Complication of CD5-positive DLBCL metachronously
after the onset of pancreatic cancer : a case report
Futoshi Eto1), Atsushi Yamaguchi2), Jyunichi Zaitsu3), Kazuya Kuraoka3), Hiroshi Kouno2),
Kiyomi Taniyama4)
Dept. of postgraduate Clinical Education1), Dept. of Gastroenterology2), Dept. of Pathology3),
President4)
National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Kure, Japan

Case Introduction【Patient】68years-old, Female 【Chief complaint】 None

【Current Medical History】
In 2006, she received antiviral therapy for chronic type C hepatitis and achieved complete remission.
In August 2012, she was found a pancreatic tumor and lung nodule on CT during follow-up for chronic type C hepatitis and introduced to our department.
【Past Medical History】 Chronic type C hepatitis(Hepatic Cirrhosis) 【Lifestyle Histories】 No drinking and smoking 【Family History】 No pancreatic cancer patients【Phisical Findings】Body Temperature：36.5℃, Pulse Rate：72bpm/min., Blood Pressure：120/70mmHg, Height：156cm, Body weight：50kg Abdomen：flat・soft【Peripheral blood】Nothing particular

Abdominal CT, and CytologyLeft) Pancreatic tumor found on contrasting CT；10mm diameter and was loss levelCenter) The lung nodule resected by operation；
the result of pathological diagnosis was metastasis of pancreatic cancer(CK7/20
positive,TTF-1 negative)
Right) Pancreatic juice cytology；intermediately differentiated adenocarcinoma

Clinical course

18months CT

EUS-FNA and Cytology(21months)

Results
Lymph nodes around thepancreas begun to enlarge

Pancreatic tumor

Abdominal Lymph node

only pancreatic cancer cells
in the juice cytology

atypical lymphocytes
from the lymph nodes

21months CT

Cervical lymph node biopsy(22months)

H.E. dyeing
Lymph nodes below the nephroticartery begun to enlarge

CD5 dyeing

CD20 dyeing

CD5 / CD20positive by immunostaining

Autopsy(32months after the outbreak)・ Caput pancreatis cancer ： multiple metastatic pulmonary and hepatic nodules
・ Diffuse large B-cell lymphoma：multiple lymphomatic metastasis(Neck, armpit, mediastinum, nearby the portal vein and the abdominal aorta,
pelvis, mesentery , groin lymph node), pancreas, liver・Cause of death：Cachexia (mainly due to DLBCL)
Left) Pancreatic cancer and DLBCL are co-existing on pancreas(H.E. ×40)
Center) Pancreatic cancer (H.E. expanded for ×100)
Right) DLBCL(H.E. expanded for ×100)

the image of DLBCL on the lower right side,and pancreatic cancer on the upper left corneras the connective tissue on the background

Discussion
Pancreatic Cancer（Diagnosed）

It’s to be well-known that…
①There is little metastasis to the para-aortic level lymph node which islower than renal vein by the pancreatic cancer.
②Even if artery and portal vein are compressed by tumor, it is hard tocause permeation and confinement for the malignant lymphoma.
1）K.Matsueda et al; Rinsho gazou 2011 ; 27 : 863-72.
2）Costello P et al; J Comput Tomogr 1984 ; 8 : 1-11.

We think, with double cancer cases of pancreas cancer and ML, lymph nodes
around the pancreas might be the primary lesion of ML, and ML would
dominantly faster progress than other tumors.
In many cases of merger with other organs, we mainly try to treat ML andmake complete remission. We suggest to inspect merger of ML and believe toimprove the prognosis.
3)S.Koyama et al; Gan no rinsho 1983; 29: 168-73

4)H.Imai et al; Fukubu gazoushinndan 1991; 11: 640-455)Lai JM et al; J Pancreas 2011; 12: 185-9

Editor Age

Gen
DuplicatedderKoyama
75et al3)

Retrope
Simultaneo
HighlyritonealM
caput
uslydifferentiated
lymph
node

Tissue typelesion

Imai et62al4)

Simultaneo IntermediatelyM
caput
uslydifferentiatedLai etal5)

70

SimultaneoFinvasive IPMN caput
usly

78

Simultaneo
PoorlyM
caput
uslydifferentiatedLai etal5)

Our
case

70

F

Preceded
MLIntermediately～poorlycaput
differentiatedLymphoma(Diagnosed）

Meta. Stage Tissue type4a

regionLN(surroundingpancreas, portal
Diffusevein）
large B cellOrgans(pancreas，liver，kidney et al）

4aDiffuselarge B cellLN(surroundingpancreas, SMA）

None

4b

follicularlymphoma

LN(Aorta-caval,retroportal,portal
hepatic）

None

3 or
4a

LN(Peripancreatic,lymphocytic
retroportal, omental,lymphoma
hepatic artery）

4b

LN(Neck, armpit,mediastinum, nearby
Diffusethe portal vein andlarge B cell the abdominal aorta,pelvis, mesentery ,groin)＃13

NoneCircumstances fordiagnosis

Treatment

Prognosis

45 months fromoutbreak

Anticancer
agents forpancreaticcancer

5months after
diagnosed as
pancreatic cancer（14days for ML）
Died with ML

1Operation (thoughtmetastasis frompancreatic cancer

Anticancer
agents for
ML afteroperation

19months
Alived with norecurrence

1Operation(notpreoperative)

GEM after
operation

12months
Alived with norecurrence

1Operation(notpreoperative)

GEM after
operation

12months
Alived with norecurrence

GEM＋
rituximab

32months after
diagnosed as
pancreatic cancer（9months for ML）
Died with MLStage

3

Lymphadenopathyon CTConclusion
We experienced the case of DLBCL that was arouse from abdominal lymph nodes metachronously after the onset of pancreatic cancer.
When we found lymphadenopathy with pancreatic cancer, we should pay attention to the forms, distributions, and pathologies, and take into consideration of othersystems except the metastasis of the pancreatic cancer.