Very rarely lymphoma primarily or secondarily involves the pancreas. Involvement of the pancreatic parenchyma with lymphoma clinically may mimic pancreatic ductal adenocarcinoma (PDA) and other mass‐forming pancreatic lesions. Endoscopic ultrasound fine needle aspiration (EUS‐FNA) is the first step in the diagnostic pathway of managing these patients by providing a cytology specimen. Cytologically, lymphoma of pancreas can be misdiagnosed for a wide variety of pancreatic neoplastic and non‐neoplastic lesions. Cytological differential diagnosis includes well‐differentiated adenocarcinoma, acinar cell carcinoma, well differentiated neuroendocrine tumor, and autoimmune pancreatitis. Gastroenterologist's skills in providing adequate sample for preparing smears, cell blocks and/or performing flow cytometry, and also cytopathologist's skills in detecting atypical lymphocytic population are crucial factors. Although cytology examination has limitations to subclassify lymphoma, it plays a key role to redirect clinicians into the right patient‐care pathway. In this article, we present two cases of pancreatic lymphoma with emphasis on the discriminating cytomorphological features, and we also review literatures with reports of primary pancreatic lymphoma (PPL) to better understand the characteristics of this rare lesion.
Co-occurrence of myelodysplastic syndrome (MDS) and plasma cell neoplasm in patients with no history of chemo and/or radiotherapy is rarely reported. Herein, we report a case of a female in her seventieth decade of life who was referred to the hospital for pancytopenia. The patient was asymptomatic and was doing well overall. Serum protein electrophoresis was remarkable for a lambda-restricted monoclonal protein (IgG) estimated at 1.8g/dL. Immunoglobulin G serum level was also elevated, and serum Kappa/Lambda free light chain ratio was decreased. At that time, a bone marrow biopsy showed myelodysplastic syndrome with excess blasts-2 (MDS-EB2) and a monoclonal plasma cell proliferation. Some studies have shown that patients with plasma cell neoplasm could be associated with an increased risk of developing MDS compared to the general population. Based on reviewing the literature, to our knowledge, the pathological mechanism of the co-occurrence of both diseases is not yet clear.
Background Early detection of sepsis in patients admitted to the emergency department (ED) is an important clinical objective to help reduce morbidity and mortality. We aimed to use data from Electronic Health Records (EHR) system to characterize the relative importance of a new biomarker called Monocyte Distribution Width (MDW) that has been recently approved by the US Food and Drug Administration (FDA) for sepsis screening in the presence of routinely available hematologic parameters and vital signs measures. Methods In this retrospective cohort study, we included ED patients admitted to the MetroHealth hospital (a large regional safety-net hospital in Cleveland, OH, USA) with suspected infection who later developed severe sepsis. All adult patients presenting to the ED were eligible for inclusion and encounters that did not have complete blood count with differential data or vital signs data were excluded. We developed seven data models and an ensemble of four high accuracy machine learning (ML) algorithms using the Sepsis-3 diagnostic criteria for validation. Using the results generated by the high accuracy ML models, we applied the Local Interpretable Model- Agnostic Explanation (LIME) and Shapley Additive Value (SHAP) post-hoc ML interpretability methods to characterize the contributions of individual hematologic parameters, including MDW, vital signs measures in screening for severe sepsis. Findings We evaluated 7071 adult patients from 303,339 adult ED visits occurring between May 1st, 2020 and August 26th, 2022. Implementation of the seven data models reflected the ED clinical workflow with incremental addition of standard complete blood count (CBC), CBC with differential, with MDW, and finally vital signs measures. Random forest and deep neural network model reported classification area under the receiver operating characteristic curve (AUC) value of up to 93% (CI 92 : 94) and 90% (CI 88 : 91) over data model with hematologic parameters and vital signs measures. We applied the LIME and SHAP ML interpretability methods on these high accuracy ML models. Both the interpretability methods were consistent in their findings that the value of MDW is grossly attenuated (low feature importance scores of 0.015 (SHAP) and 0.0004 (LIME)) in the presence of other routinely reported hematologic parameters and vital signs measures for severe sepsis detection. Interpretation Using ML interpretability methods applied to EHR data, we show that MDW can be replaced with routinely reported CBC with differential together with vital signs measures for severe sepsis screening. MDW requires specialized laboratory equipment and modification of existing care protocols; therefore, these results could guide decisions about allocation of limited resources in cost constrained care settings. Additionally, the analysis shows the practical application of ML interpretability methods in clinical decision making.
Introduction/Objective Primary cutaneous follicle center lymphoma (PCFCL) is the most common primary cutaneous B-cell lymphoma. It arises from mature germinal center B lymphocytes. Here we report two cases of PCFCL with parotid gland involvement. Methods First case is a 66-year-old male with an enlarging forehead mass for nine months and a painless nodule on the right pre-auricular skin. Second is a 39-year-old male with a history of a recurring scalp spindle cell B-cell lymphoma now presenting with an enlarging lesion on the scalp and “fullness” in the right neck. There was no nodal or other extranodal involvement found in either case. Skin and parotid gland biopsies were obtained in both cases. Results Case one: The skin and parotid gland demonstrated sheets of predominantly medium sized infiltrating lymphoma cells, positive for CD20, Bcl-6, CD5 (dim) and Bcl-2 (dim), and negative for CD10, Bcl-1, and MUM-1. The epidermis was spared. Case two demonstrated medium sized, spindle shaped lymphoma cells. The skin showed a vague follicular growth pattern, sparing the epidermis. The parotid gland showed diffuse infiltration by lymphoma cells, positive for CD20 and Bcl-6, Bcl-2 (dim) and no definite positivity for CD10. Fluorescent in situ hybridization for t(14;18) translocation was absent in both cases. Conclusion Dissemination of PCFCL to extracutaneous sites is uncommon (~10% of cases) and to our knowledge, has not been reported in the parotid gland. Here we present two unique cases, which in the absence of nodal disease, prove the diagnosis of PCFCL with parotid gland involvement.
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