A Rare Case of Subtle Antral Gastropathy Revealing Aggressive Stage IV Diffuse Large B-cell Lymphoma (DLBCL): A Review of Endoscopic Findings of Gastric DLBCL

Abstract

Lymphoma is frequently on the differential diagnosis of masses or malignant appearing mucosal changes of the stomach. We present an unusual case of aggressive stage IV diffuse large B cell lymphoma (DLBCL) involving the stomach with only the underwhelming endoscopic appearance of mild antral erythema on upper endoscopy. A 51 year-old male presented with a two-month history of rectal bleeding, progressive dyspnea on exertion, fatigue, and 30 lbs of weight loss. The patient did not have any family history of malignancy nor high risk, illicit behaviors. He was hemodynamically stable. His physical exam demonstrated a normal abdominal exam, no palpable lymphadenopathy, and rectal exam with external hemorrhoids. His hemoglobin was found to be 5.7 mg/dL from 8.7 mg/dL within one month. His white blood cell and platelet counts were normal. His ferritin was 3103 ng/mL and lactate dehydrogenase was 2070 U/L. A CT scan of his abdomen was pertinent for minimal mucosal thickening of the gastric antrum and body but no enlarged lymph nodes. Upper endoscopy was performed and showed mild linear erythema along the greater curvature of the gastric antrum without any thickened folds, ulcers, or masses noted (Figure 1). Antral and gastric body biopsies were performed, and one fragment from the antrum demonstrated atypical lymphoid infiltration. The lymphoid cells were medium to large in size with open chromatin and variable prominent nucleoli suggestive of lymphoma (Figure 2). A bone marrow biopsy confirmed stage IV DLBCL. The patient was treated with rituximab, etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin for 6 cycles with bone marrow biopsy and PET scan confirming remission. In a previous retrospective study of gastrointestinal non-Hodgkin's lymphoma, the majority of the cases were DLBCL. DLBCL varied endoscopically but, more commonly, appeared mass-like and none of which had subtle findings. An Italian multicenter study demonstrated that 10% of the low-grade gastric lymphomas had no macroscopic lesions, but all high-grade lymphomas had ulcer-type, exophytic-type, or hypertrophic-type endoscopic findings. It has been said we are limited, not by our abilities, but only by our vision. Here, we review endoscopic findings of aggressive DLBCL with this case demonstrating a unique instance of aggressive DLBCL with no macroscopic findings and a high index of suspicion for underlying pathology leading to the ultimate diagnosis and a fortunate outcome.Figure: Gastric antrum with mild linear erythema but, otherwise, no other mucosal abnormalities.Figure: A fragment of gastric mucosa showing atypical lymphoid infiltration. The atypical lymphoid cells are medium to large in size with open chromatin and variable prominent nucleoli.