1399 DLBCL Mimicking a Cholangiocarcinoma: Earlier Diagnosis, Better Outcome?

Abstract

INTRODUCTION: Diffuse Large B-Cell Lymphoma (DLBCL) is the most common subtype (∼25%) of Non-Hodgkin's Lymphoma. In 40% of cases, disease arises in extra-nodal, extra-medullary tissues, primarily in the stomach or GI tract. This is a rare case presentation of DLBCL mimicking cholangiocarcinoma. CASE DESCRIPTION/METHODS: 56-year old male with no significant past medical history presented to the ER with progressive abdominal pain for the past three months. Patient had early satiety and unintentional weight loss of sixty pounds over the past year. Labs on admission were significant for WBC: 13.55 (93% Neutrophils), Hemoglobin: 7.3, AST: 158, ALT: 150, Total Bilirubin: 17.7, Alkaline Phosphatase: 846, Albumin: 2.1, and LDH: 442. HIV was negative. Physical exam was notable for cachexia, scleral jaundice, and diffuse abdominal pain. CT of abdomen showed 2.6 × 3.4 cm mass encasing the common bile duct, intra and extra-hepatic biliary ductal dilation, retroperitoneal lymphadenopathy, suspicious liver metastases, significant ascites, and main portal, superior mesenteric, and splenic vein thrombosis, all concerning for cholangiocarcinoma. Patient was started on heparin drip for the vein thromboses. Gastroenterology attempted an ERCP, but was unable to cannulate the biliary tree. Analysis of ascitic fluid was negative for malignant cells. EGD showed large varices in lower third of esophagus and two non-bleeding gastric ulcers. Both ulcers were biopsied for histology. Gastric biopsy from EGD demonstrated diffuse large B-cell lymphoma with neoplastic cells, strongly CD20+ and weak BCL 6. Bone marrow biopsy showed no marrow involvement. Hematology Oncology recommended chemotherapy with R-CHOP. Few days later, the patient developed a GI bleed and transferred to MICU. Repeat EGD showed esophageal varices with blood clot covering fundus and body. The next day the patient was made comfort measures and passed. DISCUSSION: DLBCL has an incidence of approximately 7 cases per 100,000 persons per year. Per case report by Zakaria et al, there have been 28 reported cases of NHL to arise in the extra-hepatic bile ducts between 1982 and 2012. Diagnosis is best made by excisional lymph node biopsy or immunophenotyping. Treatment options primarily include surgery and chemotherapy. Prognosis varies among reported cases of DLBCL involving the GI tract from death within 32 days to survival greater than 72 months. DLBCL with biliary tract causing obstructive jaundice is a rare presentation, but it should among the differential diagnoses.