also noted and the Ki67 proliferation index highlighted large atypical B-cells (Figure 7). Flow cytometric report indicated a lambda light chain restricted population with CD19/CD20/CD22 positive B lymphocytes aberrantly coexpressing CD10. The above results were in keeping with a B-cell neoplasm. The morphology and the immunoprofile of the neoplastic cells were consistent with a high grade B-cell lymphoma and the differential considerations were diffuse large B-cell lymphoma versus a high grade follicular lymphoma.