An Unusual Case of a Gastric MALToma Rapidly Transforming into an Aggressive B-Cell Lymphoma

Abstract

Purpose: A 77-year-old Caucasian male with a history of diabetes and hypertension presented with progressive dysphagia to solids and liquids, persistent epigastric pain, and 25 lbs weight loss for the previous 6 weeks duration. Physical exam was unremarkable. Initial CT scan was normal so he an EGD was done and showed a circumferential friable mass with extensive central necrosis extending from the GE junction to the antrum. Histological examination was consistent with Mucosa Associated Lymphoid Tissue (MALT) lymphoma, H. pylori negative. A repeat EGD one week later showed the same findings. He presented to the hospital 2 weeks later with worsening nausea, vomiting, diarrhea and epigastric pain, and was hypotensive, lethargic, and had altered mental status. His initial laboratory work-up showed leukocytosis, acute renal failure with a high anion gap metabolic acidosis, elevations of all liver enzymes, and extremely elevated LDH, all of which were normal on the previous blood tests. PET scan done showed intense hypermetabolic activity in the liver/spleen and bone marrow as well as mediastinal lymphadenopathy involving the subcarinal/paraesophageal region. A bone marrow biopsy showed diffuse large B-cell lymphoma. The patient then developed tumor lysis syndrome and died 3 days after his admission. Discussion: We report an extremely rare case of gastric MALToma that transformed very rapidly into an aggressive diffuse large B-cell lymphoma. Gastric MALToma are usually low grade lymphomas that have a very indolent course and an excellent prognosis. Because of the common histological features, it is assumed that there is possible transformation from MALToma to diffuse large B cell lymphoma, however, this has been rarely reported. To our knowledge, this is the first case that reports such a rapid and fatal transformation of a benign MALToma. Clinicians and gastroenterologists should be aware of this possible transformation and its possible fatal consequences.Table: [695]Figure: [695] Endoscopic finding in the EGD done on 2 instances on the patient.