1267 Recurrent Mantle Cell Lymphoma to the Gall Bladder: A Peculiar PET CT

Abstract

INTRODUCTION: Mantle Cell Lymphoma (MCL) is a B-cell non-Hodgkin lymphoma that has a variable course. The initial presentation of MCL is usually nonspecific and varies based on the organ involved. Initial treatment includes a variety of chemotherapeutic options; however, almost all patients will have refractory or recurrent disease due to the rapid development of chemotherapy resistance. In this case report, we present a rare presentation of recurrent mantle cell lymphoma in the gall bladder. CASE DESCRIPTION/METHODS: Our patient is a 61-year-old female with history of mantle cell lymphoma diagnosed in 2008. At that time patient was treated with Rituxan/hyper-CVAD with an excellent response to treatment. Patient had a disease recurrence in 2012 on axillary lymph node biopsy and received 6 cycles of Bendamustine and Rituximab and achieved remission as determine by PET CT. The patient decided against allogeneic hematopoietic stem cell transplant (HCT) and was started on Rituximab maintenance therapy by 2013. Patient had another recurrence on axillary lymph node biopsy in 2017 and was placed on Ibrutinib with no FDG noted on subsequent PET-CTs in 2/2018 and 5/2018. A surveillance PET CT performed in 12/2018 showed intense avid FDG uptake involving the gallbladder (Figure 1). A MRI was performed that showed an enhancing lesion in the dorsal aspect of the descending duodenum measuring 18 mm. Upper endoscopy revealed a prominent fold with biopsies taken with no histopathologic abnormality. The patient was subsequently taken for uncomplicated cholecystectomy with one lymph node associated and sent for pathology. Pathology results showed the cystic duct lymph node and gallbladder wall involved by MCL with 40 mitoses per 15HPF and Ki-67 proliferative index of 34% (Figures 2 and 3). This suggested a more aggressive MCL. The patient was started on Revlimid and Rituximab, and will be awaiting clinical trial eligibility at a nearby facility. DISCUSSION: MCL typically follows an aggressive clinical course with high risk of recurrence regardless of chemotherapeutic regimen. One previous case with MCL to the gallbladder was found incidentally as a lymphomatous polyp. An additional case presented with intussception with a mass noted during surgical repair. Overall, there have been approximately 66 cases of B-cell lymphoma noted to the gallbladder, and two prior cases as above of MCL. Our case represents a rare presentation of relapsed MCL to the gall bladder and the wide possibility of metastasis associated with recurrent MCL.