Two cases of cystic lymphangioma of the pancreas: a rare finding in endoscopic ultrasonography

 

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Cystic lymphangioma of the pancreas is a rare, benign neoplasm classically diagnosed at surgery. We report here on two patients diagnosed using endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA).

A 70-year-old man and a 63-year-old woman both underwent computed tomography (CT) scans for evaluation of nonspecific abdominal complaints. The physical examination and laboratory evaluation were unremarkable in both. The CT scans revealed a 4.6-cm cystic lesion in the head of the pancreas in the first patient and a 3.0-cm mass near the uncinate process in the second (Figure [1]).

EUS was carried out in both patients. The first patient had a septated cystic lesion 4.6 × 2.7 cm in size in the pancreatic head (Figure [2 a]). The second patient had a septated cystic mass measuring 3.7 × 2.6 cm near the uncinate process (Figure [2 b]). The rest of the examination was normal in both patients (Figure [3]). At FNA, a thin, milky fluid was aspirated in both cases (Figure [4]). Laboratory analysis revealed a triglyceride level of > 5000 mg/dl in both cases. No disease progression or complications such as cyst infections were evident after a follow-up period of 5 months. In both cases, the chylous aspirate with a markedly elevated triglyceride level was diagnostic.

Figure 1 Computed tomograms from patient 1 (a) and patient 2 (b), showing the pancreatic cysts.

Figure 2 Radial endoscopic ultrasound images from patient 1 (a) and patient 2 (b), showing measurements of the septated cyst (cross-hairs).

Figure 3 Radial endoscopic ultrasound image from patient 1, showing the cyst in relation to the common bile duct (CBD), pancreatic duct (PD) and portal vein (PV).

Figure 4 A syringe filled with the chylous cyst aspirate.

Lymphangiomas are rare benign neoplasms that can arise in most organs. The largest reported series, including 10 surgical cases, suggested that they represent 0.2 % of pancreatic neoplasms. Many patients have been asymptomatic, with the lesion being discovered incidentally on imaging studies [1].

Most previously reported cases have been diagnosed at surgery, since imaging examinations have not been sufficient to exclude malignancy. With EUS-FNA, many cystic neoplasms can now be reliably diagnosed without surgery [2] [3] [4] [5]. Since lymphangiomas are generally believed to be benign, nonsurgical management may be reasonable if a definitive diagnosis is made [1]. In the absence of significant symptoms attributable to the cystic lymphangioma, surgical resection may be unnecessary.

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References

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B. Applebaum, M. D.

Section of Gastroenterology
University of Arizona Medical Center

1501 N. Campbell Avenue
Tucson, Arizona 85724
USA

Fax: +1-520-626-0826

Email: bapplebaum@hotmail.com