An Unusual Cause of Melena

Abstract

FIGURE 2. A, Computed tomography of the abdomen exhibited a pancreas body-tail mass with direct invasion of the gastric wall. B, Wholebody dual-modality 18F-fluorodeoxyglucose positron emission tomography/ computed tomography images disclosed multiple areas with increased 18F-fluorodeoxyglucose uptake around the stomach, pancreas, and several nodes over the substernal and superior mediastinum region. From the Division of Internal Medicine, Department of Gastroenterology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China. A 47-year-old man was hospitalized after experiencing melena and vomiting for 1 day. He also had intermittent epigastric pain concurrent with weight loss from 89 kg to 75 kg over 1 month. His own and his family’s medical histories were unremarkable. Physical examination showed epigastric tenderness without rebound pain. Initial laboratory examination revealed abnormalities as follows: leukocyte counts, 11.86 10/mL; hemoglobin level, 12.5 g/dL; blood urea nitrogen, 47 mg/dL; and creatinine, 1.4 mg/dL. Upper gastrointestinal endoscopy identified an ulcerative mass over the lower body of the stomach. Biopsies demonstrated highgrade malignant B-cell lymphoma of the gastric tissue (Figure 1, A). Immunohistochemically, the tumor cells were positive for CD20 (Figure 1, B) and Bcl-2, but negative for CK and CD3. Computed tomography of the abdomen exhibited a pancreas body-tail mass with direct invasion of the gastric wall (Figure 2, A). Whole-body dual-modality 18F-fluorodeoxyglucose positron emission tomography/computed tomography images disclosed multiple areas with increased 18Ffluorodeoxyglucose uptake around the stomach, pancreas, and several nodes over the substernal and superior mediastinum region (Figure 2, B). Primary pancreas lymphoma was excluded because of mediastinum nodal involvement and leukocytosis based on Behrns’ diagnostic criteria. Secondary malignant B-cell lymphoma of the pancreas was confirmed. Although non-Hodgkin lymphoma with secondary involvement of the pancreas is estimated to occur in about 30% to 40% of non-Hodgkin lymphoma cases, melena due to secondary malignant B-cell lymphoma of the pancreas with direct invasion of the stomach has not been reported in the literature. Our patient received the standard chemotherapy protocol for non-Hodgkin lymphoma.